踝关节扭伤的患者指南ppt课件.pptx

踝关节扭伤患者指南踝关节扭伤患者指南胜利油田中心医院手外科、足踝外科姜剑魁踝关节扭伤患者指南踝关节扭伤患者指南lAnkle Sprainl踝关节扭伤踝关节扭伤lA Patients Guide to Ankle Sprainl踝关节扭伤患者指南踝关节扭伤患者指南lIntroductionl简介简介lAnanklesprainisacommoninjuryandusuallyresultswhentheankleistwisted,orturnedin(inverted).Thetermsprainsignifiesinjurytothesofttissues,usuallytheligaments,oftheankle.l踝关节扭伤是生活中很常见的损伤，通常是由于踝关节内翻损伤所导致。术语“扭伤”一般指的是软组织的损伤，在踝关节，通常指的是韧带损伤。lThis guide will help you understandlhowananklesprainoccurslhowdoctorsdiagnosetheconditionlwhatcanbedonetotreatasprainll本指南旨在帮助你了解本指南旨在帮助你了解l踝关节扭伤是怎样发生的l如何诊断踝关节扭伤l如何治疗踝关节扭伤lAnatomyl解剖解剖lWhat part of the ankle is involved?l踝关节包括哪些结构？踝关节包括哪些结构？Anatomy解剖解剖What part of the ankle is involved?踝关节包括哪些结构？踝关节包括哪些结构？lLigamentsaretoughbandsoftissuethathelpconnectbonestogether.Threeligamentsmakeupthelateralligamentcomplexonthesideoftheanklefarthestfromtheotherankle.Theyaretheanteriortalofibularligament(ATFL),thecalcaneofibularligament(CFL),andtheposteriortalofibularligament(PTFL).Thecommoninversioninjurytotheankleusuallyinvolvestwoligaments,theATFLandCFL.Normally,theATFLkeepstheanklefromslidingforward,andtheCFLkeepstheanklefromrollinginwardonitsside.ll韧带是一种致密的带状组织，它把相邻骨关节连接在一起。踝关节外侧韧带复合体由三条韧带组成：距腓前韧带、跟腓韧带、距腓后韧带。踝关节内翻扭伤通常累及其中两条韧带：距腓前韧带和跟腓韧带。距腓前韧带防止踝关节前移，跟腓韧带防止踝关节过度内收。lAligamentismadeupofmultiplestrandsofconnectivetissue,similartoanylonrope.Asprainresultsinstretchingortearingoftheligaments.Minorsprainsonlystretchtheligament.Atearmaybeeitheracompletetearofallthestrandsoftheligamentorapartialtearofonlysomeofthestrands.Theligamentisweakenedbytheinjury;howmuchitisweakeneddependsonthedegreeofthesprain.ll韧带是由多股束带状结缔组织组成，很像是一股尼龙绳。扭伤会导致韧带的拉伤或撕裂。轻微扭伤仅仅导致韧带的拉伤。严重扭伤会导致韧带撕裂，而韧带撕裂既可能是韧带内全部束带的断裂，也可能是部分束带的断裂。韧带损伤后，其力量会减弱，具体减弱的程度取决于扭伤的程度。lThelateralligamentsarebyfarthemostcommonlyinjuredligamentsinatypicalinversioninjuryoftheankle.Inaninversioninjurytheankletiltsinward,meaningthebottomofthefootanglestowardtheotherfoot.Thisforcesallthepressureofyourbodyweightontotheoutsideedgeoftheankle.Asaresult,theligamentsontheoutsideoftheanklearestretchedandpossiblytorn.l踝关节外侧韧带损伤最常见于踝关节内翻损伤。何谓踝关节内翻损伤？就是发生扭伤时，扭伤的这只脚的足底朝向另外一只脚，这样全身的重量都集中于踝关节的外侧，结果导致了踝关节外侧韧带的拉伤或撕裂。lAsevereformofanklesprain,calledananklesyndesmosisinjury,involvesdamagetoothersupportiveligamentsintheankle.Thistypeofinjuryissometimescalledahighanklesprainbecauseitinvolvestheligamentsabovetheanklejoint.Inananklesyndesmosisinjury,atleastoneoftheligamentsconnectingthetibiaandfibulabones(thelowerlegbones)issprained.Recoveringfromevenmildinjuriesofthistypetakesatleasttwiceaslongasfromatypicalanklesprain.l有一种严重的踝关节扭伤，又称踝关节下胫腓联合损伤，累及踝关节的其他支持韧带。