Pilon骨折教學課件

Pilon骨折1.Pilon骨折1.定義:pilon骨折是指累及脛距關節(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波及脛距關節(jié)面的骨折，脛骨遠端關節(jié)面嚴重粉碎，骨缺損及遠端松質骨壓縮。常合并有腓骨下段骨折（約75%～85%)和嚴重軟組織損傷。2.定義:pilon骨折是指累及脛距關節(jié)面的脛骨遠端骨折。脛骨PDefinition：Pilonfracturereferstodistaltibiafractureswhichinvolvetibia-astragalusarticularsurface.Pilonfracturehaven’tgotcleardefinitionyet,itusuallyreferstothirddistaltibiafracturesspreadfromthejoint.Thedistaltibialarticularsurfacealwaysseriousshattered,bonedefectandremotecancellousbonecompression.ItusuallyAssociatedwiththelowerpartoffibulafractures(about75%~85%)andserioussofttissueinjury.3.Definition：Pilonfracturerefe名稱來源：1911年首先由法國放射學家Destotti提出“tibialpilon”一詞，他把脛骨遠端干骺端的形狀描述為像藥劑師的杵棒。脛骨遠端關節(jié)面形似天花板,1950年Bonin稱之為“tibialplatfond”，因此pilon骨折又稱為platfond骨折。4.名稱來源：1911年首先由法國放射學家Destotti提出“Definitionorigin:In1911,theFrenchradiologistDestottifirstlyputforwardtheword--"tibialpilon“.Hedescribedtheshapeofdistaltibiaasthepharmacist’spestle(pilon).Thedistaltibialarticularsurfaceisalsolookslikeceiling;In1950,bonincalledit“tibialplatfond”,sopilonfracturecanbecalledPlatfondfracture.5.Definitionorigin:In1911,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暴力是脛骨遠端關節(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,受傷時踝關節(jié)的位置與骨折類型密切相關.

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損傷機制：脛骨Pilon骨折最常發(fā)生于高處墜落、車禍驟Injuremechanism:TibialPilonfracturesoccurmostofteninthefall,crasharrest,skiingorstumblingbeforethefall.Axialtibialviolenceortorsionviolenceoflowerextremityarethemainreasonfordistaltibialarticularsurfacefractures.TwodifferentmechanismsofinjuryleadingtodifferentprognosisofPilonfracture.Thepositionofanklejointwhenithurtsandthetypeoffracturearecloselyrelated.7.Injuremechanism:TibialPilon骨折高度不穩(wěn)定和關節(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。_內容豐富點。列出幾點.脛骨遠端關節(jié)面嚴重粉碎，骨缺損及遠端松質骨壓縮。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

8.骨折高度不穩(wěn)定和關節(jié)軟骨損傷嚴重。治療難度大，并發(fā)癥多，致殘Fracturecharacteristic:Itisahighlyunstablefracture,andhaveseverearticularcartilagedamage.Treatmentisdifficult,withmanycomplications,highdisabilityrate,anditisoneofthemostchallengingorthopaedicproblems.9.Fracturecharacteristic:Itis

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根據關節(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關節(jié)面的損傷程度。

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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

Fractureclassify:Themainpurposeoffractureclassificationistoguidetreatmentandpromptprognosis.In1969RuediandAugowerdividedPilonfractureinto3typesaccordingtothearticularsurfaceandmetaphysealdisplacementandcrushingdegree,themeaningofthistypeliesinemphasizingthearticularsurfacedamage.11.

Fractureclassify:Themainp

Ruedi-Allgower分類系統

Ⅰ型:經關節(jié)面的脛骨遠端骨折，較小的移位;

Ⅱ型:明顯的關節(jié)面移位而粉碎程度較小;

