《中文骨折概论》PPT课件.ppt

Dept. Orthopedics, 1st Hospital SUMS,General Concept of Fracture 骨科概论,Weiming LIAO (廖威明) Dr.Med. Ph.D. Prof. Dept. of Orthopedic Surgery First Affiliated Hospital, Sun Yatsen University 中山大学附属第一医院骨科,Dept. Orthopedics, 1st Hospital SUMS,学习要点 Key points,Definition of frac. And causes of fracture 骨折定义，骨折原因 Classification of frac. 骨折分类 Stability of frac and factors causing displaced frac 骨折稳定性，引起骨折移位的因素 Factors influencing bone union (healing) 影响骨折愈合的因素,Dept. Orthopedics, 1st Hospital SUMS,Key points,Specific signs of frac 骨折特有体征 Complication of frac 骨折并发症 Principle of fracture treatment 骨折治疗原则 Emergent treatment for frac 骨折的急救处理,Dept. Orthopedics, 1st Hospital SUMS,骨折定义Definition,骨折骨的连续性中段 A fracture is a break in the continuity of a bone.,Dept. Orthopedics, 1st Hospital SUMS,外力引起骨折 Forces fracture,Direct violence (直接暴力) Indirect violence （间接暴力） Forceful pull of muscles（肌肉拉力引起撕脱骨折） Repeated stress（重复应力引起疲劳骨折） -cause fatigue fracture Bone disease（骨病变引起病理骨折） -pathological frac,Dept. Orthopedics, 1st Hospital SUMS,直接暴力引起横断骨折，粉碎性骨折 Direct violence,Dept. Orthopedics, 1st Hospital SUMS,直接暴力Direct violence,间接暴力引起螺旋型骨折 Indirect violence (rotational),骨肿瘤容易并发病理骨折 Bone tumor,Dept. Orthopedics, 1st Hospital SUMS,直接暴力Direct force,间接暴力引起骨折和脱位Fracture & dislocation caused by Indirect violence,车祸 Car accident,Dept. Orthopedics, 1st Hospital SUMS,骨折分类：闭合 / 开放骨折 Closed / open fracture,根据骨折断端是否与皮肤或体腔相通，分为开放性和闭合性骨折 Based on whether there is communication between fracture and skin (body cavities) 闭合骨折 Closed fractures 开放骨折 Open fractures: 伤口容易引致感染，因此，需要急诊手术处理伤口和骨折,Dept. Orthopedics, 1st Hospital SUMS,Open frac,Dept. Orthopedics, 1st Hospital SUMS,Patterns of fracture 骨折类型,Incomplete fracture 不全骨折 Complete fracture 完全性骨折,Dept. Orthopedics, 1st Hospital SUMS,不全骨折 Incomplete fracture: partial break,Crack fracture（裂纹骨折） Greenstick fractures in children 青枝骨折 不完全性骨折容易引起漏诊,Dept. Orthopedics, 1st Hospital SUMS,.,儿童的青枝骨折 Greenstick fracture of distal tibia occurs in children,Dept. Orthopedics, 1st Hospital SUMS,Complete fracture 完全性骨折,大多数的骨折属于完全性骨折 Complete break of the injured bone Most fractures,Dept. Orthopedics, 1st Hospital SUMS,骨折类型 Patterns of fracture,根据骨折线、形状和程度可分为 Based on fracture line / shape / degrees : Transverse fracture（横形） Oblique（斜形） Spiral （螺旋形） Comminuted (with more than two fragments）（splintered)（粉碎性） Compress fra. / crush fracture（压缩性） Impacted fracture （嵌插）,Dept. Orthopedics, 1st Hospital SUMS,Stability of fracture 骨折的稳定性,稳定型骨折 Stable fracture: 复位后不容易发生移位的骨折，如横型骨折、嵌插骨折、青枝骨折等 not easily displace after reduction transverse, compacted, greenstick 不稳定骨折 Unstable: 复位后容易发生移位，如斜型骨折、螺旋型骨折，粉碎性骨折等 a tendency to redisplace after reduction oblique, spiral and communited fracture,Dept. Orthopedics, 1st Hospital SUMS,Factors for fracture displacement 骨折移位的因素,1. Force from the injury（外力） 2. Gravity or weight of distal part of affected limb（重力） 3. Pull of muscles around the fracture （肌肉牵拉力） 4. Incorrect moving of the patient and unsuitable manipulation（人为因素）,Dept. Orthopedics, 1st Hospital SUMS,Type of fracture displacement 骨折移位类型,Angulation 成角 Lateral displacement 侧方移位 Overlap displacement 重叠 Separate displacement 分离 Rotational 旋转 Comminuted frac. 