这种类型的踝关节扭伤又称高位踝关节扭伤，因为它累及的韧带位于踝关节上方。踝关节下胫腓联合损伤发生时，至少有一条连接胫腓骨远端的韧带发生拉伤或撕裂，即使是轻微的下胫腓联合损伤，其恢复时间至少是普通踝关节扭伤的两倍。lSymptomsl症状症状lWhat does an ankle sprain feel like?l踝关节扭伤后有哪些表现？踝关节扭伤后有哪些表现？lInitiallytheankleisswollen,painful,andmayturnecchymotic(bruised).Thebruisingandswellingareduetorupturedbloodvesselsfromthetearingofthesofttissues.Mostoftheinitialswellingisactuallybleedingintothesurroundingtissues.Theankleswellsasextrafluidcontinuestoleakintothetissuesoverthe24hoursfollowingthesprain.l踝关节扭伤发生后，最初的症状是肿胀、疼痛、淤青，这是由于撕裂的软组织内血管发生破裂，进而血液渗出到踝关节周围所致。随着扭伤后24小时或更长时间，额外的液体不断渗漏入组织，踝关节发生肿胀。lPeoplewhohavesprainedanankleoftenendupsprainingtheankleagain.Iftheanklekeepsturninginwithactivity,theconditioniscalledankleinstability.Patientswhohaveankleinstabilityloseconfidenceintheirankletosupportthem,especiallyonunevenground.Theyoftenhaveswellingaroundtheanklethatdoesntgoaway.Painandswellinginajointcancauseareflexwherethebodyturnsoffthemusclesaroundthejoint.Thiscancausetimeswhentheanklefeelslikeitisgoingtogiveway,meaningitmayhaveatendencytotwistagainveryeasily.l一旦踝关节发生过一次扭伤，就很容易再次发生扭伤。如果踝关节反复多次扭伤，这被称之为“踝关节不稳”，这种情况会导致患者对他们的踝关节的功能失去信心，尤其是在凹凸不平的路面行走时。这类患者的踝关节总是反复肿胀而不能消退。关节的疼痛和肿胀会反射性地使人们不使用关节周围的肌肉。这会不时地让人们感觉踝关节似乎将要垮掉了，也说是说踝关节更容易再次扭伤。lPeoplewhohavehadseveralmildanklesprainsoroneseveresprainarepronetoimpingementproblemsintheankle.Theligamentsthatweresprainedmaybecomeirritatedandthickened,causingthemtogetpinchedneartheedgeoftheanklejoint.l反复多次的轻度踝关节扭伤或一次严重的踝关节扭伤均可导致踝关节撞击综合征。扭伤韧带会发炎并增厚，导致在踝关节边缘附近出现撞击。lDiagnosisl诊断诊断lHow do doctors diagnose the condition?l医生是如何诊断踝关节扭伤的医生是如何诊断踝关节扭伤的lThediagnosisofananklesprainisusuallymadebyexaminationoftheankleandX-raystomakesurethattheankleisnotfractured.Aphysicalexaminationisusedtodeterminewhichligamenthasbeeninjured.Thedoctorwillmoveyourankleindifferentpositionsinordertochecktheligamentsandothersofttissuesaroundtheankle.Sometestsplacestressdirectlyontheankleligamentstoseeiftheanklehasbecomeunstableandtofindoutifoneormoreligamentshasbeenpartiallyorcompletelytorn.l踝关节扭伤的诊断通常是通过体格检查，然后拍摄X片排除踝关节骨折。体格检查可以判断哪一根韧带发生损伤。你的医生会在不同方向活动你的踝关节，以检查踝关节韧带和周围软组织。一些特殊的体检试验，直接把应力施加于踝关节韧带，通过踝关节的稳定程度来判断是否有韧带损伤，一根或多跟韧带损伤，是部分还是全部撕裂。lIfacompleteruptureoftheligamentsissuspected,yourdoctormayorderstressX-raysaswell.TheseX-raysaretakenwhiletheligamentsareplacedinastretchedposition.TheX-raywillshowaslighttiltintheankleboneiftheligamentshavebeentorn.l如果你的医生怀疑你的韧带全部撕裂，他会建议你去拍摄一个应力位的X片。