儿童踝关节旋后位骨折的临床特点及治疗

Clinical features and treatment strategy of ankle supination fractures in children

目的分析儿童踝关节旋后位骨折的损伤特点，并探讨其治疗方法。方法对2012年1月至2014年7月收治的因旋后位扭伤引起踝关节骨折的89例患儿资料进行回顾性研究，根据入院时病史、查体、踝关节正、侧位X线片及cT平扫加三维重建明确Lauge—Hansen分型，根据骨折类型及移位程度选择合适的治疗方法。89例患儿中旋后内收型52例（其中腓骨远端骺板未闭合的51例患儿的外踝骨折为OdgenVII型骨折），旋后外旋型35例（三平面骨折32例，Tillaux骨折3例），另2例损伤机制不属于Lauge—Hansen分型。其中手术治疗32例，保守治疗57例。结果所有患儿治疗后获12～24个月（平均18个月）随访，尚无骨不愈合、骨关节炎、骨折畸形愈合发生。末次随访时美国足踝外科协会的踝一后足评分平均为92分（88～100分）。结论对于骺板接近闭合的患儿旋后内收型损伤通常引起外踝Salter—harris I型或Ⅱ型骨折，对于骺板未闭合的患儿通常引起骨骺的OdgenVII型骨折，旋后外旋型扭伤通常引起下胫腓联合水平的三平面骨折或Tillaux骨折。对于累及骨骺和骺板的骨折，解剖复位妥善固定是踝关节功能恢复并降低并发症的重要保障。

Objective To analyze the clinical characteristics and treatment strategy of ankle supination fracture in children. Methods From January 2012 through July 2014, 89 children were treated at our department for ankle fracture caused by supination sprain according to their medical history, physical examination, X-ray films and CT three-dimensional reconstruction of the ankle. Appropriate protocols were applied on the basis of Lauge-Hansen classification, type and displacement of their fractures. Of them, 52 belonged to the supination-adduction type （the extramalleolus fracture was of Odgen type VII in 51 children whose epiphyseal plate of distal fibula had not been closed）, 35 to the supination-extorsion type （32 cases had tri-plane fracture and 3 Tillaux fracture）, and the remaining 2 did not fit the Lauge-Hansen classification. Surgical treatment was applied in 32 cases and conservative treatment in 57 ones. Results All the children received outpatient follow-up from 12 to 24 months（mean, 18 months）. No bone nonunion, os- teoarthritis, or fracture malunion was found. The American Orthopaedic Foot ＆ Ankle Society scores averaged 92 points （range, from 88 to 100 points） at the last follow-ups. Conclusions In children whose epi- physeal plate is nearly closed, supination-adduction sprain likely causes an extramalleolus fracture of Salter-Harris type I or type 11, but in children whose epiphyseal plate is unclosed, an epiphyseal fracture of Odgen type VII is inclined to happen. A Tillaux fracture or tri-plane fracture at the level of distal tibiofibular syndesmosis results often from supination-extorsion sprain in children. For fractures involving epiphysis or epiphyseal plate, anatomical reduction and proper fixation are critical to functional recovery and reducing complications.