难复性胫骨干B型骨折的影像学特征及髓内钉应用的疗效评析  

Radiological characteristics of irreducible type B tibial shaft fractures and clinical effect of intramedullary nailing

作　　者：王海鹏 安明 董川 马保安 王育才 Wang Haipeng;An Ming;Dong Chuan;Ma Baoan;Wang Yucai(Department of Orthopedics,The Second Affiliated Hospital(Tangdu Hospital),Air Force Medical University,Xi’an 710038,China;Department of Orthopedics,The 96110 Hospital of PLA,Yinchuan 750021,China)

机构地区：[1]空军军医大学第二附属医院(唐都医院)骨科,西安710038 [2]中国人民解放军96110部队医院骨科,银川750021

出　　处：《创伤外科杂志》2023年第1期33-39,共7页Journal of Traumatic Surgery

基　　金：陕西省创新能力支撑计划资助项目(2021TD-45)。

摘　　要：目的分析难复性胫骨干B型骨折的影像学特征并探讨其在指导髓内钉应用中的疗效。方法系统回顾性研究空军军医大学唐都医院骨三科2018年4月—2021年6月采用髓内钉治疗的29例B型胫骨骨折患者资料,其中男性17例,女性12例;年龄17~66岁,平均38.4岁;左侧13例,右侧16例;道路交通伤9例,摔跌伤5例,高处坠落伤4例,军事训练伤2例,运动伤7例,重物砸伤2例。所有病例优先采用闭合复位胫骨髓内钉固定术,其中经尝试多次闭合复位困难的病例改为局部有限切开辅助复位完成髓内钉固定。收集所有患者的X线片及CT资料详细分析难复性胫骨干B型骨折的发生率及影像学特征,探讨该类型骨折复位困难的原因及解决策略。随访评价术后6个月时影像愈合RUST(radiographic union score for tibial fractures,RUST)评分,骨折愈合时间及末次随访时Johner-Wruhs评分。结果基于患者X线及CT影像资料研究发现难复性病例在骨折部位、形态学、移位程度上均有相应特征,包括骨折多发生在胫骨中远端,楔形骨块常于侧位X线片更为直观,呈“双峰征”阳性,并发生旋转、分离、垂直移位。楔形骨块近端可见粉碎小骨块,偶可见其落入髓腔,形成嵌压、绞索。CT平扫可发现“环蝶形”骨块等。29例胫骨干B型骨折患者中难复性11例,占病例总数的38%。难复性病例中10例给予切开复位,1例术中经反复调整最终行闭合复位髓内钉固定成功。患者术后均获得9~27个月随访,平均17.4个月。术后3例切口二期愈合、6例骨延迟愈合,1例发生骨不连,均给予对应处理且最终结果满意。术后6个月随访RUST评分:18~30分22例,11~17分6例,≤10分1例。末次随访时患者均获得骨性愈合,骨折愈合时间为5~26个月,平均10.3个月。末次随访时Johner-Wruhs评定标准评分结果:优20例,良7例,可2例,优良率93%。结论充分评估胫骨干B型骨折的影像学特征,鉴别髓内钉�Objective To evaluate the radiological characteristics of irreducible type B tibial shaft fractures and the curative effectiveness by intramedullary nailing.Methods A total of 29 cases of type B tibial shaft fractures treated with intramedullary nailing in the Third Department of Orthopaedics,Tangdu Hospital of Air Force Medical University from Apr.2018 to Jun.2021 were systematically analyzed.They were 17 males and 12 females aged 17-66 years,mean 38.4 years;13 on the left side and 16 on the right.There were 11 cases of road traffic injuries,5 falls,4 falls from height,2 military training related injuries,7 sports injuries and 2 crashes by blunt heavy objects.Closed reduction was the first choice for all the cases.For those failed to achieve decent reduction by all means of closed procedures,minimal invasive incision assisted reduction with intramedullary nailing was applied.All the X-ray and CT imaging data of the included cases were collected to evaluate and analyze the incidence of irreducible type B tibial shaft fractures and their radiological characteristics.The reasons why these(irreducible)fractures are hard to reduce and related solving strategies were further discussed.Radiographic union score for tibial fractures(RUST)was assessed at 6 months after operation.The fracture healing time was recorded and Johner-Wruhs score was calculated at the last follow-up.Results All the irreducible cases showed typical X-ray and CT characteristics regarding fracture site,morphology and dislocation,i.e.(1)the fracture site was mostly located at the middle and distal of the tibia;(2)the wedge-shaped fragment was more apparent in lateral view X-ray images,showing“Double peaks sign”,rotation,separation and vertical dislocation;(3)small fragments could be seen at the proximal end of the wedge-shaped fragment,occasionally inserted into the medullary cavity,causing a stuck;(4)“ring butterfly fragment”was often observed in CT scans,etc.All the 29 cases of type B tibial shaft fractures were followed up for 9-27 months

关 键 词：胫骨干骨折 影像学评估 微创治疗 内固定 并发症预防 

分 类 号：R683.42[医药卫生—骨科学]