所谓应力位X片即你拍片时，你的踝关节会被施加一个外力，以使得韧带处于张力状态。如果存在韧带撕裂，那么在X片上会表现出踝关节骨头的轻度倾斜。lTreatment治疗lWhatcanbedonefortheproblem?l如何治疗踝关节扭伤？lNonsurgicalTreatmentl非手术治疗lNonsurgicaltreatmentoptionsdependonwhetheryourproblemisananklesprainorankleinstability.l非手术治疗的选择取决于你遭受是踝关节扭伤还是踝关节不稳。lAnkleSprainl踝关节扭伤lThebestresultsafterananklespraincomewhentreatmentisstartedrightaway.Treatmentsareusedtostoptheswelling,easepain,andprotecthowmuchweightisplacedontheinjuredankle.AsimplewaytorememberthesetreatmentsisbythelettersinthewordRICE.lThesestandforrest,ice,compression,andelevation.l在扭伤发生后立即开始治疗，这有助于取得最好的结果。治疗方法包括：减轻肿胀、缓解疼痛、控制患足的负重。有一个简单的记住这些治疗手段的方法，即单词“大米”（RICE），它代表着踝关节扭伤的治疗方法：休息（rest）、冰敷（ice）、加压包扎（comprssion）、抬高患肢（elevation）lRest:Theinjuredtissuesintheankleneedtimetoheal.Crutcheswillpreventtoomuchweightfrombeingplacedontheankle.lIce:Applyingicecanhelpeasepainandmayreduceswelling.lCompression:Gentlecompressionpushesextraswellingawayfromtheankle.Thisisusuallyaccomplishedbyusinganelasticwrap.lElevation:Supportingyourankleabovethelevelofyourhearthelpscontrolswelling.l休息：损伤的组织需要时间恢复，使用拐杖有助于减少患足的负担。l冰敷：冰敷有助于缓解疼痛、减轻肿胀。l加压包扎：适当的加压包扎可以减轻踝关节的肿胀，通常是使用弹力绷带进行加压包扎l抬高患肢：将患肢抬高超过心脏水平，可以控制肿胀。lYourdoctormayalsoprescribemedications.Mildpainrelievershelpwiththediscomfort.Anti-inflammatorymedicationscanhelpeasepainandswellingandgetpeoplebacktoactivitysoonerafterananklesprain.Thesemedicationsincludecommonover-the-counterdrugssuchasibuprofen.Butneweranti-inflammatorymedicinescalledCOX-2inhibitorsshowpromisingresultsanddontseemtocauseasmuchstomachupsetandotherintestinalproblems.l你的医生也会给你开一些药物。一些止痛药可以缓解不适。消炎镇痛药物可以缓解疼痛减轻肿胀，可以让患者尽快的返回的到日常活动中去。这些药物包括常见的非处方药如布洛芬（芬必得）。还有一类新型的消炎镇痛药，属于COX-2抑制剂，具有更好的疗效，且不会引起胃部不适及一些其他的消化道问题。lAstreatmentprogresses,itishelpfultograduallybeginputtingweightthroughthejoint.Castshavefallenoutoffavorbecausesofttissuesweakenwhentheyarekeptimmobile.Butbracesthatcanbeworntosupporttheankle,butstillallowweightbearing,arethemostpopulartreatmentforhelpingreducestrainonthehealingtissues.l随着治疗的进行，患足逐步负重是有利于恢复的。石膏固定会减弱软组织的力量，所以一般不建议使用。佩戴踝关节支具既可以保护踝关节又可以允许患足负重，是帮助减少恢复中的组织扭伤的流行治疗方法。lHealingoftheligamentsusuallytakesaboutsixweeks,butswellingmaybepresentforseveralmonths.Yourdoctormaysuggestthatyouworkwithaphysicaltherapisttohelpyouregainfullrangeofanklemotion,improvebalance,andmaximizestrength.l韧带损伤的恢复通常需要六周时间，但肿胀可能会持续数月之久。你的医生会建议你与理疗师多接触，以帮助你重获踝关节的活动度、提高踝关节的平衡性及恢复踝关节的肌力。lAnkleInstabilityl踝关节不稳定lIftheankleligamentsdonothealadequately,youmayendupwithankleinstability.Thiscancausetheankletogivewayandfeeluntrustworthyonuneventerrain.Ifyourankleligamentsdonothealadequatelyfollowingananklesprain,yourdoctormaysuggestseveralthings.l如果踝关节扭伤没有得到充分的恢复，将会导致踝关节不稳。