骨科-踝关节手术课件.ppt

1、ANKLE FRACTURESNetbasert undervisning april 0501Illustrations redrawn from Malleolar Fractures and Soft Tissue Injuries of the ankle: Carr JBAnkle fractures: Marsch JL, Salzman CLComposition: Bengt stman overlege Presentation: Simen Sellevold, assistentlege Ingo Spauke, assistentlegeEpidemiology02In

2、cidence: 80130 per 100 000 persons highest in elderly women67% isolated malleolar fractures25% bimalleolar 8% trimalleolar ANKLE FRACTURESNational Hospital Discharge Register of Finland 1994Court-BrownCM, McBirnie J, Wilson G. Adult ankle fractures: an increasing problem? Acta Orthop Scand 1998;69:4

3、3-4703Incidence: Ringerike Hospital 1/8 2003 31/7 2004: 184 per 70 000 - 100 000 persons 128/184 (69%) isolated malleolar fractures 27/184 (15%) bimalleolar 29/184 (16%) trimalleolar ANKLE FRACTURESEpidemiology04ANKLE FRACTURESClassification - Why?Why do we require fracture classifications? for clin

4、ical research to understand the literature as an aid to fracture description as an aid to fracture treatment05AO (Danis/Weber)Type A below the syndesmosisType B at the level of the syndesmosisType C above the syndesmosisDanis R. Les fractures malleolaires. In: Danis R, ed. Thorie et practique de los

5、teosynthse. 1949:133-165.Weber BG. Die Verletzungen des oberen Sprunggelenkes, Berne: Hans Huber, 1966. (2nd ed. 1972)Classification AO (Danis/Weber)ANKLE FRACTURES06AO AO/OTA(Weber)3 types (A, B, C) 9 groups (A1, A2, A3, B1, B2, B3, C1, C2, C3) 27 subgroupsMller ME, Allgwer M, Schneider R, et al. M

6、anual of internal fixation, 2nd ed. Heidelberg: Springer-Verlag, 1979:282-299. (3rd ed. 1991).Orthopaedic Trauma Assocoation. Fracture and dislocation compendium. J Orthop Trauma 1996;10:1-55.Classification AO/OTAANKLE FRACTURES07AO AO/OTALauge-HansenLauge-Hansen N. Fractures of the ankle: combined

7、experimental-surgical and experimental roentgenologic investigations. Arch Surg 1950;60:957-985Classification Lauge-HansenANKLE FRACTURES08AO AO/OTA Lauge-Hansen Supination - External rotation (I, II, III, IV) Supination - Adduction (I, II) Pronation - External rotation (I, II, III, IV) Pronation -

8、Abduction (I, II, III) position deforming forceClassification Lauge-HansenANKLE FRACTURES09AO AO/OTA Lauge-Hansen Supination - External rotation (I, II, III, IV) Supination - Adduction (I, II) Pronation - External rotation (I, II, III, IV) Pronation - Abduction (I, II, III) position deforming force

9、stable ”stable” unstableClassification Lauge-HansenANKLE FRACTURES10AO AO/OTA Lauge-HansenStable versus Unstable (Tile)Tile M. Fractures of the ankle. In: Joseph Schatzker MT, ed. The rationale of operative fracture care. Berlin: Springer-Verlag, 1987:371-404.The presence or absence of a medial inju

10、ry is the key to stability of the lateral malleolar fracture. The medial injury determines stabilityClassification Stable/UnstableANKLE FRACTURES11Weber ASA I-IIWeber BSE I-IVPA I-IIIWeber CPE I-IVDanis Weber vsLauge HansenANKLE FRACTURESLauge-Hansen Classification (Supination-Adduction, SA I II)III

11、I Transverse fibula fracture or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fractureANKLE FRACTURES12Lauge-Hansen Classification (Supination-Adduction, SA I IIANKLE FRACTURES13IIII Transverse fibula fractu

12、re or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fractureRadiographic view: Supination-Adduction type II fracture with medial impaction 14ANKLE FRACTURESRadiographic view: Supination-Adduction type II fra

