踝关节骨折的治疗现状及进展_West China Medical Journal

Authors：

 梁羽 ,  方跃 , 姚相雨 , 屠重棋 , 杨天府

四川大学华西医院创伤骨科（成都，610041）;

Corresponding author：

方跃, Email: fangyue1968@163.com

Keywords：

踝关节骨折; 治疗; 内固定; 并发症

DOI：

10.7507/1002-0179.20140052

Video：

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Abstract Full text Figures/Tables Video References Cited by

踝关节骨折的发生率正随着人口老龄化的增加而逐步增长，其中，跌倒伤是踝关节骨折的主要受伤机制。关于不稳定性踝关节骨折，目前的治疗金标准仍是切开复位内固定术。关于三踝骨折的处理，应先行内外踝解剖复位坚强内固定后再行后踝处理，而后踝骨折的固定与否，由后踝骨折块的大小或胫距关节的稳定性决定。若存在踝关节上方5 cm以外的腓骨骨折或踝关节上方3.0～4.5 cm以外的腓骨骨折合并不能修复的内踝损伤应行下胫腓联合螺钉固定。若踝关节骨折合并严重的软组织损伤且明确的固定方式未定之前，临时性跨踝外支架是一种明智的选择。踝关节术后因创伤性关节炎引起的持续疼痛，去神经支配可望成为未来一种尝试性的治疗方式。踝关节镜为新型微创手术的代表,简单骨折类型如Cedell骨折、撕脱性骨折、创伤后的异化骨，都能通过该方式治疗。关于小于关节面25%的后踝骨折块是否应该固定以及下胫腓联合螺钉使用的适应证的判断有待于未来进一步的生物力学及临床研究的探索。

Citation： 梁羽, 方跃, 姚相雨, 屠重棋, 杨天府. 踝关节骨折的治疗现状及进展. West China Medical Journal, 2014, 29(1): 172-178. doi: 10.7507/1002-0179.20140052 Copy