这会造成患者在凹凸不平的路面行走时，会感觉踝关节崩溃不值得信融赖。如果在踝关节扭伤后，踝关节韧带并未充分愈合，你的医生会给你以下几个建议：lChangesinyourfootwearmaybeprescribedtohelpkeepyouranklefromturningin.Placingaheelwedgeundertheouterhalfofyourheelblockstheanklefromrolling,asdoesaflaredheelbuiltintoyourshoe.Inextremecases,doctorsmayprescribeaplasticbrace,calledanorthosis,tofirmlyholdyouranklefromrockingsidetoside.Somepatientsfeelasenseofsteadinessfromwearinghigh-toppedshoes.Patientswithankleinstabilityshouldavoidwearinghigh-heeledshoes.l首先是改变你的鞋，以防止你的踝关节总是处于内翻状态。在你足跟底部外侧半放置足跟垫，可以阻止踝关节的内翻，或穿一双足跟外展的鞋也可以起到同样的效果。对一些严重踝关节不稳的患者，医生可能会推荐使用塑料支具，即所谓矫正器，它可以牢牢的固定踝关节，防止踝关节晃动。一些患者可以穿高帮鞋，这有助于提高踝关节的稳定性。踝关节不稳患者应该避免穿高跟鞋。lPhysicaltherapytreatmentswilllikelybeinitiatedtohelprestorejointrangeofmotion,strength,andjointstability.l理疗有助于恢复踝关节活动度，增强踝关节肌力及提高踝关节稳定性。lSmallnervesensorsinsidetheligamentareinjuredwhenaligamentisstretchedortorn.Thesenervesensorsgiveyourbraininformationaboutthepositionofyourjoints,asensationcalledpositionsense.Forexample,nervesensorsinyourarmandhandgiveyoutheabilitytotouchyournosewhenyoureyesareclosed.lTheligamentsintheankleworkthesameway.Theysendinformationtoyournervoussystemtoalertyouaboutthepositionofyouranklejoint.Aphysicaltherapistwillhelpyouretrainthissensationasawaytosteadytheanklejointandprotectyoufromsprainingyourankleagain.l当踝关节韧带拉伤或撕裂时，其内的一些小的神经感受器也会发生损伤。这些感受器用来帮助大脑确定关节的位置，这叫本体感觉。比如，你胳膊和手里的位置感受器能让你在闭眼的时候也能很准确的摸到自己的鼻子。踝关节韧带里的位置感受器也起着同样的作用，它们会告诉大脑踝关节的位置。理疗师会帮助你重建本体感觉以稳定踝关节并防止踝关节再次扭伤。lManypeoplewhohaveankleinstabilityhaveweaknessinthemusclesalongtheoutsideofthelegandankle.Thesearecalledtheperonealmuscles.Strengtheningthesemusclesmayhelpcontroltheanklejointandimprovejointstability.l很多踝关节不稳的患者，其小腿及踝关节腓侧肌肉的肌力会下降，这些肌肉一般指的是腓骨长短肌。加强这些肌肉的肌力有助于增强患者对踝关节的控制并提高踝关节的稳定性。lSurgeryl手术治疗lSurgeonswilloccasionallydoproceduresrightawayinathleteswhotearalateralankleligament.Inmostothercasesoftornankleligaments,surgeonswilltrynonsurgicaltreatmentsbeforedoingreconstructivesurgeryoftheligaments.l对于一些踝关节外侧韧带撕裂的运动员，外科医生会选择立即进行手术治疗，但对于其他普通人来说，在进行外科手术治疗之前，通常建议首先尝试非手术疗法。lLigamentTighteningProcedurel韧带紧缩术lChronicankleinstabilitycanhappenwhenthelateralankleligamentsarestretchedortornandtheanklekeepsgivingway.Surgerycanbedonetotightenthestretchedligamentsandimprovethestabilityoftheankle.ThesurgeryusuallyinvolvestheATFLandtheCFL.l当踝关节外侧韧带拉伤或撕裂时，会导致慢性踝关节不稳。可以将拉伤的韧带进行紧缩以提高踝关节的稳定性。手术通常是紧缩距腓前韧带和跟腓韧带。