Ⅲ型:關節(jié)面粉碎移位及粉碎程度較嚴重。這種分型臨床常用。12.Ruedi-Allgower分類系統12.TheRuedi-Allgowerclassificationsystem:Typeone:Thearticularsurfacefracturesofdistaltibia,alittledisplacement;Typetwo:Theobviousarticularsurfaceshiftandcrushlesserdegree;Typethree:Articularsurfacecrushingshiftandthedegreeisserious.Thistypeofcommonlyusedclinical.13.TheRuedi-Allgowerclassificat診斷:根據病史、癥狀、體征，結合X片、CT等影像學檢查，診斷不難，注意血管、神經等軟組織的損傷，常見脛骨內側、前側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）。14.診斷:根據病史、癥狀、體征，結合X片、CT等影像學檢查，診斷Diagnosis:Accordingtothemedicalhistory,symptoms,signs,combinedwithX,CTimagings,diagnosisisnotdifficult,payattentiontovascular,nerve,softtissueinjury,Theinsideoftibial,anterioropenandpotentialopeninjuryarecommon,carefullycheckthebody.Payattentionnottomisstheotherpartinjuryofthebody(spinalfractures,upperfibulafractureetc).15.Diagnosis:Accordingtothemed治療（1）非手術治療：適應于Ⅰ型無移位骨折、全身情況較差不能耐受手術者、以及為延期手術做準備的治療。主要有手法復位石膏外固定、跟骨牽引等。16.治療（1）非手術治療：適應于Ⅰ型無移位骨折、全身情況較差不能Treatment(1)Nonoperationtreatment:AdaptedtothetypeIfractureswithoutdisplacement,poorgeneralconditionwhichcannottolerateoperation,aswellasthetreatmentforthedeferredoperation.Mainlywithmanipulativereductionandplasterexternalfixation,calcanealtraction,closedpinningfixation,etc.17.Treatment(1)Nonoperationtre（2）手術治療：手術指征：Ⅱ、Ⅲ型開放性骨折，骨折明顯移位或嵌插、缺損、伴有神經血管損傷、軸向對線不良、關節(jié)面骨折移位大于2mm者，均需積極行手術治療。18.（2）手術治療：18.Operationtreatment:Operationindications:TpreII,typeIIIopenfractures,fracturewasobviouslydisplacedorimpacted,defect,accompaniedbythenerveandvascularinjury,theaxialmalalignment,articularsurfacefracturedisplacementisgreaterthan2mm,theseallshouldbeactivelytreatedwithsurgicaloperation.19.Operationtreatment:19.手術原則：低能量損傷的pilon骨折積極行切開復位內固定術（ORIF）；高能量損傷者，采取有限內固定和外固定結合的治療手段。目前主張“生物學”原則：強調細致的軟組織暴露，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、進行關節(jié)面的解剖復位、提供滿足踝關節(jié)早期活動的固定。20.手術原則：低能量損傷的pilon骨折積極行切開復位內固定術（Operationprinciple:LowenergydamageofPilonfracturestreatedwithopenreductionandinternalfixationofpositive(ORIF);highenergyinjury,takelimitedinternalfixationandexternalfixationcombinedtreatment.Currentlyadvocated“biology”principle:emphasizingmeticuloussofttissueexposure,fractureblockfinitestrip,indirectreduction,doearlyexerciseafterstablefixationandlateweightbearing,etc.Treatmentgoalscanbesummarizedas“3P”,theprotectionofboneandsofttissueviability(preserve),anatomicalreductionofthearticularsurface(perform),providefixationswhichcansatisfyearlymotionoftheanklejoint(provide).21.Operationprinciple:Lowenerg手術時機：1、開放性骨折就診時間早或出現筋膜間室綜合征的患者，均應行急診手術處理。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時機，目前還存在較大的爭議，大多數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外，一般應于傷后8-10小時之內，肢體腫脹不甚嚴重，無明顯水泡形成之前急診手術為妥，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?！@個應該放在開放性骨折后面22.手術時機：1、開放性骨折就診時間早或出現筋膜間室綜合征的患者Operationtime:Patientofopenfracturestoseeadoctorearlyorturnupcompartmentsyndrome,urgentoperationtreatmentisnecessary.Fortheseriouspollution(firstdebridement),treatmenttimeoflate,severesofttissueswelling,poorconditionsofopenfractureofcalcaneustractionthatgoaheadoftherest,plastersupport,oroverarticularexternalfixatorfortreatmentoftemporaryfixed,afterswelling,blistershealed,dothesecondaryperiodoftreatment.Foraclosedfractureoftheoperationopportunity,atpresentstillexistscontroversy,Iagreewiththat,inadditiontopoorconditionsintheclosedfracturesshoulddodelayedoperation,generallymostfractureshoulddourgentsurgryin8-10hoursafterinjurywhentheswellingofalimbisnotseriousandnoblisterformation.Thisfacilitatesfracturereset.Highertensionandskindefectwound,maybeleftforsecondarytreatment.23.Operationtime:Patientofope

