踝关节骨折伴三角韧带断裂的诊断与治疗

Diagnosis and Treatment of Ankle Joint Fracture with Deltoid Ligament Fracture

旋后外旋踝关节骨折的最后阶段包括内踝横向骨折或三角韧带断裂。当三角韧带断裂时,踝关节会发生“双踝骨折”,外科医生在诊断和治疗上都面临一些挑战。在自然踝关节,三角韧带对距骨的外翻和外旋提供约束。在双踝等效踝骨折中,即使腓骨复位后也经常有明显的内侧不稳定。从理论上讲,三角韧带收缩后在非解剖位置愈合可能导致不稳定、持续的内踝疼痛和踝关节功能丧失,并有早期关节炎的风险。在轻度病例中,三角韧带损伤可能不明显,潜在的诊断技术包括术前和术中应力x线片、MRI和超声检查。最常见的损伤类型是从内踝撕脱,目前大多数修复技术包括直接修复关节囊和三角韧带损伤,包括内踝缝线锚钉和三角韧带浅、深层直接缝合。到目前为止,与单纯腓骨切开复位内固定相比,加用三角韧带修复的临床效果更好的证据有限。

The last stage of a supination-external rotation ankle fracture involves either transverse fracture of the medial malleolus or rupture of the deltoid ligament. When the deltoid ligament ruptures, a “bimalleolar equivalent” ankle fracture occurs, and the surgeon is presented with several diagnostic and therapeutic challenges. In the native ankle, the deltoid ligament provides restraint to eversion and external rotation of the talus on the tibia. In bimalleolar equivalent ankle fractures, there is of-ten gross medial instability even after fibular reduction. Retraction of the deltoid with subsequent healing in a nonanatomic position theoretically may cause instability, persistent medial gutter pain, and loss of function with risk of early arthritis. In mild cases, deltoid injury may not be obvious, and potential diagnostic techniques include preoperative and intraoperative stress radiography, MRI, and ultrasonography. The most common injury pattern is avulsion from the medial malleolus, and most current repair techniques involve direct repair of the capsular and deltoid injuries involving suture anchors in the medial malleolus and imbrication of the superficial and deep deltoid fibers. To date, there is limited evidence of superior clinical outcomes with the addition of deltoid repair compared with open reduction and internal fixation of the fibula alone.