Nork Sean E, Barei David P, Schildhauer Thomas A, Agel Julie, Holt Sarah K, Schrick Jason L, Sangeorzan Bruce J
Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA 98104, USA.
J Orthop Trauma. 2006 Sep;20(8):523-8. doi: 10.1097/01.bot.0000244993.60374.d6.
To report the results of intramedullary nailing of proximal quarter tibial fractures with special emphasis on techniques of reduction.
Retrospective clinical study.
Level 1 trauma center.
During a 36-month period, 456 patients with fractures of the tibial shaft (OTA type 42) or proximal tibial metaphysis (OTA type 41A2, 41A3, and 41C2) were treated operatively at a level 1 trauma center. Thirty-five patients with 37 fractures were treated primarily with intramedullary nailing of their proximal quarter tibial fractures and formed the study group. Thirteen fractures (35.1%) were open and 22 fractures (59.5%) had segmental comminution. Three fractures had proximal intraarticular extensions.
Alignment and reduction postoperatively and at healing. An angular malreduction was defined as greater than 5 degrees in any plane.
Fractures extended proximally to an average of 17% of the tibial length (range, 4% to 25%). The average distance from the proximal articular surface to the fracture was 67.8 mm (range, 17 mm to 102 mm, not corrected for distance magnification, included for preoperative planning purposes only). Postoperative angulation was satisfactory (average coronal and sagittal plane deformity of less than 1 degree) as was the final angulation. Acceptable alignment was obtained in 34 of 37 fractures (91.9%). Two patients had 5-degree coronal plane deformities (one varus and one valgus), and 1 patient had a 7-degree varus deformity. Two patients with open fractures with associated bone loss underwent a planned, staged iliac crest autograft procedure postoperatively. Four patients were lost to follow-up. In the remaining 31 patients with 33 fractures, the proximal tibial fractures united without additional procedures. No patient had any change in alignment at final radiographic evaluation. Secondary procedures to obtain union at the distal fracture in segmental injuries included dynamizations (n = 3) and exchange nailing (n = 1). Complications included deep infections in 2 patients that were successfully treated.
Multiple techniques were required to obtain and maintain reduction prior to nailing and included attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia. Simple articular fractures and extensions were not a contraindication to intramedullary fixation. The proximal tibial fracture healed despite open manipulations. Short plate fixations to maintain this difficult reduction, either temporary or permanent, were effective.
报告胫骨近端四分之一骨折髓内钉固定的结果，特别强调复位技术。
回顾性临床研究。
一级创伤中心。
在36个月期间，456例胫骨干骨折（OTA 42型）或胫骨近端干骺端骨折（OTA 41A2、41A3和41C2型）患者在一级创伤中心接受手术治疗。35例患者的37处骨折主要采用胫骨近端四分之一骨折髓内钉固定，构成研究组。13处骨折（35.1%）为开放性骨折，22处骨折（59.5%）有节段性粉碎。3处骨折有近端关节内延伸。
术后及愈合时的对线和复位情况。角度复位不良定义为在任何平面上大于5度。
骨折近端平均延伸至胫骨长度的17%（范围4%至25%）。从近端关节面到骨折的平均距离为67.8 mm（范围17 mm至102 mm，未校正距离放大倍数，仅用于术前规划）。术后成角情况令人满意（冠状面和矢状面平均畸形小于1度），最终成角情况也是如此。37处骨折中的34处（91.9%）获得了可接受的对线。2例患者有5度冠状面畸形（1例内翻和1例外翻），1例患者有7度内翻畸形。2例开放性骨折伴骨缺损的患者术后接受了计划性分期髂嵴自体骨移植手术。4例患者失访。在其余31例患者的33处骨折中，胫骨近端骨折未进行额外手术而愈合。在最终影像学评估中，没有患者的对线有任何变化。节段性损伤中为使远端骨折愈合而进行的二次手术包括动力化（n = 3）和更换髓内钉（n = 1）。并发症包括2例深部感染，均成功治疗。
在髓内钉固定之前，需要多种技术来实现和维持复位，包括注意合适的起始点、使用单皮质钢板以及使用应用于胫骨的股骨撑开器。单纯关节骨折和延伸并非髓内固定的禁忌证。尽管进行了开放操作，胫骨近端骨折仍愈合。采用短钢板固定来维持这种困难的复位，无论是临时还是永久的，都是有效的。
