早读 | 图文详解第五跖骨骨折:治疗、并发症及预后

学术   2024-11-27 06:10   上海  




  摘要  



第五跖骨骨折是下肢最常见的损伤之一,但对其分类和治疗还没有一致的意见,而术语“Jones骨折”在文献中的使用也不一致。

在绝大多数患者中,1区骨折采用保守治疗,效果良好。

2区和3区骨折的治疗仍有争议,应根据患者的需要和骨折的“个性”进行个体化治疗。

如果进行手术治疗,解剖复位和单枚螺钉髓内固定,仍然是治疗的“黄金标准”; 然而,最近的报道表明,采用特别设计的钢板系统进行切开复位内固定效果良好。

常见的手术并发症包括内固定失效或、软组织刺激、再骨折、不愈合、腓肠神经损伤和慢性疼痛。

患者应被告知不同的治疗方案,并参与治疗方案的选择,特别职业运动员和足功能要求较高的患者。




介绍


跖骨骨折作为足部最常见的损伤,约占医疗机构中遇到所有骨折的5-6 %, 其中约45-70%的损伤涉及第五跖骨。据报道,其发病率高达1.8/1000人-年,患者最常出现在20至50岁之间。值得注意的是,大多数年轻患者是男性,而老年患者是女性。在优秀运动员中,美国橄榄球联盟(NFL)球队的5年回顾性研究表明发病率为3.42%。除了橄榄球,第五跖骨骨折高风险人群包括足球、篮球和田径运动员。Robert Jones于1902年首次描述了利物浦四名患者的干骺端-骨干(距基底0.75英寸以内)第五跖骨骨折,后来他自己在跳舞时也遭受了同样的伤害。如今,术语“Jones骨折”仅定义了第五跖骨骨折的一种类型,即“2区”损伤,关于这些损伤的术语和治疗存在一些误解和争议。本文研究的目的是提供关于这些重要和常见损伤的治疗、并发症及预后的最新信息。



解剖学


在处理第五跖骨骨折及评估愈合潜力时,解剖学因素是至关重要的。共有四个结构附着在第五跖骨基底部;腓骨短肌附着在粗隆处,第三腓骨肌附着在干骺端-骨干连接处,小指展肌和跖筋膜的外侧束附着于跖骨基底部外侧(图1)。此外,第五跖骨的近端部分由附接到骰骨和其他跖骨的坚固韧带相对固定,保证李跖骨轴向的活动。正是这些特征导致干骺端-骨干连接处延迟愈合及不愈合的倾向增加,此外,腓侧跗余骨(os peroneum)和腓骨短肌腱籽骨(os vesalianum)是第五跖骨基底部区常见的籽骨,应该与骨折相区别。此外,在近端干骺端血液供应区和骨干部分滋养动脉供应区之间有一个分水岭区域,这是导致骨折延迟愈合、不愈合的最主要原因(图2)。最后,腓肠神经非常接近髓内螺钉固定的入口点,在手术过程中应该注意保护。


图1.第五跖骨的相关解剖及骨折分区(1区粗隆部撕脱骨折;2区干骺端骨折,骨折线累计四、五跖间关节;3区干骺端以远1.5cm的近端骨折)。


图2.第五跖骨的血供显示了2区的分水岭区域(灰色)。



生物力学


Kavanagh等人在一个受力分析中表明,骨折的发生通常需要垂直或斜向内侧的力量.反向牵引力是造成粗隆撕脱骨折的主要原因,其中腓骨短肌在站立阶段时处于收缩状态,并且当跖屈的脚受到反向应力时,跖骨结节有撕脱的可能;另一方面,足底腱膜外侧带的牢固附着与结节远端的骨折也有关。此外,Gu使用三维模型来研究着站立期间跖骨上的应力负荷,报告了应力峰值点之一在第五跖骨的近端。当改变着地角度时,他注意到在翻转过程中外侧跖骨应力激增。通过降低动态平衡能力,较弱的脚趾夹紧力也可能导致脚外侧的过载,最终导致第五跖骨骨折。


