Pilon骨折培訓課件

1、定義:pilon骨折是指累及脛距關(guān)節(jié)面的脛骨遠端骨折。脛骨Pilon骨折目前尚沒有明確的定義，一般是指脛骨遠端1/3波及脛距關(guān)節(jié)面的骨折，脛骨遠端關(guān)節(jié)面嚴重粉碎，骨缺損及遠端松質(zhì)骨壓縮。常合并有腓骨下段骨折（約75%85% )和嚴重軟組織損傷。1Pilon骨折10/3/2022定義:pilon骨折是指累及脛距關(guān)節(jié)面的脛骨遠端骨折。脛骨PDefinition：Pilon fracture refers to distal tibia fractures which involve tibia-astragalus articular surface. Pilon fracture havent

2、got clear definition yet, it usually refers to third distal tibia fractures spread from the joint. The distal tibial articular surface always serious shattered, bone defect and remote cancellous bone compression. It usually Associated with the lower part of fibula fractures (about 75% 85%) and serio

3、us soft tissue injury.2Pilon骨折10/3/2022Definition：Pilon fracture refe名稱來源：1911年首先由法國放射學家Destotti提出“tibial pilon”一詞，他把脛骨遠端干骺端的形狀描述為像藥劑師的杵棒。脛骨遠端關(guān)節(jié)面形似天花板,1950年Bonin 稱之為“tibial platfond”，因此pilon骨折又稱為platfond 骨折。3Pilon骨折10/3/2022名稱來源：1911年首先由法國放射學家Destotti提出“Definition origin:In 1911, the French radiolog

4、ist Destotti firstly put forward the word -tibial pilon“. He described the shape of distal tibia as the pharmacists pestle (pilon). The distal tibial articular surface is also looks like ceiling;In 1950,bonin called it “tibial platfond”,so pilon fracture can be called Platfond fracture. 4Pilon骨折10/3

5、/2022Definition origin:In 1911, the 損傷機制：脛骨Pilon骨折最常發(fā)生于高處墜落、車禍驟停、滑雪或絆腳前摔。脛骨軸向暴力或下肢的扭轉(zhuǎn)暴力是脛骨遠端關(guān)節(jié)面骨折的主要原因。兩種不同的損傷機制導致Pilon骨折，其預后亦不同,受傷時踝關(guān)節(jié)的位置與骨折類型密切相關(guān). 5Pilon骨折10/3/2022 損傷機制：脛骨Pilon骨折最常發(fā)生于高處墜落、車禍驟Injure mechanism:Tibial Pilon fractures occur most often in the fall, crash arrest, skiing or stumbling be

6、fore the fall. Axial tibial violence or torsion violence of lower extremity are the main reason for distal tibial articular surface fractures. Two different mechanisms of injury leading to different prognosis of Pilon fracture. The position of ankle joint when it hurts and the type of fracture are c

7、losely related.6Pilon骨折10/3/2022Injure mechanism:Tibial Pilon 骨折高度不穩(wěn)定和關(guān)節(jié)軟骨損傷嚴重。治療難度大，并發(fā)癥多，致殘率高，是最具挑戰(zhàn)性的骨科難題之一。_內(nèi)容豐富點。列出幾點.脛骨遠端關(guān)節(jié)面嚴重粉碎，骨缺損及遠端松質(zhì)骨壓縮。常合并有腓骨下段骨折（約75%85% )和嚴重軟組織損傷骨折特征7Pilon骨折10/3/2022骨折高度不穩(wěn)定和關(guān)節(jié)軟骨損傷嚴重。治療難度大，并發(fā)癥多，致殘Fracture characteristic:It is a highly unstable fracture, and have severe ar

8、ticular cartilage damage. Treatment is difficult, with many complications, high disability rate, and it is one of the most challenging orthopaedic problems.8Pilon骨折10/3/2022Fracture characteristic:It is 骨折分型：骨折分型的目的主要還是在于如何指導治療及提示預后情況。1969年Ruedi和Augower 根據(jù)關(guān)節(jié)面和干骺端的移位及粉碎程度，將Pilon骨折分為3型，這種分型的意義在于強調(diào)關(guān)節(jié)面的

9、損傷程度。 9Pilon骨折10/3/2022骨折分型：骨折分型的目的主要還是在于如何指導治療及提示預后Fracture classify: The main purpose of fracture classification is to guide treatment and prompt prognosis. In 1969 Ruedi and Augower divided Pilon fracture into 3 types according to the articular surface and metaphyseal displacement and crushing de

