Ⅰ型跟骨骨折6例漏诊报告
[摘要] 跟骨骨折是外科常见病，患者多是因为从高处坠落足跟忽然着地所致，诊断不难。但我院从2003年至2005年期间，就接诊6例跟骨首诊为正常，在复诊时为跟骨骨折，其漏诊原因：一是外科医生体格检查不够仔细，开申请单时仅要求拍摄跟骨侧位；二是放射科技师投照时亦机械“照章行事”，未采取多轴位拍摄所致。
[关键词] 跟骨；骨折；X线检查；漏诊
A Report for Drawing Wrong Conclusions of Six Broken Mode I Calcaneuses
GUO Chengjun,WU Xueqin
( Shiqiao Hospital of Jingmen ,Jingmen，Hubei 448270，China)
Abstract：Broken bone of calcaneuse is general sickness of surgical department.The patients who get this kind of sickness are mostly because they fall down from high places and their footroots hit the ground quickly first,so the doctors can draw correct conclusions easilyaccording to the patients' symptoms.But there were six wrong conclusions on broken calcaneuses from 2003 to 2005 in our hospital.The doctors thought the patients were healthy after the first checkup,but they decided that the patients had broken calcaneuses after the second checdup.Why? The first reason is that the doctors from surgical department examined the patients not carefully and wrote the applied prescriptions that only required to take calcaneus laterale photos for the patients;the second one is that the photographers from Xray department took the photos accordimg to the applied prescriptions,not took more necessary photos in axisverticalis、axis sagittalis and axis coronalis.
Key words：Calcaneus;Broken bone;Xray chedkup;Wrong conclusion
1 临床资料
1.1 一般资料
本组6例，均是从不同高处落下、足跟着地、跛行至我院门诊，就诊时间为1 h~24 h，就诊时诉足跟(foot root)部痛，查体见足后部及踝关节处不同轻重肿胀。6例患者中有男5例，女1例；年龄19岁~52岁，平均36.8岁。均为单侧跟骨(calaneus)骨折，右侧5例，左侧1例。所有患者首次检查时，遵医嘱均摄跟骨侧位片一张。
1.2 器械与方法
在复诊时均加摄轴位(axis)和对侧跟骨侧位，复诊时间3 d~5 d间。由两名有10a工作经验的放射科主治医生与技师共同参加投照与诊断，所用器械为北京东方FSK302-IA型程控X光机、8X10英寸超清晰型增感屏、天津天感胶片和LS-43OH型全自动软片冲洗机。投照条件50 mA、50 kV、0.25 s，焦片距为90 cm。轴位片均采取下上位：被检者坐摄影台上，被检侧下肢伸直，足尖向上，稍内旋，踝关节极度屈曲，足踵皮肤置胶片边缘即可。中心线向头端倾斜45°角，经内外踝边线的中点射入胶片。侧位片投照方法简单就不赘述。
1.3 X线表现
上述8例患者在首诊时，均拍摄跟骨侧位，其X线表现为跟骨形态均正常、骨小梁分布较均匀、骨皮质连续；在复诊时仔细观察同一患者两侧跟骨，侧位片上可见跟骨结节(tuder calcanei)轻微上移；再测量跟骨长度，发现病侧跟骨长径稍有缩短。轴位片上可见骨小梁分布不均匀、有部分增粗，骨皮质有不连续或稍凹陷、隆凸表现。
2 治疗
上述6例患者复诊后，均采用手法正复单纯石膏外固定，口服三七片、跌打丸等药，2周后可做足尖上翘活动小关节，6周后不负重锻炼踝关节，3月内严禁跟骨负重活动，6个月后复查恢复良好。
3 讨论
跟骨为足部最大骨骼，其主要由松质骨组成，周围有较薄皮质骨包绕，其分为前、中、后三部分，与其周围的距离(talus)、骰骨(oscuboideum)、舟骨(os naviculare)形成关节，而跟骨骨折常使足部桁架结构丧失了后方支撑，足弓塌陷，BOHLER角度小，消失甚至呈负角，跟腱相对延长，跟骨体皮质被挤而变宽，使足部生物力学破坏，严重影响足的承重、站立，行走日久后使距下关节因创伤致纤维性粘连，骨性关节炎引起长期慢性疼痛。因此，对于跟骨骨折准确复位及可靠固定有极大意义。对于Ⅰ型跟骨骨折常采用手法正复石膏外固定即可取得良好疗效，而我院6例Ⅰ型跟骨骨折漏诊，不同程度地影响了患者的康复，值得我们深思。今后，接诊患者时，对患者要详细询问，做好全面体格检查，对跟骨侧、轴位投照缺一不可，必要时可加照对侧做对比，确保诊断无误，治疗科学有效。
参考文献：
[1]Sanders R,Fortin P,Dipasquale T,et al.Operative treatment in 120 displaced intraarticular calcaneal fractures Results using a prognostic tomography scan classifiation[J].Clin Orthop，1993，290:8795.
