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    分期手術治療Ⅱ、Ⅲ型Pilon骨折
    關鍵字:治療,手術,KL,MN,IJ,GH,CD,EF,OP,QR, 發布時間:2011-08-20

    第29卷第3期 2010年8月 河南大學學報(醫學版) JournalofHenanUniversity(MedicalScience) V01.29 No.3 Aug.2010 分期手術治療Ⅱ、Ⅲ型Pilon骨折 張 松,劉 洋,李國軍,王曉,劉怡勛,王仲鋒 (河南大學淮河醫院骨科,河南開封475000) 摘要:日曲:總結Ⅱ、Ⅲ型Pilon骨折分期手術治療經驗。方法:對2006年7月至2009年9月共計25例患者Ⅱ、 Ⅲ型Pilon骨折根據傷情及分級標準分期手術治療。結景:經8~24個月(平均12個月)隨訪,手術療效滿意。結 論:針對Ⅱ、Ⅲ型Pilon骨折制定個性化治療方案,分期手術可明顯減少并發癥,提高骨折治愈率,值得推廣。 關鍵詞:Pi|on骨折;分期手術:隨訪 中圖分類號:R683.42文獻標識碼:B Pilon骨折是指累及脛距關節面的脛骨遠端骨 折,多發于車禍或高處墜落傷,常合并腓骨下段骨折 (75%~85%)和嚴重軟組織損傷,其中高能量損傷常 引起脛骨遠端關節面粉碎、干骺端壓縮、骨缺失,以及 廣泛的軟組織挫裂、碾壓傷,早期處理不當易出現骨 外露、骨髓炎、骨折不愈合,以致肢體壞死、傷殘,成為 臨床治療上最具挑戰性的骨折之一。我們在2006年 7,月至2009年5月采用分期手術治療Ⅱ、Ⅲ型Pilon 骨折25例,臨床取得了滿意的療效,結果報告如下。 文章編號:1672—7606(2010)03—0204—02 后干骺端骨缺損者取自體松質骨移植。 2結果 本組手術25例患者,經8~24個月(平均12個 月)隨訪,骨愈合時間5~11個月,平均6.5個月。拆 除外L司定架時間4~9個月,無截肢、骨髓炎等并發癥 的發生。采用Mazur評分系統對術后踝關節癥狀及 功能進行評分,其中優13例,良8例,可4例;優良率 84%。 1資料與方法 3討論 1.1臨床資料 本組25例,男18例,女7例,年齡19~55歲,平 均34歲。其中6例開放性骨折。致傷原因:交通傷 13例,高處墜落傷7例,壓砸傷5例。合并創傷性休 克3例,腦挫裂傷1例,肋骨骨折并血氣胸2例,四肢 多發性骨折4例。依據Ruedi—Allgower分型Ⅱ型16 例,Ⅲ型9例。 1.2治療方法 患者入院后首先遵循多發傷急救原則搶救生命, 糾正休克,待生命體征平穩后開放骨折予以創面清 創,必要時血管探香一期吻合,伴肌腱、血管、神經外 露的患者選用皮瓣修復LI],創面小的患者采用皮膚擴 張術閉合傷口;所有病例均行跟骨牽引。對軟組織損 傷重、污染重的不能一期閉合創面,先行徹底清創,后 肢體抬高定時換藥,應用靜脈泵待腫脹消退、創面穩 定后二期手術修復。7~14d去除骨牽引,雙切口顯 露脛、腓骨遠端,采用秀建鈦板固定腓骨骨折,應用有 限螺釘固定、聯合外固定支架穩定脛骨骨折&],復位 Ⅱ、Ⅲ型Pilon骨折系高能量損傷引發的關節內 骨折,因自身解剖結構特點。傷后肢體軟組織腫脹嚴 重、張力高,脛骨遠端骨質粉碎移位顯著,易出現血管 痙攣、動脈缺血、靜脈淤血,從而進入高張力惡性循 環,所以對于此類復雜骨折早期手術風險很大,Wyr— sch等¨J對傷后3~5d進行手術的Pilon骨折患者 進行研究,其感染率為28%,截肢率為16%。 手術時機的選擇對Ⅱ、Ⅲ型Pilon骨折的治療非 常重要,最好時機取決于軟組織的狀態¨],從保護軟 組織、防止進一步損傷角度首先是肢體抬高制動、藥 物輔以靜脈泵治療以盡早消腫,同時應用跟骨牽引初 步糾正粉碎骨折移位,恢復肢體軸線和長度,解除血 管嵌壓。