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3.	Honkanen R, Tuppurainen M, Kröger H, et al. Relationships between risk factors and fractures differ by type of fracture:a population-based study of 12,192 perimenopausal women[J]. Osteoporos Int, 1998, 8(1):25-31.
4.	Gunnes M, Mellström D, Johnell O. How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women[J]. Acta Orthop Scand, 1998, 69(5):508-512.
5.	Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly:what you get depends on where you live and who you see[J]. J Orthop Trauma, 2005, 19(9):635-639.
6.	Ali MS, Mclaren C, Rouholamin E, et al. Ankle fractures in the elderly:nonoperative or operative treatment[J]. J Orthop Trauma, 1987, 1(4):275-280.
7.	Fernandez GN. Internal fixation of the oblique, osteoporotic fracture of the lateral malleolus[J]. Injury, 1988, 19(4):257-258.
8.	Makwana NK, Bhowal B, Harper WM, et al. Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. A prospective, randomised study[J]. J Bone Joint Surg Br, 2001, 83(4):525-529.
9.	Srinivasan C, Moran CG. Internal fixation of ankle fractures in the very elderly[J]. Injury, 2001, 32(7):559-563.
10.	Beauchamp CG, Clay NR, Thexton PW. Displaced ankle fractures in patients over 50 years of age[J]. J Bone Joint Surg Br, 1983, 65(3):329-332.
11.	Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium -2007:Orthopaedic Trauma Association classification, database and outcomes committee[J]. J Orthop Trauma, 2007, 21(10 Suppl):S1-S133.
12.	Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system[J]. J Orthop Trauma, 2007, 21(5):307-315.
13.	Stricker PR, Spindler KP, Gautier KB. Prospective evaluation of history and physical examination:variables to determine radiography in acute ankle injuries[J]. Clin J Sport Med, 1998, 8(3):209-214.
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16.	Phillips WA, Schwartz HS, Keller CS, et al. A prospective, randomized study of the management of severe ankle fractures[J]. J Bone Joint Surg Am, 1985, 67(8):1303-1304.
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27.	Bevan WP, Barei DP, Nork SE. Operative fixation of osteoporotic ankle fractures[J]. Tech Foot Ankle Surg, 2006, 5(4):222-229.
28.	Ricci WM, Tornetta P, Borrelli J. Lag screw fixation of medial malleolar fractures:a biomechanical, radiographic, and clinical comparison of unicortical partially threaded lag screws and bicortical fully threaded lag screws[J]. J Orthop Trauma, 2012, 26(10):602-606.
29.	Harper MC, Hardin G. Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation[J]. J Bone Joint Surg Am, 1988, 70(9):1348-1356.
30.	Broos PL, Bisschop AP. Operative treatment of ankle fractures in adults:correlation between types of fracture and final results[J]. Injury, 1991, 22(5):403-406.
31.	Brown TD, Hurlbut PT, Hale JE, et al. Effects of imposed hindfoot constraint on ankle contact mechanics for displaced lateral malleolar fractures[J]. J Orthop Trauma, 1994, 8(6):511-519.
32.	Haut RC, Ide TM, De Camp CE. Mechanical responses of the rabbit patello-femoral joint to blunt impact[J]. J Biomech Eng, 1995, 117(4):402-408.
33.	Fitzpatrick DC, Otto JK, McKinley TO, et al. Kinematic and contact stress analysis of posterior malleolus fractures of the ankle[J]. J Orthop Trauma, 2004, 18(5):271-278.
34.	De Souza LJ, Gustilo RB, Meyer TJ. Results of operative treatment of displaced external rotation-abduction fractures of the ankle[J]. J Bone Joint Surg Am, 1986, 68(4):633-634.
35.	Langenhuijsen JF, Heetveld MJ, Ultee JM, et al. Results of ankle fractures with involvement of the posterior tibial margin[J]. J Trauma, 2002, 53(1):55-60.
36.	Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin:their role in the prognosis of malleolar fractures[J]. J Trauma, 1989, 29(11):1565-1570.
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38.	Streubel PN, Mccormick JJ, Gardner MJ. The posterior malleolus:should it be fixed and why?[J]. Curr Orthop Pract, 2011, 22(1):17-24.
