应力分散角和SchatzkerⅡ、Ⅲ型胫骨平台骨折的相关性研究

doi:10.3877/cma.j.issn.2096-0263.2024.01.005

背景

单纯通过X线诊断Schatzker Ⅲ型胫骨平台骨折易发生漏诊，我们定义了一个新的角度（应力分散角）并探索了这个角度和Schatzker Ⅱ、Ⅲ型骨折的相关性以求帮助减少Schatzker Ⅲ型胫骨平台骨折的漏诊。

方法

回顾性分析河北医科大学第三医院2015年12月至2022年10月收治的符合纳入标准的胫骨平台骨折患者145例（Schatzker Ⅱ型105例，Schatzker Ⅲ型40例），Schatzker Ⅱ型组男51例，女54例，平均年龄（46.08±1.53）岁；Schatzker Ⅲ型组男21例，女19例，平均年龄（50.10±2.09）岁。定义胫骨中线和胫骨平台外侧缘切线之间的角度为应力分散角，通过X线测量应力分散角。统计比较Schatzker Ⅱ型组和Schatzker Ⅲ型组的性别、年龄、BMI、术前合并症、致伤原因、应力分散角的差异。应用Logistic回归分析对结果进行检验。

结果

Schatzker Ⅲ型组的应力分散角（47.85±0.62）°大于Schatzker Ⅱ型组（37.38±0.38）°，差异有统计学意义（P<0.05）。与Schatzker Ⅱ型组相比，Schatzker Ⅲ型组的致伤原因差异有统计学意义（P<0.05），Schatzker Ⅲ型胫骨平台骨折受低能量损伤影响较大。2组在性别、年龄、BMI和术前并发症方面均无统计学意义（P>0.05）。将单因素分析中P<0.2的3个变量（年龄、致伤原因、应力分散角）与Schatzker Ⅱ、Ⅲ型胫骨平台骨折进行Logistic回归分析。Logistic回归分析证明只有应力分散角是Schatzker Ⅱ、Ⅲ型胫骨平台骨折的独立影响因素。

结论

应力分散角是Schatzker Ⅲ型胫骨平台骨折的影响因素，诊治应力分散角较大的膝关节外伤患者时，建议行膝关节CT检查，避免漏诊的发生。

关键词: 应力分散角, Schatzker分型, 胫骨平台骨折, 膝关节损伤

Background

Diagnosis of Schatzker type Ⅲ tibial plateau fractures by X-ray alone is prone to underdiagnosis, we defined a new angle (stress dispersion angle) and explored the correlation between this angle and Schatzker type Ⅱ and Ⅲ fractures to help reduce underdiagnosis of Schatzker type Ⅲ tibial plateau fractures.

Methods

Retrospective analysis of 145 patients with tibial plateau fractures (105 cases of Schatzker type Ⅱ and 40 cases of Schatzker type Ⅲ) admitted to the Third Hospital of Hebei Medical University from December 2015 to October 2022 who met the inclusion criteria, 51 men and 54 women in the Schatzker type Ⅱ group, with a mean age of 46.08 years; In the Schatzker type Ⅲ group, there were 21 males and 19 females, with an average age of 50.10 years. The angle between the midline of the tibia and the tangent line of the lateral margin of the tibial plateau was defined as the stress dispersion angle, and the stress dispersion angle was measured by X-ray. The differences in gender, age, BMI, preoperative comorbidities, cause of injury, and stress dispersion angle were statistically compared between the Schatzker type Ⅱ group and the Schatzker type Ⅲ group. Logistic regression analysis was applied to test the results.

Results

The stress dispersion angle in the Schatzker type Ⅲ group (47.85±0.62)° was greater than that in the Schatzker type Ⅱ group (37.38±0.38)°, and the difference was statistically significant (P<0.05). The difference in the cause of injury was statistically significant (P<0.05) in the Schatzker type Ⅲ group compared with the Schatzker type Ⅱ group, and Schatzker type Ⅲ tibial plateau fractures were more affected by low-energy injuries. There was no statistically significant difference between the 2 groups in terms of gender, age, BMI, and preoperative complications (P>0.05). Logistic regression analysis was performed to correlate the 3 variables (age, cause of injury, and stress dispersion angle) with Schatzker type Ⅱ and Ⅲ tibial plateau fractures with P<0.2 in the univariate analysis. Logistic regression analysis demonstrated that only the stress dispersion angle was an independent influence on Schatzker type Ⅱ and Ⅲ tibial plateau fractures.

Conclusion

Stress dispersion angle is an influential factor in Schatzker's type Ⅲ tibial plateau fracture, and when treating patients with knee trauma with a large stress dispersion angle, CT of the knee is recommended to avoid the occurrence of a missed diagnosis.

