旋后-外旋型踝关节骨折中三角韧带断裂的诊断与治疗

Diagnosis and management of deltoid ligament injury in the supine-external rotation ankle joint fractures

旋后-外旋型或Weber B型踝关节骨折存在稳定型和不稳定型骨折。不稳定性骨折通常在腓骨骨折的同时存在内踝的骨折或三角韧带的撕裂。现在的共识是对于不稳定型的踝关节骨折,采取切开复位内固定的方式能达到较好的临床疗效。对于内侧韧带撕裂的诊断有很多研究,但对于评估内侧韧带撕裂的最合适方法仍未达成共识。由于外旋引起的三角韧带断裂的患者数量要远比过去想象中的多。在Lauge-Hansen分型中,根据损伤的机制可以提供可能的韧带损伤的信息。通过X线的表现,运用Lauge-Hansen分型系统在评估三角韧带是否损伤具有重要的价值,但其敏感性和特异性有待考究。体格检查、应力位X线片、MRI、关节镜、B超现在已用于踝关节骨折中内侧副韧带的完整的评估,但是这些方法没有一种是便宜、简便、可靠的。现在临床医师习惯使用重力应力试验进行评估,对于可疑的病例,行关节镜探查是非常有价值的。最新的观点认为单纯腓骨骨折,可仅行腓骨骨折切开复位内固定术,对合并外踝骨折的三角韧带撕裂进行修复是没有意义的,也没有证据证明暴露并修复三角韧带对内踝结构有影响。

Supination external rotation or Weber type B ankle fracture has both stable and unstable fractures. Unstable fractures always have fibula fractures and fractures of the medial malleolus or deltoid ligament tear at the same time. A consensus has reached that for unstable ankle fractures,open reduction and internal fixation will achieve better clinical efficacy. There have been many studies on the diagnosis of medial ligament tears,but no consensus has yet been reached on the best method for assessing it. Since the number of patients with deltoid ligament tear due to external rotation is far greater than that we thought,possible information on ligament injury can be provided on the basis of the injury mechanism according to the Lauge-Hansen classification:based on X-ray,use the Lauge-Hansen classification system to evaluate if the deltoid ligament tear has important value,but its sensitivity and specificity remains to be studied. Physical examination,stress radiographs,MRI,arthroscopy,B-ultrasound have been used for a complete assessment of the medial collateral ligament in ankle fractures,but none of these methods is cheap,simple and reliable. Now clinicians are accustomed to using the gravity stress test to make the assessment,and for suspected patients,it′s quite worth their while doing arthroscopic exploration. The latest develpoment believes that the operation of open reduction and internal fixation for treating fibula fractures does no good to the repairment of the deltoid ligament tear in lateral malleolus fractures,and there is no evidence shows that the exposure and repairment of the deltoid ligament has impact on themedial malleolus structure.