骨科--踝關(guān)節(jié)手術(shù)課件(PPT 68頁)

1、ANKLE FRACTURESNetbasert undervisning april 0501Illustrations redrawn from Malleolar Fractures and Soft Tissue Injuries of the ankle: Carr JBAnkle fractures: Marsch JL, Salzman CLComposition: Bengt stman overlege Presentation: Simen Sellevold, assistentlege Ingo Spauke, assistentlege第1頁，共68頁。Epidemi

2、ology02Incidence: 80130 per 100 000 persons highest in elderly women67% isolated malleolar fractures25% bimalleolar 8% trimalleolar ANKLE FRACTURESNational Hospital Discharge Register of Finland 1994Court-BrownCM, McBirnie J, Wilson G. Adult ankle fractures: an increasing problem? Acta Orthop Scand

3、1998;69:43-47第2頁，共68頁。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 FRACTURESEpidemiology第3頁，共68頁。04ANKLE FRACTURESClassification - Why?Why do we require fractur

4、e classifications? for clinical research to understand the literature as an aid to fracture description as an aid to fracture treatment第4頁，共68頁。05AO (Danis/Weber)Type A below the syndesmosisType B at the level of the syndesmosisType C above the syndesmosisDanis R. Les fractures malleolaires. In: Dan

5、is R, ed. Thorie et practique de losteosynthse. 1949:133-165.Weber BG. Die Verletzungen des oberen Sprunggelenkes, Berne: Hans Huber, 1966. (2nd ed. 1972)Classification AO (Danis/Weber)ANKLE FRACTURES第5頁，共68頁。06AO AO/OTA(Weber)3 types (A, B, C) 9 groups (A1, A2, A3, B1, B2, B3, C1, C2, C3) 27 subgro

6、upsMller ME, Allgwer M, Schneider R, et al. 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 FRACTURES第6頁，共68頁。07AO AO/OTALauge-H

7、ansenLauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental roentgenologic investigations. Arch Surg 1950;60:957-985Classification Lauge-HansenANKLE FRACTURES第7頁，共68頁。08AO AO/OTA Lauge-Hansen Supination - External rotation (I, II, III, IV) Supination - Adduction (I,

8、II) Pronation - External rotation (I, II, III, IV) Pronation - Abduction (I, II, III) position deforming forceClassification Lauge-HansenANKLE FRACTURES第8頁，共68頁。09AO AO/OTA Lauge-Hansen Supination - External rotation (I, II, III, IV) Supination - Adduction (I, II) Pronation - External rotation (I, I

9、I, III, IV) Pronation - Abduction (I, II, III) position deforming force stable ”stable” unstableClassification Lauge-HansenANKLE FRACTURES第9頁，共68頁。10AO AO/OTA Lauge-HansenStable versus Unstable (Tile)Tile M. Fractures of the ankle. In: Joseph Schatzker MT, ed. The rationale of operative fracture car

10、e. Berlin: Springer-Verlag, 1987:371-404.The presence or absence of a medial injury is the key to stability of the lateral malleolar fracture. The medial injury determines stabilityClassification Stable/UnstableANKLE FRACTURES第10頁，共68頁。11Weber ASA I-IIWeber BSE I-IVPA I-IIIWeber CPE I-IVDanis Weber

11、vsLauge HansenANKLE FRACTURES第11頁，共68頁。Lauge-Hansen Classification (Supination-Adduction, SA I II)IIII Transverse fibula fracture or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fractureANKLE FRACTURES12第12

12、頁，共68頁。Lauge-Hansen Classification (Supination-Adduction, SA I IIANKLE FRACTURES13IIII Transverse fibula fracture or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fracture第13頁，共68頁。Radiographic view: Supinat

13、ion-Adduction type II fracture with medial impaction 14ANKLE FRACTURES第14頁，共68頁。Radiographic view: Supination-Adduction type II fracture with medial impaction15ANKLE FRACTURESCorrections Impression of medial plafondReposition of medial malleolusPlating and bone grafting of medial metaphysis第15頁，共68頁

14、。Lauge-Hansen Classification (Supination-External rotation, 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

15、 with a medial malleolus fracture or a deltoid ligament disruptionANKLE FRACTURES16第16頁，共68頁。Lauge-Hansen Classification (Supination-External rotation, SE I IV)IIIIIIIVI Anterior tibial-fibular sprainII Stable short oblique fracture of the distal fibulaIII Rupture of posterior tibial-fibular ligamen

16、t or fracture of the posterior marginIV Unstable short oblique fracture of the distal fibula with a medial malleolus fracture or a deltoid ligament disruptionANKLE FRACTURES17第17頁，共68頁。Illustration: Supination-External rotation type II, III and IV18Fixation of an oblique fracture of the distal fibul

17、aANKLE FRACTURES第18頁，共68頁。Radiographic view: Supination-External rotation type IV, (1 a)19ANKLE FRACTURES第19頁，共68頁。Radiographic view: Supination-External rotation type IV, (1 b)20ANKLE FRACTURES第20頁，共68頁。Radiographic view: Supination-External rotation type IV, (1 c)21ANKLE FRACTURES第21頁，共68頁。Radiogr