Key words: Stress dispersion angle, Schatzker classification, Tibial plateau fracture, Knee injuries

图1 应力分散角（胫骨中线和胫骨平台外侧缘切线之间的夹角）

图2 两种胫骨平台骨折患者的应力分散角比较

表1 Schatzker Ⅱ型组不同时间不同测量者的一致性检验

测量者	2023/6/1	2023/6/15	2023/6/30	ICC值	P值
测量者	Schatzker Ⅱ型组	Schatzker Ⅱ型组	Schatzker Ⅱ型组	ICC值	P值
测量者A	37.5±4.2	37.4±4.2	37.6±4.1	0.983	<0.001
测量者B	37.1±4.0	37.4±4.1	37.4±4.0	0.986	<0.001
测量者C	37.3±4.1	37.4±4.0	37.6±3.9	0.981	<0.001
ICC值	0.948	0.932	0.928
P值	<0.001	<0.001	<0.001

表1 Schatzker Ⅱ型组不同时间不同测量者的一致性检验

测量者	2023/6/1	2023/6/15	2023/6/30	ICC值	P值
测量者	Schatzker Ⅱ型组	Schatzker Ⅱ型组	Schatzker Ⅱ型组	ICC值	P值
测量者A	37.5±4.2	37.4±4.2	37.6±4.1	0.983	<0.001
测量者B	37.1±4.0	37.4±4.1	37.4±4.0	0.986	<0.001
测量者C	37.3±4.1	37.4±4.0	37.6±3.9	0.981	<0.001
ICC值	0.948	0.932	0.928
P值	<0.001	<0.001	<0.001

表2 Schatzker Ⅲ型组不同时间不同测量者的一致性检验

	2023/6/1	2023/6/15	2023/6/30	ICC值	P值
测量者	Schatzker Ⅲ型组	Schatzker Ⅲ型组	Schatzker Ⅲ型组	ICC值	P值
测量者A	47.7±4.1	47.8±4.1	47.9±4.1	0.988	<0.001
测量者B	47.6±4.0	47.8±4.0	47.8±4.1	0.989	<0.001
测量者C	48.0±3.7	47.9±3.9	48.1±3.8	0.993	<0.001
ICC值	0.948	0.951	0.947
P值	<0.001	<0.001	<0.001

表2 Schatzker Ⅲ型组不同时间不同测量者的一致性检验

	2023/6/1	2023/6/15	2023/6/30	ICC值	P值
测量者	Schatzker Ⅲ型组	Schatzker Ⅲ型组	Schatzker Ⅲ型组	ICC值	P值
测量者A	47.7±4.1	47.8±4.1	47.9±4.1	0.988	<0.001
测量者B	47.6±4.0	47.8±4.0	47.8±4.1	0.989	<0.001
测量者C	48.0±3.7	47.9±3.9	48.1±3.8	0.993	<0.001
ICC值	0.948	0.951	0.947
P值	<0.001	<0.001	<0.001

表3 Schatzker Ⅱ型组和Schatzker Ⅲ型组的相关影响因素比较

组别	例数	性别（例，男/女）	年龄（岁，±s）	BMI（kg/m²，±s）	致伤原因（例，高能量损伤/低能量损伤）	术前合并症（例，有/无）	应力分散角（°，±s）
Schatzker Ⅱ型组	105	51/54	46.08±1.53	27.98±0.33	91/14	10/95	37.38±0.38
Schatzker Ⅲ型组	40	21/19	50.10±2.09	27.22±0.51	28/12	6/34	47.85±0.62
统计值		0.179	1.592	0.175	5.468	0.885	0.012
P值		0.672	0.153	0.215	0.019	0.347	<0.001

表3 Schatzker Ⅱ型组和Schatzker Ⅲ型组的相关影响因素比较

组别	例数	性别（例，男/女）	年龄（岁，±s）	BMI（kg/m²，±s）	致伤原因（例，高能量损伤/低能量损伤）	术前合并症（例，有/无）	应力分散角（°，±s）
Schatzker Ⅱ型组	105	51/54	46.08±1.53	27.98±0.33	91/14	10/95	37.38±0.38
Schatzker Ⅲ型组	40	21/19	50.10±2.09	27.22±0.51	28/12	6/34	47.85±0.62
统计值		0.179	1.592	0.175	5.468	0.885	0.012
P值		0.672	0.153	0.215	0.019	0.347	<0.001

表4 各影响因素与Schatzker Ⅱ、Ⅲ型骨折的Logistic回归分析

入选变量	β值	Wald值	P值	OR值	95%置信区间
年龄	0.143	13.643	0.000	1.154	1.069，1.245
致伤原因	0.591	0.354	0.552	1.806	0.258，12.648
应力分散角	1.095	24.526	0.000	2.990	1.938，4.613

表4 各影响因素与Schatzker Ⅱ、Ⅲ型骨折的Logistic回归分析

入选变量	β值	Wald值	P值	OR值	95%置信区间
年龄	0.143	13.643	0.000	1.154	1.069，1.245
致伤原因	0.591	0.354	0.552	1.806	0.258，12.648
应力分散角	1.095	24.526	0.000	2.990	1.938，4.613

图3　男性，42岁，诊断：左胫骨平台骨折（Schatzker Ⅲ型），X线表现：外侧胫骨平台轻微塌陷　 图4~5　男性，42岁，诊断：左胫骨平台骨折（Schatzker Ⅲ型），CT表现：可轻易发现后外侧胫骨平台塌陷

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Relationship between stress dispersion angle and Schatzker type Ⅱ and Ⅲ tibial plateau fractures

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Relationship between stress dispersion angle and Schatzker type Ⅱ and Ⅲ tibial plateau fractures