距骨颈骨折的手术治疗

The treatment of the fractures of the talar neck

目的探讨距骨颈骨折的特点、分型、手术方法及并发症防治。方法1996年7月～2001年11月,共治疗距骨颈骨折患者47例,男32例,女15例;年龄18～49岁,平均31.6岁;坠落伤13例,车祸伤28例,其它损伤6例;合并踝部骨折12例;开放性骨折脱位4例。根据Hawkins分型方法,Ⅰ型骨折6例,Ⅱ型骨折26例,Ⅲ型骨折15例。Ⅰ型骨折为无移位、稳定性骨折,采取非负重石膏管型固定;Ⅱ、Ⅲ型骨折行急诊手术,解剖复位,松质骨拉力螺钉内固定,其中Ⅲ型骨折同时行距下关节一期融合。非负重短腿石膏管型固定8～48周,至X线片示骨折愈合后,再逐渐负重。结果全部病例均获得随访,随访时间2～5年,平均3.6年。根据患者的主诉、后跟及踝关节的外形、功能及X线征象来分析临床疗效,优17例(36.2%),良22例(46.8%),可5例(10.6%),差3例(6.4%);优良率为83.0%。术后发生距骨体坏死8例,Ⅱ型骨折3例;Ⅲ型骨折5例,其中术后3例因距骨体坏死、塌陷或疼痛性关节炎而行踝关节融合术。单纯踝关节炎4例;距骨下关节炎6例,其中3例合并踝关节炎;踝关节内侧皮肤坏死、缺损1例。结论距骨颈骨折并发症多而后果严重,宜早期诊断并进行有效解剖复位和固定,以预防距骨体缺血性骨坏死、创伤性关节炎、骨折愈合不良等并发症。

Objective To study the characteristics and classifications of the fractures of the talar neck as well as to define the appropriate treatments and its complications. Methods 47 patients of the fractures of the talar neck were referred to our department of orthopaedics from July 1996 to November 2001. There were 32 males and 15 females with an average age of 31.6 years. The injuries were caused by fall in 13, traffic accident in 28, and others in 6. According to Hawkins classification, there were type Ⅰwith nondisplaced vertical fracture in 6 patients, which were treated non-operatively, and immobilized with a non weight bearing short leg cast; type Ⅱ in 26 patients, and type Ⅲ in 15 patients, all of which were treated in emergency with anatomic reduction and fixation with 4.0 mm lag screws through anteromedial or anterolateral approaches of the ankle. Otherwise, the arthrodesis of subtalar joint in type Ⅲ fracture were primarily performed as well. The ankles were immobilized until the fracture healed. Results The patients were followed up 2 to 5 years (average, 3.6 years). By the assessment of clinical effects depending on the complaints, functions and radiological results of the ankle and subtalar joint, 17 patients were rated as excellent, 22 patients good, 5 fair, and 1 poor, the total rate of excellent and good was 83.0%. Osteonecrosis occurred in 8 patients with 3 of type Ⅱ and 5 of type Ⅲ fractures. 3 of 4 patients with talar displacement were found with osteonecrosis or painful arthritis. The subtalar arthrosis occurred in 6 patients, 4 of which were associated with ankle arthrosis. 3 patients underwent arthrodesis because of painful arthritis of the subtalar joint or osteonecrosis of the talar body. Anteromedial skin necrosis of the ankle developed in 1 patient. Conclusion If the fracture of talar neck is not managed appropriately as early as possible, its complications are common, the fractures should be treated in emergency to reduce the incidence of posttraumatic osteonecrosis, arthrosis and malunion of the fractures.