后踝骨折的治疗

A systematic review on the management of posterior malleolar fractures

虽然内踝骨折和外踝骨折的治疗原则已被广泛认可,但对于后踝骨折的治疗仍有较多争议。笔者对近几年关于后踝骨折的诊断、治疗及预后作一综述。共有33项研究950例患者(8项研究属于生物力学领域和25项属于临床医学领域)被纳入meta分析,结果提示后踝骨折患者预后较内踝和外踝骨折患者差,但并没有充分证据表明后踝骨折块的大小影响患者预后。虽然关于后踝骨折的治疗尚未有一致观点,但多数医师认为后踝骨折块的大小对治疗方案的选择有较大影响。其他因素如骨折移位情况、关节面有无台阶、胫距关节残余半脱位等对预后有影响。虽然间接的证据表明较大的后踝骨折块及骨折移位与踝关节不稳定的发生有关,因而可能需要手术固定,但是尚无充分的证据表明后踝骨折累及关节面>1/4会影响踝关节骨折的预后,故后踝骨折治疗方案的选择应该更多考虑骨折移位程度及胫距关节脱位等因素。

It is controversial about the treatment of posterior ankle fractures although therapy of fractures of medial and lateral malleolus has been widely accepted. We performed a systematic review of recent published articles about the diagnosis,management and prognosis of posterior malleolus fractures. Totally 33 studies（ 8 biomechanical and 25 clinical） including 950 patients were enrolled. The analysis showed that ankle fractures with posterior malleolar involvement had poorer prognosis compared with other kinds of ankle fractures. However,there was no compelling evidence that the size of the posterior fracture affected the prognosis. Many authors thought the size of the posterior malleolus fracture influenced their decision-making regarding treatment plans while there was no consensus. Other factors such as fracture displacement,congruency of the articular surface and residual tibiotalar subluxation were all believed to play a role in prognosis. Further evidence showed that large fracture fragments were associated with dislocations and ankle instability,and therefore might require surgical fixation. Nevertheless,it lacked evidence that fracture size bigger than 1/4 malleolus got involved in the prognosis of ankle fracture. In conclusion,this meta-analysis suggested that there was no strong evidence that the size of the posterior malleolar fractures affects the prognosis,and the decision about the treatment of this type of fracture should be based on other factors previously mentioned.