39.	Gardner MJ, Demetrakopoulos D, Briggs SM, et al. Malreduction of the tibiofibular syndesmosis in ankle fractures[J]. Foot Ankle Int, 2006, 27(10):788-792.
40.	Scheidt KB, Stiehl JB, Skrade DA, et al. Posterior malleolar ankle fractures:an in vitro biomechanical analysis of stability in the loaded and unloaded states[J]. J Orthop Trauma, 1992, 6(1):96-101.
41.	Burns WC, Prakash K, Adelaar R, et al. Tibiotalar joint dynamics:indications for the syndesmotic screw--a cadaver study[J]. Foot Ankle Int, 1993, 14(3):153-158.
42.	Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures[J]. J Bone Joint Surg Am, 1984, 66(4):490-503.
43.	Boden SD, Labropoulos PA, McCowin P, et al. Mechanical considerations for the syndesmosis screw. A cadaver study[J]. J Bone Joint Surg Am, 1989, 71(10):1548-1555.
44.	Nielson JH, Sallis JG, Potter HG, et al. Correlation of interosseous membrane tears to the level of the fibular fracture[J]. J Orthop Trauma, 2004, 18(2):68-74.
45.	Sclafani SJ. Ligamentous injury of the lower tibiofibular syndesmosis:radiographic evidence[J]. Radiology, 1985, 156(1):21-27.
46.	Takao M, Ochi M, Oae K, et al. Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle[J]. J Bone Joint Surg Br, 2003, 85(3):324-329.
47.	Beumer A, van Hemert WL, Swierstra BA, et al. A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability[J]. Foot Ankle Int, 2003, 24(4):358-363.
48.	Mizel MS. A revised method of the Cotton test for intraoperative evaluation of the syndesmosis[J]. Foot Ankle Int, 2003, 24(1):86-87.
49.	Jenkinson RJ, Sanders DW, Macleod MD, et al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures[J]. J Orthop Trauma, 2005, 19(9):604-609.
50.	Chissell HR, Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures[J]. J Bone Joint Surg Br, 1995, 77(3):435-438.
51.	Yamaguchi K, Martin CH, Boden SD, et al. Operative treatment of syndesmotic disruptions without use of a syndesmotic screw:a prospective clinical study[J]. Foot Ankle Int, 1994, 15(8):407-414.
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1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem?[J]. Acta Orthop Scand, 1998, 69(1):43-47.
2. Jensen SL, Andresen BK, Mencke S, et al. Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg, Denmark[J]. Acta Orthop Scand, 1998, 69(1):48-50.
3. Honkanen R, Tuppurainen M, Kröger H, et al. Relationships between risk factors and fractures differ by type of fracture:a population-based study of 12,192 perimenopausal women[J]. Osteoporos Int, 1998, 8(1):25-31.
4. Gunnes M, Mellström D, Johnell O. How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women[J]. Acta Orthop Scand, 1998, 69(5):508-512.
5. Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly:what you get depends on where you live and who you see[J]. J Orthop Trauma, 2005, 19(9):635-639.
6. Ali MS, Mclaren C, Rouholamin E, et al. Ankle fractures in the elderly:nonoperative or operative treatment[J]. J Orthop Trauma, 1987, 1(4):275-280.
7. Fernandez GN. Internal fixation of the oblique, osteoporotic fracture of the lateral malleolus[J]. Injury, 1988, 19(4):257-258.
8. Makwana NK, Bhowal B, Harper WM, et al. Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. A prospective, randomised study[J]. J Bone Joint Surg Br, 2001, 83(4):525-529.
9. Srinivasan C, Moran CG. Internal fixation of ankle fractures in the very elderly[J]. Injury, 2001, 32(7):559-563.
10. Beauchamp CG, Clay NR, Thexton PW. Displaced ankle fractures in patients over 50 years of age[J]. J Bone Joint Surg Br, 1983, 65(3):329-332.
11. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium -2007:Orthopaedic Trauma Association classification, database and outcomes committee[J]. J Orthop Trauma, 2007, 21(10 Suppl):S1-S133.
12. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system[J]. J Orthop Trauma, 2007, 21(5):307-315.
13. Stricker PR, Spindler KP, Gautier KB. Prospective evaluation of history and physical examination:variables to determine radiography in acute ankle injuries[J]. Clin J Sport Med, 1998, 8(3):209-214.