有许多诱发生物力学因素可以将力量转移到外侧脚,并导致第2区或第3区第五跖骨骨折。在一项尸体研究中,Aronow等人证明了孤立的腓肠肌或小腿三头肌挛缩将承重力从后脚传递到中脚和前脚。先天性骨结构不良,例如第五跖骨的足底畸形愈合或前四个跖骨中任何一个的背侧畸形愈合,也会引起第五跖骨头部的相对跖屈,并导致第五跖骨承受剪切力。肥胖患者更容易发生3区骨折,这是由于过量脂肪组织导致更大的负荷。最近对51名NFL球员的放射力学分析表明,长而直的第五跖骨具有更大的Jones骨折风险。



骨折分类


第五跖骨骨折有很多分类方法,Stewart首次在1960年根据骨折位置和形态提出分类:I型是跖骨基底部和骨干之间的关节外骨折,II型是跖骨基底的关节内骨折,III型是基底的撕脱骨折,IV型是关节内的粉碎性骨折,V型是跖骨的撕脱骨折。十五年后,Dameron等人观察到第五跖骨基底部骨折和腓骨短肌止点远端骨折愈合的差异性.基于这些发现,Lawrence和Botte后来将第五跖骨近端骨折分为三个解剖区域(图一):


  • 1区:结节撕脱骨折,累及或不累及跗跖关节(“假性琼斯”或“网球”骨折)——最常见,占第五跖骨骨折的90%以上.它们通常作为内翻性损伤出现,继发于足底筋膜外侧带和腓骨短肌腱的牵拉。

  • 2区:干骺端骨折,骨折线累计四、五跖间关节(“琼斯骨折”)。它们发生在第五跖骨间接内收,并伴有踝关节跖屈。这种足部扭转在足底筋膜的外侧带上产生拉力,同时在腓骨短肌腱上产生张力导致骨折。

  • 3区:近端骨干应力性骨折,通常位于跖跗关节的远端或第四至第五跖骨间关节的远端,即跖骨骨干近端1.5 cm处。它们是由跑步、足球和篮球等运动中的慢性重复性压力或某些生物力学异常引起的,如内翻足、胫骨内翻和近期负重活动增加。先在一侧皮质产生微骨折,随后向中间扩展,最终导致骨折。

发生在3区远端区域的骨折被称为“舞者骨折”。它们是典型的螺旋形骨折,由跖屈足的旋转力产生的轴向负荷引起。


对于骨折延迟愈合的患者,目前应用最广泛的分类是Torg基于影像学资料提出的。这些分类可以帮助临床医师调整治疗方案及预测骨折愈合时间。


  • 1型(急性期)以骨折线狭窄为特征的骨折,无髓内硬化,轻微皮质肥大,或无既往骨折史的骨膜反应(可能存在不适甚至疼痛);

  • 2型(延迟愈合期):骨折线宽度增加,涉及骨皮质、骨膜和髓腔硬化,既往有损伤或骨折史。

  • 3型(不愈合期):硬化骨髓腔,骨膜反应,通常与反复创伤史有关。



临床表现


患者的病史和体格检查对于区分急性骨折和应力性骨折非常重要。急性第五跖骨骨折患者表现为疼痛、局部肿胀、压痛、行走或负重困难,在某些情况下还有瘀斑。相反,出现应力性骨折的患者仅在前驱期的活动期间抱怨疼痛,这些症状通常会出现数周。一般来说,患者能够将疼痛局限在骨折区域,而30°至50°的脚内翻会导致最大的劳损和症状加重。由于骨折部位的活动度非常有限,因此很难触及骨折间隙和骨擦感。


应力性骨折的诱发因素,如以前的应力性骨折史、最近的剧烈活动、骨质疏松和内分泌疾病(糖尿病、甲状旁腺功能亢进、营养缺乏、绝经等)。女性患者应该评估血清钙、维生素D、营养缺乏和月经周期不规则史,因为这些可以提示代谢性骨病。最后,全面的足部和踝关节检查至关重要,评估整个下肢是否存在畸形,如高弓足或膝内翻。



影像学检查


为了减少放射学暴露,应根据渥太华足部规则(Ottawa Foot Rules)先经行查体。每个细微脚踝损伤的临床评估应该包括踝、舟骨和第五跖骨基底的触诊。如果患者中足疼痛,并且存在以下任何情况,即第五跖骨底部骨触痛、舟骨触痛以及无法立即和在急诊室内负重行走四步,则需要对足部损伤进行射线照相评估。有文献报道的这些规则的敏感性和特异性分别为100%和70%。


