Chen Kuan-Ju, Ko Chih-Yuan, Ho Tsung-Yu, Chen Hsien-Te, Hsu Horng-Chaung, Hung Chih-Hung
Department of Orthopedic Surgery, China Medical University Hospital.
Spine Center, China Medical University Hospital.
Medicine (Baltimore). 2020 Jun 26;99(26):e20862. doi: 10.1097/MD.0000000000020862.
Talar fracture accompanied with malleolar fracture is rare, and its management is complex. Ankle soft tissue is much thinner than other parts of the human body, and the shape of the ankle makes wounds difficult to close immediately after surgery, which may result in poor skin condition if the wound tension is too high. However, joint congruity and osteonecrosis are the main concerns of talar fracture.
A 57-year-old man presented at the emergency department following a motorcycle accident.
Physical examination revealed swelling and tenderness of the left ankle and midfoot. The patient had comminuted talar fracture and was indicated for dual-screw fixation or even plate with screw fixation.
We performed single screw fixation after assessing the soft tissue condition and employed a technique of using continuous longitudinal force to bring together fracture fragments (ankle ligamentotaxis) during surgery. Open reduction with a mini-hook plate and tension band wire was used for bimalleolar fracture repair using the combined anteromedial and anterolateral approach with extension of the incision. Kirschner wire for temporary fixation was performed using ligamentotaxis, and a 2.4 headless screw was inserted from the posteromedial to the anterolateral direction.
The patient was discharged with a standard short leg splint and was instructed not to bear weight on the affected ankle for 2 months. The patient walked well without discomfort, and the Hawkins sign was clearly visible. Single screw fixation preserves the integrity of the talus bone as minimal space is used for this operative technique. Single screw fixation preserves more bony stock when most of the internal fixator is located within the bone. Additionally, surgery time is shorter than multiple implantations even when performing the same procedure; as a result, there was less ankle soft tissue swelling.
This case provides evidence of using the single screw fixation technique for addressing both malleolar and talar fractures, and that talar fracture management can be less aggressive with limited weight bearing and initial limited range of motion given the presence of malleolar fracture. The alignment and stability of bony fragments also benefit from ankle ligamentotaxis.
距骨骨折伴踝关节骨折较为罕见，其治疗复杂。踝关节软组织比人体其他部位薄得多，且踝关节形状使术后伤口难以立即闭合，如果伤口张力过高可能导致皮肤状况不佳。然而，关节的一致性和骨坏死是距骨骨折的主要关注点。
一名57岁男性在摩托车事故后到急诊科就诊。
体格检查发现左踝和中足肿胀压痛。患者为粉碎性距骨骨折，适合双螺钉固定甚至钢板螺钉固定。
我们在评估软组织状况后进行了单螺钉固定，并在手术中采用了利用持续纵向力使骨折碎片复位（踝关节韧带整复术）的技术。采用联合前内侧和前外侧入路并延长切口，使用微型钩钢板和张力带钢丝进行切开复位以修复双踝骨折。利用韧带整复术进行克氏针临时固定，并从后内侧向前外侧方向插入一枚2.4无头螺钉。
患者出院时佩戴标准短腿夹板，并被指示2个月内患踝不得负重。患者行走良好，无不适，霍金斯征清晰可见。单螺钉固定保留了距骨的完整性，因为该手术技术使用的空间最小。当大部分内固定器位于骨内时，单螺钉固定保留了更多的骨量。此外，即使进行相同的手术，单螺钉固定的手术时间也比多枚植入物短；因此，踝关节软组织肿胀较轻。
本病例证明了使用单螺钉固定技术治疗踝关节和距骨骨折，并且鉴于存在踝关节骨折，在有限负重和初始有限活动范围的情况下，距骨骨折的治疗可以不那么激进。骨碎片的对线和稳定性也受益于踝关节韧带整复术。
