跟骨骨折的流行病学调查及损伤影像特征分析

发布时间：2018-05-28 18:20

本文选题：跟骨骨折 + 流行病学调查　；参考：《河北医科大学》2015年博士论文

【摘要】：跟骨是人体最大的跗骨,周围有重要软组织结构包裹,能提供独特的承重功能。跟骨骨折在跗骨骨折中最常见,占全身骨折的1%~2%,且其中75%涉及跟距关节面。早在1843年,Malgaigne等第一次报道了骨折线累及关节面的跟骨骨折。跟骨关节内骨折是非常复杂的损伤,如果诊治不当,常造成不良预后,甚至灾难性的后果。我国幅员辽阔,各地区自然条件、经济和社会发展各异,跟骨骨折致伤原因不同。随着我国建筑、交通、加工、机械制造等行业的迅猛发展,高处坠落伤、挤压伤以及交通伤等高能量暴力导致的跟骨骨折也日益增多,致伤原因的改变会导致跟骨骨折损伤类型及各类型构成比改变。为了更好地了解我国跟骨骨折损伤特征,明确跟骨骨折各类型构成比,有必要进行全国范围内跟骨骨折流行病学调查。高能量暴力导致的跟骨关节内骨折,尤其是严重粉碎的跟骨骨折,发生率逐渐增高,这类损伤诊断和治疗十分棘手。跟骨关节内骨折如不能准确评估、有效治疗,其预后欠佳,影响患者伤后生活和工作,对社会经济的发展也将有一定影响。诊断跟骨骨折最常用的影像检查手段是X线摄像,跟骨骨折AO分型既是据此进行评估、分型。除通过判断跟骨骨折损伤类型评估其损伤严重程度外,还可以在跟骨X线片上测量B?hler’s角、Gissan’s角、跟骨宽度和长度等指标来辅助评估损伤严重程度。但是,关于B?hler’s角评价跟骨关节内骨折损伤严重程度的作用、预测跟骨切开复位内固定治疗后患足功能恢复情况中所起的作用,以及B?hler’s角在跟骨手术中的指导作用则长期存在着很多争论。大量研究表明B?hler’s角和跟骨关节内移位骨折的功能恢复具有关联性,但是二者的关联性尚未明确。合并有有移位的跟骨关节内骨折的损伤类型,其严重程度多与患者术前B?hler’s角的角度存在密切的相关。我们发现关节面尤其是后距下关节面的解剖复位,恢复跟骨高度,长度,和宽度在跟骨骨折中显得尤为重要,因此B?hler’s角可以作为一个高度灵敏的术中和术后评估预测指标,但相应的恢复角度仍有待研究。因此本研究集中于解答下面的几个相关问题:1、B?hler’s角与较严重的有移位的跟骨关节内骨折之间是否存在相互关系;2、B?hler’s角的手术复位与术后功能预后情况是否存在关联性;3、如果存在关联性,为获得满意的预后结果,B?hler’s角应该手术恢复到什么程度。B?hler’s角的度数(手术后的测量值)对判断患足的功能预后结果是否具有重要的参考价值。跟骨骨折行CT扫描可以更准确地评估损伤严重程度。Sanders分型是临床广泛应用的跟骨骨折CT分型,其根据冠状面CT扫描图像上骨折线的位置划分骨折类型。在冠状面图像上选择跟骨后距下关节面最宽处,从外向内标记A、B、C三条骨折线,可将骨折块分为三部分关节面骨折块和二部分载距突骨折块。Sanders分型I型是指所有无移位骨折;Sanders分型Ⅱ型根据骨折线位置分为Ⅱa、Ⅱb、Ⅱc骨折;Sanders分型Ⅲ型是三部分骨折,根据骨折位置又为Ⅲab、Ⅲbc、Ⅲac骨折,其典型骨折有一中央压缩骨块;Ⅳ型包含3-4原发骨折线,超过2mm的关节面内移位,并且严重粉碎性骨折。Sanders等许多学者认为,即使对具有丰富经验的外科医生来说,治疗跟骨关节内移位骨折也是一个严峻的挑战。距下关节复位不良是影响跟骨关节内移位骨折预后的主要因素之一。然而,在临床上由于跟骨关节内移位骨折损伤严重、跟骨特殊的解剖结构以及医生手术经验和使用复位工具及固定物的限制,部分跟骨关节内移位骨折不能完全解剖复位关节面并有效固定。有学者报道跟骨骨折患者术后距下关节移位超过1mm即可能导致创伤性关节炎,影响患者患足功能,部分症状严重的患者需行距下关节融合等手术治疗。根据本课题组前期研究,术后早期活动患足、早期负重锻炼的患者功能恢复更好,在随访时行患侧跟骨CT检查,可以观察到术后残留的移位有减小趋势。术后早期功能锻炼、磨造距下关节是否对跟骨骨折内固定术后残留移位具有二次复位作用,是否有助于改善患者预后,尚缺乏定量研究。针对上述问题,我们开展了全国跟骨骨折流行病学调查和骨折类型分析,回顾性分析了大样本跟骨骨折患者术前、术后B?hler’s角、骨折类型及功能恢复(AOFAS评分)之间的相关关系,探讨了早期锻炼对内固定术后跟骨关节内移位骨折残留移位二次复位的作用。现报道如下:第一部分跟骨骨折的流行病学调查目的:跟骨骨折是一种常见骨折,这种骨折常常会遗留长期严重的残疾,因此给社会和患者家庭带来极大的经济负担。本文旨在回顾性研究跟骨骨折的流行病学特征及其在中国中东西部的地域特征。方法:我们从课题组建立的一个数据库中抽取资料,此数据库回顾性分析了2010年1月至2011年12月间我国83所医院的431822例骨折资料。分析在此期间纳入本研究的多个创伤中心的跟骨骨折患者,将这些患者的人口统计学详细资料及X线片均行回顾性评价。所有患者(含门诊患者)的跟骨骨折的影像学资料都依据AO分型进行分型,进而进行数据分析。跟骨骨折包含在本次研究中,除此之外,这些骨折按医院所在地分为中部地区、西部地区、东部地区三个类型。通过这三组的对比,分析这三组之间患者的年龄、性别及骨折类型的地域差异。结果:本次研究期间,共计11530名(12242例)跟骨骨折患者在我国的83所医院中进行治疗。本次研究中患者的平均年龄为38.95岁(区间为1-93岁);收治儿童跟骨骨折522例(占全部总数的4.26%),成人跟骨骨折11720例(占全部总数的95.74%);男女比为5.13:1。男患者高发的年龄组为36~40岁,女患者高发的年龄组为36~40岁和46~50岁。中国最常见的类型为82-C型,此类型占成人跟骨骨折的57.95%。东部地区发生跟骨骨折的平均年龄比西部高(P0.05),中部比西部高(P0.05)。82-C型跟骨骨折在东部、中部和西部的构成比分别为58.15%、55.44%、62.00%,统计学有显著差异(P0.001)。结论:本次研究旨在调查我国跟骨骨折的地域性和流行病学特征。男性高发年龄组为36~40岁,而女性为36~40岁和46~50岁。我国最常见的跟骨骨折类型为82-C型(AO分型)。第二部分B?hler’s角评估跟骨关节内骨折损伤严重程度及预测内固定术后功能恢复情况的效度的分析目的:关于B?hler’s角用于评价有移位的跟骨关节内骨折损伤的严重程度作用,以及预测跟骨切开复位内固定治疗后的患足功能恢复情况中所起的作用。B?hler’s的作用在跟骨手术中长期存在着很多争论。据此本实验旨在研究B?hler’s角与损伤程度,手术改善B?hler’s角与功能恢复之间的相互关系是否是存在的。方法:研究对象为在河北医科大学第三医院行手术治疗的,时间在2004年1月1日到2008年3月31日期间的,主要临床症状表现为闭合性的、单纯性的有移位的跟骨关节内骨折患者。手术之前应测量患者双侧跟骨的B?hler’s角,并以正常侧的跟骨B?hler’s角作为对照组。分别记录手术前、手术后,所有患者伤侧和健侧的B?hler’s角数值。通过对比双侧跟骨B?hler’s角的常规角度,通过计算得出伤侧B?hler’s角的改变值。依据Sander分型来评价跟骨骨折损伤的严重程度,应用AOFAS踝-后足评分系统来评价跟骨骨折术后的功能恢复结果。分析评价B?hler’s角与AOFAS踝-后足评分系统、B?hler’s角与Sander分型以及AOFAS踝至后足评分系统与Sander分型的相互关系。结果:本实验共计纳入274名患者,平均随访时间超过71个月,根据Sander分型分类,其中包含Ⅳ型骨折共计48例,Ⅲ型骨折共计121例和Ⅱ型骨折共计105例。严格遵照AOFAS踝-后足的评分系统行分类,差11例、可27例、优104例、良132例。对这三项数据的手术结束后的统计分析发现:术前的B?hler’s角、双侧跟骨的B?hler’s角的差值以及B?hler’s角的变化率均与Sande分型有关联(rs=-0.178,P=0.003;rs=-0.174,P=0.004;rs=-0.172,P=0.005),但与跟骨骨折术后的功能恢复结果没有关联性。术前的B?hler’s角、双侧跟骨的B?hler’s角的差值以及B?hler’s角的变化率与AOFAS踝-后足评分有明显相关(rs=0.223,P0.001;rs=0.224,P0.001;rs=0.220,P0.001,但是关联性较弱)。