14. Brage ME, Rockett M, Vraney R, et al. Ankle fracture classification:a comparison of reliability of three X-ray views versus two[J]. Foot Ankle Int, 1998, 19(8):555-562.
15. Anand N, Klenerman L. Ankle fractures in the elderly:MUA versus ORIF[J]. Injury, 1993, 24(2):116-120.
16. Phillips WA, Schwartz HS, Keller CS, et al. A prospective, randomized study of the management of severe ankle fractures[J]. J Bone Joint Surg Am, 1985, 67(8):1303-1304.
17. Nonnemann HC, Plösch J. Dislocation fractures of the upper ankle joint. Classification--treatment--results[J]. Aktuelle Traumatol, 1993, 23(4):183-186.
18. Toker S, Morgan S, Hak DJ. Fixing the almost healed ankle fracture.Are surgery, reduction, and complication rate different from acute open reduction and internal fixation?[J]. Curr Orthop Pract, 2012, 23(1):34-37.
19. Brodie IA, Denham RA. The treatment of unstable ankle fractures[J]. J Bone Joint Surg Br, 1974, 56(2):256-262.
20. Curtis MJ, Michelson JD, Urquhart MW, et al. Tibiotalar contact and fibular malunion in ankle fractures. A cadaver study[J]. Acta Orthop Scand, 1992, 63(3):326-329.
21. Schaffer JJ, Manoli A. The antiglide plate for distal fibular fixation. A biomechanical comparison with fixation with a lateral plate[J]. J Bone Joint Surg Am, 1987, 69(4):596-604.
22. Kim SK, Oh JK. One or two lag screws for fixation of Danis-Weber type B fractures of the ankle[J]. J Trauma, 1999, 46(6):1039-1044.
23. Panchbhavi VK. Technique of internal fixation in osteoporotic ankle fracture[J]. Tech Foot Ankle Surg, 2004, 3(4):231-234.
24. Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures[J]. J Orthop Trauma, 2001, 15(4):271-274.
25. Lee YS, Huang CC, Chen CN, et al. Operative treatment of displaced lateral malleolar fractures:the Knowles pin technique[J]. J Orthop Trauma, 2005, 19(3):192-197.
26. Appleton P, Mcqueen M. The fibula nail for treatment of ankle fractures in elderly and high risk patients[J]. Tech Foot Ankle Surg, 2006, 5(3):204-208.
27. Bevan WP, Barei DP, Nork SE. Operative fixation of osteoporotic ankle fractures[J]. Tech Foot Ankle Surg, 2006, 5(4):222-229.
28. Ricci WM, Tornetta P, Borrelli J. Lag screw fixation of medial malleolar fractures:a biomechanical, radiographic, and clinical comparison of unicortical partially threaded lag screws and bicortical fully threaded lag screws[J]. J Orthop Trauma, 2012, 26(10):602-606.
29. Harper MC, Hardin G. Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation[J]. J Bone Joint Surg Am, 1988, 70(9):1348-1356.
30. Broos PL, Bisschop AP. Operative treatment of ankle fractures in adults:correlation between types of fracture and final results[J]. Injury, 1991, 22(5):403-406.
31. Brown TD, Hurlbut PT, Hale JE, et al. Effects of imposed hindfoot constraint on ankle contact mechanics for displaced lateral malleolar fractures[J]. J Orthop Trauma, 1994, 8(6):511-519.
32. Haut RC, Ide TM, De Camp CE. Mechanical responses of the rabbit patello-femoral joint to blunt impact[J]. J Biomech Eng, 1995, 117(4):402-408.
33. Fitzpatrick DC, Otto JK, McKinley TO, et al. Kinematic and contact stress analysis of posterior malleolus fractures of the ankle[J]. J Orthop Trauma, 2004, 18(5):271-278.
34. De Souza LJ, Gustilo RB, Meyer TJ. Results of operative treatment of displaced external rotation-abduction fractures of the ankle[J]. J Bone Joint Surg Am, 1986, 68(4):633-634.
35. Langenhuijsen JF, Heetveld MJ, Ultee JM, et al. Results of ankle fractures with involvement of the posterior tibial margin[J]. J Trauma, 2002, 53(1):55-60.
36. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin:their role in the prognosis of malleolar fractures[J]. J Trauma, 1989, 29(11):1565-1570.
37. Heim UF. Trimalleolar fractures:late results after fixation of the posterior fragment[J]. Orthopedics, 1989, 12(8):1053-1059.
38. Streubel PN, Mccormick JJ, Gardner MJ. The posterior malleolus:should it be fixed and why?[J]. Curr Orthop Pract, 2011, 22(1):17-24.
39. Gardner MJ, Demetrakopoulos D, Briggs SM, et al. Malreduction of the tibiofibular syndesmosis in ankle fractures[J]. Foot Ankle Int, 2006, 27(10):788-792.
