Pilon 骨折

Pilon骨折2010级骨伤专业叶青谢君定义:pilon骨折是指累及胫距关节面的胫骨远端骨折。胫骨Pilon骨折目前尚没有明确的定义，一般是指胫骨远端1/3波及胫距关节面的骨折，胫骨远端关节面严重粉碎，骨缺损及远端松质骨压缩。常合并有腓骨下段骨折（约75%～85%)和严重软组织损伤。•Definition：Pilonfracturereferstodistaltibiafractureswhichinvolvetibia-astragalusarticularsurface.Pilonfracturehaven’tgotcleardefinitionyet,itusuallyreferstothirddistaltibiafracturesspreadfromthejoint.Thedistaltibialarticularsurfacealwaysseriousshattered,bonedefectandremotecancellousbonecompression.ItusuallyAssociatedwiththelowerpartoffibulafractures(about75%~85%)andserioussofttissueinjury.名称来源：1911年首先由法国放射学家Destotti提出“tibialpilon”一词，他把胫骨远端干骺端的形状描述为像药剂师的杵棒。胫骨远端关节面形似天花板,1950年Bonin称之为“tibialplatfond”，因此pilon骨折又称为platfond骨折。•Definitionorigin:In1911,theFrenchradiologistDestottifirstlyputforwardtheword--tibialpilon“.Hedescribedtheshapeofdistaltibiaasthepharmacist’spestle(pilon).Thedistaltibialarticularsurfaceisalsolookslikeceiling;In1950,bonincalledit“tibialplatfond”,sopilonfracturecanbecalledPlatfondfracture.损伤机制：胫骨Pilon骨折最常发生于高处坠落、车祸骤停、滑雪或绊脚前摔。胫骨轴向暴力或下肢的扭转暴力是胫骨远端关节面骨折的主要原因。两种不同的损伤机制导致Pilon骨折，其预后亦不同,受伤时踝关节的位置与骨折类型密切相关.•Injuremechanism:TibialPilonfracturesoccurmostofteninthefall,crasharrest,skiingorstumblingbeforethefall.Axialtibialviolenceortorsionviolenceoflowerextremityarethemainreasonfordistaltibialarticularsurfacefractures.TwodifferentmechanismsofinjuryleadingtodifferentprognosisofPilonfracture.Thepositionofanklejointwhenithurtsandthetypeoffracturearecloselyrelated.骨折高度不稳定和关节软骨损伤严重。治疗难度大，并发症多，致残率高，是最具挑战性的骨科难题之一。_内容丰富点。列出几点.胫骨远端关节面严重粉碎，骨缺损及远端松质骨压缩。常合并有腓骨下段骨折（约75%～85%)和严重软组织损伤骨折特征•Fracturecharacteristic:Itisahighlyunstablefracture,andhaveseverearticularcartilagedamage.Treatmentisdifficult,withmanycomplications,highdisabilityrate,anditisoneofthemostchallengingorthopaedicproblems.骨折分型：骨折分型的目的主要还是在于如何指导治疗及提示预后情况。1969年Ruedi和Augower根据关节面和干骺端的移位及粉碎程度，将Pilon骨折分为3型，这种分型的意义在于强调关节面的损伤程度。•Fractureclassify:Themainpurposeoffractureclassificationistoguidetreatmentandpromptprognosis.In1969RuediandAugowerdividedPilonfractureinto3typesaccordingtothearticularsurfaceandmetaphysealdisplacementandcrushingdegree,themeaningofthistypeliesinemphasizingthearticularsurfacedamage.Ruedi-Allgower分类系统Ⅰ型:经关节面的胫骨远端骨折，较小的移位;Ⅱ型:明显的关节面移位而粉碎程度较小;Ⅲ型:关节面粉碎移位及粉碎程度较严重。这种分型临床常用。TheRuedi-Allgowerclassificationsystem:•Typeone:Thearticularsurfacefracturesofdistaltibia,alittledisplacement;•Typetwo:Theobviousarticularsurfaceshiftandcrushlesserdegree;•Typethree:Articularsurfacecrushingshiftandthedegreeisserious.Thistypeofcommonlyusedclinical.