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1、EPIDEMIOLOGY OF ANKLE FRACTURES,1.芬兰大于60岁的人群，踝关节骨折的发生人数从每10万57人（1970年），增加到130人（1994年）。 2.危险因素：体重指数的增加；吸烟的影响 3.绝经和一般身体状况的好坏与踝关节骨折的发生无关.,Radiographic Measurements of Alignment and Stability,Radiographic appearance of the normal ankle on mortise view. The condensed subchondral bone should form a contin
2、uous line around the talus. Talocrural angle should be approximately 83 degrees. When the opposite side can be used as a control, the talocrural angle of the injured side should be within a few degrees of the noninjured side. The medial clear space should be equal to the superior clear space between
3、 the talus and the distal tibia and less than or equal to 4 mm on standard radiographs. The distance between the medial wall of the fibula and the incisural surface of the tibia, the tibiofibular clear space, should be less than 6 mm.,The condensed subchondral bone should form a continuous line arou
4、nd the talus.,Talocrural angle should be approximately 83 degrees.,Medial Clear Space,Evaluation of Syndesmosis,Evaluating syndesmotic widening is perhaps the most difficult task when interpreting ankle radiographs for alignment and stability. The simplest approach is to measure the distance between
5、 the medial wall of the fibula and the incisural surface of the tibia. This tibiofibular clear space should be less than 6 mm on both AP and mortise views We find this approach simpler than measuring overlap of the anterior tubercle of the tibia on the fibula, because the latter measure is rotationa
6、lly dependent.,Classifications in Current Use,Lauge-Hansen Classification AO/Orthopaedic Trauma Association Fracture Classification,Lauge-Hansen Classification,1.依据踝关节骨折损伤时,足的位置和外力作用的方向. 2.足的位置:旋前和旋后 3.外力致使距骨外旋,内翻,外翻. 4.分为旋后-外旋(SER),旋后-内收,旋前-外旋(PER),旋前-外展.,Anteroposterior and lateral radiographs sho
7、w an unstable supination-external rotation stage IV ankle fracture with the characteristic oblique distal fibula fracture and a medial side injury.,An anteroposterior radiograph of a supination-adduction ankle fracture with a transverse fibula fracture and an impacted medial malleolar fracture.,An a
8、nteroposterior radiograph of a typical pronation-abduction ankle fracture. The fibula is laterally comminuted.,特殊骨折,Dupuytren骨折一种少见的旋前外展型损伤，即腓骨高位骨折，胫骨下端腓骨切迹撕脱骨折，三角韧带断裂同时有下胫腓分离。,Tillaux骨折旋前外旋型2度，胫骨远端前结节撕脱骨折。 Maisonneuve骨折旋前外旋型骨折中，如果腓骨骨折达到中上1/3或腓骨颈骨折或上胫腓分离。,AO/Orthopaedic Trauma Association Fracture C
9、lassification,It is an extension of the classification introduced by Danis and modified by Weber, and it was popularized by the AO during a time when malleolar fractures were increasingly treated by operative reduction and fixation rather than by closed reduction.,Fractures were categorized into A,
10、B, and C based on the level of the fibular fracture, with A fractures below the level of the distal tibial fibularsyndesmosis, B fractures at the level of the syndesmosis, and C fractures above the syndesmosis.,This simple classification provided initial guidelines for surgical treatment because A f
11、ractures frequently do not require surgical treatment, B fractures are treated by stabilization of the lateral malleolus, and C fractures require syndesmosis fixation in addition to stabilization of the lateral malleolus. This classification was attractive for its simplicity and because it guided tr
12、eatment.,治疗,目标：骨折解剖复位，恢复关节功能。 手术适应症： 1保守治疗失败 2有移位或不稳定的双踝骨折，且有距骨脱位或踝穴增宽超过12mm。 3后踝骨折涉及关节面超过25，且关节面的移位超过2mm。 4垂直压缩型骨折 5开放骨折,单独外踝骨折,1多为旋后外旋2度或AO的B1型 2多数保守治疗 3是否手术有争议 Bauer（1985）认为保守治疗的功能优良为9498。 Yue（1980）认为旋后外旋2度的手术治疗的结果并不优于保守治疗。,单独内踝骨折,1多为旋前外旋或旋前外展的1度损伤。 2多保守治疗（无移位的） 3有移位的使用松质骨螺钉固定,下胫腓联合损伤,固定的指征 内固定的选
13、择 固定时踝关节的位置 内固定物是否取出,固定的指征,内踝三角韧带损伤，腓骨骨折高于踝关节水平间隙上方3cm。 下胫腓联合损伤合并腓骨近端骨折，如Maisonneuve骨折 陈旧的下胫腓分离,内固定的选择,公认的是使用螺钉固定。 一般均使用3.5-4.5mm的皮质骨螺钉。 有学者认为必要时可使用2枚。,螺钉的使用,1螺钉的位置McBryde（1997）认为胫距关节间隙上方2cm是最佳位置。 2螺钉方向平行胫距关节面且向前倾斜2530度。 3是否使用拉力螺钉不使用。下胫腓螺钉的主要目的是维持下胫腓联合的正常位置，加压易导致下胫腓联合变窄，导致踝关节背伸受限。,固定时踝关节的位置,因为距骨体前宽后窄，多数学者认为应在踝关节最大背伸时进行下胫腓联合的固定。 Griend（1996）认为踝关节最大背伸时进行下胫腓联合的固定将使的踝穴一直处于最宽，易出现不稳倾向，他建议踝关节背伸5度位固定。,内固定物是否取出,多数学者认为术后常规取出下胫腓螺钉 术后1216周取螺钉比较合适 AO取出踝关节其他内固定物的同时取出下胫腓螺钉。,谢谢！,