青少年胫骨远端三平面骨折的诊治

Diagnosis and treatment of triplane fractures of the distal tibia in teenagers

目的探讨青少年胫骨远端三平面骨折的诊断、治疗和预后。方法2005年2月至2008年10月收治胫骨远端三平面骨折11例，男8例，女3例；年龄12．5～15．3岁，平均13．8岁。右踝9例，左踝2例。X线片示11例患者均为外侧二部分关节内三平面骨折，其中2例伴腓骨骨折。采用闭合复位石膏固定6例，切开复位内固定5例。结果11例患者获平均24个月（6～36个月）随访。踝关节功能采用美国足踝外科协会（AOFAS）踝与后足功能评分标准进行评估：优6例，良3例，一般2例。手术患者中2例（预后一般的病例）出现感染及伤口周围皮肤局部坏死。结论胫骨远端三平面骨折是青少年踝关节所特有的复杂骨折，其骨折形态由损伤时骨骺骨化的程度和所受暴力的大小所决定。术前CT多维重建是获得准确诊断，选择合理入路的前提。如果骨折移位〉2mm或保守治疗不能达到解剖复位或复位无法维持，建议切开复位内固定。理想预后的基础是解剖复位。

Objective To investigate the diagnosis, treatment and prognosis of the triplane fractures of distal tibia in the teenagers. Methods From February 2005 to October 2008, 11 young patients with triplane fractures of the distal tibia were treated in our department. They were 8 boys and 3 girls, with an average age of 13.8 （12.5 to 15.3） years. The fight ankle was involved in 9 cases and the left in 2. X-ray examination revealed lateral two-fragment triplane fractures in all the 11 patients, 2 of whom presented with fibular fractures. Six patients were treated with closed reduction and plaster immobilization, while 5 with open reduction and internal fixation （ORIF）. Results All the 11 patients had a mean follow-up of 24 （range, 6 to 36） months. The American Orthopaedic Foot ＆ Ankle Society（AOFAS） ankle and hindfoot scale revealed 6 excellent （90 to 100 points） patients, 3 good （75 to 89 points） ones and 2 fair （50 to 74 points） ones. Of the 5 patients treated surgically, 2 experienced superficial infection and partial skin necrosis around the incisions. Conclusions The severity of triplane fracture of the distal tibia in teenagers de- pends on the degree of physis ossification and the magnitude of injury force. Preoperative CT scan and reconstruction are essential to an accurate diagnosis and selection of operative approach. ORIF is recommended when the fracture displacement is over 3mm, or when anatomical reduction cannot be achieved and maintained with close treatments. Anatomical reduction is the key to good prognosis.