13、cture with medial impaction15ANKLE FRACTURESCorrections Impression of medial plafondReposition of medial malleolusPlating and bone grafting of medial metaphysisLauge-Hansen Classification (Supination-External rotation, SE I IV)IIIIIIIVI Anterior tibial-fibular sprainII Stable short oblique fracture

14、of the distal fibulaIII Rupture of posterior tibial-fibular ligament or fracture of the posterior marginIV Unstable short oblique fracture of the distal fibula with a medial malleolus fracture or a deltoid ligament disruptionANKLE FRACTURES16Lauge-Hansen Classification (Supination-External rotation,

15、 SE I IV)IIIIIIIVI Anterior tibial-fibular sprainII Stable short oblique fracture of the distal fibulaIII Rupture of posterior tibial-fibular ligament or fracture of the posterior marginIV Unstable short oblique fracture of the distal fibula with a medial malleolus fracture or a deltoid ligament dis

16、ruptionANKLE FRACTURES17Illustration: Supination-External rotation type II, III and IV18Fixation of an oblique fracture of the distal fibulaANKLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 a)19ANKLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 b)20AN

17、KLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 c)21ANKLE FRACTURESRadiographic view: Supination-External rotation type IV, (1 d)22ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (2 a)23ANKLE FRACTURESRadiographic view: Supination-External rotation typ

18、e IV (2 b)24ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 a)25ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 b)26ANKLE FRACTURESIII IVTypical fracture line pattern for a SE type fracture IIRupture of the posterior tibio-fibular ligamentRupture o

19、f the deltoid ligament IIOblique fracture of the distal fibula IAnterior tibio-fibular sprainRadiographic view: Supination-External rotation type IV (3 c)27ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 d)28ANKLE FRACTURESRadiographic view: Supination-External rotation typ

20、e IV (3 e)29ANKLE FRACTURESRadiographic view: Supination-External rotation type IV (3 f)30ANKLE FRACTURESMale 64 years of age, was proposed a re-operation but chosed to accept the present situation after proper informationLauge-Hansen Classification (Pronation-Abduction, PA I III)IIIIIII Isolated me

21、dial malleolus or deltoid ligament ruptureII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Bending fracture of the lateral malleolus with a transverse and often comminuted pattern with possible lateral tibial impactionANKLE FRACTURES31Lauge-Hansen Classification

22、 (Pronation-Abduction, PA I III)IIIIIII Isolated medial malleolus or deltoid ligament ruptureII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Bending fracture of the lateral malleolus with a transverse and often comminuted pattern with possible lateral tibial im

23、pactionANKLE FRACTURES32Illustration: Pronation-Abduction type III33Fixation of a comminuted fibula fractureANKLE FRACTURESRadiographic view: Pronation-Abduction type III, lateral plafond impaction (1 a)34Limbird and Aaron JBJS Am 69:881, 1987ANKLE FRACTURESRadiographic view: Pronation-Abduction typ

24、e III, lateral plafond impaction (1 b)35Limbird and Aaron JBJS Am 69:881, 1987ANKLE FRACTURESIII II ILateral impactionMedial malleolus fractureComminuted lateral malleolus fractureNo spiral fracturepattern in the fibulaAvulsion ofChaputs tubercleRadiographic view: Pronation-Abduction type III, later

25、al plafond impaction (1 c)36ANKLE FRACTURESLimbird and Aaron JBJS Am 69:881, 1987Radiographic view: Pronation-Abduction type III, lateral plafond impaction (1 d)Corrections (mortise view)lenght of the fibulalateral plafond impactionfracture of the medial malleolusposterior malleolar fracture 37ANKLE

26、 FRACTURESLimbird and Aaron JBJS Am 69:881, 1987Radiographic view: Pronation-Abduction type III, lateral plafond impaction (1 e)38Corrections (lateral view)lenght of the fibulalateral plafond impactionfracture of the medial malleolusposterior malleolar fracture ANKLE FRACTURESLimbird and Aaron JBJS

