在转子间骨折中，往往存在冠状位骨折并且发生率较高。冠状位的骨折形态可能会改变转子间骨折的分类。本文将介绍外侧壁与冠状位骨折线关系，及其对骨折稳定性判断和骨折分类的作用。 转子间骨折中的冠状位骨折线 根据3D-CT重建技术所得到的影像学图像，我们对于股骨转子间骨折的形态学认识愈发全面，能够发现许多X线片获取不到的信息。实际上，股骨转子间骨折大多存在冠状位骨折线，只是之前由于很难获得优质的股骨近端侧位片，才被我们所忽视。 早在1949年，Boyd-Griffin分型中就提及到冠状位骨折，其中II型为粉碎骨折，主要骨折线仍顺转子间走行，骨皮质有多处碎裂，且存在冠状面骨折线，复位更难。（图1）
2017年，Cho JW 等在文献中报告，通过X片发现，在股骨转子间骨折中：
冠状位骨折线与外侧壁 下图（图3和图4）总结了股骨转子间骨折冠状位骨块的累及情况。
根据冠状位骨块的累及情况，进一步划分为2种类型6种亚型（详见表1）：
——单纯大转子骨块 ——大-小转子骨块 ——大小转子连同后内侧皮质骨块
——大转子和小转子两个骨块 ——大转子骨块和小转子连同后侧皮质骨块 ——大小转子整体骨块和后内侧皮质骨块 其中，大转子冠状位骨块往往累及部分外侧壁（即后外侧）。
从研究结果中可以看出，在冠状位上只有单纯的大转子骨块时，外侧壁才是完整且安全的，其余情况外侧壁都是危险的或已经损伤的。 冠状位骨折线相关的骨折分型 冠状位骨折线在股骨转子间骨折中是广泛存在的，由于对冠状位骨折线的认识，不稳定骨折的范畴可能会扩大，部分A1型骨折可能也不稳定，甚至A1型骨折也需重新明确定义。 2015年，Tan BY 等提出外上方缺损对股骨转子间骨折稳定性的影响不容忽视，而且常常成为术中的技术陷阱。 也有不少学者将冠状位骨折线纳为新的分型特征，日本学者Futamura K等和我国的李开南教授就此做出了新的分型尝试。 Futamura K提出的外侧壁骨折亚型分型（图4）：
李开南教授提出的六部分骨折分型方法（图5）包括：
冠状位骨折线与外侧壁损伤分类 冠状位骨折线在股骨转子间骨折中的发生率高达约90%，且冠状位骨折线往往累及外侧壁后部，髓内钉固定时，主钉近端常部分裸露于骨质外。 马卓等认为，除了像AO分型、Evans-Jansen分型等基于正位判断股骨转子间骨折的稳定性外，还应该联合侧位、多角度判断骨折的稳定性：
研究方向 冠状位骨块的存在毋庸置疑。一系列问题需要在今后的临床研究中逐一证实：
参考文献： [1] Boyd HB, Griffin LL. Classifications andtreatment of trochanteric fractures. Arch Surg， 1949,58: 853–66. [2] Cho JW, Kent WT, Yoon YC, et al. Fracture morphology of AO/OTA 31-A trochantericfractures: A 3D CT study with an emphasis on coronal fragments. Injury, 2017, 48(2):277-284. [3] Tan BY, Lau AC, Kwek EB. Morphology and fixation pitfalls of ahighly unstable intertrochanteric fracture variant. J Orthop Surg (Hong Kong), 2015,23(2): 142-145. [4] Futamura K, Baba T, Homma Y, et al. New classification focusing onthe relationship between the attachment of the iliofemoral ligament and thecourse of the fracture line for intertrochanteric fractures. Injury, 2016,47(8): 1685-91. [5] Ma Z, Yao XY, Chang SM. The classification of intertrochantericfractures based on the integrity of lateral femoral wall. Injury, 2017, 48(10):2367-8. [6] 郑颖捷, 导师: 李开南. 基于计算机技术对股骨转子间骨折六部分分型的相关研究[D]:[硕士学位论文]. 遵义: 遵义医学院, 2017. 附文：Jae-Woo, Cho等发表论文的争论 【2017发表在 Injury】 针对Jae-Woo, Cho等2017年发表在Injury的论文，有读者评论 LETTER-TO-EDITOR： 时间: Oct 2017 来源：Ma Z, Yao XZ, Chang SM. The classification of intertrochanteric fractures based on the integrityof lateral femoral wall: Letter to the editor, Fracture morphology of AO/OTA31-A trochanteric fractures: A 3D CT study with an emphasis on coronalfragments Injury, 2017, 48(10): 2367-2368. 原文： Dear Editor, With great interest we read the article by Cho JW et al. entitled “Fracture morphology of AO/OTA 31-A trochanteric fractures: A 3D CT study with an emphasison coronal fragments”. In the conclusion of the article, coronal fragments of intertrochanteric fractures are objectively present and have a high incidence[1]. It is proven that 3D-CT plays an important role in entirely analyzing morphology of intertrochanteric fractures. The new knowledge of morphology of coronal fragments may change the classification of intertrochanteric fractures. We have some view about the classification of intertrochanteric fractures after reading this article. In the result, 10 cases of A1 have two part Great Trochater and Lesser Trochater coronal fragments [1]. According the AO/OTA classification, posteromedial fragment with lesser trochanter in pertrochanteric fracture is the characteristic of the type 31-A2. It means that pertrochanteric fracture is the type A2 if it has lesser