CT在Pilon骨折术前评估中的意义

Computed tomography in preoperative assessment for Pilon fractures

目的探讨CT对胫骨远端Pilon骨折术前评估的意义。方法总结了2000年1月～2005年6月具有完整X线片及CT随访资料的Pilon骨折52例,术前评估结合X线片和关节面CT平扫对骨折进行分型,并描绘骨折线的走行,测量骨折角,分析关节骨块的解剖特点。根据软组织条件、骨折类型、骨折线走行、骨折角、关节骨块位置设计个性化的治疗方案。石膏固定5例,闭合复位经皮螺钉固定加石膏外固定5例,微创钢板接骨术(MIPPO)技术钢板固定治疗17例,外固定结合有限内固定16例,切开复位内固定治疗9例。结果术后平均随访17.2个月。CT改变了9例Rüedi-Allgwer分型,21例发现了新的骨折块。CT平扫中主要骨折线呈冠状面走行的占61.5%,呈矢状面走行的占34.6%,对这两类骨折采用了不同的入路和内固定方式。用Mazur方法评估术后功能:优30例,良13例,可8例,差1例,总优良率82.7%,Ⅲ型的优良率为57.1%,CT显示有冲床死骨的优良率仅为44.4%。结论结合CT对Pilon骨折分型更准确;Ⅲ型骨折只要软组织条件允许,应切开复位关节面骨折;依据主要骨折线的走行和骨块的位置选择切口和内固定方式;对冲床死骨需直视下复位,但此类病例预后较差。

Objective To explore the significance of computed tomography in preoperative classification and surgical planning for Pilon fractures. Methods A retrospective analysis was done for 52 cases of Pilon fracture who had been admitted to our hospital from January 2000 to June 2005 and whose X-ray, Axial CT scan and follow-up data were complete. In the preoperative evaluation, the fractures were classified, the fracture angles measured and the anatomy of fragments analyzed on the basis of their plain radiographs and CT scans. The operative methods and approaches were based on the specific fracture types, fracture angles and courses of fracture line on the CT scans. Five patients received manipulative reduction and plaster splint, five closed reduction and internal fixation with lag screws coupled with plaster splint, 17 closed reduction and internal fixation with minimally invasive per- cutaneous plate osteosynthesis （MIPPO）, 16 closed reduction and external fixation combined with limited internal fixation; and nine open reduction and internal fixation （ORIF） . Results The average follow-up was 17.2 months. CT scan revealed an increased number of fragments in 21 patients. The fracture types were changed in nine patients according to new CT discoveries which revealed coronal main fracture lines in 61.5% of the cases and sagittal in 34. 6%. The approaches and internal fixation positions varied according to the two different kinds of fracture. According to Mazur＇ s criteria, the postoperative surgical results were evaluated as excellent in 30 cases, good in 13, fair in eight and poor in one. On average, the good to excellent rate was 82. 7% for all the patients, 57. 1% for patients with type Ⅲ fractures, but only 44.4% for patients with die-punch fragments in CT scan. Conclusions CT scan can increase accuracy in classification of Pilon fractures. Open reduction of articular surface is preferred for type Ⅲ fractures. Operative approaches and positions of the internal fixation should be based on the anatomy of main fracture lines and fragments. Die-punch fragments should be reduced under direct visualization and indicate unfavorable prognosis.