骨科踝關(guān)節(jié)手術(shù)教學(xué)提綱

1、骨科踝關(guān)節(jié)手術(shù)03Incidence: Ringerike Hospital 1/8 2003 31/7 2004: 184 per 70 000 - 100 000 persons 128/184 (69%) isolated malleolar fractures 27/184 (15%) bimalleolar 29/184 (16%) trimalleolar ANKLE FRACTURESEpidemiology04ANKLE FRACTURESClassification - Why?Why do we require fracture classifications? for c

2、linical research to understand the literature as an aid to fracture description as an aid to fracture treatment05AO (Danis/Weber)Type A below the syndesmosisType B at the level of the syndesmosisType C above the syndesmosisDanis R. Les fractures malleolaires. In: Danis R, ed. Thorie et practique de

3、losteosynthse. 1949:133-165.Weber BG. Die Verletzungen des oberen Sprunggelenkes, Berne: Hans Huber, 1966. (2nd ed. 1972)Classification AO (Danis/Weber)ANKLE FRACTURES06AO AO/OTA(Weber)3 types (A, B, C) 9 groups (A1, A2, A3, B1, B2, B3, C1, C2, C3) 27 subgroupsMller ME, Allgwer M, Schneider R, et al

4、. Manual of internal fixation, 2nd ed. Heidelberg: Springer-Verlag, 1979:282-299. (3rd ed. 1991).Orthopaedic Trauma Assocoation. Fracture and dislocation compendium. J Orthop Trauma 1996;10:1-55.Classification AO/OTAANKLE FRACTURES07AO AO/OTALauge-HansenLauge-Hansen N. Fractures of the ankle: combin

5、ed experimental-surgical and experimental roentgenologic investigations. Arch Surg 1950;60:957-985Classification Lauge-HansenANKLE FRACTURES08AO AO/OTA Lauge-Hansen Supination - External rotation (I, II, III, IV) Supination - Adduction (I, II) Pronation - External rotation (I, II, III, IV) Pronation

6、 - Abduction (I, II, III) position deforming forceClassification Lauge-HansenANKLE FRACTURES09AO AO/OTA Lauge-Hansen Supination - External rotation (I, II, III, IV) Supination - Adduction (I, II) Pronation - External rotation (I, II, III, IV) Pronation - Abduction (I, II, III) position deforming for

7、ce stable ”stable” unstableClassification Lauge-HansenANKLE FRACTURES10AO AO/OTA Lauge-HansenStable versus Unstable (Tile)Tile M. Fractures of the ankle. In: Joseph Schatzker MT, ed. The rationale of operative fracture care. Berlin: Springer-Verlag, 1987:371-404.The presence or absence of a medial i

8、njury is the key to stability of the lateral malleolar fracture. The medial injury determines stabilityClassification Stable/UnstableANKLE FRACTURES11Weber ASA I-IIWeber BSE I-IVPA I-IIIWeber CPE I-IVDanis Weber vsLauge HansenANKLE FRACTURESLauge-Hansen Classification (Supination-Adduction, SA I II)

9、IIII Transverse fibula fracture or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fractureANKLE FRACTURES12Lauge-Hansen Classification (Supination-Adduction, SA I IIANKLE FRACTURES13IIII Transverse fibula fra

10、cture or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fractureRadiographic view: Supination-Adduction type II fracture with medial impaction 14ANKLE FRACTURESRadiographic view: Supination-Adduction type II

11、fracture with medial impaction15ANKLE FRACTURESCorrections Impression of medial plafondReposition of medial malleolusPlating and bone grafting of medial metaphysisLauge-Hansen Classification (Supination-External rotation, SE I IV)IIIIIIIVI Anterior tibial-fibular sprainII Stable short oblique fractu

12、re of the distal fibulaIII Rupture of posterior tibial-fibular ligament or fracture of the posterior marginIV Unstable short oblique fracture of the distal fibula with a medial malleolus fracture or a deltoid ligament disruptionANKLE FRACTURES16Lauge-Hansen Classification (Supination-External rotati

13、on, SE I IV)IIIIIIIVI Anterior tibial-fibular sprainII Stable short oblique fracture of the distal fibulaIII Rupture of posterior tibial-fibular ligament or fracture of the posterior marginIV Unstable short oblique fracture of the distal fibula with a medial malleolus fracture or a deltoid ligament

14、disruptionANKLE FRACTURES17Illustration: Supination-External rotation type II, III and IV18Fixation of an oblique fracture of the distal fibulaANKLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 a)19ANKLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 b)2

15、0ANKLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 c)21ANKLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 d)22ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (2 a)23ANKLE FRACTURESRadiographic view: Supination-External rotation

16、type IV (2 b)24ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 a)25ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 b)26ANKLE FRACTURESIII IVTypical fracture line pattern for a SE type fracture IIRupture of the posterior tibio-fibular ligamentRuptur