trochanter fragment. Thus, we consider these 10 cases with two part Great Trochater and Lesser Trochater coronal fragments as A2 rather than A1. In our opinion, the type A1 fracture may have only single coronal fragment. In the AO/OTA classification, 31-A1 is simple pertrochanteric fracture with only two fragments. By this article, a high incidence of coronal fragments in intertrochanteric fracture including the type A1 is known. The description of the type 31-A1 may need to be revised. The classic type A1 fracture has a low incidence. The 31-A1 fractures with GLT coronal fragment only have a small remaining anterior portion of lateral femoral wall in fact. The lateral femoral wall of this typeis partially fractured. Therefore, they are unstable pertrochanteric fractures. In other words, not all of the type A1 fractures are stable. A new classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures was mentioned by using 3D-CT[2]. Coronal fragments of intertrochanteric fractures were also observed. Maybe it is time to change the past classification of intertrochanteric fractures. By Cho JW et al. coronal fracture lines start at the trochanteric summit and exit either through intertrochanteric crest, the lesser trochanter, or the posteromedial cortex[1]. When coronal fracture line exits through the lesser trochanter or the posteromedial cortex, the lateral femoral wall is partially fractured. We try to divide intertrochanteric fractures based on the integrity of Lateral Femoral Wall into three groups (Fig. 1). Group A fractures have the intact lateralfemoral wall, with Great Trochanter coronal fragement or not. Group B fractures are partial lateral femoral wall fractures. Group C fractures are complete lateral femoral wall fractures. This classification of intertrochanteric fractures is based on the integrity of lateral femoral wall on lateral view andlateral femoral wall can be considered as articular surface. Group B and C fractures are unstable and can’t be treated with SHS.
Disruption of lateral femoral wall converts an intertrochanteric fracture into a reverse oblique fracture equivalent and should be given a strong consideration in the decision matrix[3]. The classification of intertrochanteric fractures based on the integrity of Lateral Femoral Wall on lateral view may be useful for the decision matrix. 参考文献： [1] ChoJW, Kent WT, Yoon YC, Kim Y, Kim H, Jha A, et al. Fracture morphology of AO/OTA31-A trochanteric fractures: a 3D CT study with an emphasis on coronal fragments.Injury 2017; 48: 277–84. [2] Futamura K, Baba T, Homma Y, Mogami A, Kanda A, Obayashi O, et al. New classification focusing on the relationship between the attachment of the iliofemoral ligamentand the course of the fracture line for intertrochanteric fractures. Injury 2016; 47:1685–91. [3] Tawari AA, Kempegowda H, Suk M, Horwitz DS. What makes an intertrochanteric fractureunstable in 2015? Does the lateral wall play a role in the decision matrix?. J Orthop Trauma 2015; 29(Suppl. 4): S4–9. — END — |
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▲ 图1 股骨近端骨折的 Boyd-Griffin 分类
▲ 图2 A2型股骨转子间骨折的冠状位骨折线
▲ 图3 股骨转子间骨折冠状位骨折线穿出点的位置：a.大转子 b.小转子 c.后内侧皮质 
▲ 图4 股骨转子间骨折冠状位骨折线穿出点的位置示意图：1.大转子 2.小转子 3.后内侧皮质
▲表1 股骨转子间骨折AO/OTA各种分型的冠状位骨折线特征
▲ 图4 Futamura K提出的外侧壁骨折亚型分型
▲ 图5 李开南教授提出的六部分骨折分型方法
▲ 图5 侧位外侧壁损伤分型：A.完整 B.部分损伤 C.完全损伤