需要三个标准的负重位放射学检查,即前后位、侧位和30度或45度斜位。如果病人不能忍受负重带来的疼痛,可以在侧位视图中增加轻度的旋后位,以减少骨重叠。多达77%的撕脱骨折(特别是那些在结节尖端的)在标准足部x光片上可能会被遗漏,需要定期反复影像学检查。


应力性骨折的影像学特征在早期不显示。清晰的线状透光影通常出现在最初损伤后2-6周,伴有不同程度的骨膜反应。核磁共振成像和骨扫描可以指导医生在早期诊断可疑病例。CT可用于评估延迟愈合和不愈合,确认愈合或再骨折。双能X射线吸收测定法在多次骨折或反复出现骨不连的情况下可能是有用的。有些患者可能需要进行骨代谢检查,比如维生素D水平等。



治疗


保守或手术治疗取决于骨折类型、相关损伤和患者个体特征。有太多的非手术方法,包括弹性绷带支撑、非承重石膏、硬底鞋、短腿步行石膏和凸轮步行靴。手术方法包括髓内螺钉固定,张力带结构固定,以及低切迹钢板。


1区非移位和移位的结节撕脱性骨折

Dameron是第一个报道跖骨粗隆骨折在数周内临床愈合率高达97%;其他团队也报告了相同的结果。普遍认为,所有无移位或移位轻微的粗隆撕脱骨折应保守治疗;一项系统综述和荟萃分析表明,不同保守方法之间的骨折愈合率和再骨折率没有显著差异。3周的弹性包裹是足够的,硬底鞋、短腿鞋或凸轮步行靴也可以作为治疗选择。


移位大于2 mm或1区骨折粉碎时推荐手术,手术方案有很多种。超过三分之一的跖骨关节受累可能需要切开复位,使用张力带钢丝或小碎片螺钉(2.0-2.7毫米)进行螺钉固定;然而,研究发现后者临床效果更优越。使用远端尺骨钩板对于移位的粗隆撕脱骨折也具有良好的效果。最近的一项研究表明,1区骨折手术和非手术治疗的临床和放射学结果是相同的。在我们的实践中,我们很少手术治疗1区骨折,无论是移位的还是未移位的。即使骨折在放射学上没有“愈合”,无痛的纤维愈合也可能形成,因此不需要手术(图3)。临床效果不佳是罕见的,可能是由于骨性纤维愈合、关节不协调或骨痂内腓神经分支的卡压导致的。


图3.保守处理的1区损伤。(A)显示1区损伤的损伤正位、邪位和侧位X光照片。(B)在第6周,患者进入纤维无痛愈合。


2区Jones骨折

这些骨折的最佳治疗是有争议的,治疗应根据患者的需要和期望而个体化。一个问题是术语“Jones骨折”被运用于区域2和区域3骨折。总的来说,真正的Jones骨折应该用非负重治疗,因为负重会增加骨不连的发生率,尽管也有向“功能性治疗”发展的趋势,该“功能性治疗”包括完全负重并伴有全范围的活动。一些作者报道了成功的保守治疗。然而,由于该区域的分水岭区域,据报道,在非手术治疗后,2区和3区的不愈合率高达21%。愈合从内侧到外侧开始,6-8周后出现骨痂。如果在此期间没有骨痂,可以使用脉冲电磁场治疗试验,据报道愈合时间为3个月,范围为2-4个月。Portland记录了22例患者用螺钉固定后100%的愈合率,而一项随机试验报道急性Jones骨折石膏治疗与手术治疗相比有44%的失败率。Portland在利用4.5毫米的空心螺钉固定显示了100%的愈合率和无再骨折,恢复运动的平均时间为7.5周。Low等人研究了86名NFL运动员,显示手术和非手术治疗的愈合率分别为94%和80%98).几个系统综述得出结论,手术导致更短的愈合时间和更少的延迟愈合或不愈合。


髓内螺钉固定在临床被广泛运用(图4)。为了避免内固定失效(图5)和断裂,目前已有研究来评估螺钉在骨折部位实现复位和断端加压的临床效果。螺钉的直径应不小于4.5 mm,以便在骨折线上获得足够的压力,并且应始终使用能实现与致密皮质骨最大接触界面的最大螺钉。放射学研究证实,应该通过保持螺钉长度小于第五跖骨长度的68%来避免过长。有趣的是,年龄、直段长度和髓腔直径之间没有相关性。男性和女性的髓腔直径(5.2-4.8毫米)和第五跖骨弯曲处存在差异(无统计学意义)。外科医生在置入克氏针时应该考虑到这一点。