结论:仅发现手术之后的B?hler’s角与行跟骨骨折手术之后患者的功能恢复效果之间存在着相互的关联性,术前患者B?hler’s角与患者的有移位的跟骨关节内骨折的严重程度相关。第三部分早期功能锻炼对跟骨骨折术后二次复位作用的影像学研究目的:本文旨在探讨经皮撬拨复位、应用跟骨解剖接骨板-加压骨栓微创固定治疗跟骨关节内移位骨折术后早期功能锻炼对跟骨关节面的二期复位作用以及对足部功能恢复的影响。方法:将我院2012年12月后收治的单侧跟骨关节内移位骨折患者纳入本研究,所有患者均行经皮撬拨复位、应用跟骨解剖接骨板-加压骨栓微创固定治疗。根据术后是否早期锻炼及负重随机分配为实验组和对照组。实验组患者术后早期进行功能锻炼,术后2~3天行足底研磨瓶子,术后3周部分负重,12周完全负重;对照组按照常规进行康复锻炼,术后6周部分负重,骨折愈合后完全负重。术后随访患者,术后第1天、4周、8周、12周行CT扫描,在矢状位、水平位和冠状位图像上测量骨折最大移位。术后12个月根据AOFAS评分对患足功能进行评估,在足侧位X线片上测量B?hler’s角和Gissane角,统计学分析评估术后早期功能锻炼对距下关节残留移位是否具有二次复位作用以及改善后足功能的作用。结果:实验组和对照组患者在年龄、性别和骨折类型等方面差异无统计学意义。术后第1天、4周、8周、12周在CT矢状位、水平位和冠状位图像上测量骨折最大移位,并进行重复测量设计的方差分析显示实验组和对照组组间差异有统计学意义,组别与时间点间存在交互作用,各时间点除第一时间点外两组差别均有统计学意义;实验组在各时间点间差异均有统计学意义。术后12个月AOFAS评分与术后12周CT矢状位、水平位和冠状位重建图像上测量的骨折最大移位具有显著相关性,与AOFAS相关性由大到小依次为矢状位移位、冠状位移位和水平位移位。B?hler’s角、Gissan角与AOFAS的相关系数比较差异均无统计学意义。结论:跟骨关节内移位骨折微创复位坚强内固定治疗后建议早期行康复锻炼,早期行功能锻炼及负重可以模造距下关节,减小关节面残留移位,改善足部功能恢复。
[Abstract]:Calcaneus is the largest tarsal bone, surrounded by an important soft tissue structure, which provides unique bearing function. Calcaneus fracture is the most common fracture of the tarsal bone, which accounts for 1%~2% of the whole body fracture, and 75% of them involve the heel articular surface. As early as 1843, Malgaigne was the first time to report the fracture of the calcaneus with the fracture of the articular surface. Folding is a very complicated injury. If the diagnosis and treatment are unsuitable, it often causes bad prognosis and even disastrous consequences. China has a vast territory, natural conditions, economic and social development in various regions, and the causes of calcaneus fracture are different. The calcaneus fracture, which is caused by high energy violence such as injury, is also increasing. The change of the cause of the injury will lead to the type of calcaneal fracture and the change of the type of constitution. In order to understand the characteristics of the calcaneus fracture in our country and the ratio of all types of calcaneus fracture, it is necessary to carry out an epidemiological investigation of calcaneus fracture throughout the country. The incidence of intra-articular fractures of calcaneus, especially severe comminuted calcaneal fractures, is increasing. The diagnosis and treatment of these types of injuries is very difficult. The intra-articular fractures of the calcaneus can not be accurately evaluated, effective treatment, poor prognosis, the life and work of the patients after injury, and the development of the social and economic development will also have some influence. The most commonly used imaging method for calcaneal fracture is X ray photography. The AO subtype of calcaneal fracture is assessed and typed. In addition to judging the severity of calcaneal fracture damage by judging the type of calcaneal fracture damage, the B? Hler 's angle, Gissan' s angle, bone width and length can be measured on the calcaneus X-ray film to assist in assessing the severity of the injury. However, the role of B? Hler 's angle in evaluating the severity of intra-articular fracture of calcaneus, the role of predicting the recovery of foot function after open reduction and internal fixation for calcaneus, and the guiding role of B hler' s in calcaneus surgery have long been controversial. A large number of studies have shown B? Hler 's angle and calcaneus. The functional recovery of intra-articular displaced fractures is associated, but the association of the two is not clear. The type of fracture of the displaced intra-articular fracture of the calcaneus is closely related to the angle of the