手术jones骨折第5跖骨基底骨折切开复位内固定术.docx

手术jones骨折第5跖骨基底骨折切开复位内固定术.docx

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手术jones骨折第5跖骨基底骨折切开复位内固定术

Jonesmann骨折指第五跖干骺端与骨干连接部骨折。

英国骨科医生Sir Robert Jones（1857–1933）自己跳舞后发生此类骨折并首先描述，故此得名。

Jonesfracturesoccurinasmallareaofthefifthmetatarsalthat receiveslessblood andisthereforemorepronetodifficultiesinhealing.AJonesfracturecanbeeitherastressfracture（atinyhairlinebreakthatoccursovertime）oranacute（sudden）break.Jonesfracturesarecausedbyoveruse,repetitivestress,ortrauma.Theyarelesscommonandmoredifficulttotreatthanavulsionfractures.

     A Jonesfracture isa fracture ofthe diaphysis ofthe fifthmetatarsal ofthe foot.Thefifthmetatarsalisatthebaseofthesmall toe.The proximalend,wheretheJonesfractureoccurs,isinthemidportionofthefoot.PatientswhosustainaJonesfracturehave pain overthisarea,swelling,anddifficultywalking.Thefracturewasfirstdescribedby British orthopedicsurgeonSir RobertJones,whosustainedthisinjuryhimselfwhiledancing,inthe AnnalsofSurgery in1902.

      Fracturesofthefifthmetatarsalofthefootaresurprisinglycontroversialamongradiologists,particularlyconcerningproximalmetatarsalfractures.Sometermthesefractures Jonesfractures,others dancersfractures,whileotherssimplytermthem proximalmetatarsalfractures.AccordingtoOrthopedicRadiology（AdamGreenspan,3rdedition）,a"trueJones"fractureoccursoneinchdistaltothebaseofthefifthmetatarsal.Itis notduetoperoneusbrevistendonavulsionbutratheratwistinginversioninjurytothefoot.GreenspanstatesthatmoreproximalinjuriesarefrequentlymisinterpretedasJonesfracturesbutreallyareavulsionfracturesbytheperoneusbrevistendon.Theselatterfractureshealquickly,whilemoredistalfracturesmayundergofibrousuniononly.

Apatientsteppedoffacurbandsustainedafractureoftheproximalaspectofthefifthmetatarsal.AccordingtoGreenspan,thiswouldbetermeda"trueJonesfracture."

Incontradistinction,thispatientsustainedafractureoftheproximalaspectofthefifthmetatarsal.Greenspantermsthisanavulsioninjury.Inanavulsionfracture,asmallpieceofboneispulledoffthemainportionofthebonebyatendonorligament.Thistypeoffractureistheresultofaninjuryinwhichtheanklerolls.Avulsionfracturesareoftenoverlookedwhentheyoccurwithananklesprain.

Treatment：

IfaJonesfractureisnotsignificantlydisplaced,itcanbetreatedwitha cast,splintorwalkingbootforfourtoeightweeks.Patientsshouldnotplaceweightonthefootuntilinstructedbytheirdoctor.Three-fourthsoffracturestreatedlikethisshouldheal.

Inthecaseofacutefractureinanathlete,adynamiccompressionplatecanbeplacedonthetensionsideofthefracture,K-WirewithMonofiamentwireinafigure8fashionduetothenatureofatransversefracture.Internalfixationwithcorticalorcancellousscrewwouldrequireanobliquefracturethatcouldbeaddressedthrough"Theruleof2's"inregardstoInternalfixationwithscrews.

Othertreatmentscommonlyencouragedareincreasedintakeof vitaminD and calcium.

Thisinjurymustbedifferentiatedfromthephysiologicdevelopmental apophysis commonlyandnormallyoccurringatthissiteinadolescents.Differentiationispossiblebycharacteristicssuchasabsenceofsclerosisofthefracturededges（inacutecases）andorientationofthelucentline:

transverse（at90degrees）tothemetatarsalaxisforthefracture（duetoavulsionpullbytheperoneusbrevismuscleinsertingattheproximaltip）-andparalleltothemetatarsalaxisinthecaseoftheapophysis.

Jonesfracturescanbecomechronicconditionsifthefracturefailstounite,orheal.Ifthisisthecase,surgerywilllikelyberecommendedtosecurethefractureinplacewithascrew,andbonegraftmaybeusedtostimuateahealingresponse.