图4.显示3区损伤的术前正位和斜位x光照片。(B)显示髓内螺钉放置的术中透视。(C)术后3个月的正位和斜位x光照片显示完全愈合。


图5.(A)使用直径较小的髓内螺钉的术后视图。(B)术后2个月的x光照片显示髓内螺钉断裂。


新鲜骨折手术技术:病人仰卧位躺在射线可透过的桌子上,在同侧臀部下垫一个垫子,并使用止血带。用记号笔画出第五跖骨的线,并在靠近基部约2-3cm的近侧位置平行于第五跖骨髓腔做一个1cm的切口。识别并牵开任何小的腓肠神经分支,识别腓骨短肌和足底筋膜外侧带之间的间隔,并直接解剖至第五跖骨基底。切入点是至关重要的,经典地描述为“高且内”,即在背侧和内侧,正好在结节边缘的内侧和上方。将导针插入并推进到经过骨折处的髓腔中,然后将空心钻在导针上穿过几次以到达骨折部位,来打磨髓腔内硬化骨(陈旧性骨折)。根据手术前的模板尺寸,最初在导丝上使用较小的,例如5.5毫米的司工,并且基于其在C臂肉丝的间隙,最终使用适当尺寸的丝攻,例如6.5毫米。移除丝攻,最后将适当长度的螺钉推进到髓腔中,以实现良好的骨折压缩。空心螺钉不是优选的,因为它们的强度较低,容易出现内固定断裂及骨折不愈合。


在对延迟愈合或不愈合(Torg II和III型)进行手术时,切口从近端结节0.5 cm到骨折部位的远端,通常总长度约为3 cm。在切口的远端方面,暴露骨折部位,清除所有组织,并且用高速钻头和2.0 mm导丝打磨骨折断端硬化区,用于在其近端和远端方面制造多个钻孔。空心钻在骨折部位通过几次,试图打破髓内硬化。必要时可以在短短的植骨,随后,如前所述将实心螺钉穿过。在多个平面中获得最终的透视图像。可能的并发症包括再骨折,腓肠神经损伤、畸形愈合、延迟愈合/不愈合、螺钉头突出或慢性低位疼痛。适当的手术技术和适当的术后方案是减少这些并发症的关键。据报道,运动员的再骨折率相对较高,高达30%,因此可以采用替代方法,例如钢板固定.Duplantier的一项尸体研究显示了足底外侧钢板固定的良好结果,因为钢板可以抵抗来自第五跖骨的更大张力,并且比髓内螺钉承受更大的峰值载荷。在最近对38名运动员进行的足底固定研究中,有10.5%的再骨折率。这种技术在第五跖骨侧向弯曲或粉碎性骨折的情况下可能是优选的,但需要进一步的临床研究来更好地确定其作用。


在我们的实践中,通过知情同意程序,根据患者的需求和期望进行个体化治疗。如果决定进行非手术治疗,予以患者短腿石膏外固定,非承重6周,此后在疼痛允许的情况下,他们将被使用带有承重的凸轮步行靴。一旦患者无症状,开始物理治疗,在12周内逐渐恢复活动。在应力性骨折的情况下,非承重通常延长12周,并且通过临床和放射学对患者进行密切随访,以确定反应是否已经消退,即硬化的减少和髓腔的重建。如果准备对患者实施手术治疗,髓内螺钉固定是我们通常的首先,如上所述。术后,患者在1周后被置于非承重夹板中,并在另外3周内过渡到非承重石膏,然后在疼痛允许的情况下,在另外2周内逐渐过渡到在可拆卸的靴子和拐杖中部分承重。此时,允许患者进行某种程度的活动,例如固定自行车或游泳。在6周时,对愈合情况进行临床和影像学评估,如果骨折已经愈合,则允许完全承重,并逐渐恢复完全活动。如果骨折没有愈合,则建议使用骨刺激器,患者将恢复非负重状态,并通过临床和影像学密切观察愈合情况。在延迟愈合或不愈合的情况下,患者常规进行代谢检查以纠正任何缺陷,随后用如上所述的初次或修正髓内螺钉和骨移植骨髓抽吸浓缩物进行手术治疗对于竞技运动员来说,在完全恢复比赛之前,CT确认愈合是有保证的。