手術方法：Ⅰ型：有時為了避免非手術治療可能發(fā)生的骨折移位縮短外固定的時間，采用有限切開簡單內固定加石膏外固定,閉合復位后經皮空心螺釘固定術,微創(chuàng)經皮鋼板接骨術(MIPPO技術)

。24.手術方法：24.Operationmethod:TypeI:sometimesinordertoavoidnonoperationtreatmentofpossibledisplacementoffractureandshortenthetimeofexternalfixation,wechooselimitedopensimpleinternalfixationcombinedwithexternalfixationofplaster.Afterclosedreductionandpercutaneoushollowscrewfixation,minimallyinvasivepercutaneousplateosteosynthesis(MIPPOtechnology);25.Operationmethod:25.Ⅱ型：關節(jié)面雖有移位，但并未粉碎和壓縮，以有限切開復位內固定為宜。近年來有主張關節(jié)鏡結合環(huán)形外固定架的治療和關節(jié)鏡輔助下復位經皮螺釘內固定術。26.Ⅱ型：關節(jié)面雖有移位，但并未粉碎和壓縮，以有限切開復位內固定TypeII:Thearticularsurfacedisplaced,butnotcrushedandcompressed,limitedopenreductionandinternalfixationisappropriate.Inrecentyears,someonehaveadvocatedthearthroscopycombinedwithcircularexternalfixation;Arthroscopicassistedreductionandpercutaneousscrewfixationhavealsobeenused.27.TypeII:ThearticularsurfaceⅢ型：閉合性的高度不穩(wěn)定骨折，關節(jié)面嚴重粉碎者，行經典的切開復位內固定術加植骨術。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GustiloⅡ、Ⅲ型患者行有限的切開復位內固定結合外固定支架是較好的選擇。也有主張行分期重建內固定的方法，先固定腓骨，同時使用外固定支架保持肢體的長度和力線，經過10－21d的中間期，使軟組織的條件得以充分改善以減少術后軟組織的并發(fā)癥；再對脛骨遠端的關節(jié)面進行標準的切開復位內固定。28.Ⅲ型：閉合性的高度不穩(wěn)定骨折，關節(jié)面嚴重粉碎者，行經典的切開TypeIII:Closedhighlyunstablefractures,comminutedarticularsurface,chooseclassicopenreductionwithinternalfixationandbonegraft.Severecomminutionhavenoanatomicalreductionpotentialofhighenergyinjury,massivebonedefects,severesofttissueinjury,openfractureoftheGustiloII,typeIIIweretreatedwithlimitedinternalfixationcombinedwithexternalfixationisagoodchoice.Somebodyclaimsreconstructionmethodsoffixationbystages,fixfibulafirstly,atthesametimeusingexternalfixationtomaintainlimblengthandlineofforce,after10-21dintermediateperiod,sothatthesofttissueconditionscanbefullyimprovedtoreducepostoperativesofttissuecomplications;then,thestandardopenreductionandinternalfixationareusedinthedistaltibialarticularsurface.29.TypeIII:Closedhighlyunstab關節(jié)融合術和關節(jié)置換術：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，由于骨折后關節(jié)軟骨下骨發(fā)生壞死、塌陷變化，也就不可避免創(chuàng)傷性關節(jié)炎的發(fā)生。因而踝關節(jié)融合術、關節(jié)置換術的時機選擇,應根據具體情況而定。一般宜在傷后1－2年內根據癥狀、體征、X線表現及患者要求行融合術或置換術。30.關節(jié)融合術和關節(jié)置換術：由于Pilon骨折的患者不是都能達Arthrodesisandanklejointreplacement:BecausenotallofPilonfracturepatientscanachievecompleteanatomicreduction,evencanachieveanatomicreduction,duetoarticularsubchondralbonenecrosisandcollapseafterfracture,,itisinevitablethattheoccurrenceoftraumaticosteoarthritis.Thusthearthrodesisandreplacementoftheanklejointtiming,shouldbebasedonthespecificcircumstancesofthecase.Generallyafterinjuryin1-2yearsaccordingtothesymptoms,signs,Xrayperformanceandpatientsrequirefusionandreplacementsurgery.31.Arthrodesisandanklejointre總之：從文獻報道的有關Pilon骨折治療的臨床研究來看,制定合理而完善的術前計劃、有限內固定結合外固定治療以及根據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，能最大限度地減少針道感染、關節(jié)僵硬等并發(fā)癥。32.總之：從文獻報道的有關Pilon骨折治療的臨床研究來看,制Inconclusion,fromtheliteraturereportsaboutPilonclinicalstudyontreatmentofview,establishreasonableandperfectpreoperativeplanning,limitedinternalfixationcombinedwithexternalfixationinthetreatmentofsofttissueinjuryandaccordingtothestagingoftreatment,havereducedthesofttissuedamagewhichleadstothecomplicationrate,andobviousadvantageshavebeenproved.Atthesametime,duringthetreatmentofanklejointandearlyfunctionalexercise,avoidprolongedexternalfixation,canminimizethepintractinfection,jointstiffnessandothercomplications.33.Inconclusion,fromthelitera切開復位內固定原則：（1）恢復腓骨長度并做內固定;（2）力求解剖復位，重建脛骨遠端關節(jié)面（關鍵骨折塊、Chaput結節(jié)等）;（3）干骺端骨缺損處植骨（支撐關節(jié)面、填補空缺、刺激成骨、促進骨折愈合）;（4）脛骨內側支撐鋼板固定，重新連接骨干與干骺端，早期功能鍛煉，晚負重。