40. Scheidt KB, Stiehl JB, Skrade DA, et al. Posterior malleolar ankle fractures:an in vitro biomechanical analysis of stability in the loaded and unloaded states[J]. J Orthop Trauma, 1992, 6(1):96-101.
41. Burns WC, Prakash K, Adelaar R, et al. Tibiotalar joint dynamics:indications for the syndesmotic screw--a cadaver study[J]. Foot Ankle Int, 1993, 14(3):153-158.
42. Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures[J]. J Bone Joint Surg Am, 1984, 66(4):490-503.
43. Boden SD, Labropoulos PA, McCowin P, et al. Mechanical considerations for the syndesmosis screw. A cadaver study[J]. J Bone Joint Surg Am, 1989, 71(10):1548-1555.
44. Nielson JH, Sallis JG, Potter HG, et al. Correlation of interosseous membrane tears to the level of the fibular fracture[J]. J Orthop Trauma, 2004, 18(2):68-74.
45. Sclafani SJ. Ligamentous injury of the lower tibiofibular syndesmosis:radiographic evidence[J]. Radiology, 1985, 156(1):21-27.
46. Takao M, Ochi M, Oae K, et al. Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle[J]. J Bone Joint Surg Br, 2003, 85(3):324-329.
47. Beumer A, van Hemert WL, Swierstra BA, et al. A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability[J]. Foot Ankle Int, 2003, 24(4):358-363.
48. Mizel MS. A revised method of the Cotton test for intraoperative evaluation of the syndesmosis[J]. Foot Ankle Int, 2003, 24(1):86-87.
49. Jenkinson RJ, Sanders DW, Macleod MD, et al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures[J]. J Orthop Trauma, 2005, 19(9):604-609.
50. Chissell HR, Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures[J]. J Bone Joint Surg Br, 1995, 77(3):435-438.
51. Yamaguchi K, Martin CH, Boden SD, et al. Operative treatment of syndesmotic disruptions without use of a syndesmotic screw:a prospective clinical study[J]. Foot Ankle Int, 1994, 15(8):407-414.
52. Amendola A. Controversies in diagnosis and management of syndesmosis injuries of the ankle[J]. Foot Ankle Int, 1992, 13(1):44-50.
53. Harris J, Fallat L. Effects of isolated Weber B fibular fractures on the tibiotalar contact area[J]. J Foot Ankle Surg, 2004, 43(1):3-9.
54. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift[J]. J Bone Joint Surg Am, 1976, 58(3):356-357.
55. Burns WC, Prakash K, Adelaar R, et al. Tibiotalar joint dynamics:indications for the syndesmotic screw--a cadaver study[J]. Foot Ankle Int, 1993, 14(3):153-158.
56. Pereira DS, Koval KJ, Resnick RB, et al. Tibiotalar contact area and pressure distribution:the effect of mortise widening and syndesmosis fixation[J]. Foot Ankle Int, 1996, 17(5):269-274.
57. Riegels-Nielsen P, Christensen J, Greiff J. The stability of the tibio-fibular syndesmosis following rigid internal fixation for type C malleolar fractures:an experimental and clinical study[J]. Injury, 1983, 14(4):357-360.
58. Kennedy JG, Soffe KE, Dalla Vedova P, et al. Evaluation of the syndesmotic screw in low Weber C ankle fractures[J]. J Orthop Trauma, 2000, 14(5):359-366.
59. Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures[J]. J Orthop Trauma, 2005, 19(2):102-108.
60. Thompson MC, Gesink DS. Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws[J]. Foot Ankle Int, 2000, 21(9):736-741.
61. Buckley R. Tricortical screws were as effective as quadricortical screws in ankle fractures at 1 year[J]. J Bone Joint Surg Am, 2005, 87(2):465.
62. Høiness P, Strømsøe K. Tricortical versus quadricortical syndesmosis fixation in ankle fractures:a prospective, randomized study comparing two methods of syndesmosis fixation[J]. J Orthop Trauma, 2004, 18(6):331-337.
63. Olerud C. The effect of the syndesmotic screw on the extension capacity of the ankle joint[J]. Arch Orthop Trauma Surg, 1985, 104(5):299-302.
64. Tornetta P, Spoo JE, Reynolds FA, et al. Overtightening of the ankle syndesmosis:is it really possible?[J]. J Bone Joint Surg Am, 2001, 83-A(4):489-492.
65. McBryde A, Chiasson B, Wilhelm A, et al. Syndesmotic screw placement:a biomechanical analysis[J]. Foot Ankle Int, 1997, 18(5):262-266.
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