Malleol kırıkları ve kırıklı çıkık BT bulguları

Özet

Malleol kırıkları medial, lateral veya posterior eklem kenarını tek başına ya da birlikte tutabilir; kırıklı çıkıkta mortis içindeki talus da yer değiştirir. Grafiler posterior malleol tutulumunu ve eklem içi serbest cisimleri yeterince değerlendiremeyebilir; BT bu bulguların saptanmasına katkı sağlayabilir. Kırıklı çıkıkta BT, eklem yüzü yaralanmalarının ve olası eklem uyumsuzluğunun değerlendirilmesine ve cerrahi planlamaya katkı sağlayabilir. Kırıklı çıkıklarda eklem içi serbest cisimler ve eklem uyumsuzluğu eşlik edebileceğinden, değerlendirmede bu bulguların aranması önemlidir.

Faz ve pencere

Kontrastsız tanısal: Medial malleol, distal fibula/lateral malleol ve posterior tibial kenarda kortikal kırık, deplasman, eklem yüzü basamağı; distal tibiofibular incisurada fibula konumu ve talusun mortis içindeki translasyonu değerlendirilir. Kemik yaralanmasının değerlendirilmesinde BT, kemik lezyonları için en iyi görüntüleme yöntemidir; yumuşak doku patolojisinde ise MRG öne çıkar. Aksiyel kemik rekonstrüksiyonları posterior plafond ve fibular incisura katılımını; koronal-sagittal rekonstrüksiyonlar fragmanların eklem yüzleriyle ilişkisini, talar subluksasyonu ve eklem içi serbest parçaları gösterir.

Önerilen pencereler: Kemik (G 1800 / M 400).

BT bulguları

Medial malleol kırığı — medial tibial çıkıntıda eklem yüzüne uzanan veya eklem dışı kortikal ayrılma.
Lateral malleol kırığı — distal fibula kırık hattının sindezmoz seviyesinin altında, hizasında veya üstünde seyri.
Posterior malleol kırığı — posterior plafond kenarını içeren fragman; incisura fibularis içine uzanabilir.
Talar translasyon — talus, tibial plafond altında anterior, posterior, medial veya lateral yönde yer değiştirebilir.
Sindezmoz uyumsuzluğu — fibula incisura içinde normal konturuna oturmaz veya distal tibiofibular ilişki bozulur.
Osteokondral impaksiyon — talar kubbe ya da tibial plafond subkondral yüzünde çökme ve osteokondral fragman.
Eklem içi serbest fragman — malleol/plafond kırığından kopmuş parça tibia-talus eklem aralığında ayrı izlenir.

Ölçütler ve sınıflamalar

Danis-Weber: Danis-Weber sınıflaması distal fibula kırığını tibial plafond ve sindezmoza göre konumlandırır: A sindezmoz altında, B sindezmoz düzeyinde, C sindezmoz üstündedir. Medial ve posterior malleol yaralanmalarını tek başına tanımlamaz.
Lauge-Hansen: Yaralanmayı ayağın başlangıç pozisyonu ve uygulanan kuvvet yönüne göre mekanizma temelli evrelere ayırır; BT'de görülen her kemik fragmanının yerini ayrıca tarif etmek gerekir.

Normalde

Distal tibiofibular ilişki, BT'de distal fibulanın tibial incisura içindeki konumu değerlendirilerek incelenir.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s0685; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Pilon kırığı: distal tibia eklem yüzünün geniş bölümü ve metafiz birlikte parçalanır; malleol kenar kırıklarıyla sınırlı değildir.
Posterior malleol fragmanının şekli, fibular incisurayı tutup tutmadığı ve eklem yüzündeki basamak değerlendirilir; BT temelli sınıflamalar fragman morfolojisini tanımlamaya yardımcı olur.
Talar kubbe osteokondral lezyonu: ayak bileği kırıklı çıkıklarında talus veya distal tibial plafond kaynaklı osteokondral lezyonlar eşlik edebilir.
Distal fibula avulsiyon fragmanı: nonunion avulsion fracture, os subfibulare ile karşılaştırıldığında BT'de daha düzensiz şekilli ve pürüzlü kenarlı olabilir.
Maisonneuve yaralanması: ayak bileği sindezmoz bulgularına proksimal fibula kırığı eşlik eder; yalnız ayak bileği BT'si proksimal yaralanmayı dışlamaz.

Tuzaklar

Talus merkezlenmiş görünebilirken tek bir eklem yüzünde küçük osteokondral çökme bulunabilir; talar kubbeyi koronal ve sagittal düzlemlerde de tara.
Redüksiyon sonrası AP, lateral ve mortis grafileri redüksiyonun yeterliliğini değerlendirmeye yardımcı olur.
Sadece lateral malleol fragmanına odaklanıp posterior malleol ve incisura uzanımını atlama; bu uzanım sindezmoz mimarisini açıklar.
Ayak bileği görüntü alanı fibula başını içermiyorsa Maisonneuve kırığını dışlanmış kabul etme; tüm fibula grafisi veya uygun görüntüleme gereksinimini belirt.

Kendini dene

Ayak bileği BT'sinde fibula kırığı sindezmoz seviyesinin üzerinde ve talus laterale yer değiştirmiştir. En uygun yorum hangisidir?
Cevabı göster
Suprasindezmotik lateral malleol kırığına lateral tibiotalar çıkık eşlik ediyor. Kırık sindezmozun üzerinde olduğundan suprasindezmotik konumdadır; AO/OTA sınıflamasında 44C suprasindezmotik yaralanmayı belirtir. Talusun laterale yer değiştirmesi lateral tibiotalar çıkık yönünü tanımlar.
Üç ayrı kırık hattı medial malleolde, distal fibulada ve posterior plafond kenarında görülüyor. Bu örüntünün adı nedir?
Cevabı göster
Trimalleoler kırık. Medial, lateral ve posterior malleolün birlikte kırılması trimalleoler örüntüdür. Pilon kırığı, distal tibianın yük taşıyan eklem yüzünü tutan bir kırık örüntüsüdür; trimalleoler kırıklı çıkık ise kaynakta ayrı bir örnek olarak tanımlanmıştır.

İlgili konular

Kaynaklar

Bu sayfadaki 42 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 10 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.