10、gree,the meaning of this type lies in emphasizing the articular surface damage.10Pilon骨折10/3/2022Fracture classify: The main p Ruedi-Allgower分類系統(tǒng) 型:經(jīng)關(guān)節(jié)面的脛骨遠端骨折，較小的移位; 型:明顯的關(guān)節(jié)面移位而粉碎程度較小; 型:關(guān)節(jié)面粉碎移位及粉碎程度較嚴重。這種分型臨床常用。11Pilon骨折10/3/2022 Ruedi-Allgower分類系統(tǒng)11Pilon骨折10The Ruedi-Allgower classification syste

11、m:Type one:The articular surface fractures of distal tibia, a little displacement;Type two:The obvious articular surface shift and crush lesser degree;Type three:Articular surface crushing shift and the degree is serious. This type of commonly used clinical.12Pilon骨折10/3/2022The Ruedi-Allgower class

12、ificat診斷:根據(jù)病史、癥狀、體征，結(jié)合X片、CT等影像學檢查，診斷不難，注意血管、神經(jīng)等軟組織的損傷，常見脛骨內(nèi)側(cè)、前側(cè)開放性及潛在開放性損傷，認真查體，注意勿遺漏身體其他部位的損傷（脊柱骨折、腓骨上段骨折等）。13Pilon骨折10/3/2022診斷:根據(jù)病史、癥狀、體征，結(jié)合X片、CT等影像學檢查，診斷Diagnosis:According to the medical history,symptoms, signs, combined with X, CT imagings, diagnosis is not difficult, pay attention to vascular

13、, nerve, soft tissue injury, The inside of tibial, anterior open and potential open injury are common, carefully check the body. Pay attention not to miss the other part injury of the body (spinal fractures, upper fibula fracture etc).14Pilon骨折10/3/2022Diagnosis:According to the med治療（1）非手術(shù)治療：適應于型無移

14、位骨折、全身情況較差不能耐受手術(shù)者、以及為延期手術(shù)做準備的治療。主要有手法復位石膏外固定、跟骨牽引等。15Pilon骨折10/3/2022治療（1）非手術(shù)治療：適應于型無移位骨折、全身情況較差不能Treatment(1) Non operation treatment: Adapted to the type I fractures without displacement, poor general condition which can not tolerate operation, as well as the treatment for the deferred operation.

15、Mainly with manipulative reduction and plaster external fixation, calcaneal traction, closed pinning fixation,etc.16Pilon骨折10/3/2022Treatment(1) Non operation tre（2）手術(shù)治療：手術(shù)指征： 、型開放性骨折，骨折明顯移位或嵌插、缺損、伴有神經(jīng)血管損傷、軸向?qū)€不良、關(guān)節(jié)面骨折移位大于2mm者，均需積極行手術(shù)治療。17Pilon骨折10/3/2022（2）手術(shù)治療：17Pilon骨折10/2/2022Operation treatment

16、:Operation indications: Tpre II, type III open fractures, fracture was obviously displaced or impacted, defect, accompanied by the nerve and vascular injury, the axial malalignment, articular surface fracture displacement is greater than 2mm, these all should be actively treated with surgical operat

17、ion.18Pilon骨折10/3/2022Operation treatment:18Pilon骨折1手術(shù)原則：低能量損傷的pilon骨折積極行切開復位內(nèi)固定術(shù)（ORIF） ；高能量損傷者，采取有限內(nèi)固定和外固定結(jié)合的治療手段。目前主張“生物學”原則：強調(diào)細致的軟組織暴露，骨折塊的有限剝離，間接復位，穩(wěn)定固定后早期活動和晚期負重等.治療目的可歸納為“3P”，即保護骨與軟組織活力、進行關(guān)節(jié)面的解剖復位、提供滿足踝關(guān)節(jié)早期活動的固定。 19Pilon骨折10/3/2022手術(shù)原則：低能量損傷的pilon骨折積極行切開復位內(nèi)固定術(shù)（Operation principle: Low energy d

18、amage of Pilon fractures treated with open reduction and internal fixation of positive ( ORIF ); high energy injury, take limited internal fixation and external fixation combined treatment. Currently advocated“ biology” principle: emphasizing meticulous soft tissue exposure, fracture block finite st

19、rip, indirect reduction, do early exercise after stable fixation and late weight bearing,etc. Treatment goals can be summarized as “ 3P”, the protection of bone and soft tissue viability (preserve ), anatomical reduction of the articular surface (perform), provide fixations which can satisfy early m

20、otion of the ankle joint (provide).20Pilon骨折10/3/2022Operation principle: Low energ手術(shù)時機：1、開放性骨折就診時間早或出現(xiàn)筋膜間室綜合征的患者，均應行急診手術(shù)處理。對于污染嚴重的（先清創(chuàng)）、就診時間晚、腫脹嚴重、軟組織條件差的開放性骨折主張先行跟骨牽引、石膏托固定、或超關(guān)節(jié)外固定架臨時固定等治療，待腫脹消退，水泡愈合后行二期處理。2、對于閉合性骨折的手術(shù)時機，目前還存在較大的爭議，大多數(shù)人傾向于認為除軟組織條件差的閉合性骨折需行延期手術(shù)外，一般應于傷后8-10小時之內(nèi)，肢體腫脹不甚嚴重，無明顯水泡形成之前急診手

