van den Bekerom Michel P J, Mutsaerts Eduard L A R, van Dijk C Niek
Department of Orthopaedic Surgery, Academic Medical Centre/University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
Arch Orthop Trauma Surg. 2009 Feb;129(2):227-35. doi: 10.1007/s00402-008-0768-6. Epub 2008 Oct 25.
Review the literature concerning modalities to evaluate the integrity of the deltoid ligament in patients with supination external rotation ankle fractures.
The electronic databases Pubmed/Medline, CINAHL and Embase were searched from 1987 to November 2007 to identify all published original studies concerning diagnostic modalities to evaluate the integrity of the deltoid ligament in adult ankle fractures.
This review included nine studies involving 423 ankle fractures. Three trails investigated medial tenderness; two studies, ecchymosis; two studies, swelling; one study, an injury radiograph; six studies, a type of radiographic stress view; one study, the Lauge-Hansen classification; one study, MRI; and one article studied arthroscopy in the evaluation of the deltoid ligament integrity.
Swelling, ecchymosis, medial tenderness, initial injury radiographs and the Lauge-Hansen classification are less adequate predictors of the integrity of the deltoid ligament. Manual or the less painful variant, the gravity external rotation stress radiographs are considered the gold standard. The amount of medial clear space widening indicative of a positive external rotation stress test has been somewhat variable in the literature but > or =5 mm is generally regarded as most reliable. Achieving adequate external rotation of the foot when obtaining stress radiographs is more important than positioning the ankle in the appropriate degree of ankle flexion. The amount of applied force necessary when performing an external rotation stress radiograph is not well defined and mainly determined by the patient's pain level. The indication for surgery should not be based on the absolute value of one parameter but on the combination of several parameters. If nonoperative treatment is chosen despite a positive stress radiograph, close follow-up is critical because subluxation of the ankle joint is still possible. MRI could be useful in individual cases.
回顾关于评估旋后外旋型踝关节骨折患者三角韧带完整性方法的文献。
检索1987年至2007年11月的电子数据库PubMed/Medline、CINAHL和Embase，以识别所有已发表的关于评估成人踝关节骨折三角韧带完整性诊断方法的原始研究。
本综述纳入9项研究，涉及423例踝关节骨折。三项试验研究了内侧压痛；两项研究了瘀斑；两项研究了肿胀；一项研究了损伤X线片；六项研究了一种X线应力位片；一项研究了Lauge-Hansen分型；一项研究了MRI；还有一篇文章研究了关节镜在评估三角韧带完整性中的应用。
肿胀、瘀斑、内侧压痛、初始损伤X线片和Lauge-Hansen分型对三角韧带完整性的预测价值较低。手动或疼痛较轻的重力外旋应力X线片被认为是金标准。文献中提示外旋应力试验阳性的内侧间隙增宽量有所不同，但一般认为≥5mm最为可靠。获取应力X线片时使足部充分外旋比将踝关节置于适当的屈曲角度更重要。进行外旋应力X线片检查时所需的施加力大小尚无明确界定，主要由患者的疼痛程度决定。手术指征不应基于单一参数的绝对值，而应基于多个参数的综合判断。如果尽管应力X线片阳性仍选择非手术治疗，密切随访至关重要，因为踝关节仍有可能发生半脱位。MRI在个别病例中可能有用。