粉碎 mix together 混合 多数骨折为混合型骨折,Dept. Orthopedics, 1st Hospital SUMS,骨折的类型与移位,与治疗选择有关 与预后有关,Dept. Orthopedics, 1st Hospital SUMS,.,完全 Complete frac 横型 Transverse frac. 成角 Angulation 稳定 Stable frac.,Dept. Orthopedics, 1st Hospital SUMS,.,完全 Complete frac. 斜型 Oblique frac. 不稳定 Unstable frac. 成角 Angulation disp.,Dept. Orthopedics, 1st Hospital SUMS,.,完全 Complete frac. 螺旋 Spiral frac. 短缩重叠 Shortening (overlap) 侧方移位 Lateral disp. 分离 Separate frac. 不稳定 Unstable frac.,Dept. Orthopedics, 1st Hospital SUMS,.,粉碎 Comminuted frac.,Dept. Orthopedics, 1st Hospital SUMS,多发骨折 Multiple fracture,Dept. Orthopedics, 1st Hospital SUMS,.,多发 Multiple segmental frac. 粉碎 Comminuted frac.,Dept. Orthopedics, 1st Hospital SUMS,.,Coxa Vara 髋内翻 分离 Separate 粉碎 comminuted,Dept. Orthopedics, 1st Hospital SUMS,.,请分析骨折类型 What is the type of fra.?,Dept. Orthopedics, 1st Hospital SUMS,Healing of fracture 骨折愈合,骨折愈合时间与众多因素有关，包括年龄，全身情况，局部血供，骨折部位和类型 骨折愈合通常需要68周以上 How long does a fracture take to unite? Depend on many factors: - age, patient condition, local blood supply, type and site of fracture,Dept. Orthopedics, 1st Hospital SUMS,.,骨痂 Callus in fracture healing,Dept. Orthopedics, 1st Hospital SUMS,Factors that influence union 影响骨折愈合因素,General condition全身情况 Age 年龄 Healthy condition 健康状况 疾病情况,Dept. Orthopedics, 1st Hospital SUMS,影响骨折愈合的局部因素 Local factor for fracture union,Types of bone 骨的类型 Sites, types, severity of fracture 骨折因素 多发骨折、分离骨折、粉碎骨折、股骨颈骨折、胫骨远端骨折等影响骨折愈合 union multiple frac. Separate frac. Comminuted frac. femoral neck frac. distal part of tibia,Dept. Orthopedics, 1st Hospital SUMS,影响骨折愈合的局部因素 Local factor for fracture union,Blood supply 血供，局部血供与骨折的解剖部位、骨折类型、严重程度、软组织损伤程度和感染有关 Related with anatomical site, types, severity of fracture and soft tissue injure Severe injury of soft tissue Infection,Dept. Orthopedics, 1st Hospital SUMS,影响骨折愈合的因素 Factors that influence union,不恰当的处理 Unsuitable management: 反复多次复位 repeated reduction 过度牵引 excessive traction: separation 不恰当的运动 unsuitable immobility: movement 固定不可靠 unstable fixation,Dept. Orthopedics, 1st Hospital SUMS,Clinical manifestation of fracture (骨折临床表现）,History: injury 外伤史 General condition 全身情况: Shock? Hemorrhage? 是否有休克、出血 Damage to brain? To lungs and heart? To abdomen? To spinal cord? To others? 是否有重要器官损伤？ It is important to look for other injuries. 重视重要器官损伤是重要的,Dept. Orthopedics, 1st Hospital SUMS,骨折的局部表现 Local manifestation,Specific signs of fracture 骨折特有体征 Deformity 畸形 Abnormal mobility (movement between the fragments) 反常活动 Crepitus 骨擦感或骨擦音 三者中有一可作出诊断，但三者都没有不可以否定骨折 One of them can make diagnosis Caution: none of them is found in some fractures.,Dept. Orthopedics, 1st Hospital SUMS,骨折的其他表现，但没有特异性 Other signs of fracture not specific,Swelling 肿胀 Bruising (ecchymosis) 淤斑 Tenderness 压痛 Impairment of function 功能障碍 以上表现没有特征性，但可提供参考 All sings above are not specific to fracture.,Dept. Orthopedics, 1st Hospital SUMS,当你处理骨折患者时，需要了解Ask yourself when you deal with a fracture,A wound? Open fracture?