骨科踝关节手术课件.ppt

ANKLE FRACTURES,Netbasert undervisning april 05,01,Illustrations redrawn from Malleolar Fractures and Soft Tissue Injuries of the ankle:Carr JBAnkle fractures:Marsch JL,Salzman CL,Composition:Bengt stman overlege Presentation:Simen Sellevold,assistentlege Ingo Spauke,assistentlege,Epidemiology,02,Incidence:80130 per 100 000 persons highest in elderly women67%isolated malleolar fractures25%bimalleolar 8%trimalleolar,ANKLE FRACTURES,National Hospital Discharge Register of Finland 1994Court-BrownCM,McBirnie J,Wilson G.Adult ankle fractures:an increasing problem?Acta Orthop Scand 1998;69:43-47,03,Incidence:Ringerike Hospital 1/8 2003 31/7 2004:184 per 70 000-100 000 persons 128/184(69%)isolated malleolar fractures 27/184(15%)bimalleolar 29/184(16%)trimalleolar,ANKLE FRACTURES,Epidemiology,04,ANKLE FRACTURES,Classification-Why?,Why do we require fracture classifications?for clinical research to understand the literature as an aid to fracture description as an aid to fracture treatment,05,AO(Danis/Weber)Type A below the syndesmosisType B at the level of the syndesmosisType C above the syndesmosisDanis R.Les fractures malleolaires.In:Danis R,ed.Thorie et practique de losteosynthse.1949:133-165.Weber BG.Die Verletzungen des oberen Sprunggelenkes,Berne:Hans Huber,1966.(2nd ed.1972),Classification AO(Danis/Weber),ANKLE FRACTURES,06,AO AO/OTA(Weber)3 types(A,B,C)9 groups(A1,A2,A3,B1,B2,B3,C1,C2,C3)27 subgroupsMller ME,Allgwer M,Schneider R,et al.Manual of internal fixation,2nd ed.Heidelberg:Springer-Verlag,1979:282-299.(3rd ed.1991).Orthopaedic Trauma Assocoation.Fracture and dislocation compendium.J Orthop Trauma 1996;10:1-55.,Classification AO/OTA,ANKLE FRACTURES,07,AO AO/OTALauge-HansenLauge-Hansen N.Fractures of the ankle:combined experimental-surgical and experimental roentgenologic investigations.Arch Surg 1950;60:957-985,Classification Lauge-Hansen,ANKLE FRACTURES,08,AO AO/OTA Lauge-Hansen Supination-External rotation(I,II,III,IV)Supination-Adduction(I,II)Pronation-External rotation(I,II,III,IV)Pronation-Abduction(I,II,III),position deforming force,Classification Lauge-Hansen,ANKLE FRACTURES,09,AO AO/OTA Lauge-Hansen Supination-External rotation(I,II,III,IV)Supination-Adduction(I,II)Pronation-External rotation(I,II,III,IV)Pronation-Abduction(I,II,III),position deforming force stable”stable”unstable,Classification Lauge-Hansen,ANKLE FRACTURES,10,AO AO/OTA Lauge-HansenStable versus Unstable(Tile)Tile M.Fractures of the ankle.In:Joseph Schatzker MT,ed.The rationale of operative fracture care.Berlin:Springer-Verlag,1987:371-404.,The presence or absence of a medial injury is the key to stability of the lateral malleolar fracture.The medial injury determines stability,Classification Stable/Unstable,ANKLE FRACTURES,11,Weber A,SA I-II,Weber B,SE I-IV,PA I-III,Weber C,PE I-IV,Danis Weber vsLauge Hansen,ANKLE FRACTURES,Lauge-Hansen Classification(Supination-Adduction,SA I II),II,I,I Transverse fibula fracture or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fracture,ANKLE FRACTURES,12,Lauge-Hansen Classification(Supination-Adduction,SA I II,ANKLE FRACTURES,13,II,I,I Transverse fibula fracture or rupture of talofibular ligamentsII Vertical medial malleolus fracture with a transverse distal fibula fracture and possible medial plafond fracture,Radiographic view:Supination-Adduction type II fracture with medial impaction,14,ANKLE FRACTURES,Radiographic view:Supination-Adduction type II fracture with medial impaction,15,ANKLE FRACTURES,Corrections Impression of medial plafondReposition of medial malleolusPlating and bone grafting of medial metaphysis,Lauge-Hansen Classification(Supination-External rotation,SE I IV),II,I,III,IV,I Anterior tibial-fibular sprainII