34.切開復位內固定原則：34.Openreductionandinternalfixationprinciples:(1)restorationoffibularlengthandinternalfixation;(2)achieveanatomicalreduction,reconstructionofdistaltibialarticularsurface(criticalfractureblock,Chaputnoduleetc.);(3)bonegraftofmetaphysealbonedefect(supportingthejointsurface,fillingthevacancy,stimulationofosteogenesis,acceleratefracturehealing);(4)thetibialmedialbuttressplatefixation,reconnectthebackboneandthemetaphysis,earlyfunctionalexercise,lateweightbearing.35.Openreductionandinternalfi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骨折成敗的關鍵。注意預防皮膚壞死、感染、創(chuàng)傷性關節(jié)炎、關節(jié)僵硬、畸形愈合、骨不愈合、延遲愈合。有報道用帶關節(jié)的外固定架治療高能量損傷的pilon骨折療效滿意，避免了關節(jié)僵硬。中西醫(yī)結合防治并發(fā)癥。36.治療中的常見問題及并發(fā)癥的防治：36.Commonproblemsinthetreatmentandpreventionofcomplications:Pilonfracture,especiallyhighenergyinjuryPilonfracture,havehighincidenceofcomplications,thetreatmentaboutcomplicationproblemscanbesaidtobecriticaltothesuccessofthetreatmentofPilonfracture.Payattentiontothepreventionofskinnecrosis,infection,traumaticarthritis,jointstiffness,deformity,bonenonunion,delayedhealing.TherehavebeenreportswitharticulatedexternalfixatorinthetreatmentofhighenergyinjuryPilonfracturegotcurativeeffectsatisfaction,ithavepreventedjointstiffness.IntegratedtraditionalChineseandWesternmedicineinthepreventionandtreatmentofcomplicationsisagoodchoose.37.Commonproblemsinthetreatme病案1:患者xx，男，52歲，2小時前在工地干活時從高約3米處跌下致傷。查體：右脛骨遠端及踝關節(jié)腫脹畸形，右內踝上方可見一2*3cm的傷口,可在皮下觸及骨折斷端，有假關節(jié)活動，右足背動脈可捫及。身體其他部位未見異常，內科情況穩(wěn)定。38.病案1:患者xx，男，52歲，2小時前在工地干活時從高約339.39.病案2:患者xx，男，44歲，1天前從高處跌下致傷。查體可見明顯的左側pilon骨折體征（不贅述），閉合性，局部腫脹嚴重，多處張力性水泡形成，左足背動脈可捫及。內科情況穩(wěn)定。40.病案2:患者xx，男，44歲，1天前從高處跌下致傷。查體可2.43.43.Thankyou!44.Thankyou!44.Pilon骨折45.Pilon骨折1.定義:pilon骨折是指累及脛距關節(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波及脛距關節(jié)面的骨折，脛骨遠端關節(jié)面嚴重粉碎，骨缺損及遠端松質骨壓縮。常合并有腓骨下段骨折（約75%～85%)和嚴重軟組織損傷。46.定義:pilon骨折是指累及脛距關節(jié)面的脛骨遠端骨折。脛骨PDefinition：Pilonfracturereferstodistaltibiafractureswhichinvolvetibia-astragalusarticularsurface.Pilonfracturehaven’tgotcleardefinitionyet,itusuallyreferstothirddistaltibiafracturesspreadfromthejoint.Thedistaltibialarticularsurfacealwaysseriousshattered,bonedefectandremotecancellousbonecompression.ItusuallyAssociatedwiththelowerpartoffibulafractures(about75%~85%)andserioussofttissueinjury.47.Definition：Pilonfracturerefe名稱來源：1911年首先由法國放射學家Destotti提出“tibialpilon”一詞，他把脛骨遠端干骺端的形狀描述為像藥劑師的杵棒。脛骨遠端關節(jié)面形似天花板,1950年Bonin稱之為“tibialplatfond”，因此pilon骨折又稱為platfond骨折。48.名稱來源：1911年首先由法國放射學家Destotti提出“Definitionorigin:In1911,theFrenchradiologistDestottifirstlyputforwardtheword--"tibialpilon“.Hedescribedtheshapeofdistaltibiaasthepharmacist’spestle(pilon).Thedistaltibialarticularsurfaceisalsolookslikeceiling;In1950,bonincalledit“tibialplatfond”,sopilonfracturecanbecalledPlatfondfracture.49.Definitionorigin:In1911,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暴力是脛骨遠端關節(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,受傷時踝關節(jié)的位置與骨折類型密切相關.