-SurgicalTreatment:

（JonesFrx）; 

  -patientispositioninpartiallateralpositiononbeanbag; 

  - flouroscopy:

     -underflourscopicguidence,aKwireisinsertedfordeterminationofproperpositionandlength; 

     - mostcommonmistakeistodirectthedrillplantarly,ratherthanparallelw/theshaftofmetatarsal; 

     - secondmistakeistoopositiontheguidewireusingtheobliqueview; 

         -notethatthemetatarsalshaftismorenarrowontheAPview,anditis possibleforthepintobecenteredontheobliqueview

                          whereasonAPviewthepiniseccentricallypositioned; 

   - incision:

         -longitudinalincisionismadeoverdistalmetatarsal; 

     -takecaretoavoidbranchesofthesuralnervewhichcancoursedorsally,andlaterallyovermetatarsal; 

     -peroneusbrevisisretractedinferiorly; 

     - insertionofthistendonmayobscuretheproperdrillentrysite; 

   - localbonegraft:

     -canbeobtainedfromtuberosityandfrombonebitsfromthedrill; 

   - implants:

         -considerinsertionof 4.5cancellousbonescrews, 4.5mmcannulatedscrews（whichareusedinmostcases）buthave available5.5cannulated（and solid） screwsand6.5mmcannulatedscrews; 

                 -diametershoulddependonwidthofthecanal（letthescrewtaphelpdeterminethebestsize）; 

         -ineithercase,threadsmustcrossthefrxline; 

     -lengthisusuallybetween40-55mm; 

     -considercountersinkingthescrewtoavoidprominenceofthescrewhead; 

     -in reportbyIPKelly, authorsnotedthatfailureismorelikelywhensmallerdiameterscrews areused; 

                 -experimentalJonesfractureswerecreatedin23pairsofhumancadaverfifthmetatarsals,whichwerefixedusingeither5.0mmor6.5mmscrews; 

         -frxstiffnessandpull-outstrengthsweremeasuredforeitherscrewtypeand relationshipswithbone densityand canaldiameterweredetermined; 

         -poorthreadpurchasewithinthemedullarycanalwasnotedwiththe5.0mmscrews,whileexcellentpurchasewasnotedwith6.5mmscrews; 

                 -pull-outstrengthtestingrevealedsignificantlyhigherpulloutstrengthsforthelarger6.5mmscrews; 

         -theauthorsconcludethatlargerdiameterscrewsmaybemoreappropriateforintramedullaryscrewfixationofJonesfractures; 

          -ref:

TreatmentofJonesFractureNonunionsandRefracturesintheEliteAthleteOutcomesofIMScrewFixationWithBoneGrafting

    - postop:

patientswill requireprotectedpostoperative wtbearing;

1、解剖方面考虑：

恢复跖骨头的队列关系是非常重要的前足的力学目标：

如下图示：

在正位，应是“顺流而下”的表现，且与对侧足对称，这是恢复正常跖骨长度的保证。

另一个需要恢复的重要结构是跖骨水平线，需保持其均在一个水平线上。

需要注意的是，在第一跖骨，是籽骨在承重，而不是第一跖骨头，因此，序列对应关系应与籽骨为准。

任何力线改变均可引起站立相和推离相时疼痛及胼胝形成。

2、螺钉或钢板固定：

固定这种骨折，因尽可能使其稳定。

横行骨折线时，单独拉力螺钉固定即可。

3、手术入路：

详见后。

4、复位：

骨折在直视下复位，因为其为横形骨折，复位满意后用复位钳保持复位。

5、拧入螺钉：

从腓骨短肌肌腱止点处，稍向内侧倾斜方向打入导针，这样可以抓住远骨折端的内侧骨皮质，增加稳定。

骨折近端应做成滑动孔，以允许骨折块间加压，螺钉直径应根据骨情况来选择，常选用3.5或4.0mm螺钉固定。

6、另一种固定方式：

髓内螺钉固定：

选髓内螺钉固定，螺钉直径要与髓腔匹配，螺钉必须有充足直径以获得稳定加压固定，根据髓腔的大小，可选用3.5或4.5mm皮质螺钉固定，在体型高大患者，可能需用6.5mm松质骨螺钉固定。

1、注意保护血运：

避免广泛深度暴露、过度牵拉；多个跖骨骨折应采用单独切口，避免增加软组织损伤；在足部保护静脉回流是非常重要的。

2、解剖：

小隐静脉位于切口部位的皮下；在静脉的深面是小趾外展肌；腓肠神经（与小隐静脉伴行）的分支应给予保护。

3、皮肤切口：

切口开始于可触及的第5跖骨茎突处，依据需要向远端延伸。

切口要位于足部掌侧皮肤与背侧皮肤的交界处。

4、深层分离：

显露第5小趾外展肌筋膜，并纵向切开。

5、骨质显露：

使用拉钩，向背侧牵开皮肤及背侧筋膜，向掌侧牵开肌肉，显露第5跖骨基底。