B? Hler 's angle before the operation. We found that the articular surface, especially the posterior lower part of the joint, is anatomic and restored to the calcaneus. Height, length, and width are particularly important in calcaneus fractures, so the B? Hler 's angle can be used as a highly sensitive and post-operative assessment of postoperative and postoperative assessment, but the corresponding recovery angle remains to be studied. Therefore, this study focuses on the following questions: 1, B? Hler' s angle and the more displaced calcaneus joint Is there a correlation between internal fractures; 2, whether there is a correlation between the surgical reduction of B? Hler 's angle and postoperative functional prognosis; 3, if there is a correlation, to obtain a satisfactory outcome, the degree of.B? Hler's s angle to the B? Hler' s angle (postoperative measurement value) is to determine the functional prognosis of the patient's foot. The CT scan of calcaneal fracture can be used to evaluate the severity of the injury more accurately,.Sanders typing is a clinically widely used CT type of calcaneal fracture, which divides the fracture type according to the position of the fracture line on the coronary CT scan image. The three fracture lines of A, B, and C can be divided into three parts of the articular fracture block and two part of the carrier fracture block.Sanders type I, which refers to all non displaced fractures; the Sanders type II type is divided into II A, II B, and II C fracture according to the position of the fracture line, and the Sanders type III type is three partial fractures, according to the fracture position III AB, B III B C, III AC fractures have a central compression bone in typical fractures; type IV contains 3-4 primary fracture lines, more than 2mm in the articular surface, and severe comminuted fracture.Sanders, and many scholars believe that the treatment of intra-articular displaced fractures of the calcaneus is also a severe challenge for the experienced surgeon. Malposition is one of the major factors affecting the prognosis of intra-articular displaced fractures of the calcaneus. However, the displaced fractures in the calcaneus can not be completely dissected by displaced fractures in the calcaneus, due to the severe fracture of the calcaneus, the special anatomical structure of the calcaneus, the surgical experience of the calcaneus, and the use of the reduction tools and fixtures. Some scholars have reported that the dislocation of the subtalar joint after the calcaneus fracture is more than 1mm, which may lead to traumatic arthritis, affect the patient's foot function, and the patients with serious symptoms need surgical treatment of the subtalar joint fusion. Better recovery, CT examination of the calcaneus on the side of the patient during follow-up, it can be observed that the residual displacement has a decreasing trend. Early functional exercise after operation, whether or not the residual dislocation of the subtalar joint has two reposition effects after the internal fixation of calcaneus fracture, whether it is helpful to improve the patient's preview, is still lack of quantitative study. For the above problems, we The national calcaneus fracture epidemiological survey and fracture type analysis were carried out. The relationship between B? Hler 's angle, fracture type and function recovery (AOFAS score) was analyzed retrospectively. The two reposition of the residual displacement of the displaced fracture in the calcaneal joint after internal fixation was discussed. The