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非脱位过伸型胫骨平台骨折的临床特征及治疗

The clinical characteristics and management strategy of non-dislocated hyperextension tibial plateau fractures

摘要:

目的:探索非脱位过伸型胫骨平台骨折的流行病学特点、临床特征、治疗策略及临床结果。方法:收集收集2018年1月至2018年12月共25例非脱位过伸型胫骨平台骨折患者资料,其中男12例,女13例,年龄(51±15)岁(范围:27~79岁)。损伤原因:车祸18例,重物砸伤2例,摔伤5例。胫骨平台骨折Schatzker分型:Ⅱ型4例,Ⅳ型5例,Ⅴ型13例,Ⅵ型3例;三柱理论分型:单纯外侧柱4例,单纯内侧柱5例,内侧柱+外侧柱7例,三柱9例。25例后倾角术前-5.2°±4.2°(范围:-10°~0°)。术前MR检查示合并膝关节内侧副韧带(medial collateral ligament,MCL)损伤5例,合并膝关节后外侧结构复合体(posterolateral complex,PLC)损伤3例,合并PLC+膝关节后交叉韧带(posterior cruciate ligament,PCL)损伤2例,合并半月板损伤10例。合并韧带损伤患者胫骨平台后倾角改变均>10°,其中5例患者后倾角改变>15°,5例患者后倾角改变>10°,而后倾角改变<10°患者无合并韧带损伤;合并韧带损伤患者单纯外侧柱或内侧柱骨折患者6例,内侧柱+外侧柱骨折患者2例,三柱骨折患者2例。结果:25例随访时间16.4个月(范围:12~24个月)。手术时间(124±33)min(范围:65~180 min),出血量(106±48)ml(范围:20~200 ml)。所有患者均采用切开复位内固定方式进行治疗,根据骨折特点进行针对性关节面复位及下肢力线纠正,固定钢板偏前方放置固定骨折块。术后骨折复位评价:解剖复位20例,复位良好5例(关节面塌陷2~5 mm),骨折复位优良率100%。内固定方式:单纯外侧钢板4例,单纯内侧钢板2例,内侧+外侧钢板治疗15例,内侧钢板+外侧铆钉1例,内侧钢板+后方螺钉1例,外侧钢板+腓骨螺钉1例,内外侧钢板+外侧铆钉1例。8例术中进行了半月板修复,其中内侧5例,外侧3例。所有患者末次随访时获得骨性愈合,骨折愈合时间3~6个月(平均3.3个月)。术后Rasmussen评分(24.9±3.5)分(范围:18~29分),术后膝关节活动度118°±9°(范围:90°~130°)。2例出现术后伤口表浅感染。结论:非脱位过伸型胫骨平台骨折主要影像学特征为胫骨平台后倾角改变,单纯前内侧柱/前外侧柱损伤时易合并"对角线"损伤,胫骨平台后倾角改变>10°时易合并周围韧带损伤;通过采用切开复位内固定、恢复关节面平整及下肢力线,修复韧带软组织结构,重建膝关节稳定性,可取得满意的疗效。

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abstracts:

Objective:To explore the epidemiological characteristics, clinical characteristics, treatment strategies and clinical results of non-dislocated hyperextension tibial plateau fracture.Methods:A total of 25 cases of non-dislocated hyperextension tibial plateau fracture patients were collected, including 12 males and 13 females, aged 27-79 years with an average age of 51±15 years. Causes of injury: 18 cases of traffic accident, 2 cases of heavy injury, 5 cases of falling injury. Schatzker classification of tibial plateau fracture: 4 cases of type II, 5 cases of type IV, 13 cases of type V, 3 cases of type VI. Three columns theoretical classification: 4 cases of simple lateral column, 5 cases of simple medial column, 7 cases of medial column+lateral columns, 9 cases of three columns. Preoperative tibial plateau posterior slope angle was -10-0 degrees, average-5.2 degrees. Preoperative MRI showed 5 cases of medial collateral ligament (MCL) injury, 3 cases of posterolateral complex (PLC) complex injury, 2 cases of PLC+ posterior cruciate ligament (PCL) injury and 10 cases of menisci injury. The change of tibial plateau posterior slope angle was more than 10 degrees in patients with ligament injury, 5 patients had a tibial plateau posterior slope angle change more than 15 degrees, 5 patients had a tibial plateau posterior slope angle change more than 10 degrees, and the patients with a tibial plateau posterior slope angle change less than 10 degrees had no ligament injury; 6 patients with simple lateral column or medial column fracture had a ligament injury, 2 patients with medial column+lateral column fracture had a ligament injury, and 2 patients with three column fracture had a ligament injury.Results:All patients were followed up for 12-24 months, with an average of 16.4 months. The operation time was 124±33 min (65-180 min), and the bleeding volume was 106±48 ml (20-200 ml). All patients were treated by open reduction and internal fixation. According to the characteristics of fracture, targeted reduction of articular surface and restoration of lower limb force line were carried out. The plate was placed on the anterior part of tibial plateau to fix the fracture fragment. Evaluation of postoperative fracture reduction: 20 cases were anatomic reduction, 5 cases were good reduction (between 2-5 mm articular surface collapse), and the excellent rate of fracture reduction was 100%. Internal fixation: 4 cases were treated with simple lateral plate, 2 cases with simple medial plate, 15 cases with medial+ lateral plate, 1 case with medial plate+ lateral anchor suture, 1 case with medial plate+ posterior screw, 1 case with lateral plate+ fibular screw, 1 case with medial plate + lateral plate+ lateral anchor suture. The meniscus was repaired in 8 patients, including 5 medial and 3 laterals. The fracture healing time was 3-6 months (mean 3.3 months). The postoperative knee Rasmussen score was 24.9±3.5 (18-29), and the postoperative knee joint mobility was 118°±9° (90°-130°). Superficial infection occurred in 2 patients.Conclusion:The main imaging characteristic of "non-dislocated hyperextension tibial plateau fracture" is the change of tibial plateau posterior slope angle. The injury of single anteromedial column/anterolateral column fracture is easy to combine with the "diagonal" injury, and when the tibial plateau posterior slope angle changes more than 10 degrees, it is easy to be associated with peripheral ligament injury. By using open reduction and internal fixation, restoring the joint articular surface and lower limb force line, repairing the soft tissue structure and ligament, and reconstructing the stability of knee joint, we can achieve satisfactory results.

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期刊: 《中华骨科杂志》2020年40卷18期 1266-1274页 ISTICPKUCSCDCA
栏目名称: 临床论著
DOI: 10.3760/cma.j.cn121113-20200313-00159
发布时间: 2020-09-28
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