新鲜高能量跖跗关节骨折脱位的临床特点及治疗策略

Characteristics and treatment strategy of fresh high-energy fracture dislocation of tarsometatarsal joints

[目的]回顾分析空心螺钉结合克氏针或单纯空心螺钉内固定方法的临床和影像学资料,探讨新鲜高能量跖跗关节骨折脱位的临床特点及治疗策略。[方法]2002年9月-2008年4月应用空心螺钉结合克氏针或单纯空心螺钉内固定治疗43例新鲜高能量跖跗关节骨折脱位患者,男35例,女8例;年龄18～55岁,平均37.5岁。致伤原因:交通事故伤15例,重物压砸伤21例,高处坠落伤7例。左足28例,右足15例。按照Myerson分型:A型9例,B1型2例,B2型25例,C1型4例,C2型3例。其中开放性损伤8例(GustiloⅠ型6例,GustiloⅡ型2例),闭合性损伤35例。伤后至手术内固定的时间平均4.6d(2.5h～21d)。所有患者术后4～6周拆除石膏开始功能锻炼,术后16～18周去除内固定后开始部分负重行走。[结果]43例获得13～38个月(平均26个月)随访。无感染、断钉、内固定松动、骨不连和足弓塌陷等并发症。参照周许辉疗效标准,优26例,良15例,中2例,优良率为95.3%。6例出现创伤性关节炎,均伴有伤后关节面的损伤。[结论]对新鲜高能量跖跗关节骨折脱位患者采取正确的诊断方法和标准均能确诊。早期诊断和正确分型、把握手术时机、解剖复位、合理的内固定和外固定及适时的功能锻炼是提高疗效的关键。

[Objective] To investigate the characteristics and treatment strategy for fresh high energy fracture dislocation of tarsometatarsal joints in a retrospective study. [Method] From September 2002 to April 2008,43 patients with fresh high energy fracture dislocation of tarsometatarsal joints were treated with cannulated screw combined with Kirschner wire fixation or Kirschner wire fixation alone. There were 35 males and 8 females ,with a mean age of 37.5 years （ range, 18 to 55 years）. The injury was caused by a road accident in 15 patients,by a heavy crash in 21 patients,and by a fall from a height in 7 patients. According to the Myerson damage typing,there were 9 cases of type A ,2 cases of type of B1,25 cases of type B2,4 cases of type C1 and 3 cases of type C2. Eight were open injuries （6 of Gustilo-Anderson type I and 2 of type Ⅱ）and 35 closed injuries. Internal fixation were undertaken at an average of 4.6 days after injury （ range,2.5 hours to 21 days）. At 4 -6 weeks all the patients began functional exercises ＇after removal of the plaster casts. At 16 - 18 weeks all the patients began to walk with partial weigh loading after removal of the internal fixators. [Result] All the 43 patients were followed up for 26 months on average（ range, 13 to 38 months）. No infection, breakage,loosening of internal fixator, nonunion or longitudinal arch collapse was found. According to ZHOU＇S assay standard,excellent result was achieved in 26 cases, good in 14 cases, and fair in 3 cases,with excellent to good results of 95.3%. Six patients had post-traumatic arthritis, which was complicated with injured articular surface. [Conclusion] Fresh high-energy fracture dislocation of tarsometatarsal joints can be diagnozed correctly. Early diagnosis and correct classification, proper operation timing, anatomical reduction,rational internal and external fixation and timely functional training are essential for patients to achieve good clinical result.