3区近端骨干应力性骨折

这些骨折通常出现较晚,称为“应力性骨折”。如果是急性的,非承重石膏与手术治疗的试验应与患者进行讨论。然而,后者可能在高需求的个体中更受欢迎,例如精英运动员。治疗类似于2区损伤如上所述。


Dancer骨折—骨干螺旋骨折

一般来说,非手术治疗对于这些骨折是优选的,并且非常有效,即使在竞技运动员中也不会留下后遗症。在最近的一项研究中,33名患者接受了靴子或硬底鞋治疗,至少随访了10个月,无论移位、缩短或旋转的程度如何,结果都很好。有9%延迟愈合,然而,所有患者最终愈合,平均愈合时间为8.3周。与靴子相比,硬底鞋表现出更好的结果。值得注意的是,尽管传统上与高性能运动员有关,因此被称为“舞者骨折”,但最近的一项研究显示,40岁以上女性的发病率增加,当该组出现低能量创伤时,应将其视为早期脆性骨折,应经行骨代谢检查。



并发症


尽管手术结果普遍成功,并发症依然可能出现,主要包括内固定失效(图5)和再断裂、腓肠神经损伤、畸形愈合、延迟愈合/不愈合、螺钉头突出、慢性低位疼痛,以及医源性骨折表1总结了第五跖骨骨折不愈合的原因。


表1.第五跖骨骨折不愈合原因。


高达12%的髓内螺钉固定病例会发生再骨折或骨不连。然而,在最近的研究中,对于髓内螺钉固定,优秀运动员的再骨折率可能高达30%,相对于钢板固定的10.5%。表2总结了评估骨不连发生率和后续治疗策略的文献。失败的可能原因可能与技术相关,例如螺钉尺寸/生物学不合适,未能同时解决诱发因素,如高弓足,以及术后管理不充分。在过去,据报道,在使用传统螺钉的髓内螺钉固定患者中,有多达30%的患者出现症状性硬件,现在使用骨折专用螺钉并且作者经常使用它们(图4B)。不建议使用埋头螺钉,因为难以拆卸。据报道,多达31%的病例发取出了内固定。值得注意的是,拆除内固定可能会产生压力,需要特别小心,尤其是运动员,在这种情况下,建议仅在退役后取出内固定,同时通过特定保护靴保护。


表2.第五跖骨骨折治疗方式的选择和骨不连发生率对比



结论


第五跖骨骨折的治疗存在挑战,特别是在运动员中。骨折位置和血管损害对治疗策略至关重要。骨折分为近端和远端,近端骨折因破坏滋养动脉而愈合困难。因此形成了所谓的“无血管区”。因此,在治疗策略中,应始终考虑骨折位置和潜在的血管损害。Jones骨折的定义存在分歧,建议使用Lawrence和Botte’s分类结合Torg的分类。


保守治疗和手术治疗是根据骨折类型、相关损伤和患者个体特征来决定的。关于第五跖骨骨折的手术治疗选择仍然存在争议,髓内钉固定伴或不伴植骨、张力带结构固定,以及低切迹钢板固定是最受欢迎的,尤其是在普通大众中。然而,根据骨折区域的不同,其中一些可以进行非手术治疗;手术固定可以使用髓内螺钉,尤其是对于2区和3区损伤的精英运动员,仍然需要手术治疗。相比之下,被认为具有并发症易感性的手术“高风险”患者,例如血管病或糖尿病神经病变患者,应接受非手术治疗。然而,需要进一步的高质量研究来评估其疗效和长期并发症。


治疗第五跖骨骨折的未来留下了几个研究领域。首先,应该进行尸体研究,评估骨髓腔几何形状的差异。影响手术效果的差异在其他领域也有发现,如髋关节成形术。通过髓内螺钉结合高阻力缝线(2号纤维线缝线环扎)固定,也提出了新的手术技术。在这次文献研究中,我们提供了一个思想框架;然而,最佳的策略应该是个性化的,以适应骨折和病人的因素。应该寻求多学科团队的意见,应该对患者进行全面的教育,并让其积极参与决策过程。



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