胫骨近端骨折的髓内钉固定术后可能会遗留力线问题,例如下肢内外翻或前后凸。产生的原因是什么?如何预防?这篇论文进行了讲解。
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Table 1 summarizes the various nailing options for proximal tibial fractures. It outlines different patient positioning and surgical approaches like nailing in flexion (patellar tendon-splitting or medial parapatellar tendon approach) versus extended/semi-extended nailing (medial parapatellar, suprapatellar/retropatellar, or extra-articular approach). It also lists the different reduction tools that can be used such as reduction clamps, Schanz screws, external fixators, large femoral distractors. The use of Poller screws, either temporary or permanent, is highlighted. Additionally, the option of using a supplemental plate, either temporary or permanent, is mentioned.
表1总结了胫骨近端骨折的各种髓内钉选择。它概述了不同的患者手术体位和手术入路,如屈曲位髓内钉(髌腱劈裂或髌腱旁入路)与伸直/半伸直髓内钉(内侧髌旁、髌上/髌后或关节外入路)。它还列出了可以使用的不同复位工具,如复位夹、Schanz螺钉、外固定器、大型股骨牵引器。阻挡钉的使用,无论是临时的还是永久的,都很重要。此外,还提到了使用临时或永久性补充接骨板的选项。
Table 2 outlines the various risk factors that can contribute to deformity when nailing proximal tibial fractures. It categorizes them into anatomy-related factors like bone shape, fracture plane orientation, and muscle force distribution. It also covers surgical factors like level of skin incision, nail starting point, nail insertion vector and depth, and lack of deformity neutralization techniques. Finally, it mentions patient comorbidities like poor bone stock from osteoporosis as an additional risk factor for deformity. Breaking down the risk factors into these categories provides a comprehensive framework to understand and mitigate the risks.、表2列出了胫骨近端骨折髓内钉固定时可能导致畸形的各种风险因素。它将它们分类为与解剖学相关的因素,如骨折形态,骨折平面方向和肌肉力量分布。它还涵盖了手术因素,如皮肤切口水平、髓内钉起点、髓内钉插入方向和深度,以及缺乏畸形中和技术。最后,它提到患者的合并症,如骨质疏松症导致的骨量不足,是畸形的额外风险因素。将风险因素分为这些类别提供了一个全面的框架来理解和减轻风险。
以上两幅图,展示了胫骨近端骨折的髓内钉的开口位置应根据骨折形态不同而不同。同时也涉及了阻挡钉的位置(符合锐角原则)。
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论文要点
英文为准,中文仅供参考
Introduction 介绍
Nailing of proximal tibial fractures is challenging due to high risk of malalignment
胫骨近端骨折的髓内钉固定具有挑战性,因为对线不良的风险很高
Common deformities: valgus, apex anterior procurvatum
常见畸形:外翻、前凸
Understanding risk factors and techniques can help avoid deformity
了解风险因素和技术可以帮助避免畸形
Risk Factors for Deformity
畸形的风险因素
Distal skin incision 皮肤切口偏远
Incorrect nail starting point
髓内钉起点不正确
Insufficient nail insertion angle
髓内钉插入角度不足
Insufficient deformity neutralization
畸形纠正不足
Extensor mechanism causes procurvatum
伸肌机制导致前屈
Lateral muscle attachments cause valgus
外侧肌肉附着导致外翻
Oblique fractures increase instability/deformity risk
斜向骨折会增加不稳定/畸形风险
'Deformity rule' - fracture deforms to open/blunt angle side
“畸形规则”-骨折向张开侧/钝角侧变形
Large medullary cavity diameter vs nail diameter
髓腔直径比髓内钉直径过大
Asymmetry/eccentricity of medullary cavity
髓腔不对称/偏心
Triangular cross-section of metaphysis
干骺端三角形断面
Anatomy 解剖
Fracture Plane 断裂面
Muscle Forces 肌肉力
Surgical Factors 手术因素
Avoiding Deformity 避免畸形
Block incorrect nail path based on deformity rule
根据畸形规则阻塞不正确的髓内钉路径
Fracture table, external fixator, distractor, reduction clamps
骨折台、外固定器、牵引器、复位钳
Extended/semi-extended position
伸展/半伸展位置
Patellar tendon splitting
髌腱断裂
Medial parapatellar 内侧髌旁
Patient Positioning/Approach
患者定位/入路
Reduction Tools 预防工具
Plate-Assisted Nailing 接骨板辅助髓内钉
Poller Screws Poller螺丝
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关键问题问答
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Questions 问题 | Answers 答案 |
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What is the most common deformity after nailing proximal tibial fractures? 胫骨近端骨折髓内钉固定后最常见的畸形是什么? | Valgus and apex anterior procurvatum 外翻和前凸 |
What anatomic factor increases deformity risk? 什么解剖因素增加畸形风险? | Large discrepancy between medullary cavity diameter and nail diameter 髓腔直径与髓内钉直径之间存在较大差异 |
What does the 'deformity rule' describe? “畸形规则”描述了什么? | Fractures tend to deform towards the open/blunt fracture angle side 骨折倾向于朝向开口/钝性骨折角度侧变形 |
What muscle forces contribute to procurvatum deformity? 什么样的肌肉力量会导致前屈肌畸形? | Pull of the extensor mechanism (patellar tendon) 伸肌拉伸机制(髌腱) |
What surgical factor increases valgus risk? 什么手术因素增加外翻风险? | A medial nail starting point 髓内钉起点偏内 |
What technique can help neutralize deformity? 什么技术可以帮助消除畸形? | Poller screws to block incorrect nail path 阻挡钉阻塞了不正确的髓内钉路径 |
What approach avoids the fracture table? 有什么办法避免专用骨折手术牵引床? | Patellar tendon splitting approach 髌腱劈开入路 |
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