Stable short oblique fracture of the distal fibulaIII Rupture of posterior tibial-fibular ligament or fracture of the posterior marginIV Unstable short oblique fracture of the distal fibula with a medial malleolus fracture or a deltoid ligament disruption,ANKLE FRACTURES,16,Lauge-Hansen Classification(Supination-External rotation,SE I IV),II,I,III,IV,I Anterior tibial-fibular sprainII Stable short oblique fracture of the distal fibulaIII Rupture of posterior tibial-fibular ligament or fracture of the posterior marginIV Unstable short oblique fracture of the distal fibula with a medial malleolus fracture or a deltoid ligament disruption,ANKLE FRACTURES,17,Illustration:Supination-External rotation type II,III and IV,18,Fixation of an oblique fracture of the distal fibula,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV,(1 a),19,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV,(1 b),20,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV,(1 c),21,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV,(1 d),22,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV(2 a),23,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV(2 b),24,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV(3 a),25,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV(3 b),26,ANKLE FRACTURES,III,IV,Typical fracture line pattern for a SE type fracture,II,Rupture of the posterior tibio-fibular ligament,Rupture of the deltoid ligament,II,Oblique fracture of the distal fibula,I,Anterior tibio-fibular sprain,Radiographic view:Supination-External rotation type IV(3 c),27,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV(3 d),28,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV(3 e),29,ANKLE FRACTURES,Radiographic view:Supination-External rotation type IV(3 f),30,ANKLE FRACTURES,Male 64 years of age,was proposed a re-operation but chosed to accept the present situation after proper information,Lauge-Hansen Classification(Pronation-Abduction,PA I III),II,I,III,I Isolated medial malleolus or deltoid ligament ruptureII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Bending fracture of the lateral malleolus with a transverse and often comminuted pattern with possible lateral tibial impaction,ANKLE FRACTURES,31,Lauge-Hansen Classification(Pronation-Abduction,PA I III),II,I,III,I Isolated medial malleolus or deltoid ligament ruptureII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Bending fracture of the lateral malleolus with a transverse and often comminuted pattern with possible lateral tibial impaction,ANKLE FRACTURES,32,Illustration:Pronation-Abduction type III,33,Fixation of a comminuted fibula fracture,ANKLE FRACTURES,Radiographic view:Pronation-Abduction type III,lateral plafond impaction(1 a),34,Limbird and Aaron JBJS Am 69:881,1987,ANKLE FRACTURES,Radiographic view:Pronation-Abduction type III,lateral plafond impaction(1 b),35,Limbird and Aaron JBJS Am 69:881,1987,ANKLE FRACTURES,III,II,I,Lateral impaction,Medial malleolus fracture,Comminuted lateral malleolus fracture,No spiral fracturepattern in the fibula,Avulsion ofChaputs tubercle,Radiographic view:Pronation-Abduction type III,lateral plafond impaction(1 c),36,ANKLE FRACTURES,Limbird and Aaron JBJS Am 69:881,1987,Radiographic view:Pronation-Abduction type III,lateral plafond impaction(1 d),Corrections(mortise view)lenght of the fibulalateral plafond impactionfracture of the medial malleolusposterior malleolar fracture,37,ANKLE FRACTURES,Limbird and Aaron JBJS Am 69:881,1987,Radiographic view:Pronation-Abduction type III,lateral plafond impaction(1 e),38,Corrections(lateral view)lenght of the fibulalateral plafond impactionfracture of the medial malleolusposterior malleolar fracture,ANKLE FRACTURES,Limbird