旋前-外旋型踝关节骨折中隐匿后踝骨折的漏诊原因分析及治疗

Missed diagnosis of hiding posterior marginal fracture of ankle with pronation external rotation type and its treatment

目的：探讨旋前-外旋型踝关节骨折中隐匿后踝骨折相关漏诊病例的原因及治疗。方法：自2002年3月至2010年6月，收治旋前-外旋型踝关节骨折103例，其中9例后踝骨折漏诊，男6例，女3例；年龄18～55岁，平均35.2岁；根据Lauge-Hansen分型均为旋前-外旋型损伤。术中经C形臂X线透视发现4例，术后住院期间发现2例，余3例为外院术后于门诊随访时发现。手术入路采用踝关节后外侧入路，直视下复位后采用空心螺钉或锁定钢板固定。手术后根据美国足踝外科医师协会（American Orthopaedic Foot and Ankle Society，AOFAS）踝-后足功能评分进行功能评定。结果：9例术后均获随访，时间14～30个月，平均17个月。无切口感染，切口均I期愈合。末次随访AOFAS踝-后足功能评分83.0±4.4，其中术中发现并处理4例平均分85.0±2.9，二次手术处理5例平均分81.0±5.3，差异无统计学意义。术后平均2.2个月经X线片证实全部病例骨性愈合，未发现内固定松动、退钉、断裂及血管神经损伤等并发症。结论：旋前-外旋型踝关节骨折可能合并隐匿性后踝骨折，临床医师需充分了解其暴力传导机制，仔细阅读X线侧位片，对可疑后踝损伤者可行CT或MRI检查；同时，术中内外踝固定满意后附加侧位透视有助于避免漏诊。

Objective： To analyze causes of missed diagnosis of hiding post-malleolar fractures in treating ankle joint fractures of pronation-external rotation type according to Lauge-Hansen classification and assess its medium-term outcomes. Methods： Among 103 patients with ankle joint fracture of pronation-external rotation type treated from March 2002 to June 2010,9 patients were missed diagnosis,including 6 males and 3 females,with a mean age of 35.2 years old（ranged,18 to 55 years old） . Four patients were diagnosed during operation,2 patients were diagnosed 2 or 3 days after first surgery and 3 patients came from other hospital. All the patients were treated remedially with lag screws and lock plates internal fixation. After operation,ankle joint function was evaluated according to American Orthopaedic Foot and Ankle Society（AOFAS）. Results： All the 9 patients were followed up,and the duration ranged from 14 to 30 months（averaged,17 months）. No incision infection was found,and all incision healed at the first stage. At the latest follow-up,AOFAS was 83.0±4.4,the score of 4 patients diagnosed during operation was 85.0±2.9,and the score of 5 patients treated by secondary operation was 81.0±5.3. All the patients got fracture union observed by X-ray at a mean time of 2.2 months after operation. There were no complications such as internal fixation loosing,broken and vascular or nerve injuries.Conclusion： Ankle joint fracture of pronation-external rotation type may be combined with hiding post-malleolar fractures. So to patients with ankle joint fracture of pronation-external rotation type,lateral X-ray should be read carefully,and if necessary,CT or MRI examination should be performed. If adding lateral X-ray examination after reduction of exterior and interior ankle joint fixation,the missed diagnosis may be avoided.