距骨手术入路----后内侧入路
1、Indications 指征
This approach is utilized for posterior fractures of the talar body or posterior process fractures of the talus. This is a difficult-to-reach anatomical area, and medial or lateral osteotomies do not allow visualization here. A posteromedial approach provides an adequat
e view for fixation of fractures and debridement of debris.
此手术入路适用于距骨体后部骨折或距骨后侧突骨折。此区域不容易显露，内侧或外侧截骨，后内侧入路提供充足的固定骨折和清理碎骨块视野。
The posteromedial approach is ud rarely and would expo a fracture of the posterior process of the talus, but would not give visualization of the talar body, or the subtalar joint.
Fractures of the body of the talus most often require, particularly if they are more posterior, an osteotomy of the medial malleolus.
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后内侧入路通常很少使用，可以显露距骨后突骨折块，但是却无法看见距骨体，距下关节。距骨体骨折常常要求，特别是后方骨折块，内踝截骨。
Cas by courtesy of Dr. Steven Steinlauf, Florida, USA.上图Dr. Steven Steinlauf提供
almostAnatomy 解剖
tea
This rarely-ud approach is extremely uful and follows the plane between flexor hallucislongus and the Achilles tendon. The neurovascular structures lieposteromedially behind the medial malleolus and must be protected.
金星网此入路沿屈踇长肌和跟腱之间，血管神经束位于内踝的后内侧必须加以保护。
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全美超模大赛 谢霆锋Incision 切口
Skin incision 皮肤切口
Using the Achilles as the lateral boundary, and the neurovascular structures posteromedially, a skin incision is made centered over the subtalar joint using image intensification.
把跟腱作为外侧界，血管神经束的后内方，在CB透视下沿距下关节作纵行切口。
Superficial disction 浅层分离
The structures that run behind the medial malleolus are very important here. The most posterior structure, flexor hallucislongus, is identified so the surgeon can go posterior and lateral to it and medial to the Achilles tendon.
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切口位于屈踇长肌和跟腱
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Deep disction 深层分离
The tendon sheath of the flexor hallucislongus must be opened. This allows the retraction of the tendon together with the neurovascular bundle and gains exposure of the fracture. Lateral to the tendon sheath of the FHL is the posterior tubercle of the talus.
The surgeon must be careful not to be too proximal and mistake the distal tibia for the talus. Fixation and debridement can now be completed.distinct是什么意思
打开屈踇长肌腱鞘，这就可以牵开神经血管束并获得骨折端的显露。
屈踇长肌肌腱鞘外侧是距骨后结节
圣诞节的英文手术必须小心不要靠上，以免把胫骨认为是距骨，确认距骨后固定和清除碎骨块就可以开始了。