21、術(shù)為妥，有利于骨折復位。張力較高及皮膚缺損者，可留待創(chuàng)面行二期處理。這個應該放在開放性骨折后面21Pilon骨折10/3/2022手術(shù)時機：1、開放性骨折就診時間早或出現(xiàn)筋膜間室綜合征的患者Operation time: Patient of open fractures to see a doctor early or turn up compartment syndrome, urgent operation treatment is necessary. For the serious pollution ( first debridement ), treatment time of

22、late, severe soft tissue swelling, poor conditions of open fracture of calcaneus traction that go ahead of the rest, plaster support, or over articular external fixator for treatment of temporary fixed, after swelling, blisters healed , do the secondary period of treatment. For a closed fracture of

23、the operation opportunity, at present still exists controversy, I agree with that, in addition to poor conditions in the closed fractures should do delayed operation, generally most fracture should do urgent surgry in 8-10 hours after injury when the swelling of a limb is not serious and no blister

24、formation.This facilitates fracture reset. Higher tension and skin defect wound, may be left for secondary treatment.22Pilon骨折10/3/2022Operation time: Patient of ope 手術(shù)方法：型：有時為了避免非手術(shù)治療可能發(fā)生的骨折移位縮短外固定的時間，采用有限切開簡單內(nèi)固定加石膏外固定,閉合復位后經(jīng)皮空心螺釘固定術(shù),微創(chuàng)經(jīng)皮鋼板接骨術(shù)(MIPPO技術(shù)) 。23Pilon骨折10/3/2022 手術(shù)方法：23Pilon骨折10/2/2022Ope

25、ration method:Type I: sometimes in order to avoid non operation treatment of possible displacement of fracture and shorten the time of external fixation, we choose limited open simple internal fixation combined with external fixation of plaster. After closed reduction and percutaneous hollow screw f

26、ixation, minimally invasive percutaneous plate osteosynthesis ( MIPPO technology );24Pilon骨折10/3/2022Operation method:24Pilon骨折10/2型：關(guān)節(jié)面雖有移位，但并未粉碎和壓縮，以有限切開復位內(nèi)固定為宜。近年來有主張關(guān)節(jié)鏡結(jié)合環(huán)形外固定架的治療和關(guān)節(jié)鏡輔助下復位經(jīng)皮螺釘內(nèi)固定術(shù)。25Pilon骨折10/3/2022型：關(guān)節(jié)面雖有移位，但并未粉碎和壓縮，以有限切開復位內(nèi)固定Type II: The articular surface displaced, but not cr

27、ushed and compressed, limited open reduction and internal fixation is appropriate. In recent years ,someone have advocated the arthroscopy combined with circular external fixation ;Arthroscopic assisted reduction and percutaneous screw fixation have also been used .26Pilon骨折10/3/2022Type II: The art

28、icular surface型：閉合性的高度不穩(wěn)定骨折，關(guān)節(jié)面嚴重粉碎者，行經(jīng)典的切開復位內(nèi)固定術(shù)加植骨術(shù)。嚴重粉碎已無解剖復位可能的高能量損傷、大塊骨缺損、嚴重軟組織損傷、開放性骨折的Gustilo 、型患者行有限的切開復位內(nèi)固定結(jié)合外固定支架是較好的選擇。也有主張行分期重建內(nèi)固定的方法，先固定腓骨，同時使用外固定支架保持肢體的長度和力線，經(jīng)過1021d的中間期，使軟組織的條件得以充分改善以減少術(shù)后軟組織的并發(fā)癥；再對脛骨遠端的關(guān)節(jié)面進行標準的切開復位內(nèi)固定。27Pilon骨折10/3/2022型：閉合性的高度不穩(wěn)定骨折，關(guān)節(jié)面嚴重粉碎者，行經(jīng)典的切開Type III: Closed hig

29、hly unstable fractures, comminuted articular surface, choose classic open reduction with internal fixation and bone graft. Severe comminution have no anatomical reduction potential of high energy injury, massive bone defects, severe soft tissue injury, open fracture of the Gustilo II, type III were

30、treated with limited internal fixation combined with external fixation is a good choice. Somebody claims reconstruction methods of fixation by stages, fix fibula firstly , at the same time using external fixation to maintain limb length and line of force, after 10-21d intermediate period, so that th

