張候(Z-H)骨折

1、張候骨折（張候骨折（Z-H骨折）骨折）脛骨下脛骨下1/3螺旋骨折合并后踝骨折螺旋骨折合并后踝骨折段彪段彪2016.8.15定義定義脛骨下脛骨下1/3螺旋骨折，后踝骨折與脛骨骨折線不連續(xù)，為一獨(dú)立骨塊螺旋骨折，后踝骨折與脛骨骨折線不連續(xù)，為一獨(dú)立骨塊病因病因脛骨骨折脛骨骨折多由于間接暴力所致運(yùn)動(dòng)中足踝部固定，患肢由于慣性繼續(xù)向前運(yùn)動(dòng)并向外側(cè)旋轉(zhuǎn)，旋轉(zhuǎn)外力持續(xù)作用于脛骨骨干，造成脛骨遠(yuǎn)端1/3薄弱部位（脛骨骨干由三邊形移形為四邊形）發(fā)生螺旋骨折，骨折線由內(nèi)下到外上病因病因后踝骨折后踝骨折下脛腓后韌帶受到較強(qiáng)內(nèi)旋力的牽拉致后踝骨折足部固定后身體由于慣性繼續(xù)向前運(yùn)動(dòng),與距骨發(fā)生剪切造成后踝骨折踝關(guān)節(jié)受

2、到扭轉(zhuǎn)應(yīng)力和垂直應(yīng)力的作用,距骨向后上撞擊后踝造成骨折后踝的骨小梁縱向排列，骨折線常與脛骨縱軸平行Z-HZ-H骨折分型骨折分型顯性骨折后踝骨折移位較大，通過X線檢查即能確診的Z-H骨折Z-H骨折骨折隱形骨折X線不能檢出，經(jīng)過CT或MR檢查確診即使普通X片未發(fā)現(xiàn)后踝骨折，但體格檢查時(shí)如后踝存在壓痛應(yīng)加做CT或MR以除外隱形Z-H骨折，術(shù)中踝關(guān)節(jié)X片也非常必要Z-H骨折分度I度：X線和CT未檢出后踝損傷，MR檢出后踝損傷II度：X線未檢出后踝損傷，CT和MR檢出后踝損傷III度：X線檢出后踝損傷，X片上表現(xiàn)為無移位或移位2mmIV度：X線檢出后踝損傷，后踝骨折塊明顯移位或分離2mm漏診原因分析漏診

3、原因分析對(duì)1685例成人脛腓骨骨干骨折患者進(jìn)行回顧性分析，發(fā)現(xiàn)脛骨下1/3螺旋形骨折合并后踝骨折28例，放射科漏診率67.9%，臨床骨科醫(yī)師漏診率53.6%漏診漏診原因原因?qū)γ劰窍? /3 螺旋形骨折合并后踝骨折的認(rèn)識(shí)認(rèn)識(shí)不夠,忽略了脛骨骨折有合并后踝骨折的可能性,尤其存在隱性后踝骨折隱性后踝骨折一些醫(yī)院X 線片的清晰程度清晰程度影響了對(duì)骨折的診斷,甚至攝X 線片時(shí)只包括了膝關(guān)節(jié)而未包括踝關(guān)踝關(guān)節(jié)節(jié)多數(shù)骨科醫(yī)師只注意到明顯移位的脛腓骨螺旋形骨折,忽略忽略脛骨遠(yuǎn)端的微小的顯性后踝骨折脛骨后踝骨折X 線片正位很難看到骨折線,而側(cè)位片由于有腓骨腓骨的重疊的重疊,尤其是合并腓骨遠(yuǎn)段骨折時(shí),更加難以分辨

4、According to our retrospective study, in the 1,685 fractures of the tibia, 288 cases showed spiral fractures of the tibia, whichwere combined with PMFs in 28 cases, the PMF incidencewas 9.7%. However, in our prospective study, 30 (88.2%) of34 fractures of the tibia were combined with the PMFs. Plain

5、 radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures. Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures

6、that may not be evident on plain radiographs. Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures.Concomitant ipsilateral ankle and distal one-third spiral tibial shaft fractures

7、 are more common thanpreviously reported. Utilizing a new imaging protocol, wefound that the incidence of this combined injury was 84 %.Recognition of the ankle fracture component in this tibialshaft cohort can be important as it may alter the surgicalplan and postoperative management分度與治療方式的選擇分度與治療

8、方式的選擇I度度II度度III度度IV度度后踝可后踝可不予特不予特殊處理殊處理手術(shù)時(shí)密切注手術(shù)時(shí)密切注意并保護(hù)后踝，意并保護(hù)后踝，髓內(nèi)釘不要過髓內(nèi)釘不要過長、螺釘不要長、螺釘不要打入骨折線打入骨折線 ，必要時(shí)后踝行必要時(shí)后踝行克氏針或拉力克氏針或拉力螺釘固定螺釘固定手術(shù)時(shí)應(yīng)首手術(shù)時(shí)應(yīng)首先固定后踝先固定后踝骨折，以防骨折，以防操作中后踝操作中后踝骨折塊發(fā)生骨折塊發(fā)生移位移位后踝骨折后踝骨折塊應(yīng)予復(fù)塊應(yīng)予復(fù)位固定位固定,恢恢復(fù)踝關(guān)節(jié)復(fù)踝關(guān)節(jié)的穩(wěn)定性的穩(wěn)定性和完整性和完整性脛骨遠(yuǎn)端骨折合并后踝骨折，術(shù)中應(yīng)先固定后踝脛骨遠(yuǎn)端骨折合并后踝骨折，術(shù)中應(yīng)先固定后踝美國學(xué)者 Harish Kempegowda

9、 進(jìn)行了一項(xiàng)回顧性研究，分析脛骨遠(yuǎn)端骨折和后踝骨折的關(guān)系，并探討其骨折固定的先后次序。研究發(fā)現(xiàn)，后踝骨折常常伴有脛骨遠(yuǎn)端螺旋型骨折。為了避免術(shù)中骨折塊移位，作者建議為了避免術(shù)中骨折塊移位，作者建議先固定后踝先固定后踝，再行再行髓內(nèi)釘髓內(nèi)釘固定脛骨固定脛骨those treated with a mode of fixation other than an intramedullary nail for a tibial shaft fracture were excluded from the study.Posterior malleolar fracture was considered

10、as displaced if there was an intra-articular step off 2mm or there was a fracture gap of 2mmThe reduction for a posterior malleolus fracture was considered poor if there was an intra-articular step off 1mm or there was a fracture gap of 1mmOutcomes measured intra-operative displacement quality ofreduction(posterior malleolar fragment)病例分享張水金，女，54歲，入院日期：2016.6跌倒致右小腿腫痛3小時(shí)診斷：開放性脛腓骨骨折（gustiloI型）后踝髓內(nèi)釘