From the Orthopaedic Trauma Services, Mission Hospital, Asheville, NC (Dr. Large), the Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ (Dr. Adams), the Atrium Health Department of Orthopaedic Surgery, OrthoCarolina Hand Center, Charlotte, NC (Dr. Loeffler),and the Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA (Dr. Gardner).
J Am Acad Orthop Surg. 2019 Nov 1;27(21):794-805. doi: 10.5435/JAAOS-D-18-00225.
Posttraumatic avascular necrosis (AVN) is osteonecrosis from vascular disruption, commonly encountered after fractures of the femoral neck, proximal humerus, talar neck, and scaphoid. These locations have a tenuous vascular supply; the diagnosis, risk factors, natural history, and treatment are reviewed. Fracture nonunion only correlates with AVN in the scaphoid. In the femoral head, the risk is increased for displaced fractures, but the time to surgery and open versus closed treatment do not seem to influence the risk. Patients with collapse are frequently symptomatic, and total hip arthroplasty is the most reliable treatment. In the humeral head, certain fracture patterns correlate with avascularity at the time of injury, but most do not go on to develop AVN due to head revascularization. Additionally, newer surgical approaches and improved construct stability appear to lessen the risk of AVN. The likelihood of AVN of the talar body rises with increased severity of talar injury. The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures. In proximal pole scaphoid fractures, delays in diagnosis and treatment elevate the risk of AVN, which is often seen in cases of nonunion. The need for vascularized versus nonvascularized bone grafting when repairing scaphoid nonunions with AVN remains unclear.
创伤后股骨头坏死（AVN）是由于血管破裂引起的骨坏死，常见于股骨颈、肱骨近端、距骨颈和舟骨骨折后。这些部位的血管供应脆弱；本文回顾了其诊断、危险因素、自然史和治疗。只有舟骨骨折不愈合与 AVN 相关。在股骨头，移位骨折的风险增加，但手术时间和开放性与闭合性治疗似乎并不影响风险。有塌陷的患者常出现症状，全髋关节置换术是最可靠的治疗方法。在肱骨头，某些骨折模式与受伤时的缺血性相关，但由于头部再血管化，大多数不会发展为 AVN。此外，新的手术方法和更好的结构稳定性似乎降低了 AVN 的风险。距骨体 AVN 的可能性随着距骨损伤严重程度的增加而增加。AVN 的发展与预后更差相关，并增加了继发性手术的可能性。在近端舟骨骨折中，诊断和治疗的延迟会增加 AVN 的风险，而 AVN 在不愈合的情况下很常见。在修复有 AVN 的舟骨不愈合时，需要血管化骨还是非血管化骨移植仍不清楚。