50.

損傷機制：脛骨Pilon骨折最常發(fā)生于高處墜落、車禍驟Injuremechanism:TibialPilonfracturesoccurmostofteninthefall,crasharrest,skiingorstumblingbeforethefall.Axialtibialviolenceortorsionviolenceoflowerextremityarethemainreasonfordistaltibialarticularsurfacefractures.TwodifferentmechanismsofinjuryleadingtodifferentprognosisofPilonfracture.Thepositionofanklejointwhenithurtsandthetypeoffracturearecloselyrelated.51.Injuremechanism:TibialPilon骨折高度不穩(wěn)定和關節(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。_內容豐富點。列出幾點.脛骨遠端關節(jié)面嚴重粉碎，骨缺損及遠端松質骨壓縮。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

52.骨折高度不穩(wěn)定和關節(jié)軟骨損傷嚴重。治療難度大，并發(fā)癥多，致殘Fracturecharacteristic:Itisahighlyunstablefracture,andhaveseverearticularcartilagedamage.Treatmentisdifficult,withmanycomplications,highdisabilityrate,anditisoneofthemostchallengingorthopaedicproblems.53.Fracturecharacteristic:Itis

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根據關節(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關節(jié)面的損傷程度。

54.

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

Fractureclassify:Themainpurposeoffractureclassificationistoguidetreatmentandpromptprognosis.In1969RuediandAugowerdividedPilonfractureinto3typesaccordingtothearticularsurfaceandmetaphysealdisplacementandcrushingdegree,themeaningofthistypeliesinemphasizingthearticularsurfacedamage.55.

Fractureclassify:Themainp

Ruedi-Allgower分類系統

Ⅰ型:經關節(jié)面的脛骨遠端骨折，較小的移位;

Ⅱ型:明顯的關節(jié)面移位而粉碎程度較小;