27、Am 69:881, 1987Lauge-Hansen Classification (Pronation-External rotation, PE I IV)I Isolated medial malleolus or deltoid ligament disruptionII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Short spiral fracture above the syndesmosisIV Disruption of the inferior t

28、ibiofibular ligament or a posterior malleolar fractureIIVIIIIIANKLE FRACTURES39Lauge-Hansen Classification (Pronation-External rotation, PE I IV)IIVIIIIITo be noticed!The typical direction of the fracture line in the fibula (lateral view) is different in a Pronation-External rotation type of fractur

29、e compared with a Supination-External rotation type of fractureSE II-IVPE III-IVANKLE FRACTURES40Lauge-Hansen Classification (Pronation-External rotation, PE I IV)I Isolated medial malleolus or deltoid ligament disruptionII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular liga

30、mentIII Short spiral fracture above the syndesmosisIV Disruption of the inferior tibiofibular ligament or a posterior malleolar fractureIIVIIIIIANKLE FRACTURES41Illustration: Pronation External rotation type IV42ANKLE FRACTURESRadiographic view: Pronation-External rotation type I? II? III? IV? (1 a)

31、43ANKLE FRACTURESRadiographic view: Pronation-External rotation type I? II? III? IV? (1 b)44ANKLE FRACTURESRadiographic view: Pronation-External rotation type III or IV (1 c)45ANKLE FRACTURESRadiographic view: Pronation-External rotation type I? II? III? or IV? (2 a)46ANKLE FRACTURESRadiographic vie

32、w: Pronation-External rotation type I? II? III? or IV? (2 b)47ANKLE FRACTURESIVAvulsion of Chaputs tubercle II IAvulsion type fracture of the medial malleolus Posterior malleolus fracture IIAvulsion of Chaputs tubercle?III?Radiographic view: Pronation-External rotation type I? II? III? or IV? (2 c)4

33、8ANKLE FRACTURESIII!Radiographic view: Pronation-External rotation type I? II? III? or IV? (2 d)49ANKLE FRACTURES IIAvulsion of Chaputs tubercle?IVPosterior malleolus fracture IMedial malleolus fracture Illustration: SE type III and IV - PE type (II), III and IV PA type II and III 50Fixation of a to

34、tal rupture of the syndesmosisANKLE FRACTURESIllustration: SE type IV - SA type II PE type I-IV PA type I-III51Fixation of the medial malleolusANKLE FRACTURESClassification of distal tibia fractures (Rdi and Allgwer 79)52ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)IIIIIIClassi

35、fication of distal tibia fractures (Mller, Allgwer, and Schneider et al. 91)53ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)A1A2A3B1B2B3C1C2C3Illustration: axial loading injuries54ANKLE FRACTURES axial loading injuries (Pilon or Plafond fractures)Plafond fracture due to axial fo

36、rce, - 46, Male55ANKLE FRACTURESPlafond fracture due to axial force, - 46, Male56ANKLE FRACTURESCombination of Axial loading force and Supination-external rotation (1 a)57ANKLE FRACTURESCombination of Axial loading force and Supination-external rotation (1 b)58ANKLE FRACTURESCombination of Axial loa

37、ding force and Supination-external rotation (1 c)59ANKLE FRACTURESCombination of Axial loading force and Supination-external rotation (1 d)60ANKLE FRACTURESAxial loading force (2 a)61ANKLE FRACTURESAxial loading force (2 b)62ANKLE FRACTURESAxial loading force (2 c)63ANKLE FRACTURES IIAvulsion of Cha

38、puts tubercle?Large posterior malleolus fracture IVSeveral articular fragmentsAxial loading force (2 d) Peroperative photo64ANKLE FRACTURESAxial loading force (2 d) Peroperative photo65ANKLE FRACTURESAxial loading force (2 e)66ANKLE FRACTURESRemember to focus on the whole patient, not only the fracture lines67ANKLE FRACTURES and you will be rewarded Thank you for your attention68ANKLE FRACTURES