除開放性骨折外,我們主張延遲到傷后7~ 14d進行手術。 復雜Pilon骨折的治療結果取決于軟組織覆蓋 的狀況和關節葦建的質量。 臨床發現Ⅱ、Ⅲ型Pilon骨折腓骨骨折相對損傷 輕,首先對腓骨骨折固定可有效恢復肢體長度,有利 收稿日期:2010—05—28 作者簡介:張松(1970一),男,河南雎縣人,副主任醫師,從事骨科疾病的診治工作。 萬方數據 換頁 張松,等:分期手術治療Ⅱ、Ⅲ犁Pilon骨折 205 于脛骨骨折端的穩定和關節面的解剖復位。 外固定支架可最大限度保護骨折處骨膜和軟組 織血供,可隨時對骨折對位、力線進行調整,便于創面 觀察與引流,利于患肢早期功能鍛煉。 由于外固定架本身對骨折端復位,特別是粉碎骨 折的作用有限,所以較多的結合有限內固定的形式¨] 常采用拉力螺釘進行骨塊間的解剖重建陽]。傳統外 固定架限制了踝關節的早期活動,選用單側超踝外固 定架町保證踝關節早期功能鍛煉,有效改善關節營養 和愈合,促進肢體功能恢復¨]。 由于關節面松質骨嵌壓、壓縮。Ⅱ、Ⅲ型Pilon骨 折常伴有骨缺損,術中自體骨填充是修復關節面的關 鍵環節,早期充分植骨可有效防止干骺端延遲愈合或 不愈合,80%的Ⅱ、Ⅲ捌骨折需要植骨"]。 高能量損傷引發的Ⅱ、Ⅲ型Pilon骨折并發癥發 生率高且嚴重,是目前最難治療的下肢骨折之一,早 期判斷、處理是否得當關系蕈大。我們采用分期手術 治療Ⅱ、Ⅲ型Pilon骨折25例取得了滿意的療效,進 一步證實了Sirkin等∞3提出的分步延期治療法的科 學性。 參考文獻: [1]王磊.谷增泉.外固定支架聯合皮瓣治療軟組織缺損的 Pilon骨折體會[J].海南醫學.2009,20(4):108~109. [2]張松,手維.王曉,等.螺釘內闖定~期植骨結合外固定支 架治療Ⅲ型Pilon骨折[J].中困骨與關爺損傷雜志, 2003.18(6):419—420. [3]王景治.于敬賀,朱海心.分階段手術治療Ⅱ型Pilon骨折 [J].局解手術學雜志,2006。15(1):32. [4]。E滿宜.楊慶銘。曾炳芳,等.骨折治療的A()原則[M].北 京:華夏出版社,2003:539. [5]EndresT,GrassR,BiewenerA,eta1.Advantagesof minimally—invasivereposition,retention,and Ilizarav一 (hybrid)fixationforpilon—tibial—fratureswithparticular emphasis OHC2/C3fratures[J].Unfallchirurg,2004,107 (4):273. [6]許杰,馬若凡。丁悅.Ⅱ、Ⅲ型Pilon骨折外科治療難點及 處理對策[J].中圍骨與關節損傷雜志,2006。21(3):201— 202. [7]KralingerF,LutzM。Wam bacherM.eta1..Artho- scopicallyassistedreconstructionandPercutaneousScrew fixationofapilontibialfracture[J].Arthroscopy,2003, 19:45 [8]SirkinM.SandersR.TheTreatmentofpilonfractures [J].OrthopClinNorthAm,2001,32:91—102. [責任編輯李武營] 萬方數據 換頁

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