是否开放骨折 Any impairment of circulation? 局部血液循环情况 Any evidence of nerve injury? 是否有神经损伤？ Any evidence of visceral injury? 是否有重要器官损伤？ Compartment syndromes? 是否有骨筋膜室综合 骨筋膜室综合征,Dept. Orthopedics, 1st Hospital SUMS,Test for checking circulation 检查患肢血循环,Color 皮肤颜色 Warmth 皮温 Arterial pulse 搏动 Capillary return 毛细血管回流 Nerve conductivity 神经功能 Specific tests: Doppler ultrasonography or arteriography 特殊检查：超声，血管造影,Dept. Orthopedics, 1st Hospital SUMS,影像学检查 Radiographic examination,X线检查是最基本、最必须的检查 X线照片可明确骨折的部位、类型 X-ray (plain film) is important, basic and inevitable for diagnosis and treatment. X-ray can show: fracture Site of fracture Type of fracture,Dept. Orthopedics, 1st Hospital SUMS,X线检查 X-ray examination,需要对有怀疑骨折的病人进行X线检查 Must take X-ray film for each suspect fracture,Dept. Orthopedics, 1st Hospital SUMS,股骨粗隆间骨折 Intertrochanteric facture of femur,Dept. Orthopedics, 1st Hospital SUMS,多发骨折 Multiple frac,Dept. Orthopedics, 1st Hospital SUMS,A-P view show normal,Lateral view show displacement,正侧位检查的必要性,Dept. Orthopedics, 1st Hospital SUMS,A-P view,Lateral view,X线检查的正侧位 Two direction views,Dept. Orthopedics, 1st Hospital SUMS,CT or MRI,骨盆、脊柱等一些特殊部位需要CT或MRI检查 意义：骨折移位情况，与周围结构的关系，指导治疗 Necessary in fractures of spine and pelvis, or in some specific frac. Significance: displacement of fragments Relation between fragments and nearby structure Guide for treatment,Dept. Orthopedics, 1st Hospital SUMS,髋臼骨折 Acetabular frac.,Dept. Orthopedics, 1st Hospital SUMS,Complication of fracture 骨折并发症,Early complication 早期并发症 1. Shock 休克 2. Infection 感染 3. Viscera injury 内脏损伤 肋骨骨折 Rib fracture injure to lungs, liver, spleen(rupture) 骨盆骨折 Pelvic fracture injure to bladder, rectal,Dept. Orthopedics, 1st Hospital SUMS,Complication of fracture,4. Main artery or vein injury 血管损伤 5. Spinal cord injury 脊髓损伤 6. Peripheral nerve injury 周围神经损伤 7. Lipoembolization 脂肪栓塞 8. compartment syndrome 骨筋膜室综合征,Dept. Orthopedics, 1st Hospital SUMS,Middle and late stage complication 后期并发症,1. Pneumonia 肺炎 2. Bed sore 褥疮 3. DVT 深静脉血栓形成 4. Ossification (ossifying myositis) 骨化性肌炎,Dept. Orthopedics, 1st Hospital SUMS,Complication of fracture,5. Traumatic arthritis 创伤性关节炎 6. Stiff of joint 关节僵硬 7.ischemic necrosis of the affected bone 骨坏死 8.Ischemic contrature of the affected muscle 缺血性肌挛缩 9. Bone atrophy, Sudecks atrophy 骨萎缩 10.感染、骨髓炎,Dept. Orthopedics, 1st Hospital SUMS,Treatment of fracture 骨折治疗,First aid 急救: 1. Save lives 抢救生命 2.dressing of wound and control bleeding (hemostasia) 包扎伤口，止血 3.temporary immobilization of the fractured limbs 骨折临时固定 4.rapid transportation 迅速送医院,Dept. Orthopedics, 1st Hospital SUMS,Princeple of Treatment for fracture 骨折治疗原则,Reduction 复位 Immobilization 固定 Preservation of function or functional exercise 功能锻练,Dept. Orthopedics, 1st Hospital SUMS,Reduction 复位,Restore to normal position - Correct deformity 注意骨折的对线和对位 Alignment is more important than apposition,Dept. Orthopedics, 1st Hospital