诊断:根据病史、症状、体征，结合X片、CT等影像学检查，诊断不难，注意血管、神经等软组织的损伤，常见胫骨内侧、前侧开放性及潜在开放性损伤，认真查体，注意勿遗漏身体其他部位的损伤（脊柱骨折、腓骨上段骨折等）。•Diagnosis:Accordingtothemedicalhistory,symptoms,signs,combinedwithX,CTimagings,diagnosisisnotdifficult,payattentiontovascular,nerve,softtissueinjury,Theinsideoftibial,anterioropenandpotentialopeninjuryarecommon,carefullycheckthebody.Payattentionnottomisstheotherpartinjuryofthebody(spinalfractures,upperfibulafractureetc).治疗•（1）非手术治疗：适应于Ⅰ型无移位骨折、全身情况较差不能耐受手术者、以及为延期手术做准备的治疗。主要有手法复位石膏外固定、跟骨牵引等。Treatment•(1)Nonoperationtreatment:AdaptedtothetypeIfractureswithoutdisplacement,poorgeneralconditionwhichcannottolerateoperation,aswellasthetreatmentforthedeferredoperation.Mainlywithmanipulativereductionandplasterexternalfixation,calcanealtraction,closedpinningfixation,etc.（2）手术治疗：•手术指征：Ⅱ、Ⅲ型开放性骨折，骨折明显移位或嵌插、缺损、伴有神经血管损伤、轴向对线不良、关节面骨折移位大于2mm者，均需积极行手术治疗。•Operationtreatment:•Operationindications:TpreII,typeIIIopenfractures,fracturewasobviouslydisplacedorimpacted,defect,accompaniedbythenerveandvascularinjury,theaxialmalalignment,articularsurfacefracturedisplacementisgreaterthan2mm,theseallshouldbeactivelytreatedwithsurgicaloperation.•手术原则：低能量损伤的pilon骨折积极行切开复位内固定术（ORIF）；高能量损伤者，采取有限内固定和外固定结合的治疗手段。目前主张“生物学”原则：强调细致的软组织暴露，骨折块的有限剥离，间接复位，稳定固定后早期活动和晚期负重等.治疗目的可归纳为“3P”，即保护骨与软组织活力、进行关节面的解剖复位、提供满足踝关节早期活动的固定。•Operationprinciple:LowenergydamageofPilonfracturestreatedwithopenreductionandinternalfixationofpositive(ORIF);highenergyinjury,takelimitedinternalfixationandexternalfixationcombinedtreatment.Currentlyadvocated“biology”principle:emphasizingmeticuloussofttissueexposure,fractureblockfinitestrip,indirectreduction,doearlyexerciseafterstablefixationandlateweightbearing,etc.Treatmentgoalscanbesummarizedas“3P”,theprotectionofboneandsofttissueviability(preserve),anatomicalreductionofthearticularsurface(perform),providefixationswhichcansatisfyearlymotionoftheanklejoint(provide).•手术时机：1、开放性骨折就诊时间早或出现筋膜间室综合征的患者，均应行急诊手术处理。对于污染严重的（先清创）、就诊时间晚、肿胀严重、软组织条件差的开放性骨折主张先行跟骨牵引、石膏托固定、或超关节外固定架临时固定等治疗，待肿胀消退，水泡愈合后行二期处理。2、对于闭合性骨折的手术时机，目前还存在较大的争议，大多数人倾向于认为除软组织条件差的闭合性骨折需行延期手术外，一般应于伤后8-10小时之内，肢体肿胀不甚严重，无明显水泡形成之前急诊手术为妥，有利于骨折复位。张力较高及皮肤缺损者，可留待创面行二期处理。——这个应该放在开放性骨折后面•Operationtime:Patientofopenfracturestoseeadoctorearlyorturnupcompartmentsyndrome,urgentoperationtreatmentisnecessary.Fortheseriouspollution(firstdebridement),treatmenttimeoflate,severesofttissueswelling,poorconditionsofopenfractureofcalcaneustractionthatgoaheadoftherest,plastersupport,oroverarticularexternalfixatorfortreatmentoftemporaryfixed,afterswelling,blistershealed,dothesec