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。