螺旋CT三维重建在踝关节骨折诊治中的应用

发布时间：2018-04-19 17:09

本文选题：踝关节骨折 + Lauge-Hansen分型　；参考：《大连医科大学》2017年硕士论文

【摘要】：【目的】研究螺旋CT重建在踝关节骨折诊治中的临床价值,检验Lauge-Hansen分型在踝关节骨折诊断中的准确性。分析Lauge-Hansen分型适用范围,发现X线漏诊骨折及分型本身缺陷,探讨其解决方案。【方法】回顾性分析2014年1月~2016年9月本院踝关节骨折均行X线、CT重建检查的病例133例,男73例,女60例,平均年龄44.83岁。分别按Lauge-Hansen分型,并根据术中所见检验二者分型的准确性,二者间进行对比,发现X线漏诊骨折,分析Lauge-Hansen分型本身的适用性。收集患者术前外伤史、查体、影像学资料及术中所见情况,应用Digimizer测量软件分析影像学图片。踝关节正位X线片:下胫腓重叠阴影(TFO)、下胫腓间隙(TFCS)、Shenton线、硬币征;踝穴位片:距骨内踝间隙(MCS),距骨胫骨间隙(TCS)、距腿角、胫距角。重建CT:下胫腓间隙(TFCS)、距骨内踝间隙(MCS)。术中:外展外旋应力试验、Cotton试验、前抽屉试验、向前应力位X线侧位片、外翻应力位片、内翻应力下踝关节正位X线片、内翻应力试验。结合外伤史、查体、影像学诊断标准,对每个病例均根据X线、CT重建、术中所见分别按Lauge-Hansen分型,分为X线组、CT重建组、术中组,以术中所见为标准,检验X线及CT分析,对比二者诊断的准确性。在这之中,发现X线漏诊骨折,并用CT重建结果及术中所见检验X线Lauge-Hansen分型的可靠性。【结果】两种影像学分型均具有较高准确性,基于X线分型的符合率为88.72%,基于CT重建分型的符合率为95.49%,二者差异具有统计学意义(χ2=7.1111,P0.01),其中Lauge-Hansen分型本身不适用5例,占3.75%,Lauge-Hansen分型本身适用率为96.24%,在其适用的骨折中,临床证实分型准确率达100%。基于X线分型错误的有9例,不存在X线型正确而CT重建分型错误的情况。X线中漏诊骨折的病例有7例,其中有2例通过Lauge-Hansen分型得以弥补。踝关节X线漏诊的情况较多见于:韧带损伤、高位腓骨骨折、后踝撕脱骨折、细小骨折、临近骨折块影响、损伤机制的初始。对于高能创伤、垂直暴力、直接暴力引起的踝关节骨折应用Lauge-Hansen分型存在一定局限性。Lauge-Hansen分型的另一缺陷是没有明确区分PAB-1型与PER-1型、PAB-2型与PER-2型,分型对此类暴力起始机制引起的踝关节损伤评定存在一定缺陷。【结论】X线、CT重建检查结合Lauge-Hansen分型在踝关节骨折诊断中具有较高的准确性,CT重建检查在立体直观表现骨折及发现微小骨折方面更具优势,Lauge-Hansen分型本身在该类骨折中适用性较强,尤其在间接暴力引起的骨折中预测韧带损伤、发现隐匿骨折等方面有较大优势。在踝关节骨折的诊治中,X线检查是不可或缺的,结合Lauge-Hansen分型、影像学诊断指标、查体、外伤史,能使诊断达到较高的准确率;对于行X线检查有疑问或创伤较重需住院继续治疗的病例,可行CT重建检查,三维立体而准确地展现踝关节损伤程度,为治疗技术的方案选择提供可靠的参考。
[Abstract]:[objective] to study the clinical value of spiral CT reconstruction in the diagnosis and treatment of ankle fracture and to test the accuracy of Lauge-Hansen classification in the diagnosis of ankle fracture.The scope of application of Lauge-Hansen classification was analyzed, and the defects of X-ray misdiagnosis fracture and classification itself were found. [methods] A retrospective analysis was made of 133 cases (73 males) who underwent X-ray CT reconstruction examination of ankle fractures from January 2014 to September 2016 in our hospital.There were 60 females with an average age of 44.83 years.According to the Lauge-Hansen classification, and according to the intraoperative results to test the accuracy of the two typing, the comparison between the two, found X-ray missed fracture, analysis of the applicability of the Lauge-Hansen classification itself.The preoperative trauma history, body examination, imaging data and intraoperative findings were collected. The imaging images were analyzed with Digimizer software.X-ray films of ankle joint: inferior tibiofibular overlap shadow: TFOO, inferior tibiofibular space TFCSC / Shenton line, coin sign; ankle acupoint film: medial malleolus space MCSA, talus tibia space TCSA, talus angle, tibiotalar angle.CTS: TFCSS of inferior tibiofibular space, MCSA of medial malleolus of talus.Intraoperative: extravasation stress test cotton test, front drawer test, forward stress position X-ray lateral film, valgus stress position film, ankle joint positive position X-ray film under varus stress, varus stress test.According to the diagnostic criteria of trauma