17、e of the deltoid ligament IIOblique fracture of the distal fibula IAnterior tibio-fibular sprainRadiographic view: Supination-External rotation type IV (3 c)27ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 d)28ANKLE FRACTURESRadiographic view: Supination-External rotation

18、type IV (3 e)29ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 f)30ANKLE FRACTURESMale 64 years of age, was proposed a re-operation but chosed to accept the present situation after proper informationLauge-Hansen Classification (Pronation-Abduction, PA I III)IIIIIII Isolated

19、 medial malleolus or deltoid ligament ruptureII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Bending fracture of the lateral malleolus with a transverse and often comminuted pattern with possible lateral tibial impactionANKLE FRACTURES31Lauge-Hansen Classificat

20、ion (Pronation-Abduction, PA I III)IIIIIII Isolated medial malleolus or deltoid ligament ruptureII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Bending fracture of the lateral malleolus with a transverse and often comminuted pattern with possible lateral tibial

21、 impactionANKLE FRACTURES32Illustration: Pronation-Abduction type III33Fixation of a comminuted fibula fractureANKLE FRACTURESRadiographic view: Pronation-Abduction type III, lateral plafond impaction (1 a)34Limbird and Aaron JBJS Am 69:881, 1987ANKLE FRACTURESRadiographic view: Pronation-Abduction

22、type III, lateral plafond impaction (1 b)35Limbird and Aaron JBJS Am 69:881, 1987ANKLE FRACTURESIII II ILateral impactionMedial malleolus fractureComminuted lateral malleolus fractureNo spiral fracturepattern in the fibulaAvulsion ofChaputs tubercleRadiographic view: Pronation-Abduction type III, la

23、teral plafond impaction (1 c)36ANKLE FRACTURESLimbird and Aaron JBJS Am 69:881, 1987Radiographic view: Pronation-Abduction type III, lateral plafond impaction (1 d)Corrections (mortise view)lenght of the fibulalateral plafond impactionfracture of the medial malleolusposterior malleolar fracture 37AN

24、KLE FRACTURESLimbird and Aaron JBJS Am 69:881, 1987Radiographic view: Pronation-Abduction type III, lateral plafond impaction (1 e)38Corrections (lateral view)lenght of the fibulalateral plafond impactionfracture of the medial malleolusposterior malleolar fracture ANKLE FRACTURESLimbird and Aaron JB

25、JS Am 69:881, 1987Lauge-Hansen Classification (Pronation-External rotation, PE I IV)I Isolated medial malleolus or deltoid ligament disruptionII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Short spiral fracture above the syndesmosisIV Disruption of the inferio

26、r tibiofibular ligament or a posterior malleolar fractureIIVIIIIIANKLE FRACTURES39Lauge-Hansen Classification (Pronation-External rotation, PE I IV)IIVIIIIITo be noticed!The typical direction of the fracture line in the fibula (lateral view) is different in a Pronation-External rotation type of frac

27、ture compared with a Supination-External rotation type of fractureSE II-IVPE III-IVANKLE FRACTURES40Lauge-Hansen Classification (Pronation-External rotation, PE I IV)I Isolated medial malleolus or deltoid ligament disruptionII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular l

28、igamentIII Short spiral fracture above the syndesmosisIV Disruption of the inferior tibiofibular ligament or a posterior malleolar fractureIIVIIIIIANKLE FRACTURES41Illustration: Pronation External rotation type IV42ANKLE FRACTURESRadiographic view: Pronation-External rotation type I? II? III? IV? (1

29、 a)43ANKLE FRACTURESRadiographic view: Pronation-External rotation type I? II? III? IV? (1 b)44ANKLE FRACTURESRadiographic view: Pronation-External rotation type III or IV (1 c)45ANKLE FRACTURESRadiographic view: Pronation-External rotation type I? II? III? or IV? (2 a)46ANKLE FRACTURESRadiographic

30、view: Pronation-External rotation type I? II? III? or IV? (2 b)47ANKLE FRACTURESIVAvulsion of Chaputs tubercle II IAvulsion type fracture of the medial malleolus Posterior malleolus fracture IIAvulsion of Chaputs tubercle?III?Radiographic view: Pronation-External rotation type I? II? III? or IV? (2

31、c)48ANKLE FRACTURESIII!Radiographic view: Pronation-External rotation type I? II? III? or IV? (2 d)49ANKLE FRACTURES IIAvulsion of Chaputs tubercle?IVPosterior malleolus fracture IMedial malleolus fracture Illustration: SE type III and IV - PE type (II), III and IV PA type II and III 50Fixation of a

32、 total rupture of the syndesmosisANKLE FRACTURESIllustration: SE type IV - SA type II PE type I-IV PA type I-III51Fixation of the medial malleolusANKLE FRACTURESClassification of distal tibia fractures (Rdi and Allgwer 79)52ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)IIIIIIClassification of distal tibia fractures (Mller, Allgwer, and Schneider et al. 91)53ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)A1A2A3B1B2B3C1C2C3Illustration: axial loading injuries54ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)Plaf