儿童严重不稳定型Lisfranc损伤的手术治疗

Surgical treatment of severe unstable Lisfranc fracture in children

目的探讨儿童严重不稳定型Lisfranc损伤的临床特点及其手术治疗方法。方法选取2009年6月至2016年10月北京积水潭医院收治的7例严重不稳定型Lisfranc损伤患儿,X线示患侧Lisfranc关节分离>3 mm。根据Hardcastle分型标准:B型骨折3例,C型骨折4例。7例患儿中开放性骨折2例,行外固定架结合空心钉及克氏针固定;闭合性骨折5例,行切开复位内固定,其中有2例因严重骰骨塌陷骨折辅以外侧柱外固定架撑开植骨。新鲜骨折6例,陈旧骨折1例,合并跟骰关节骨关节炎,行跟骰关节撑开融合术。结果随访43.7个月(10~96个月)。手术时间(80.1±11.7)min,术中出血量(53.3±27.4)ml。7例患儿均于术后6周拔除克氏针,术后3个月去除内、外固定。所有患儿均获得骨性愈合,未见中足慢性疼痛。1例陈旧骨折患儿术后扁平外翻足畸形获得矫正,跟骰关节疼痛消失。末次随访时,3例患者出现自发的第2跖跗关节融合。结论不稳定型儿童Lisfranc损伤的特点是以骨折脱位为主,单纯的韧带撕裂及关节囊破损较少见,常合并严重的粉碎塌陷骨折。其治疗应以恢复骨性结构稳定及内、外侧柱长度为主。跨关节外固定架的使用有助于维持复位及恢复内、外侧柱的长度。

] Objective To investigate the clinical features and surgical methods for severe unstable Lis- franc injury in children. Methods From June 2009 to October 2016, 7 patients were surgical treated for un-stable Lisfranc fracture-dislocation. More than 3 mm displacement of Lisfranc joint were found in all patients. According to Hardcastle classification, there were 3 cases of type B, 4 cases of type C. Two cases of open frac-ture were treated by external fixator combined with canulate screw and K-wire. Open reduction and internal fixa-tion were performed in the other 5 cases of closed fractures. In addition, 2 cases who had severe collapse cuboid fracture, were performed distraction bone graft with external fixator. One case of old fracture combined with cal-caneocuboid joint arthritis were treated with arthrodesis by distraction bone block. Results All patients were followed-up 47. 6 months （ ranged from 10 to 96 months）. The operation time was （80.1 ± 11. 7 ） min, blood loss was （53. 3 ±27.4） ml. All K-wires were removed at 6 weeks postoperatively. Other internal and external fixation were removed at 3 months after operation. X-ray showed bone healing in all patients. No chronic mid-foot pain was occurred. Vfilgus deformity was corrected and pain was relieved in one patient with old fracture. Three patients sufferred from the 2nd tarsometatarsal joint spontaneous fusion at the final follow-up. Conclusion Fracture-dislocation is the main type of unstable Lisfranc injury in children, usually combined with severe collapse tarsal bone fracture. Simple injury of ligament and joint capsule are rare. The goals of treatment are to restore the stable bony structure and the length of medial and lateral column. Transarticular external fixator is useful for maintaining reduction and bone morphology.