history, physical examination and imaging, each case was reconstructed according to X-ray CT. According to the Lauge-Hansen classification, each case was divided into X ray group and CT reconstruction group, the intraoperative group was divided into two groups: X ray and CT analysis according to the standard of intraoperative findings.The accuracy of diagnosis was compared.Among them, it was found that X-ray fracture was missed, and the reliability of X-ray Lauge-Hansen classification was tested by CT reconstruction results and intraoperative findings. [results] the two imaging types had high accuracy.The coincidence rate based on X-ray classification was 88.72 and that based on CT reconstruction was 95.49. The difference between them was statistically significant (蠂 ~ 2 / 7.1111 / P0.01). Among them, Lauge-Hansen classification itself was not applicable in 5 cases, accounting for 3.75% Lauge-Hansen classification.The accuracy of clinical classification was 100%.There were 9 cases of misclassification based on X-ray classification. There were 7 cases of misdiagnosis of fracture in X-ray without correct X-ray pattern and wrong classification of CT reconstruction. Among them, 2 cases were compensated by Lauge-Hansen classification.The missed X-ray diagnosis of ankle joint was more common in ligament injury, high fibula fracture, posterior malleolus avulsion fracture, small fracture, near fracture block, and initial injury mechanism.Lauge-Hansen classification of ankle fractures caused by high energy trauma, vertical violence and direct violence has some limitations. Another defect of Lauge-Hansen classification is that there is no clear distinction between PAB-1 type and PER-1 type PAB-2 type and PER-2 type.[conclusion] X-ray CT reconstruction combined with Lauge-Hansen classification has high accuracy in the diagnosis of ankle fracture. [conclusion] X-ray CT reconstruction combined with Lauge-Hansen classification has a higher accuracy in the diagnosis of ankle fracture. [conclusion] X-ray CT reconstruction combined with Lauge-Hansen classification has a high accuracy in the diagnosis of ankle fracture. [conclusion] CT reconstruction is more accurate in the diagnosis of ankle fracture.Lauge-Hansen classification is more suitable for this kind of fractures.Especially in indirect violence in the fracture prediction ligament injury, found hidden fracture and other aspects have a greater advantage.X-ray examination is indispensable in the diagnosis and treatment of ankle fracture. Combined with Lauge-Hansen classification, imaging diagnostic index, body examination and trauma history, the diagnosis rate can reach a higher accuracy.For the patients whose X-ray examination is doubtful or whose trauma is serious, it is feasible for CT reconstruction to show the degree of ankle joint injury in three dimensional and accurate way, which provides a reliable reference for the choice of treatment technique.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R683;R816.8

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