and Aaron JBJS Am 69:881,1987,Lauge-Hansen Classification(Pronation-External rotation,PE I IV),I Isolated medial malleolus or deltoid ligament disruptionII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Short spiral fracture above the syndesmosisIV Disruption of the inferior tibiofibular ligament or a posterior malleolar fracture,I,IV,III,II,ANKLE FRACTURES,39,Lauge-Hansen Classification(Pronation-External rotation,PE I IV),I,IV,III,II,To be noticed!The typical direction of the fracture line in the fibula(lateral view)is different in a Pronation-External rotation type of fracture compared with a Supination-External rotation type of fracture,SE II-IV,PE III-IV,ANKLE FRACTURES,40,Lauge-Hansen Classification(Pronation-External rotation,PE I IV),I Isolated medial malleolus or deltoid ligament disruptionII Avulsion of Chaputs tubercle or disruption of the anterior tibiofibular ligamentIII Short spiral fracture above the syndesmosisIV Disruption of the inferior tibiofibular ligament or a posterior malleolar fracture,I,IV,III,II,ANKLE FRACTURES,41,Illustration:Pronation External rotation type IV,42,ANKLE FRACTURES,Radiographic view:Pronation-External rotation type I?II?III?IV?(1 a),43,ANKLE FRACTURES,Radiographic view:Pronation-External rotation type I?II?III?IV?(1 b),44,ANKLE FRACTURES,Radiographic view:Pronation-External rotation type III or IV(1 c),45,ANKLE FRACTURES,Radiographic view:Pronation-External rotation type I?II?III?or IV?(2 a),46,ANKLE FRACTURES,Radiographic view:Pronation-External rotation type I?II?III?or IV?(2 b),47,ANKLE FRACTURES,IV,Avulsion of Chaputs tubercle,II,I,Avulsion type fracture of the medial malleolus,Posterior malleolus fracture,II,Avulsion of Chaputs tubercle?,III,?,Radiographic view:Pronation-External rotation type I?II?III?or IV?(2 c),48,ANKLE FRACTURES,III,!,Radiographic view:Pronation-External rotation type I?II?III?or IV?(2 d),49,ANKLE FRACTURES,II,Avulsion of Chaputs tubercle?,IV,Posterior malleolus fracture,I,Medial malleolus fracture,Illustration:SE type III and IV-PE type(II),III and IV PA type II and III,50,Fixation of a total rupture of the syndesmosis,ANKLE FRACTURES,Illustration:SE type IV-SA type II PE type I-IV PA type I-III,51,Fixation of the medial malleolus,ANKLE FRACTURES,Classification of distal tibia fractures(Rdi and Allgwer 79),52,ANKLE FRACTURES axial loading injuries(Pilon or Plafond fractures),I,II,III,Classification of distal tibia fractures(Mller,Allgwer,and Schneider et al.91),53,ANKLE FRACTURES axial loading injuries(Pilon or Plafond fractures),A1,A2,A3,B1,B2,B3,C1,C2,C3,Illustration:axial loading injuries,54,ANKLE FRACTURES axial loading injuries(Pilon or Plafond fractures),Plafond fracture due to axial force,-46,Male,55,ANKLE FRACTURES,Plafond fracture due to axial force,-46,Male,56,ANKLE FRACTURES,Combination of Axial loading force and Supination-external rotation(1 a),57,ANKLE FRACTURES,Combination of Axial loading force and Supination-external rotation(1 b),58,ANKLE FRACTURES,Combination of Axial loading force and Supination-external rotation(1 c),59,ANKLE FRACTURES,Combination of Axial loading force and Supination-external rotation(1 d),60,ANKLE FRACTURES,Axial loading force(2 a),61,ANKLE FRACTURES,Axial loading force(2 b),62,ANKLE FRACTURES,Axial loading force(2 c),63,ANKLE FRACTURES,II,Avulsion of Chaputs tubercle?,Large posterior malleolus fracture,IV,Several articular fragments,Axial loading force(2 d)Peroperative photo,64,ANKLE FRACTURES,Axial loading force(2 d)Peroperative photo,65,ANKLE FRACTURES,Axial loading force(2 e),66,ANKLE FRACTURES,Remember to focus on the whole patient,not only the fracture lines,67,ANKLE FRACTURES,and you will be rewarded Thank you for your attention,68,ANKLE FRACTURES,