【摘要】：目的:脛骨平臺(tái)骨折是一種常見(jiàn)但復(fù)雜的損傷,包括各種各樣的骨折類(lèi)型,也常常與重要軟組織損傷有關(guān)聯(lián)。偶爾,相關(guān)的關(guān)節(jié)內(nèi)損傷也需要解決。他們可以發(fā)生在任何年齡,但呈現(xiàn)雙峰分布,高能量損傷通常發(fā)生在年輕的具有良好骨質(zhì)量的成年人而低能量骨折通常發(fā)生在骨質(zhì)量差的老年患者。這主要與軸向、彎曲和旋轉(zhuǎn)力或這些力相結(jié)合有關(guān)。手術(shù)治療有位移及不穩(wěn)定的骨折是越來(lái)越常見(jiàn)。這些骨折常用Schatzker和AO/OTA分類(lèi)系統(tǒng)來(lái)描述。對(duì)于手術(shù)治療時(shí)機(jī)的選擇,了解膝關(guān)節(jié)周?chē)浗M織的損傷程度是至關(guān)重要的,除非利用一個(gè)純粹的經(jīng)皮方法。雖然手術(shù)執(zhí)行越早技術(shù)上來(lái)說(shuō)復(fù)位也越簡(jiǎn)單,但手術(shù)延遲對(duì)降低傷口并發(fā)癥的風(fēng)險(xiǎn)有意義。理想的手術(shù)入路不僅僅是顯露骨折部位,足以促使骨折復(fù)位和固定植入物的應(yīng)用,也能使傷口感染、骨折不愈合等并發(fā)癥的風(fēng)險(xiǎn)降到最低。精細(xì)的解剖和防止損傷軟組織的操作是必要的,以避免神經(jīng)與血管的損傷或?qū)浗M織的醫(yī)源性損傷。因此,外科醫(yī)生準(zhǔn)備操作這些骨折必須從各種手術(shù)入路中選擇最恰當(dāng)?shù)摹Ｈ肼返倪x擇主要取決于骨折類(lèi)型,同時(shí)考慮軟組織的情況、患者自身因素和其他損傷(如需要血管修復(fù)或筋膜切開(kāi)術(shù)),偶爾需要改變手術(shù)方案。計(jì)算機(jī)斷層掃描(CT)的使用大大提高了我們對(duì)損傷類(lèi)型的理解能力。矢狀面和冠狀CT掃描可以獲得所有脛骨近端骨折的重建。如果根據(jù)受傷情況外固定是必要的,CT掃描可以推遲到外固定后,閉合復(fù)位之前進(jìn)行。骨折類(lèi)型的詳細(xì)分析,特別是骨折斷面,關(guān)節(jié)表面的位移、粉碎,對(duì)骨折復(fù)位和固定植入物的應(yīng)用是必要的,因此決定手術(shù)入路是至關(guān)重要的。脛骨近端骨折的早期治療技術(shù)依賴(lài)直接的前正中線(xiàn)方法,需要?jiǎng)冸x大量軟組織皮瓣來(lái)顯露相應(yīng)的骨折。為了處理相關(guān)的側(cè)韌帶和半月板損傷,改良使用一個(gè)倒“L”型切口在標(biāo)記的關(guān)節(jié)線(xiàn)以上。隨著時(shí)間的推移,軟組織管理的重要性和解剖復(fù)位導(dǎo)致的相關(guān)結(jié)果引導(dǎo)了骨折的具體治療方法。自從Tscherne和Lobenhoffer 20年前發(fā)表了他們的觀點(diǎn)后,髕周切口在減少使用,后內(nèi)側(cè)的和后外側(cè)入路的說(shuō)明及常用的雙入路技術(shù)在逐步演進(jìn)。由于膝關(guān)節(jié)和脛骨上端皮下部分中間沒(méi)有太多的軟組織,這些損傷可造成明顯的軟組織損傷。對(duì)于高能量膝關(guān)節(jié)損傷或脛骨平臺(tái)骨折來(lái)說(shuō),周?chē)浗M織通過(guò)成功的處理恢復(fù)滿(mǎn)意,是至關(guān)重要的好結(jié)果。對(duì)大多數(shù)患者來(lái)說(shuō),膝關(guān)節(jié)缺少軟組織保護(hù),尤其是由于創(chuàng)傷或內(nèi)部原因(骨折碎片的的移位)引起的脛骨近端軟組織挫傷,會(huì)增加患者的易感性。這就增加了高能量損傷所致脛骨近端骨折的治療中產(chǎn)生并發(fā)癥的風(fēng)險(xiǎn)。脛骨平臺(tái)骨折的治療是具有挑戰(zhàn)性的,病人要面對(duì)包括感染、畸形愈合、骨不連和僵硬等不良預(yù)后的風(fēng)險(xiǎn)。準(zhǔn)確的診斷和早期治療可以減輕這些并發(fā)癥的影響。我們將脛骨平臺(tái)骨折分為單髁與雙髁兩類(lèi)來(lái)總結(jié)該類(lèi)損傷的術(shù)后風(fēng)險(xiǎn)和并發(fā)癥處理策略。與單髁脛骨平臺(tái)骨折相比,雙髁損傷通過(guò)相應(yīng)手術(shù)治療后出現(xiàn)的并發(fā)癥明顯高。它們通常由高能量創(chuàng)傷引起,例如嚴(yán)重的粉碎性骨折、開(kāi)放性骨折、血管損傷,以及骨筋膜室綜合征的風(fēng)險(xiǎn)。此外,雙髁骨折可能需要更廣泛的手術(shù)分離及術(shù)中對(duì)軟組織的操作,這對(duì)已經(jīng)脆弱的軟組織造成了額外傷害。因此,脛骨平臺(tái)骨折,特別是雙髁骨折,現(xiàn)在需要一套獨(dú)特的要求。良好的結(jié)果需要仔細(xì)的術(shù)前規(guī)劃,復(fù)位,和盡全力保護(hù)軟組織,并早期識(shí)別和治療術(shù)后急性并發(fā)癥。方法:通過(guò)查找大量相關(guān)外文文獻(xiàn),本文歸納總結(jié)了脛骨平臺(tái)骨折各種常用手術(shù)入路、相關(guān)軟組織損傷和術(shù)后并發(fā)癥的治療方案,為此類(lèi)骨折的臨床治療提供幫助。
[Abstract]:OBJECTIVE: Tibial plateau fractures are common but complex injuries, including a variety of fracture types, and are often associated with important soft tissue injuries. Occasionally, the associated intra-articular injuries need to be addressed. They can occur at any age, but are bimodal in distribution. High-energy injuries usually occur in young adults with good bone quality. In adults, low-energy fractures usually occur in elderly patients with poor bone mass. This is mainly related to axial, bending and rotating forces or the combination of these forces. Surgical treatment of displaced and unstable fractures is becoming increasingly common. These fractures are often described by Schatzker and AO/OTA classification systems. For timing of surgical treatment, understand The degree of soft tissue damage around the knee joint is crucial unless a pure transdermal approach is used. Although the earlier the operation is performed, the simpler the reduction is