Trimalleoler kırık

Özet

Trimalleoler kırıkta medial ve lateral malleole posterior tibial kenar kırığı eklenir; yaralanmaya mortis içinde talar subluksasyon veya çıkık eşlik edebilir. BT, üç parçanın yönelimini, posterior fragmanın incisura ve eklem yüzü ilişkisini ve arada kalmış serbest parçaları gösterir. Düz grafiye göre BT, posterior malleolus kırıklarını daha doğru şekilde saptar ve karakterize eder. Talar kayma veya eklem içi parça gözden kaçarsa kırıklı çıkığın eklem uyumu ve kemik bileşenleri eksik belgelenir.

Okuma sırası

1. Posterior malleol ve tibial plafond. Posterior malleolü aksiyel ve sagittal BT kesitlerinde izleyerek fragman boyutunu ve tibial eklem yüzü tutulumunu değerlendir.
2. Posterior malleol ve incisura. Posterior tibial kenarı aksiyel kesitlerde tarayın; fragmanın medial uzanımını ve fibular incisuranın arka sınırını tutup tutmadığını belirleyin.
3. Talar kubbe ve tibiotalar aralık. Ayak bileği kırıklı çıkığında BT ile eklem içi serbest parça bulunup bulunmadığını değerlendirin.
4. Eklem içi yapılar ve sindezmoz. Son olarak tibiotalar eklemdeki osteokondral lezyonlar, intra-artiküler serbest parçalar ve sinezdzmotik uyumsuzluk değerlendirilir.

Faz ve pencere

Kontrastsız tanısal

Trimalleoler kırıkta BT ile posterior malleol morfolojisi, incisura tutulumu ve eklem içi serbest parçalar değerlendirilir. Aksiyel, koronal ve sagittal kemik algoritmalı rekonstrüksiyonlar fragman yönelimini ve eklem yüzü uzanımını gösterir; intravenöz kontrast gerekmez.

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

BT bulguları

• Medial malleol kırığı — ayak bileği mortisini oluşturan medial malleolde gelişen kırık.
• Lateral malleol kırığı — distal fibulada kırık; seviyesi sindezmoza göre tarif edilir.
• Posterior malleol kırığı — posterior tibial eklem dudağında ayrılmış, deplase veya parçalı fragman.
• Posterior incisura uzanımı — posterior fragman distal fibulanın oturduğu çentiğin arka sınırını içerir.
• Talar subluksasyon/çıkık — talar kubbe mortis merkezinden kayar; eklem aralığı asimetrikleşir veya temas kaybolur.
• Eklem içi serbest parça — kırık kaynaklı kemik veya osteokondral parça tibia-talus eklem aralığında kalır.
• Talar kubbe osteokondral lezyonu — ayak bileği kırıklı çıkıklarına talus ve distal tibial plafondda osteokondral lezyonlar eşlik edebilir.
• Distal fibulanın incisura içindeki konumu ve rotasyonu BT'de değerlendirilebilir; sindezmoz uyumunun değerlendirilmesinde karşı taraf referans olarak kullanılabilir.

Ölçütler ve sınıflamalar

Lauge–Hansen

Ayak pozisyonu ve kuvvet yönüne dayalı mekanizma sınıflamasıdır; bazı bimalleoler ve trimalleoler örüntüler bu sisteme uymayabilir, posterior fragmanın BT morfolojisini tek başına tarif etmez.

Bartoníček–Rammelt posterior malleol sınıflaması

BT tabanlı beş tipli sınıflama posterior fragmanın incisura ve medial uzanımını da morfolojik olarak tarif eder. Haraguchi, Bartoníček–Rammelt ve Mason sistemleri kullanılmaktadır; literatürde evrensel olarak yerleşmiş tek bir sınıflama yoktur.

Normalde

Normal anatomide ayak bileği mortisini medial ve lateral malleoller ile distal tibia plafondu oluşturur. Aynı düzeylerde karşı tarafı kullanarak posterior eklem dudağını, tibiotalar aralığı ve sindezmoz kemik ilişkisini kıyaslayın; kırık kenarları ile düzgün normal korteksi ayırın. Ayak bileği mortisini oluşturan malleoller ve distal tibial plafond ile talusu mortis içinde stabilize eden bağlar dikkate alınarak talar konumu değerlendirilir; sindezmoz uyumunu değerlendirirken karşı taraf referans alınabilir.

Ayırıcı tanı

Bimalleoler kırık

medial ve lateral malleol kırıkları birlikte bulunur; posterior malleol kırığı da eşlik edebileceğinden ayrıca değerlendirilmelidir.

Pilon kırığı

plafondun daha geniş eklem yüzü ve metafiz bölgesi parçalanır; yalnız üç malleol fragmanıyla sınırlı değildir.

Posterior malleol kırığı

posterior tibial kenar fragmanı vardır, ancak diğer iki malleol kırık olmayabilir.

Talar osteokondral kırık

defekt talar kubbe yüzeyindedir ve tibial/medial/lateral malleol kırıklarının yerini tutmaz.

Eski malleol avulsiyon fragmanları

nonkaynamış lateral malleol avulsiyon fragmanları, os subfibulareye göre daha düzensiz şekilli ve pürüzlü kenarlı olabilir.

Tuzaklar

• Lateral ve posterior fragmanların üst üste geldiği grafi görünümünden posterior bileşeni atlama; BT'de posterior plafondu aksiyel ve sagittal düzlemde izle.
• Redüksiyon sonrası grafiler redüksiyonun yeterliliğini değerlendirmek için kullanılır; ayak bileği kırıklı çıkıklarında BT, grafilerde gözden kaçabilen eklem içi serbest parçaları gösterebilir.
• Posterior parçayı yalnız büyüklüğüne göre özetleme; incisura, medial uzanım, eklem basamağı ve interkaler fragman olup olmadığını ekle.
• Mortis içindeki her küçük kemik yoğunluğunu serbest parça sayma; kırık donör alanını ve parça çevresindeki kortikal kenarı takip et.

Kendini dene

1. Medial ve lateral malleol kırıklarına posterior plafond fragmanı da eşlik ediyor. Yaralanma örüntüsü nasıl adlandırılır?

   • Trimalleoler kırık
   • Bimalleoler kırık
   • Pilon kırığı
   • Maisonneuve kırığı
   Cevabı göster

   Trimalleoler kırık. Üçüncü bileşen posterior malleol kırığıdır; medial, lateral ve posterior malleolün birlikte tutulması trimalleoler örüntüyü tanımlar. Bimalleoler iki malleolü içerir; pilon plafond-metafiz parçalanmasını, Maisonneuve ise proksimal fibula yaralanmasını ifade eder.

2. Üç malleol kırığına ek olarak talus posteriora kaymış ve eklem aralığında ayrı bir kemik parçası görülüyor. BT raporunda hangi iki bulgu özellikle belirtilmeli?

   • Talar translasyon ve eklem içi parça
   • Kalkaneal çökme ve subtalar efüzyon
   • Naviküler skleroz ve Lisfranc aralığı
   • Aşil kalınlığı ve plantar fasya
   Cevabı göster

   Talar translasyon ve eklem içi parça. Talar translasyon mortis uyumunu, eklem içi parça ise olası mekanik engel oluşturan kemik bileşenini tarif eder. Diğer seçenekler ayak bileğinin trimalleoler yaralanma örüntüsüne ait değildir.

İlgili konular

• Malleol kırıkları ve kırıklı çıkık
• Posterior malleol kırığı
• Sindezmoz avulsiyon kırıkları
• Pilon kırığı

Kaynaklar

Bu sayfadaki 44 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.