lInthisprocedure,anincisionismadeintheskinthatliesoverthelateralligaments.Usingascalpel,thesurgeoncutstheATFLandCFLinhalf.l沿着踝关节外侧韧带表面取切口，切开后皮肤后，显露距腓前韧带和跟腓韧带，使用刀片自其中部切断。lHolesaredrilledalongthelowerendofthefibulabone,thesmallboneofthelowerleg.Thetwoendsofthecutligamentareoverlappedandsewntogether.Thesurgeonusesthedrillholesinthefibulatoholdthestitchestothebone.l在腓骨（小腿的小骨头）远端钻孔，将切断的韧带两个断端重叠并缝合，通过腓骨远端的孔将韧带固定于腓骨。lAlargebandofconnectivetissuecrossesthefrontoftheanklejustbelowthelateralligaments.Thisband,calledtheankleretinaculum,holdsthetendonsinplace.Thesurgeonpullsthetopedgeoftheankleretinaculumupwardandsewsitintothefibula.Thishelpsreinforcethereconstructedligaments.ll踝关节下支持带，位于踝关节前方，恰好走形于踝关节外侧韧带的下方。通常，外科医生会将踝关节下支持带的上半部分缝合于腓骨远端，以加强重建韧带的力量。lThefollowingimagesshoweachstepoftheligamenttighteningprocedure:l下图将描述韧带紧缩术的过程：l第一步：自韧带中部切断l第二步；腓骨远端钻孔l第三步：韧带缝合于腓骨l第四步：缝合踝关节下支持带。lTendonGraftProcedurel肌腱移植术lAnothertypeofreconstructionisdoneusingatendongraft.Ifyoursurgeonfeelsthatthestretchedandscarredligamentsarenotstrongenoughtosimplyrepairinaligamenttighteningprocedure,thentheligamentsmustbereinforcedwithatendongraft.l另一种韧带重建术需要肌腱移植。如果外科医生认为将仅仅对拉伤或疤痕化的韧带进行紧缩重建，依然不够牢固，这时就需要移植肌腱来强化韧带。lInthisprocedure,thesurgeonremovesaportionofoneofthenearbytendonstouseasatendongraft.Thetendonmostcommonlyusedattachestheperoneusbrevismuscletotheoutsideedgeofthesmalltoe.Asectionofthistendonisputinplaceofthetornlateralligaments.l在这一手术过程中，术者会切取踝关节外侧临近肌腱的一部分进行移植。通常，会切取腓骨短肌腱的一部分，然后将其缝合于撕裂的外侧韧带。lAftermakingtheskinincision,thesurgeondrillsaholeinthefibulaneartheattachmentoftheoriginalligament.Aseconddrillholeismadeintheareawheretheligamentattachesonthetalus(theanklebone).l完成皮肤切口后，术者在踝关节外侧韧带于腓骨远端及距骨的止点附近钻孔。lThetendongraftisthenremoved(orharvested)andwovenbetweentheseholestorecreatetheligamentcomplex.l然后切取腓骨短肌腱，穿过腓骨与距骨的钻孔，以重建外侧韧带复合体。lAftersurgery,youwillprobablybeplacedinacastorbraceforaboutsixweekstoallowthetendonreconstructiontoheal.Followingremovalofthecast,physicaltherapywillberequiredtoregainfulluseoftheankle.l术后，踝关节需要使用石膏或支具固定六周，以使重建的韧带愈合。拆除石膏后，马上开始理疗，以获得踝关节功能完整的恢复。l康复lWhatwillittaketomakemyanklehealthyagain?l如何使踝关节重获健康。lNonsurgicalRehabilitationl非手术治疗后的康复lEvenifyoudontneedsurgery,youmayneedtofollowaprogramofrehabilitationandexercise.Doctorsrecommendthattheirpatientsworkwithaphysicaltherapistfortwotofourweeks.Yourtherapistcancreateaprogramtohelpyouregainanklefunction.Itisveryimportanttoimprovestrengthandcoordinationintheankle.l即使你没有接受手术治疗，你也需要接受一系列的康复锻炼计划。医生会推荐你在康复师的指导下进行康复锻炼，这一般需要两到四周的时间。理疗师会帮你制定康复计划，以恢复恢复踝关节的功能。