股骨粗隆间骨折的髓内固定治疗

佘国荣,股骨粗隆间骨折的髓内固定治疗,股骨粗隆间骨折,分型,描述解剖学特征评估骨折稳定性提示预后内固定物选择指导术后康复,Evans classification (1949),Evans classification (1949),Type I: Undisplaced 2-fragment fractureType II: Displaced 2-fragment fractureType III: 3-fragment fracture without posterolateral support, owing to displacement of greater trochanter fragmentType IV: 3-fragment fracture without medial support, owing to displaced lesser trochanter or femoral arch fragmentType V: 4-fragment fracture without posterolateral and medial support (combination of Type III and Type IV)R: Reversed obliquity fracture,AO classification (1981),AO classification (1981),A1: Simple (2-fragment) pertrochanteric area fracturesA1.1 Fractures along the intertrochanteric lineA1.2 Fractures through the greater trochanterA1.3 Fractures below the lesser trochanterA2: Multifragmentary pertrochanteric fracturesA2.1 With one intermediate fragment (lesser trochanter detachment)A2.2 With 2 intermediate fragmentsA2.3 With more than 2 intermediate fragmentsA3: Intertrochanteric fracturesA3.1 Simple, obliqueA3.2 Simple, transverseA3.3 With a medial fragment,内固定物选择,髓内固定 Gamma钉、PFN、PFNA 髓外固定 DHS、LCP、DCS ,内固定物选择,内固定物选择,内固定物选择,临床病例,临床病例,小结,对于不稳定骨折髓内固定较髓外固定的力学性能更好，力臂更短。术后股骨头切割、髋内翻、短缩和内固定松动、断裂风险更低。,Gamma钉 1990年，Grosse首先报道,能较好传递应力、防止髋内翻防止旋转和短缩移位闭式操作、创伤小、早期下地远端应力集中、股骨干骨折、锁钉断裂拉力螺钉切出股骨头,PFN Gamma钉的改良,进一步保护生物学特性解剖设计，无需扩髓避免应力集中，防止旋转可早期负重活动,PFN,股骨头颈双钉固定增加防旋螺钉（防旋、抗压、抗拉）,尾端固定钉(抗旋转螺钉),股骨颈螺钉（负重螺钉）,PFN,延长远端螺钉与髓内钉尾距离静态锁定与动态锁定结合远端加长设计，减小应力集中远端可屈性设计，增加弹性,PFN,双钉固定缺点Z效应 两枚螺钉承受的负荷不同，一枚承受张力负荷，另一枚抵抗压力负荷，当一枚螺钉退出时，另一枚可能进一步穿透股骨头。,PFNA,PFNA,螺旋刀片锁定技术 内芯直径逐渐增大，打入时逐步填压骨质。良好的骨质填压和优良的锚合力,一个内植物实现抗旋转和稳定支撑,PFNA,骨质填压技术的优势,A=81.3 mm2,A=26.7 mm2,入钉点,插入导引钢针,开髓,插入PFN,预安装,前后位,轴向,插入导引钢针,摄片确认位置,测量尾部固定钉长度,打洞,测量FNS长度,打洞,打入FNS,加压,远端锁定孔,打入锁定钉,拧入尾帽,临床病例,临床病例,临床病例,术后,术后40天,临床病例,术后两月,术后1年半,面对股骨粗隆间