胫骨远段螺旋形骨折伴踝关节损伤的研究

Distal tibial spiral fracture and ankle injury

目的探讨低能量损伤造成胫骨远段螺旋形骨折后,同侧踝关节的损伤情况。方法回顾性分析2010年3月到2021年3月济宁医学院附属医院创伤骨科收治的80例胫骨远段螺旋形骨折患者资料。男61例,女19例;年龄(43.5±12.5)岁;随访时间67.0(38.5,90.0)个月。所有患者均在术前进行X线片检查,64例进行CT检查,30例进行MRI检查。80例患者,3例石膏托外固定保守治疗;3例予以闭合复位髓内钉固定,74例患者采用钢板固定。分别统计后踝骨折发生率和骨折线特点、同侧踝关节正常匹配率、术中同侧踝关节Cotton试验和应力外旋试验阳性率、随访时被动旋前外旋及旋后外旋应力试验阳性率、治疗后近期(≤2年)、中长期(>2年)踝关节疼痛发生率,下胫腓前韧带、内踝三角韧带深层、后踝的损伤率,踝关节损伤率。结果后踝骨折X线片诊断率为16.3%(13/80),CT为60.9%(39/64),MRI为76.7%(23/30);后踝骨折线开口于外侧的占74.5%(35/47);同侧踝关节正常匹配率为96.3%(77/80);术中同侧踝关节Cotton试验、应力外旋试验阳性率分别为34.8%(8/23)、7.1%(1/14);随访时被动旋前外旋及旋后外旋应力试验阳性率分别为46.2%(12/26)、34.6%(9/26);术后近期、中长期踝关节疼痛发生率分别为37.7%(29/77)、20.8%(16/77);MRI检查下胫腓前韧带、内踝三角韧带深层、后踝损伤率分别为80.0%(24/30)、80.0%(24/30)、76.7%(23/30);踝关节损伤率为88.8%(71/80)。结论胫骨远段螺旋形骨折高概率伴发同侧踝关节损伤,内踝、外踝、后踝分别容易发生如下隐匿性损伤:三角韧带深层不同程度损伤、下胫腓前韧带断裂及后踝骨折,而踝关节大多匹配正常,为此踝关节损伤极易漏诊;继发于小腿的旋前外旋、旋后外旋扭转伤力很可能造成同侧踝关节的损伤。

Objective To characterize the injury to the ipsilateral ankle joint after low energy spiral fracture of the distal tibia.Methods A retrospective study was conducted to analyze the 80 patients with distal tibial spiral fracture who had been treated at Department of Traumatic Orthopedics,Affiliated Hospital of Jining Medical University from March 2010 to March 2021.There were 61 males and 19 females with an age of(43.5±12.5)years.Their mean follow-up time was 67.0(38.5,90.0)months.All patients underwent preoperative X-ray examination,64 ones preoperative CT examination,and 30 ones preoperative MRI examination.Of the 80 patients,3 received conservative treatment with plaster external fixation,3 closed reduction and intramedullary nail fixation,and 74 plate fixation.Statistically analyzed were incidence of posterior malleolus fracture,characteristics of posterior malleolus fracture lines,normal matching rate of the ipsilateral ankle joint,positive rate of intraoperative Cotton test or stress external rotation test of ipsilateral ankle joint,positive rates of passive pronation-external rotation and supination-external rotation stress tests during follow-up,incidences of short-term ankle pain(≤2 years)and medium-long term pain(>2 years)after operation,injuries to the anterior inferior tibiofibular ligament,the deep medial malleolus deltoid ligament and the posterior malleolus,and incidence of ankle injury.Results The diagnostic rate for posterior malleolus fracture was 16.3%(13/80)on X-ray film,60.9%(39/64)on CT and 76.7%(23/30)on MRI.74.5%(35/47)of the posterior malleolus fracture lines opened on the lateral side.The normal matching rate of the ipsilateral ankle joint was 96.3%(77/80).The positive rates of intraoperative Cotton test and stress external rotation test were 34.8%(8/23)and 7.1%(1/14),respectively.The positive rates of passive pronation-external rotation and supination-external rotation stress tests during follow-up were 46.2%(12/26)and 34.6%(9/26).The incidences of postoperative short term(≤2 years)and medium-long term(>2 years)ankle pain were 37.7%(29/77)and 20.8%(16/77).MRI examination showed that the rates of injury to the anterior inferior tibiofibular ligament,deep medial malleolus deltoid ligament and posterior malleolus were 80.0%(24/30),80.0%(24/30)and 76.7%(23/30).The incidence of ankle injury was 88.8%(71/80).Conclusions It is highly probable that spiral fracture of the distal tibia is complicated with ipsilateral ankle injury.The medial malleolus,lateral malleolus,and posterior malleolus are prone to the following hidden injuries while the ankle joint is normally matched in the most cases:injury to the deep deltoid ligament in different degrees,rupture of the inferior tibiofibular anterior ligament and posterior malleolus fracture.Therefore,the ankle injury is likely to be missed in diagnosis.The secondary torsion injuries to the pronation-external rotation and supination-external rotation at the leg are likely to cause ipsilateral ankle injury.