present report is as follows: Part 1 epidemiological investigation of calcaneal fracture: calcaneus fracture is a common fracture, which often leads to long and severe disability, and therefore brings great economic burden to the society and the family. This article aims to review the epidemiological characteristics of calcaneal fracture and the Chinese things in China. Method: We extracted data from a database established by the group. This database reviewed 431822 cases of fracture data in 83 hospitals between January 2010 and December 2011. All patients (including outpatient) of the calcaneus fracture were classified according to the AO classification and then analyzed. The calcaneus fracture was included in this study. Apart from this, these fractures were divided into three types in the central region, the western region and the eastern region. A total of 11530 (12242) patients with calcaneus fractures were treated in 83 hospitals in our country during this study. The average age of the three patients in this study was 38.95 years (1-93 years of age), and 522 cases of calcaneal fractures in children were admitted to this study. (4.26% of the total number of total), 11720 cases of calcaneal fracture in adults (95.74% of the total number); the age group with high incidence of male and female compared to 5.13:1. men is 36~40 years old, and the age group of high incidence of female patients is 36~40 and 46~50. The most common type in China is 82-C type, which accounts for calcaneus fracture in the eastern region of the calcaneal fracture of the human body. The average age was higher than that in the West (P0.05), and the high (P0.05).82-C calcaneus fracture in the middle and western regions was in the East, the ratio of the middle and western regions was 58.15%, 55.44%, 62%, respectively (P0.001). Conclusion: This study was designed to investigate the regional and epidemiological characteristics of calcaneus fracture in China. The age group of male high incidence is 36~40 years old, and the female is at the age of 36~40. The most common type of calcaneal fracture in China is type 82-C (AO type). The second part of the B? Hler 's angle is used to evaluate the severity of intra-articular fracture in calcaneus and to predict the validity of functional recovery after internal fixation: the B? Hler' s angle is used to evaluate the severity of the displaced intra-articular fracture of the calcaneus. Degree action, and the role of.B? Hler 's in the recovery of foot function after calcaneus open reduction and internal fixation, there are many controversies in the calcaneus operation. This experiment aims to study the relationship between the B? Hler' s angle and the degree of injury, and the relationship between the s angle of B hler, and the functional recovery of the B? Hler. Methods: the study was performed at the Third Hospital of Hebei Medical University. The time was from January 1, 2004 to March 31, 2008. The main clinical symptoms were closed, simple and displaced intra-articular fractures of the calcaneus. The B? Hler 's angle of the bilateral calcaneus should be measured before the operation, and the normal side should be measured in the normal side. The B? Hler 's angle of the calcaneus was used as the control group. The B? Hler' s angle values of the injured side and the healthy side of all patients were recorded before and after the operation. The values of the B? Hler 's angle of the injured side were calculated by comparing the conventional angles of the B? Hler' s angle of the bilateral calcaneus. The posterior