Ⅲ型:關節(jié)面粉碎移位及粉碎程度較嚴重。這種分型臨床常用。56.Ruedi-Allgower分類系統12.TheRuedi-Allgowerclassificationsystem:Typeone:Thearticularsurfacefracturesofdistaltibia,alittledisplacement;Typetwo:Theobviousarticularsurfaceshiftandcrushlesserdegree;Typethree:Articularsurfacecrushingshiftandthedegreeisserious.Thistypeofcommonlyusedclinical.57.TheRuedi-Allgowerclassificat診斷:根據病史、癥狀、體征，結合X片、CT等影像學檢查，診斷不難，注意血管、神經等軟組織的損傷，常見脛骨內側、前側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）。58.診斷:根據病史、癥狀、體征，結合X片、CT等影像學檢查，診斷Diagnosis:Accordingtothemedicalhistory,symptoms,signs,combinedwithX,CTimagings,diagnosisisnotdifficult,payattentiontovascular,nerve,softtissueinjury,Theinsideoftibial,anterioropenandpotentialopeninjuryarecommon,carefullycheckthebody.Payattentionnottomisstheotherpartinjuryofthebody(spinalfractures,upperfibulafractureetc).59.Diagnosis:Accordingtothemed治療（1）非手術治療：適應于Ⅰ型無移位骨折、全身情況較差不能耐受手術者、以及為延期手術做準備的治療。主要有手法復位石膏外固定、跟骨牽引等。60.治療（1）非手術治療：適應于Ⅰ型無移位骨折、全身情況較差不能Treatment(1)Nonoperationtreatment:AdaptedtothetypeIfractureswithoutdisplacement,poorgeneralconditionwhichcannottolerateoperation,aswellasthetreatmentforthedeferredoperation.Mainlywithmanipulativereductionandplasterexternalfixation,calcanealtraction,closedpinningfixation,etc.61.Treatment(1)Nonoperationtre（2）手術治療：手術指征：Ⅱ、Ⅲ型開放性骨折，骨折明顯移位或嵌插、缺損、伴有神經血管損傷、軸向對線不良、關節(jié)面骨折移位大于2mm者，均需積極行手術治療。62.（2）手術治療：18.Operationtreatment:Operationindications:TpreII,typeIIIopenfractures,fracturewasobviouslydisplacedorimpacted,defect,accompaniedbythenerveandvascularinjury,theaxialmalalignment,articularsurfacefracturedisplacementisgreaterthan2mm,theseallshouldbeactivelytreatedwithsurgicaloperation.63.Operationtreatment:19.手術原則：低能量損傷的pilon骨折積極行切開復位內固定術（ORIF）；高能量損傷者，采取有限內固定和外固定結合的治療手段。目前主張“生物學”原則：強調細致的軟組織暴露，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、進行關節(jié)面的解剖復位、提供滿足踝關節(jié)早期活動的固定。64.手術原則：低能量損傷的pilon骨折積極行切開復位內固定術（Operationprinciple:LowenergydamageofPilonfracturestreatedwithopenreductionandinternalfixationofpositive(ORIF);highenergyinjury,takelimitedinternalfixationandexternalfixationcombinedtreatment.Currentlyadvocated“biology”principle:emphasizingmeticuloussofttissueexposure,fractureblockfinitestrip,indirectreduction,doearlyexerciseafterstablefixationandlateweightbearing,etc.Treatmentgoalscanbesummarizedas“3P”,theprotectionofboneandsofttissueviability(preserve),anatomicalreductionofthearticularsurface(perform),providefixationswhichcansatisfyearlymotionoftheanklejoint(provide).65.Operationprinciple:Lowenerg手術時機：1、開放性骨折就診時間早或出現筋膜間室綜合征的患者，均應行急診手術處理。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時機，目前還存在較大的爭議，大多數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外，一般應于傷后8-10小時之內，肢體腫脹不甚嚴重，無明顯水泡形成之前急診手術為妥，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?！@個應該放在開放性骨折后面66.手術時機：1、開放性骨折就診時間早或出現筋膜間室綜合征的患者Operationtime:Patientofopenfracturestoseeadoctorearlyorturnupcompartmentsyndrome,urgentoperationtreatmentisnecessary.Fortheseriouspollution(firstdebridement),treatmenttimeoflate,severesofttissueswelling,poorconditionsofopenfractureofcalcaneustractionthatgoaheadoftherest,plastersupport,oroverarticularexternalfixatorfortreatmentoftemporaryfixed,afterswelling,blistershealed,dothesecondaryperiodoftreatment.Foraclosedfractureoftheoperationopportunity,atpresentstillexistscontroversy,Iagreewiththat,inadditiontopoorconditionsintheclosedfracturesshoulddodelayedoperation,generallymostfractureshoulddourgentsurgryin8-10hoursafterinjurywhentheswellingofalimbisnotseriousandnoblisterformation.Thisfacilitatesfracturereset.Highertensionandskindefectwound,maybeleftforsecondarytreatment.67.Operationtime:Patientofope

手術方法：Ⅰ型：有時為了避免非手術治療可能發(fā)生的骨折移位縮短外固定的時間，采用有限切開簡單內固定加石膏外固定,閉合復位后經皮空心螺釘固定術,微創(chuàng)經皮鋼板接骨術(MIPPO技術)