31、e soft tissue conditions can be fully improved to reduce postoperative soft tissue complications; then , the standard open reduction and internal fixation are used in the distal tibial articular surface.28Pilon骨折10/3/2022Type III: Closed highly unstab關(guān)節(jié)融合術(shù)和關(guān)節(jié)置換術(shù)：由于Pilon 骨折的患者不是都能達到完全的解剖復位，即使可以解剖復位，由

32、于骨折后關(guān)節(jié)軟骨下骨發(fā)生壞死、塌陷變化，也就不可避免創(chuàng)傷性關(guān)節(jié)炎的發(fā)生。因而踝關(guān)節(jié)融合術(shù)、關(guān)節(jié)置換術(shù)的時機選擇,應根據(jù)具體情況而定。一般宜在傷后12 年內(nèi)根據(jù)癥狀、體征、X 線表現(xiàn)及患者要求行融合術(shù)或置換術(shù)。29Pilon骨折10/3/2022關(guān)節(jié)融合術(shù)和關(guān)節(jié)置換術(shù)：由于Pilon 骨折的患者不是都能達Arthrodesis and ankle joint replacement: Because not all of Pilon fracture patients can achieve complete anatomic reduction, even can achieve anatom

33、ic reduction, due to articular subchondral bone necrosis and collapse after fracture,it is inevitable that the occurrence of traumatic osteoarthritis. Thus the arthrodesis and replacement of the ankle joint timing, should be based on the specific circumstances of the case. Generally after injury in

34、1-2 years according to the symptoms, signs, X ray performance and patients require fusion and replacement surgery.30Pilon骨折10/3/2022Arthrodesis and ankle joint re總之：從文獻報道的有關(guān)Pilon 骨折治療的臨床研究來看,制定合理而完善的術(shù)前計劃、有限內(nèi)固定結(jié)合外固定治療以及根據(jù)軟組織損傷情況分期治療, 降低了軟組織損傷導致的并發(fā)癥發(fā)生率，已顯示出其明顯的優(yōu)越性。同時，治療過程中踝關(guān)節(jié)早期功能鍛煉，避免過長時間的外固定，能最大限度地減少

35、針道感染、關(guān)節(jié)僵硬等并發(fā)癥。31Pilon骨折10/3/2022總之：從文獻報道的有關(guān)Pilon 骨折治療的臨床研究來看,制In conclusion, from the literature reports about Pilon clinical study on treatment of view, establish reasonable and perfect preoperative planning, limited internal fixation combined with external fixation in the treatment of soft tissue

36、injury and according to the staging of treatment, have reduced the soft tissue damage which leads to the complication rate, and obvious advantages have been proved. At the same time, during the treatment of ankle joint and early functional exercise, avoid prolonged external fixation, can minimize th

37、e pin tract infection, joint stiffness and other complications.32Pilon骨折10/3/2022In conclusion, from the litera切開復位內(nèi)固定原則：（1）恢復腓骨長度并做內(nèi)固定;（2）力求解剖復位，重建脛骨遠端關(guān)節(jié)面（關(guān)鍵骨折塊、Chaput結(jié)節(jié)等）;（3）干骺端骨缺損處植骨（支撐關(guān)節(jié)面、填補空缺、刺激成骨、促進骨折愈合）;（4）脛骨內(nèi)側(cè)支撐鋼板固定，重新連接骨干與干骺端，早期功能鍛煉，晚負重。33Pilon骨折10/3/2022切開復位內(nèi)固定原則：33Pilon骨折10/2/2022Open red

38、uction and internal fixation principles:( 1) restoration of fibular length and internal fixation;( 2) achieve anatomical reduction, reconstruction of distal tibial articular surface ( critical fracture block, Chaput nodule etc.);( 3) bone graft of metaphyseal bone defect ( supporting the joint surfa

39、ce, filling the vacancy, stimulation of osteogenesis, accelerate fracture healing );( 4) the tibial medial buttress plate fixation, reconnect the backbone and the metaphysis, early functional exercise, late weight bearing.34Pilon骨折10/3/2022Open reduction and internal fi治療中的常見問題及并發(fā)癥的防治：Pilon骨折，尤其是高能量損傷的Pilon骨折，并發(fā)癥的發(fā)生率很高，處理好并發(fā)癥的問題可以說是治療Pilon骨折成敗的關(guān)鍵。注意預防皮膚壞死 、感染、創(chuàng)傷性關(guān)節(jié)炎、關(guān)節(jié)僵硬、畸形愈合、骨不愈合、延遲愈合。 有報道用帶關(guān)節(jié)的外固定架治療高能量損傷的pilon骨折療效滿意，避免了關(guān)節(jié)僵硬。中西醫(yī)結(jié)合防治并發(fā)癥。35Pilo