Zwipp H, Amlang M
UniversitätsCentrum für Orthopädie und Unfallchirurgie, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland,
Orthopade. 2014 Apr;43(4):332-8. doi: 10.1007/s00132-013-2168-z.
Osteoporotic fractures of the ankle were observed three times more often in the year 2000 than in the year 1970 and it is predicted that this will increase another three times by the year 2030. The most important predictive values for ankle fractures in the elderly are smoking, multipharmacy and poor mobility.
Conservative treatment only seems to be successful in stable ankle fractures with good surrounding soft tissue. Pronation-abduction (PA) fractures most commonly affect elderly females and 90% of the cases present as the very unstable type III. Unstable fractures, such as PA type III, supination-eversion (SE) and pronation-eversion (PE) fractures type IV can be treated better by 2-stage open reduction internal fixation (ORIF). Because the PA type III fracture is often associated with dorsal dislocation of the foot it is proposed that this type should be classified as type IV, which needs urgent surgery to prevent further soft tissue damage.
Recommended techniques are the K-wire cage or fibula-pro-tibia technique. Locking plates are also preferred for stable fracture fixation. According to the recommended preoperative computed tomography (CT) scan a Volkmann's fracture should be fixed through a posterolateral approach. The additional tibiotarsal internal transfixation should remain for 6-8 weeks after ORIF until it is changed to a protective lower leg cast after wound healing. An underlying osteoporosis should be diagnosed and inpatient treatment of this entity should be initiated by trauma surgeons whereby coordination training is also important.
Due to the increasing number of ankle fractures in the elderly particularly in postmenopausal women with osteoporosis, the insufficient diagnostics and therapy of osteoporosis and because the number of these difficult to treat fractures will increase by a factor of 3 by 2030, special surgical techniques and particularly implants are necessary for unstable ankle fractures types PA III, SE IV and PE.
2000年踝关节骨质疏松性骨折的发生率是1970年的3倍，预计到2030年还将再增加3倍。老年人踝关节骨折最重要的预测因素是吸烟、多种药物治疗和活动能力差。
保守治疗似乎仅对周围软组织良好的稳定型踝关节骨折有效。旋前外展（PA）型骨折最常累及老年女性，90%的病例为极不稳定的III型。不稳定骨折，如PA III型、旋后外翻（SE）和旋前外翻（PE）IV型骨折，采用两阶段切开复位内固定（ORIF）治疗效果更佳。由于PA III型骨折常伴有足背侧脱位，因此建议将该型归类为IV型，需要紧急手术以防止进一步的软组织损伤。
推荐的技术是克氏针笼或腓骨-胫骨技术。锁定钢板也更适合用于稳定骨折的固定。根据推荐的术前计算机断层扫描（CT），Volkmann骨折应通过后外侧入路固定。胫距关节内固定应在ORIF后保留6 - 8周，直至伤口愈合后更换为小腿保护性石膏。应诊断潜在的骨质疏松症，创伤外科医生应启动对该疾病的住院治疗，同时协调训练也很重要。
由于老年人尤其是患有骨质疏松症的绝经后女性踝关节骨折数量不断增加，骨质疏松症的诊断和治疗不足，且到2030年这些难以治疗的骨折数量将增加3倍，因此对于PA III型、SE IV型和PE型不稳定踝关节骨折，需要特殊的手术技术，尤其是植入物。