SUMS,Methods of reduction 复位,Close reduction (manual) 闭合复位 Open reduction (operation)开放复位,Dept. Orthopedics, 1st Hospital SUMS,Close reduction (manual) 手法复位,Dept. Orthopedics, 1st Hospital SUMS,Immobilization 固定 - Maintain position after reduction,Methods 固定方法: 非手术：石膏、小夹板 手术：各种内固定,Dept. Orthopedics, 1st Hospital SUMS,牵引 Continuous Traction,具有复位和固定的作用，需要较长时间的卧床 Effect: Reduction and Immobilization,Dept. Orthopedics, 1st Hospital SUMS,牵引类型 Types of traction,皮肤牵引 Skin traction 骨牵引 Skeletal traction,Dept. Orthopedics, 1st Hospital SUMS,外固定支架，用于开放性骨折 External fixation instrument special use for open fracture,Dept. Orthopedics, 1st Hospital SUMS,Dept. Orthopedics, 1st Hospital SUMS,骨折治疗的选择 Choice of treatment method,保守治疗 Conservative treatment 手术治疗 operation,Dept. Orthopedics, 1st Hospital SUMS,保守治疗的适应症 Indication of Conservative treatment,多数的闭合稳定型骨折 不适合手术者,Dept. Orthopedics, 1st Hospital SUMS,手术适应症 Indication for operation,闭合复位失败 Close reduction is difficult or fail 不稳定骨折 Unstable fracture 开放骨折 Open fracture 关节内骨折 Fracture involve joint 并发神经血管损伤 Complicate blood vessel and nerve injury 多发骨折 multiple fractures 需要早期活动者 Need early mobility for some patients,Dept. Orthopedics, 1st Hospital SUMS,手术治疗的优点 Advantages of operation for fracture,解剖复位 Anatomical reduction 早期活动 Allow Early exercise 避免长期卧床 Avoid to lie in bed for a long time 避免关节僵硬 Avoid joint stiff,Dept. Orthopedics, 1st Hospital SUMS,内固定的形式 Some Examples of internal fixation,Dept. Orthopedics, 1st Hospital SUMS,., Intramedullary nail Special for intertrochanteric Frac. & proximal part fracture of femur.,Dept. Orthopedics, 1st Hospital SUMS,手术的缺点 Disadvantages and Complications of operation,感染机会 Infection 内植物失败 Implant failure 手术风险 Dangerous to some patients,Dept. Orthopedics, 1st Hospital SUMS,Examples of operation,.,Dept. Orthopedics, 1st Hospital SUMS,Interlocking medullary nail 交锁髓内钉,Dept. Orthopedics, 1st Hospital SUMS,Plate and screw,Dept. Orthopedics, 1st Hospital SUMS,Frac. Healing After removing plate and screw,Dept. Orthopedics, 1st Hospital SUMS,Interlocking medullary nail,Dept. Orthopedics, 1st Hospital SUMS,A-p position,Lateral position,Supracondylar frac.,Dept. Orthopedics, 1st Hospital SUMS,.,A-p position,Lateral position,Fixed by plate and screw,Dept. Orthopedics, 1st Hospital SUMS,Fixed by K wire,Fixed by k-wire,Dept. Orthopedics, 1st Hospital SUMS,Plate broken,Replaced by interlocking nail,Dept. Orthopedics, 1st Hospital SUMS,Both conservative and operative method are available,Dept. Orthopedics, 1st Hospital SUMS,A-P view,Dept. Orthopedics, 1st Hospital SUMS,.,DCS Dynamic Condylar Screw,Comminuted frac. Of femoral intercondyle,Dept. Orthopedics, 1st Hospital SUMS,.,Multiple frac. Indication for op,Dept. Orthopedics, 1st Hospital SUMS,Dept. Orthopedics, 1st Hospital SUMS,.,Fixed by Special medullar nail and wire,Dept. Orthopedics, 1st Hospital SUMS,Frac. In both legs,Dept. Orthopedics, 1st Hospital SUMS,Interlocking Intromedullary nail,Dept. Orthopedics, 1st Hospital SUMS,Multiple frac.,Dept. Orthopedics,