胫骨Pilon骨折术后康复治疗1例

A Case Report of Postoperative Rehabilitation Treatment for Tibial Pilon Fracture

摘要: 病史摘要：患者，47岁男性，因“摔伤致左踝关节肿痛伴活动受限12天”，入院后行“左侧胫骨骨折切开复位钢板内固定术”。术后早期床旁康复治疗，术后1周转入康复医学科。症状体征：左踝关节肿胀疼痛伴活动受限、行走不能。VAS：4分。左下肢徒手肌力评定：左侧踝背伸–踇背伸–踝跖屈肌力约0-1-0级；左踝关节跖屈30˚状态，未见明显主动活动，PROM：背伸0˚，跖屈受限约30˚~38˚，内外翻0˚。AOFAS踝与后足功能评分20分。Barthel指数60分。诊断方法：患者有明确外伤史和手术史，左踝关节CT、MRI、超声及下肢神经电生理等相关检查提示左侧胫骨远端骨折、韧带损伤、胫后肌腱部分断裂和神经损伤，结合患者体征和功能受限诊断。治疗方法：在药物治疗的基础上，早期床旁康复介入，转科后予以运动疗法、手法治疗、作业治疗、神经肌肉电刺激、针刺、蜡疗、中药熏蒸等综合康复治疗。临床转归：疼痛评分下降，左踝关节主被动活动度改善，AOFAS踝与后足功能评分提升，Barthel指数明显改善，支具辅助下患者日常生活活动基本自理，回归家庭。

Abstract: History Summary: A 47-year-old male patient was admitted due to “swelling, pain, and limited mobility in the left ankle joint for 12 days following a fall injury”. He underwent “open reduction and internal fixation with a plate for a left tibial fracture”. Early bedside rehabilitation commenced postoperatively. He was transferred to the Department of Rehabilitation Medicine one week after surgery. Symptoms and Signs: Swelling, pain, and limited mobility in the left ankle joint; inability to walk. VAS: 4 points. Manual Muscle Testing (MMT) of the left lower limb: strength of left ankle dorsiflexion - great toe dorsiflexion - ankle plantarflexion approximately 0-1-0. The left ankle was fixed in approximately 30˚ of plantarflexion with no significant active movement observed. Passive Range of Motion (PROM): dorsiflexion 0˚, plantarflexion limited to approximately 30˚~38˚, inversion and eversion 0˚. AOFAS Ankle-Hindfoot Scale score: 20 points. Barthel Index: 60 points. Diagnostic Methods: The diagnosis was established based on a clear history of trauma and surgery, combined with findings from left ankle CT, MRI, ultrasound, and lower limb neurophysiological studies (electrophysiology). These investigations indicated a left distal tibial fracture, ligamentous injury, partial rupture of the posterior tibial tendon, and nerve injury, consistent with the patient’s clinical signs and functional limitations. Treatment Methods: Building upon pharmacotherapy, early bedside rehabilitation intervention was initiated. After transfer to the rehabilitation department, comprehensive treatment was implemented, including exercise therapy, manual therapy, occupational therapy, neuromuscular electrical stimulation (NMES), acupuncture, paraffin wax therapy, and traditional Chinese medicine herbal fumigation. Clinical Outcome: The pain score decreased. Active and passive range of motion in the left ankle joint improved. The AOFAS Ankle-Hindfoot Scale score increased. The Barthel Index showed significant improvement. With brace assistance, the patient achieved basic independence in activities of daily living (ADLs) and was discharged home.