[2]Anatomia corporis humani ISBN 711700083X/R.84.
荆门市拾桥卫生院，湖北 荆门 448270, http://www.100md.com(郭成军，吴雪琴)
[关键词] 跟骨；骨折；X线检查；漏诊
A Report for Drawing Wrong Conclusions of Six Broken Mode I Calcaneuses
GUO Chengjun,WU Xueqin
( Shiqiao Hospital of Jingmen ,Jingmen，Hubei 448270，China)
Abstract：Broken bone of calcaneuse is general sickness of surgical department.The patients who get this kind of sickness are mostly because they fall down from high places and their footroots hit the ground quickly first,so the doctors can draw correct conclusions easilyaccording to the patients' symptoms.But there were six wrong conclusions on broken calcaneuses from 2003 to 2005 in our hospital.The doctors thought the patients were healthy after the first checkup,but they decided that the patients had broken calcaneuses after the second checdup.Why? The first reason is that the doctors from surgical department examined the patients not carefully and wrote the applied prescriptions that only required to take calcaneus laterale photos for the patients;the second one is that the photographers from Xray department took the photos accordimg to the applied prescriptions,not took more necessary photos in axisverticalis、axis sagittalis and axis coronalis.
Key words：Calcaneus;Broken bone;Xray chedkup;Wrong conclusion
1 临床资料
1.1 一般资料
本组6例，均是从不同高处落下、足跟着地、跛行至我院门诊，就诊时间为1 h~24 h，就诊时诉足跟(foot root)部痛，查体见足后部及踝关节处不同轻重肿胀。6例患者中有男5例，女1例；年龄19岁~52岁，平均36.8岁。均为单侧跟骨(calaneus)骨折，右侧5例，左侧1例。所有患者首次检查时，遵医嘱均摄跟骨侧位片一张。
1.2 器械与方法
在复诊时均加摄轴位(axis)和对侧跟骨侧位，复诊时间3 d~5 d间。由两名有10a工作经验的放射科主治医生与技师共同参加投照与诊断，所用器械为北京东方FSK302-IA型程控X光机、8X10英寸超清晰型增感屏、天津天感胶片和LS-43OH型全自动软片冲洗机。投照条件50 mA、50 kV、0.25 s，焦片距为90 cm。轴位片均采取下上位：被检者坐摄影台上，被检侧下肢伸直，足尖向上，稍内旋，踝关节极度屈曲，足踵皮肤置胶片边缘即可。中心线向头端倾斜45°角，经内外踝边线的中点射入胶片。侧位片投照方法简单就不赘述。
1.3 X线表现
上述8例患者在首诊时，均拍摄跟骨侧位，其X线表现为跟骨形态均正常、骨小梁分布较均匀、骨皮质连续；在复诊时仔细观察同一患者两侧跟骨，侧位片上可见跟骨结节(tuder calcanei)轻微上移；再测量跟骨长度，发现病侧跟骨长径稍有缩短。轴位片上可见骨小梁分布不均匀、有部分增粗，骨皮质有不连续或稍凹陷、隆凸表现。
2 治疗
上述6例患者复诊后，均采用手法正复单纯石膏外固定，口服三七片、跌打丸等药，2周后可做足尖上翘活动小关节，6周后不负重锻炼踝关节，3月内严禁跟骨负重活动，6个月后复查恢复良好。
3 讨论
跟骨为足部最大骨骼，其主要由松质骨组成，周围有较薄皮质骨包绕，其分为前、中、后三部分，与其周围的距离(talus)、骰骨(oscuboideum)、舟骨(os naviculare)形成关节，而跟骨骨折常使足部桁架结构丧失了后方支撑，足弓塌陷，BOHLER角度小，消失甚至呈负角，跟腱相对延长，跟骨体皮质被挤而变宽，使足部生物力学破坏，严重影响足的承重、站立，行走日久后使距下关节因创伤致纤维性粘连，骨性关节炎引起长期慢性疼痛。因此，对于跟骨骨折准确复位及可靠固定有极大意义。对于Ⅰ型跟骨骨折常采用手法正复石膏外固定即可取得良好疗效，而我院6例Ⅰ型跟骨骨折漏诊，不同程度地影响了患者的康复，值得我们深思。今后，接诊患者时，对患者要详细询问，做好全面体格检查，对跟骨侧、轴位投照缺一不可，必要时可加照对侧做对比，确保诊断无误，治疗科学有效。
参考文献：
[1]Sanders R,Fortin P,Dipasquale T,et al.Operative treatment in 120 displaced intraarticular calcaneal fractures Results using a prognostic tomography scan classifiation[J].Clin Orthop，1993，290:8795.
[2]Anatomia corporis humani ISBN 711700083X/R.84.
荆门市拾桥卫生院，湖北 荆门 448270, http://www.100md.com(郭成军，吴雪琴)