其中，最重要的是恢复踝关节的力量及协调性。lSwellingandpainaretreatedwithiceandelectricalstimulation.Ifswellingintheankleissevere,therapistsmayalsoapplymassagestrokesfromtheankletowardthekneewithyourlegkeptinanelevatedposition.Thishelpsgettheswellingmovingoutoftheankleandbackintocirculation.Yourtherapistmayissueacompressionwrapandinstructyoutowrapyourankleandlowerlimbandtoelevateyourleg.l肿胀和疼痛可以通过冰敷和电刺激疗法进行治疗。如果肿胀很严重，理疗师可能还会采用按摩疗法，将你的患肢抬高，然后自踝关节向膝关节进行按摩。这有助于踝关节的消肿，并促使渗液返回入循环系统。理疗师会对你进行加压包扎，并指导你如何包扎你的踝关节和小腿。lTherapistsalsoapplyspecializedhands-ontreatmentcalledjointmobilizationtoimprovenormaljointmotion.Thesetreatmentsrestoretheglidingmotionwithintheanklejointwherethelowerlegmeetsthetalusbone.Thisformoftreatmentspeedshealingafterananklesprain,andithelpsreturnpeopleandplayersmorequicklytotheiractivityorsport.l理疗师还会采用特殊手动疗法，即所谓的关节活动疗法，用来提高踝关节的活动度。这些疗法可以提高胫距关节面的滑动度，加快踝关节扭伤后的康复速度，并使得普通患者和运动员更快的返回日常生活和运动中去。lAneffectivetreatmentforanklesprainsisdisctraining,whichusesacircularplatformwithasmallsphereunderit.Patientsplacetheirfeetonitwhiletheysitorstandandworktheanklebytiltingthediscinvariouspositions.Thisformofexercisestrengthensthemusclesaroundtheankle,anditimprovesjointsense(mentionedearlier).l还有一种踝关节扭伤的锻炼方式，称为圆盘训练。使用一个底部有一个小球的圆盘，患者可取站立位或坐位，将脚放置于圆盘之上，然后往不同方向旋转圆盘。这种形式的锻炼可以加强踝关节周围肌肉的肌力，并提高踝关节的本体感觉。lWhenyougetfullanklemovement,yourankleisntswelling,andyourstrengthisimproving,youllbeabletograduallygetbacktoyourworkandsportactivities.Ananklebracemaybeissuedforathleteswhointendtoreturnquicklytotheirsport.l当你的踝关节活动度得到完全的恢复，没有肿胀且肌力足够时，你就能逐步返回你的日常工作和运动中去。对于那些想尽快回到运动中去的运动员来说，最好穿戴踝关节支具。lAfterSurgeryl手术后的康复lPatientsusuallytakepartinformalphysicaltherapyaftersurgery.Rehabilitationaftersurgerycanbeaslowprocess.Youwillprobablyneedtoattendtherapysessionsfortwotothreemonths,andyoushouldexpectfullrecoverytotakeuptosixmonths.l接受手术治疗的患者术后通常会进行正式的理疗，术后的康复锻炼通常是一个缓慢的过程。你可能需要进行两到三个月的康复锻炼，而踝关节功能得到完全的恢复则需要半年时间。lRehabilitationproceedscautiouslyafterreconstructionoftheankleligaments.Mostpatientsareprescribedananklebracetowearwhentheyareupandabout,andtheyarestronglyadvisedtofollowtherecommendationsabouthowmuchweightcanbebornewhilestandingorwalking.Youmaybeinstructedtoputlittleornoweightonyourfootwhenstandingorwalkingforupto12weeks.Yourphysicaltherapistwillworkwithyoutomakesureyouareusingcrutchessafelyandonlybearingtherecommendedamountofweightonyourfoot.l踝关节韧带重建后的康复锻炼需要小心谨慎的进行。绝大多数的患者都需要穿戴踝关节支具，并且在站立或行走时，严格控制患足的负重量。术后12周内，确保你的患足不负重或轻微负重。你的理疗师会一直与你保持联系，以确保你能安全的使用拐杖，且患足承受适当负重量。lThefirstfewphysicaltherapytreatmentsaredesignedtoh