。68.手術方法：24.Operationmethod:TypeI:sometimesinordertoavoidnonoperationtreatmentofpossibledisplacementoffractureandshortenthetimeofexternalfixation,wechooselimitedopensimpleinternalfixationcombinedwithexternalfixationofplaster.Afterclosedreductionandpercutaneoushollowscrewfixation,minimallyinvasivepercutaneousplateosteosynthesis(MIPPOtechnology);69.Operationmethod:25.Ⅱ型：關節(jié)面雖有移位，但并未粉碎和壓縮，以有限切開復位內固定為宜。近年來有主張關節(jié)鏡結合環(huán)形外固定架的治療和關節(jié)鏡輔助下復位經皮螺釘內固定術。70.Ⅱ型：關節(jié)面雖有移位，但并未粉碎和壓縮，以有限切開復位內固定TypeII:Thearticularsurfacedisplaced,butnotcrushedandcompressed,limitedopenreductionandinternalfixationisappropriate.Inrecentyears,someonehaveadvocatedthearthroscopycombinedwithcircularexternalfixation;Arthroscopicassistedreductionandpercutaneousscrewfixationhavealsobeenused.71.TypeII:ThearticularsurfaceⅢ型：閉合性的高度不穩(wěn)定骨折，關節(jié)面嚴重粉碎者，行經典的切開復位內固定術加植骨術。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GustiloⅡ、Ⅲ型患者行有限的切開復位內固定結合外固定支架是較好的選擇。也有主張行分期重建內固定的方法，先固定腓骨，同時使用外固定支架保持肢體的長度和力線，經過10－21d的中間期，使軟組織的條件得以充分改善以減少術后軟組織的并發(fā)癥；再對脛骨遠端的關節(jié)面進行標準的切開復位內固定。72.Ⅲ型：閉合性的高度不穩(wěn)定骨折，關節(jié)面嚴重粉碎者，行經典的切開TypeIII:Closedhighlyunstablefractures,comminutedarticularsurface,chooseclassicopenreductionwithinternalfixationandbonegraft.Severecomminutionhavenoanatomicalreductionpotentialofhighenergyinjury,massivebonedefects,severesofttissueinjury,openfractureoftheGustiloII,typeIIIweretreatedwithlimitedinternalfixationcombinedwithexternalfixationisagoodchoice.Somebodyclaimsreconstructionmethodsoffixationbystages,fixfibulafirstly,atthesametimeusingexternalfixationtomaintainlimblengthandlineofforce,after10-21dintermediateperiod,sothatthesofttissueconditionscanbefullyimprovedtoreducepostoperativesofttissuecomplications;then,thestandardopenreductionandinternalfixationareusedinthedistaltibialarticularsurface.73.TypeIII:Closedhighlyunstab關節(jié)融合術和關節(jié)置換術：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，由于骨折后關節(jié)軟骨下骨發(fā)生壞死、塌陷變化，也就不可避免創(chuàng)傷性關節(jié)炎的發(fā)生。因而踝關節(jié)融合術、關節(jié)置換術的時機選擇,應根據具體情況而定。一般宜在傷后1－2年內根據癥狀、體征、X線表現及患者要求行融合術或置換術。74.關節(jié)融合術和關節(jié)置換術：由于Pilon骨折的患者不是都能達Arthrodesisandanklejointreplacement:BecausenotallofPilonfracturepatientscanachievecompleteanatomicreduction,evencanachieveanatomicreduction,duetoarticularsubchondralbonenecrosisandcollapseafterfracture,,itisinevitablethattheoccurrenceoftraumaticosteoarthritis.Thusthearthrodesisandreplacementoftheanklejointtiming,shouldbebasedonthespecificcircumstancesofthecase.Generallyafterinjuryin1-2yearsaccordingtothesymptoms,signs,Xrayperformanceandpatientsrequirefusionandreplacementsurgery.75.Arthrodesisandanklejointre總之：從文獻報道的有關Pilon骨折治療的臨床研究來看,制定合理而完善的術前計劃、有限內固定結合外固定治療以及根據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，能最大限度地減少針道感染、關節(jié)僵硬等并發(fā)癥。76.總之：從文獻報道的有關Pilon骨折治療的臨床研究來看,制Inconclusion,fromtheliteraturereportsaboutPilonclinicalstudyontreatmentofview,establishreasonableandperfectpreoperativeplanning,limite