18、aphic view: Supination-External rotation type IV, (1 d)22ANKLE FRACTURES第22頁，共68頁。Radiographic view: Supination-External rotation type IV (2 a)23ANKLE FRACTURES第23頁，共68頁。Radiographic view: Supination-External rotation type IV (2 b)24ANKLE FRACTURES第24頁，共68頁。Radiographic view: Supination-External rot

19、ation type IV (3 a)25ANKLE FRACTURES第25頁，共68頁。Radiographic 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 ligamentRupture of the deltoid ligament IIOblique fracture of the distal fib

20、ula IAnterior tibio-fibular sprain第26頁，共68頁。Radiographic view: Supination-External rotation type IV (3 c)27ANKLE FRACTURES第27頁，共68頁。Radiographic view: Supination-External rotation type IV (3 d)28ANKLE FRACTURES第28頁，共68頁。Radiographic view: Supination-External rotation type IV (3 e)29ANKLE FRACTURES第2

21、9頁，共68頁。Radiographic 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 information第30頁，共68頁。Lauge-Hansen Classification (Pronation-Abduction, PA I III)IIIIIII Isolated medial mall

22、eolus 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 FRACTURES31第31頁，共68頁。Lauge-Hansen Classificatio

23、n (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 i

24、mpactionANKLE FRACTURES32第32頁，共68頁。Illustration: Pronation-Abduction type III33Fixation of a comminuted fibula fractureANKLE FRACTURES第33頁，共68頁。Radiographic view: Pronation-Abduction type III, lateral plafond impaction (1 a)34Limbird and Aaron JBJS Am 69:881, 1987ANKLE FRACTURES第34頁，共68頁。Radiographi

25、c view: Pronation-Abduction 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 tubercle第35頁，共68頁。Radiographic

26、view: Pronation-Abduction type III, lateral plafond impaction (1 c)36ANKLE FRACTURESLimbird and Aaron JBJS Am 69:881, 1987第36頁，共68頁。Radiographic view: Pronation-Abduction type III, lateral plafond impaction (1 d)Corrections (mortise view)lenght of the fibulalateral plafond impactionfracture of the m

27、edial malleolusposterior malleolar fracture 37ANKLE FRACTURESLimbird and Aaron JBJS Am 69:881, 1987第37頁，共68頁。Radiographic view: Pronation-Abduction type III, lateral plafond impaction (1 e)38Corrections (lateral view)lenght of the fibulalateral plafond impactionfracture of the medial malleolusposter

28、ior malleolar fracture ANKLE FRACTURESLimbird and Aaron JBJS Am 69:881, 1987第38頁，共68頁。Lauge-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 Sho

29、rt spiral fracture above the syndesmosisIV Disruption of the inferior tibiofibular ligament or a posterior malleolar fractureIIVIIIIIANKLE FRACTURES39第39頁，共68頁。Lauge-Hansen Classification (Pronation-External rotation, PE I IV)IIVIIIIITo be noticed!The typical direction of the fracture line in the fi

30、bula (lateral view) is different in a Pronation-External rotation type of fracture compared with a Supination-External rotation type of fractureSE II-IVPE III-IVANKLE FRACTURES40第40頁，共68頁。Lauge-Hansen Classification (Pronation-External rotation, PE I IV)I Isolated medial malleolus or deltoid ligamen

31、t disruptionII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Short spiral fracture above the syndesmosisIV Disruption of the inferior tibiofibular ligament or a posterior malleolar fractureIIVIIIIIANKLE FRACTURES41第41頁，共68頁。Illustration: Pronation External rotat

32、ion type IV42ANKLE FRACTURES第42頁，共68頁。Radiographic view: Pronation-External rotation type I? II? III? IV? (1 a)43ANKLE FRACTURES第43頁，共68頁。Radiographic view: Pronation-External rotation type I? II? III? IV? (1 b)44ANKLE FRACTURES第44頁，共68頁。Radiographic view: Pronation-External rotation type III or IV

33、(1 c)45ANKLE FRACTURES第45頁，共68頁。Radiographic view: Pronation-External rotation type I? II? III? or IV? (2 a)46ANKLE FRACTURES第46頁，共68頁。Radiographic view: Pronation-External rotation type I? II? III? or IV? (2 b)47ANKLE FRACTURESIVAvulsion of Chaputs tubercle II IAvulsion type fracture of the medial

34、malleolus Posterior malleolus fracture IIAvulsion of Chaputs tubercle?III?第47頁，共68頁。Radiographic view: Pronation-External rotation type I? II? III? or IV? (2 c)48ANKLE FRACTURESIII!第48頁，共68頁。Radiographic view: Pronation-External rotation type I? II? III? or IV? (2 d)49ANKLE FRACTURES IIAvulsion of C

35、haputs tubercle?IVPosterior malleolus fracture IMedial malleolus fracture 第49頁，共68頁。Illustration: SE type III and IV - PE type (II), III and IV PA type II and III 50Fixation of a total rupture of the syndesmosisANKLE FRACTURES第50頁，共68頁。Illustration: SE type IV - SA type II PE type I-IV PA type I-III

36、51Fixation of the medial malleolusANKLE FRACTURES第51頁，共68頁。Classification of distal tibia fractures (Rdi and Allgwer 79)52ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)IIIIII第52頁，共68頁。Classification of distal tibia fractures (Mller, Allgwer, and Schneider et al. 91)53ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)A1A2A3B1B2B3C1C2C3第53頁，共68頁。Illustration: axial loading injuries54ANKLE FRACTURES axial loading