距骨骨折手术入路----前内入路

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1、Indications   指征Theanteromedialapproachisusuallyemployedincombinationwiththeanterolateralapproachinordertoobtainananatomicreductionofdisplacedandcomminutedfractures.前内入路通常与前外入路联合应用，以便对距骨获得解剖复位。Inthelesscommonsituationwherethefractureofthetalarneckisnotcomminuted,onecanobtain

2、ananatomicreductionandfixationusingonlytheanteromedialapproach.少数情况下，当距骨颈不是粉碎骨折，可以使用单纯前内入路获得解剖复位和固定。         Anatomy   解剖Onemustnotdamagethebloodsupplytothetalus.Theneckofthetalusreceivesbranchesfromthemedialandlateralside.Thebodyofthetalusissuppliedalmostexclusivelyfromitsp

3、osteromedialaspect.必须避免损伤距骨血供，距骨颈血运来自内侧和外侧面，距骨体则由后正中单独供应。           Theanteromedialapproachavoidsthesetwoneurovascularbundlesandprovidesaccesstothemedialtalusandsurroundingjoints.入路应避免两个神经血管束（隐神经大隐静脉束/胫后神经血管束）， 显露距骨内侧和周围关节           Skinincision   皮肤切口Thisincisionrunsfromthe

4、medialmalleolusproximallytothebaseofthefirstmetatarsaldistally.Formorecomplexfracturestheincisionmaybeextendedproximally. 切口起自内踝下级至第一跖骨基底。多数复杂骨折可能需要显露下极。         Itismostimportantnottodamagethedeltoidbrancheswhichariseposteromediallyandsupplythemedialtwothirdsofthetalarbody.

5、 不要损伤从后内侧分出供应距骨体2/3部分血管分支。          Exposureoftheanteromedialtalarneck显露前内侧距骨颈Onceskinandfasciaareincised,oneencountersthefracturehematomawhichshouldbeevacuatedinordertoexposetheunderlyinginfero-medialaspectoftheneck,andthefracture.切开皮肤和筋膜后，清除骨折端血肿，显露下面距骨颈下内侧面和骨折。Thearrowpoi

6、ntstoasimplefractureofthetalarneck,whichislesscommon. 下图显示个简单距骨颈骨折，这个损伤很少见。     Debridementofsubtalarjoint    切开距下关节Thefracturesonthemedialsideareoftenmultifragmentary.Fragmentswhicharedisplacedintothesubtalarjointmustbedebridedtoallowananatomicreductionofthesubtalarjoint.内侧

7、面骨折都通常都是复杂骨折，骨折块落入距下关节必须被清除，以便解剖复位距下关节。Restorationoflength,ifthefractureiscomminuted,dependsonanatomicreductionofthelateralaspectofthetalarneck.如果骨折是复杂的，距骨外侧面解剖复位可以恢复距骨长度。