距骨骨折手術(shù)入路----前內(nèi)入路

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1、Indications???指征Theanteromedialapproachisusuallyemployedincombinationwiththeanterolateralapproachinordertoobtainananatomicreductionofdisplacedandcomminutedfractures.前內(nèi)入路通常與前外入路聯(lián)合應用，以便對距骨獲得解剖復位。Inthelesscommonsituationwherethefractureofthetalarneckisnotcomminuted,onecanobtain

2、ananatomicreductionandfixationusingonlytheanteromedialapproach.少數(shù)情況下，當距骨頸不是粉碎骨折，可以使用單純前內(nèi)入路獲得解剖復位和固定。?????????Anatomy???解剖Onemustnotdamagethebloodsupplytothetalus.Theneckofthetalusreceivesbranchesfromthemedialandlateralside.Thebodyofthetalusissuppliedalmostexclusivelyfromitsp

3、osteromedialaspect.必須避免損傷距骨血供，距骨頸血運來自內(nèi)側(cè)和外側(cè)面，距骨體則由后正中單獨供應。???????????Theanteromedialapproachavoidsthesetwoneurovascularbundlesandprovidesaccesstothemedialtalusandsurroundingjoints.入路應避免兩個神經(jīng)血管束（隱神經(jīng)大隱靜脈束/脛后神經(jīng)血管束），?顯露距骨內(nèi)側(cè)和周圍關(guān)節(jié)???????????Skinincision???皮膚切口Thisincisionrunsfromthe

4、medialmalleolusproximallytothebaseofthefirstmetatarsaldistally.Formorecomplexfracturestheincisionmaybeextendedproximally.?切口起自內(nèi)踝下級至第一跖骨基底。多數(shù)復雜骨折可能需要顯露下極。?????????Itismostimportantnottodamagethedeltoidbrancheswhichariseposteromediallyandsupplythemedialtwothirdsofthetalarbody.

5、?不要損傷從后內(nèi)側(cè)分出供應距骨體2/3部分血管分支。??????????Exposureoftheanteromedialtalarneck顯露前內(nèi)側(cè)距骨頸Onceskinandfasciaareincised,oneencountersthefracturehematomawhichshouldbeevacuatedinordertoexposetheunderlyinginfero-medialaspectoftheneck,andthefracture.切開皮膚和筋膜后，清除骨折端血腫，顯露下面距骨頸下內(nèi)側(cè)面和骨折。Thearrowpoi

6、ntstoasimplefractureofthetalarneck,whichislesscommon.?下圖顯示個簡單距骨頸骨折，這個損傷很少見。?????Debridementofsubtalarjoint????切開距下關(guān)節(jié)Thefracturesonthemedialsideareoftenmultifragmentary.Fragmentswhicharedisplacedintothesubtalarjointmustbedebridedtoallowananatomicreductionofthesubtalarjoint.內(nèi)側(cè)

7、面骨折都通常都是復雜骨折，骨折塊落入距下關(guān)節(jié)必須被清除，以便解剖復位距下關(guān)節(jié)。Restorationoflength,ifthefractureiscomminuted,dependsonanatomicreductionofthelateralaspectofthetalarneck.如果骨折是復雜的，距骨外側(cè)面解剖復位可以恢復距骨長度。