张候(Z-H)骨折.pptxVIP

张候骨折（Z-H骨折）胫骨下1/3螺旋骨折合并后踝骨折段彪2016.8.15定义胫骨下1/3螺旋骨折，后踝骨折与胫骨骨折线不连续，为一独立骨块病因——胫骨骨折多由于间接暴力所致运动中足踝部固定，患肢由于惯性继续向前运动并向外侧旋转，旋转外力持续作用于胫骨骨干，造成胫骨远端1/3薄弱部位（胫骨骨干由三边形移形为四边形）发生螺旋骨折，骨折线由内下到外上下胫腓后韧带受到较强内旋力的牵拉致后踝骨折①足部固定后身体由于惯性继续向前运动,与距骨发生剪切造成后踝骨折②踝关节受到扭转应力和垂直应力的作用,距骨向后上撞击后踝造成骨折③病因——后踝骨折后踝的骨小梁纵向排列，骨折线常与胫骨纵轴平行Z-H骨折Z-H骨折分型隐形骨折X线不能检出，经过CT或MR检查确诊显性骨折后踝骨折移位较大，通过X线检查即能确诊的Z-H骨折即使普通X片未发现后踝骨折，但体格检查时如后踝存在压痛应加做CT或MR以除外隐形Z-H骨折，术中踝关节X片也非常必要Z-H骨折分度IV度：X线检出后踝损伤，后踝骨折块明显移位或分离＞2mmIII度：X线检出后踝损伤，X片上表现为无移位或移位≤2mmII度：X线未检出后踝损伤，CT和MR检出后踝损伤I度：X线和CT未检出后踝损伤，MR检出后踝损伤漏诊原因分析对1685例成人胫腓骨骨干骨折患者进行回顾性分析，发现胫骨下1/3螺旋形骨折合并后踝骨折28例，放射科漏诊率67.9%，临床骨科医师漏诊率53.6%多数骨科医师只注意到明显移位的胫腓骨螺旋形骨折,忽略胫骨远端的微小的显性后踝骨折对胫骨下1 /3 螺旋形骨折合并后踝骨折的认识不够,忽略了胫骨骨折有合并后踝骨折的可能性,尤其存在隐性后踝骨折漏诊原因一些医院X 线片的清晰程度影响了对骨折的诊断,甚至摄X 线片时只包括了膝关节而未包括踝关节胫骨后踝骨折X 线片正位很难看到骨折线,而侧位片由于有腓骨的重叠,尤其是合并腓骨远段骨折时,更加难以分辨According to our retrospective study, in the 1,685 fractures of the tibia, 288 cases showed spiral fractures of the tibia, whichwere combined with PMFs in 28 cases, the PMF incidencewas 9.7%. However, in our prospective study, 30 (88.2%) of34 fractures of the tibia were combined with the PMFs. Plain radiographs are often insuf?cient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures. Using a preoperative CT protocol for tibial shaft fractures can signi?cantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs. Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures.Concomitant ipsilateral ankle and distal one-third spiral tibial shaft fractures are more common thanpreviously reported. Utilizing a new imaging protocol, wefound that the incidence of this combined injury was 84 %.Recognition of the ankle fracture component in this tibialshaft cohort can be important as it may alter the surgicalplan and postoperative management分度与治疗方式的选择IV度