foot scoring system was used to evaluate the functional recovery of calcaneal fractures. Analysis and evaluation of the relationship between the B? Hler 's angle and the AOFAS ankle postfoot scoring system, B hler' s angle and Sander typing, and the AOFAS ankle to hind foot scoring system and the Sander classification. Results: this experiment included 274 patients with an average follow-up time of more than 71 months, according to Sa. Nder classification, including 48 cases of type IV fracture, 121 cases of type III fracture and 105 cases of type II fracture, strictly followed the scoring system of AOFAS ankle foot, 11 cases, 27 cases, excellent 104 cases, 132 good cases. The statistical analysis of these three data after operation concluded that the preoperative B? Hler 's angle, B? Hler bilateral calcaneus, hler The difference in the s angle and the change rate of the B? Hler 's angle were all associated with the Sande typing (rs=-0.178, P=0.003; rs=-0.174, P=0.004; rs=-0.172, P=0.005), but had no correlation with the results of functional recovery after calcaneus fracture. The score has a significant correlation (rs=0.223, P0.001; rs=0.224, P0.001; rs=0.220, P0.001, but weakly associated). Conclusion: there is a mutual association between the s angle of B? Hler 'after operation and the functional recovery effect of the patients after the operation of calcaneus fracture, the B? Hler' s angle of the preoperative patients and the displaced intra-articular fracture of the calcaneus in patients. The third part of the early functional exercise for the two reduction of calcaneal fracture: the purpose of this study was to explore the two stage reduction of the calcaneal joint surface after the early functional exercise after the percutaneous pry reduction and the treatment of the calcaneus intra-articular displaced fracture with the calcaneus compression bone bolt minimally invasive fixation. Methods: the effects on the functional recovery of the foot. Methods: the patients with unilateral calcaneal displaced fractures admitted after December 2012 were included in the study. All patients were treated with percutaneous pry reduction and applied calcaneus anatomic plate compression bone thrombus minimally invasive fixation. In the control group, the patients in the experimental group were exercised early after operation, and the plantar lapping bottles were performed on 2~3 days after operation. The patients were weight-bearing 3 weeks after the operation and 12 weeks were completely weighed. The control group was rehabilitative after 12 weeks, 6 weeks after the operation and completely weighed after the fracture healing. After the operation, the patients were followed up for first days, 4 weeks, 8 weeks and 12 weeks after the operation, in the sagittal position and water. The maximum fracture displacement was measured on the horizontal and coronal images. 12 months after the operation, the foot function was evaluated according to the AOFAS score. The B? Hler 's angle and Gissane angle were measured on the foot lateral X ray. Statistical analysis was made to assess whether the early functional exercise had two reposition effects on the residual dislocation of the subtalar joint and the improvement of the function of the posterior foot. Results: there was no significant difference in age, sex and fracture type between the experimental group and the control group. After first days, 4 weeks, 8 weeks, 12
【学位授予单位】：河北医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R683.4

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