technically, the later the operation is performed is meaningful in reducing the risk of wound complications. The use of implants can also minimize the risk of complications such as wound infection, nonunion, etc. Fine anatomy and procedures to prevent injuries to soft tissues are necessary to avoid nerve and vascular injuries or iatrogenic injuries to soft tissues. The choice of approach depends primarily on the type of fracture, taking into account the condition of soft tissue, patient's own factors and other injuries (such as revascularization or fasciotomy), and occasional changes in surgical procedures. The use of computed tomography (CT) greatly improves our understanding of the type of injury. Sagittal and coronal CT All proximal tibial fractures can be reconstructed by scanning. If external fixation is necessary according to the condition of injury, CT scan can be postponed until after external fixation and before closed reduction. Detailed analysis of fracture types, especially fracture section, displacement of joint surface, comminution, is necessary for fracture reduction and the application of fixed implants. Early treatment of proximal tibial fractures relies on a direct anterior median approach, requiring the removal of a large number of soft tissue flaps to expose the corresponding fracture. To deal with related lateral ligament and meniscus injuries, an inverted "L" incision was modified above the marked articular line. Since Tscherne and Lobenhoffer published their views 20 years ago, peripatellar incisions have been reduced in use, posteromedial and posterolateral approaches have been described and commonly used dual approaches have evolved. There is not much soft tissue between the upper tibia and the subcutaneous portion of the upper tibia. These injuries can cause significant soft tissue damage. Successful treatment of the surrounding soft tissue for high-energy knee injuries or tibial plateau fractures is a crucial good outcome. For most patients, the knee joint lacks soft tissue protection, especially This increases the risk of complications in the treatment of proximal tibial fractures due to high-energy injuries. The treatment of tibial plateau fractures is challenging and involves infection and deformities. Accurate diagnosis and early treatment can alleviate the impact of these complications. We classify tibial plateau fractures into unicondylar and bicondylar fractures to summarize the risk and complication management strategies for such injuries. Bicondylar injuries are treated by surgery as compared with unicondylar tibial plateau fractures. Complications are significantly higher after treatment. They are usually caused by high-energy trauma, such as severe comminuted fractures, open fractures, vascular injuries, and the risk of osteofascial compartment syndrome. Injury. Therefore, tibial plateau fractures, especially bicondylar fractures, now require a unique set of requirements. Good results require careful preoperative planning, reduction, and full protection of soft tissue, and early identification and treatment of postoperative acute complications. Common surgical approaches, related soft tissue injuries and postoperative complications of the treatment of such fractures to provide help for clinical treatment.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R687.3

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