骨质疏松性病理性骨折的治疗进展.ppt

OrthopedicTrauma,PrinciplesofFracturesandDislocations,DescriptionoffracturesBiomechanicsoffracturesClassificationoffracturesbythemechanismofinjuryClinicalfeaturesoffracturesClinicalfeaturesofdislocationsEmergencymanagementoffracturesDefinitivetreatmentoffracturesFracturecareRehabilitationfollowingfractures,DescriptionofFractures,FracturesByanatomicallocationProximal,middle,ordistalthirdoftheshaft;supracondylar;subtrochantericBythedirectionofthefracturelineTransverse,oblique,spiralBywhetherthefractureislinearorcomminutedGreenstickfracturesOpenfractures,closedfracturePathologicandstressfractures,OpenFracture,Definition:Breakintheskinandunderlyingsofttissuesleadsdirectlyintoorcommunicateswiththefractureanditshematoma.Classification:Gustilo-AndersonIrrigationanddebridementImmediateorearlyamputationversuslimbsalvageMangledextremityseverityscore(MESS)MESSscore7amputationStabilizationofthebone,DescriptionofFractures,Greenstickfractures(commoninchildren)Incompletelyfractured,withpartofthecortexandperiosteumremainingintactonthecompressionsidePathologicandstressfractures,GreenstickFx,Path.Fx,StressFx,BiomechanicsofFractures,ExtrinsicfactorsThemagnitude,duration,anddirectionoftheforcesactingonthebone,aswellastherateatwhichtheboneisloadedIntrinsicfactorsEnergy-absorbingcapacity,modulusofelasticity(youngsmodulus),fatiguestrength,anddensityBiomechanicalpropertiesofboneFatigue(stress)fracturesHolesinboneEffectofmetallicimplants,ExtrinsicFactors,Force=MassxAccelerationStress=Load/Areaonwhichtheloadacts(kg/cm2)Strainisdefinedasthechangeinlineardimensionsofabodyresultingfromtheapplicationofaforceoraload.Tensilestrain.Compressionstrain.Shearstrain.Tensionandcompressionstrainsarealwaysassociatedwithshearstrains,IntrinsicFactors(1),Energy-AbsorbingCapacityWork=ForcexDistance(ftlbs)(kgcm)(Nm)Strainenergyistheenergyabodyiscapableofabsorbingbychangingitsshapeundertheapplicationofanexternalload.Themorerapidlyaboneisloaded,thegreaterwillbetheenergyabsorptionbeforefailure.Fracturesassociatedwithslowloadingaregenerallylinear,whereasrapidloadinginfusesenormousstrainenergysothatanexplosionofthebonetakesplaceatfailure,givingrisetotheseverecomminutionofhigh-energyfractures.,IntrinsicFactors(2),Youngsmodulusandstress-straincurvesElasticstrain,plasticstrain,breakpointThesteeperthecurve,thestifferthematerial;Thegradientisknownasthemodulusofelasticity(E)oryoungsmodulus.FatiguestrengthFatiguefailure(subjectedtorepeatedorcyclicalstresses),BiomechanicalPropertiesofBone(1),Boneisatwo-phasematerialconsistingofmatrix,whichismostlycollagen,andbonemineral.Bonemineral(hydroxyapatite)ismorerigidthanboneandisstrongerincompressionthanintension.Bonecollagenoffersnoresistancetocompressionbuthasatensilestrengthfivetimesthatofbone.Whencomparedwithcastiron,boneisthreetimesaslightandtentimesmoreflexible,butbothmaterialshaveaboutthesametensilestrength.Boneisnotasimpleelasticsubstanceasismildsteel.Boneisaviscoelasticmaterial.Thestrengthofboneisdependentonthedensityofthebone,themineralcontent,andthequalityandamountofcollagen.,BiomechanicalPropertiesofBone(2),Fatigue(stress)fracturesFatiguefracturesaremostcommonlyseeninmilitaryinstallationsFrankelandBurstein:akeyfactor:musclefatigueThepatternoffracture:AtransversefractureformedonthetensionsideAnobliquefractureformedonthecompressionside.HolesinboneWhenthediameteroftheholeisgreaterthan30%ofthediameterofbone,theweakeningeffectbecomesexponential.,BiomechanicalPropertiesofBone(3),EffectofmetallicimplantsOrthopaedicimplantsweakenbonebystressshieldingPredisposetofracturebyincreasingthestiffnessofasegmentofbonesothatthereisanabrupttransitionbetweenthedegreeofelasticityofthesupportedandunsupportedsegmentsofbone,ClassificationofFracturesbyMechanismofInjury,DirecttraumaTappingfracturesCrushfracturesPenetrating(gunshot)fractures,IndirecttraumaTractionortensionfracturesAngulationfracturesRotationalfracturesCompressionfracturesFracturesduetoangulation,rotation,andaxialcompression,DirectTrauma,LowV,HighV,IndirectTrauma(1),Transverse,Spiral,IndirectTrauma(2),IndirectTrauma(3),ClinicalFeaturesofFractures,PainandtendernessLossoffunctionDeformityAttitudeAbnormalmobilityandCrepitusNeurovascularinjuryNoexaminationforsuspectedfractureiscompletewithoutcarefulevaluationofperipheralnervefunctionandvascularity.Radiographicfindings,ClinicalFeaturesofFractures,Radiographicfindings,ClinicalFeaturesofDislocations,PainLossofnormalcontourandrelationshipofbonypointsLossofmotionAttitudeRadiographicfindingsNeurovascularinjury,EmergencyManagementofFractures,Thetreatmentoffractures:emergencycare,definitivetreatment,andrehabilitationSplintingFurthersoft-tissueinjurymaybeavertedand,mostimportantly,closedfracturesaresavedfrombecomingopen.Immobilizationrelievespain.Splintingmaywelllowertheincidenceofclinicalfatembolismandshock.Patienttransportationandradiographicstudiesarefacilitated.Idealfirst-aidsplint:efficient,light,inexpensive,easilyapplied,easilystoredorcarried,andradiolucent.,TheTreatmentofFractures,Reduction:Closereduction(CR)Openreduction(OR)ImmobilizationTractionFixationExternalskeletalfixation(ESF)Internalskeletalfixation(IF)CR+Immob.,CRIF,CRESF,ORIF,ORESF.,Untilthegeneralconditionofthepatienthasstabilized.ClosedTreatmentReduction(Ligmentasis)TractionReversingtheMechanismofInjuryAligningtheFragmentThatCanBeControlledImmobilizationPlaster-of-ParisCastsPlaster-of-ParisSplintsFiberglassCastsImmobilizationbyContinuousTraction,DefinitiveTreatmentofFractures(1),Plaster-of-ParisCasts(1),CaSO4H2O+H2OCaSO42H2O+heatMethodsofApplication,Plaster-of-ParisCasts(2),Upper-extremitycastsLower-extremitycastsPatellartendon-bearingcastsCastbracesHipandshoulderSpicasWedgingPlaster-of-PariscastsWindowsincasts,Plaster-of-ParisSplints,RadialslabSugartongsplint,TheEfficacyofPlasterImmobilization,WillworkonlyWherethesoft-tissuehingeisintactWherethereisinherentstabilityofthereducedfractureWherethecastisproperlyappliedusingathree-pointsystemCharnley:Withinherentstabilityagainstshortening(transversefracture)Withpotentialstabilityagainstshortening(obliquefracturelessthan450tothelongaxisoftheboneWithnostabilityagainstshortening(oblique,spiral,andcomminutedfractures).Onlythefirsttwocategories,hebelieved,aresuitableforimmobilizationbycastsalone.,ImmobilizationbyContinuousTraction,SkintractionNomorethan8poundsSkeletaltractionTractionforfemoralfracturesDistalfemoraltractionCalcanealtractionTractionthroughtheolecranonTractionbyplaster:Hangingcast(humeralfracture)Pinsandplaster,ComplicationsofPlasterCastsandTraction,PlasterSoresTheTightCastThermalEffectsofPlasterThrombophlebitisandEquinusPositionTheCastSyndromeInfectionSecondarytoCastApplicationAllergicReactionsTractionHazards,DefinitiveTreatmentofFractures(2)ExternalFixationofFractures,IndicationsfortheuseofexternalfixationTheprimeindicationforexternalfixationiswhenothermeansoffixationclearlyareinappropriate.(MostclassIIIandmanyclassIIinjuries)TypesofexternalfixationSimplepinFixatorsThefracturemustbereducedbeforeapplicationClampFixatorsAllowforfinalreductionofthefractureafterapplicationRingFixatorsAllowgradualandprecisecorrectionofangulatoryandrotationaldeformity,ExternalFixationofFracturesSimplePinFixators,TheRogerAndersonSystemTheWagnerApparatusTheOrthofixFixator(DynamicAxialFixator)TheAO/ASIFFixatorUnilateralFrameBilateralFrameTriangulatedAssembly,W,O,AO,ExternalFixationofFracturesClampFixators,TheHoffmannSystemCarbon-FiberFixators(TraumaFix)Thecarbonrodismorerigidthanthemetaltubeandis40%lighter.Itisalsomoreresistanttofatigue.,Hoffmann,T-F,RigidityofFixation,Rigidity:enhancedbyincreasingThenumberofpinsThesizeofpins(nomorethan6mm)TheirstiffnessormodulusofelasticityThedistancebetweenpinsByhavingpinsindifferentplanesBehrens:toaddrigiditytoframesemployinghalfpinsDecreasingthedistancebetweentheboneandthelongitudinalrodIncreasingthepin-to-pindistanceUseoftwo-planeconfigurationsUseofananteriorframewithtwolongitudinalbars,ExternalFixationofFracturesRingFixators,TheIlizarovFrameTheMonticelliSpinelliFixatorTheAce-FischerFixator,Ilizarov,Monticelli,DefinitiveTreatmentofFractures(3)CombinedInternalandExternalFixationofFractures,ComplicationsofExternalFixation,PinTractInfectionRommens:minor:9.4%,major:9.1%PinLooseningandBreakageBurny:(4mmpins)Interfacefracture:0.5%;pinfracture:5.2%LimitationofJointMotionNeurovascularDamageandCompartmentSyndromeMal