內踝垂直骨折固定

Medial, vertical fracture: lag screw and buttress plate

內側，垂直骨折：拉力螺釘和支撐鋼板

1 Principles 原理

Lag screw principles

拉力螺釘原理

As the thread advances in the main body of the tibia, the head pushes the medial fragment towards the tibia. 

當螺紋進入脛骨主體，（螺釘）頭部朝著脛骨推動內側骨塊。

The smooth shaft of the screw prevents any significant hold between the screw and the surrounding bone. 

螺釘光滑的杆防止在螺釘和周圍的骨質間有任何明顯的把持。

The length of the screw shaft must be chosen so that the threaded part of the screw lies fully beyond the fracture line and within the epiphyseal cancellous bone of the distal tibia. 

必須選擇螺釘杆的長度，使螺釘的螺紋部分完全位於骨折線以外和脛骨遠端的骺松質骨內。

To prevent the screw head from sinking into the thin cortex, the use of a washer is recommended. 

為了預防螺釘頭沉入薄的皮質內，推薦使用墊片。

Buttress plate

支撐鋼板

The function of a buttress plate is to neutralize any vertical shearing force. 

支撐鋼板的作用是中和任何垂直的剪切力量。

2 Reduction 復位

Cleaning the fracture site 

清理骨折部位

Remove any small, loose fragments which may prevent anatomic reduction and free the periosteum from the bone edges. 

去除任何小的，游離的可能阻礙解剖復位的骨塊，將骨膜從骨邊緣剝離。

It is important to visualize and inspect the joint, searching for bone and cartilage fragments detached from the medial malleolus or from the talus, and any impaction of the articular surface at the margin of the fracture. 

直視下檢查關節是重要的，尋找從內踝或距骨脫落的骨和軟骨碎片，和在骨折邊緣的任何關節面的嵌塞。

If the articular surface has been impacted, this must carefully disimpacted before the medial fragment is reduced. 

如果關節面被嵌塞，必須在內踝骨塊復位以前仔細的解除嵌塞。

Anatomical reduction 

解剖復位

Reduce the fracture anatomically with the help of small pointed reduction forceps. 

在小點氏復位鉗輔助下解剖復位骨折。

Take care with the soft tissues. 

注意軟組織。

Depending on fracture configuration and size of the fragment you may need to use large pointed reduction forceps through a lateral stab incision. 

取決於骨折形狀和骨塊大小，可能需要通過外側刺入切口應用大的點式復位鉗。

Do not strip the periosteum more than necessary. 

不要不必要的剝離骨膜。

In the presence of an impacted medial corner fragment, gently open the main vertical fracture plane by retraction of the medial malleolus medially (opening the book). 

在存在嵌塞的內側拐角處的骨塊的情況下，通過向內側拉內踝輕輕地打開主要垂直骨折平面（開書）。

The impacted 「corner」 fragment, usually identifiable by its articular cartilage, after irrigation if necessary, can then be seen. 

嵌塞的「拐角處」的骨塊，通常可通過關節軟骨確認，如必要經過衝洗，然後可被看到。

Disimpact and carefully tease back the fragment into its anatomical position. 

解除嵌塞，小心挑撥骨塊至解剖位置。

Then close the book by careful reduction of the medial malleolus. 

然後通過小心復位內踝使其關書。

Preliminary fixation 

初步固定

Insert a 1.6 mm K-wire as perpendicularly as possible to the fracture plane, about 1 cm proximal to the level of the horizontal tibio-talar joint line. 

儘可能垂直骨折平面插入一枚1.6mm鋼針，約在水平的脛距關節線水平的近端1cm。

As decided in preoperative planning, this K-wire should be placed posteriorly in order not to interfere with the planned position of the plate. 

正如在術前計劃中決定的，這根鋼針應在後側放置，為了不幹擾鋼板的計劃位置。

Check the reduction under image intensification.

圖像增強檢查復位。

3 Fixation 固定

Drilling 

鑽孔

With the protection of a drill sleeve, drill a 2.5 mm hole as perpendicularly as possible to the fracture plane and parallel to the K-wire.

在鑽孔套筒保護下，儘可能垂直骨折平面、與鋼針平行鑽一2.5mm的孔。

Do not drill the far lateral cortex. 

鑽孔勿超外側皮質。

Avoid penetration of the ankle joint and the syndesmosis. 

避免踝關節和韌帶聯合的穿透。

Tap cortical bone 

攻絲皮質骨

Measure the drill depth and then tap the near cortex only with the 4.0 mm cancellous bone tap, using the protection sleeve. 

測量鑽孔深度，然後用4.0mm松質骨絲錐攻絲單側皮質，應用保護套筒。

Insert anterior lag screw 

擰入前方拉力螺釘

Insert the chosen 4.0 mm cancellous bone screw so that it comes to rest with its threads completely in main body of the distal tibia. 

擰入選擇的4.0mm松質骨螺釘，取決於它的螺紋完全位於脛骨遠端主體內。

The use of a washer is recommended, especially in osteoporotic bone. 

推薦使用墊片，尤其在骨質疏鬆骨。

Insert the screw without excessive tightening. 

螺釘別擰的過緊。

Insert posterior lag screw 

擰入後方拉力螺釘

Remove the K-wire and widen its track with a 2.5 mm drill through a protection sleeve. 

去除鋼針，通過保護套筒用2.5mm鑽擴寬鋼針軌跡。

After measuring the length and tapping the near cortex, insert the second 4.0 mm cancellous bone screw, fitted with a washer. 

測長，攻絲單側皮質，擰入第二枚4.0mm松質骨螺釘，配有墊片。

Prepare plate application 

準備鋼板應用

Use a 3 hole one-third tubular plate to buttress this shear fracture. 

用一3孔1/3管型鋼板支撐這種剪切骨折。

Position the plate firmly by hand so that two holes lie on the main body of the tibia and one hole on the malleolar fragment. 

用手牢固地安置鋼板使兩個孔位於脛骨主體、一個孔位於踝骨塊。

Plan the position of the first proximal screw near the fracture. 

設計靠近骨折的第一枚近端螺釘的位置。

This screw must be located in the main fragment, 3 mm proximal to the apex of the fracture plane. 

這枚螺釘必須位於主骨塊上，位於骨折平面的頂點近端3mm。

Use the 2.5 mm drill bit and protection sleeve. 

用2.5mm鑽頭和保護套。

Drill both cortices, but exercise great care not to over penetrate laterally. 

鑽頭雙側皮質，但是要小心別過度向外側穿透。

Buttressing effect 

支撐效應

Measure the depth and tap both cortices with the 3.5 mm tap, using the protection sleeve. 

測深，用3.5mm絲錐攻絲雙側皮質，用保護套。

Carefully apply the uncontoured plate. 

小心使用非生物型鋼板。

Insert the first, more distal cortex screw. 

擰入第一枚，更遠端的螺釘。

By tightening the screw, the plate will act as a buttress on the distal fragment. 

通過擰緊螺釘，鋼板將對遠端骨塊起到支撐作用。

Finally, insert the second 3.5 mm cortex screw as described above.

最後，擰入上述上方的第二枚3.5mm皮質螺釘。

實戰：

術前：內踝垂直骨折（旋後內收型）

術後：lag screw and buttress plate

重點： buttress plate的應用