外科学课件：Fracture of Upper Extremities-02

1、Fracture of Upper Extremities,Section II-Part III,Part III: Supracondylar Fractures,supracondylar fractures,Definition fractures occur at the medial and lateral humeral supracondylar ridge,Medial epicondyle,Lateral epicondyle,Supracondylar fracture,Anatomy Median nerve and brachial artery overlie th

2、e brachialis and the anterior capsule. ulnar nerve winds around the medial epicondyle. Radial nerve traverse the joint anterolaterally between the brachioradialis and brachialis muscles.,supracondylar fractures,Understanding neurovascular anatomy is crucial in evaluating trauma and in preventing iat

3、rogenic injury.,Brachial artery,Proximal fragment,Classification extension type: produced by a fall on the extended elbow and is stable in significant flexion flexion type: produced by a fall on the flexed elbow and is relatively stable in extension,Pathogenesis: Indirect force displacement: Proxima

4、l fragment anteroinferiorly Distal fragment posterosuperiorly,The extension type Supracondylar fractures,The extension type Supracondylar fractures,Clinical features 1.Supracondylar fracture is the most common fracture in children and elderly patients 2.swelling,pain,deformity,disfunction of elbow,P

5、hysical examination Careful neurovascluar examination of the arm is essential. brachial artery may be lacerated by the proximal fracture fragment , either at the time of injury or during reduction, compartment syndrome may be developed. Radial and median nerves are the most commonly affected among t

6、he three major nerves,The extension type Supracondylar fractures,X-ray: Roentgenogram may identify the site of the damage , displacement of fragment, type of fractures and degree of comminuting,The extension type Supracondylar fractures,Treatment Closed reduction,immobilization with arm splint ,main

7、taining elbow joint flexing about 80 degree for 46 weeks,The extension type Supracondylar fractures,Open reduction Indication: closed reduction fail open fracture neurovascular injuries,The extension type Supracondylar fractures,Choice of implants Crossed screws or crossed pins can be used successfu

8、lly Reconstructive plates and screws,Pre-oper,Post-oper,Fracture healing,Fixation with crossed screws,Olecroanon,The extension type Supracondylar fractures,Olecroanon pin traction the elbow is grossly swollen and difficult to treat by closed and open reduction Marked comminution precludes stable fix

9、ation Lengthy hospitalization is necessary if traction treatment is the definitive therapy,The flexion type of Supracondylar fractures,Pathogenesis Indirect force: a fall on the flexed elbow,Proximal posteroinferiorly,distal anterosuperiorly,The flexion type Supracondylar fractures,Clinical features

10、 Swelling, deformity,disfunction and acute pain of the elbow Physical examination: a careful assessment of vascular and nerve injuries is very essential,The flexion type Supracondylar fractures,Radiographic evaluation: it includes anteroposterior and lateral elbow views,The flexion type Supracondyla

11、r fractures,Treatment Closed reduction and immobilization with long-arm splint,maintaining elbow flexion 4050 degrees for 46 weeks,The flexion type Supracondylar fractures,Open reduction and fixation crossed pin or crossed screws anatomic plate and screws,Complications Cubitus varus and valgus Loss

12、of elbow motion Tardy ulnar nerve palsy,Section III-Part I,Part I: Fractures of shaft of radius and ulna,fractures of shaft of radius and ulna,Anatomy of forearm Two bones There is a interosseous membrane between the bones Five joints: radiohumeral, ulnohumeral, proximal radioulnar, radiocarpal and

13、distal radioulnar joints. These joints make it possible for the radius to rotate by rolling over the ulnar,fractures of shaft of radius and ulna,Anatomy of forearm The forearm consists of mostly of muscles, of which those on the anterior aspect are mainly flexors of the wrist joint and fingers, and

14、those on the posterior aspect extensor.,Interosseous membrane,Flexors of wrist and fingers,Extensors of wrist and fingers,fractures of shaft of radius and ulna,Pathogenesis The majority of forearm fractures result from a single episode of trauma. The mechanism of injury is most likely a direct blow.

15、,Direct blow,Indirect force,Indirect force,Direct force,fractures of shaft of radius and ulna,Clinical features Pain,crepitus,swelling secondary to fracture hematoma and soft-tissue injury. Apparent deformity:results from the high energy and the multitude of deforming muscle force. Skin:should be th

16、roughly inspected for any breaks that may communicate with fracture.,fractures of shaft of radius and ulna,More severe swelling Tense forearm compartments Pain out of proportion to the injury Pain with passive extension of fingers These may point to compartment syndrome Any signs of compartment synd

17、rome warrants immediate fasciotomy,Clinical features,Neuromotor examination: Radia nerve: extensor digitorum communis with a neutral wrist Media nerve: abductor pollicis brevis Ulnar nerve: abductor small finger,Clinical features,Sensory examination Radia nerve: the first web space Median nerve: vol

18、ar pad of index finger Ulnar nerve: volar pad of small finger,fractures of shaft of radius and ulna,Vascular examination Palpation of the brachial, radial and ulnar pulse, along with examination of distal capillary refill,fractures of shaft of radius and ulna,Radiographic evaluation Anteroposterior

19、and lateral views of the forearm is necessary for the assessment of a suspected forearm fractures The elbow and wrist must be included on each film to help evaluate the extent of injury,fractures of shaft of radius and ulna,Two special fractures of forearm Monteggia fracture: proximal ulnar fracture

20、 associated with radial head dislocation. Galeazzi fracture: distal radial shaft fracture associated with distal radioulnar joint disruption.,Monteggia fracture,Galeazzi fracture,fractures of shaft of radius and ulna,Displacement of fragment Fractures of radius above level of insertion of pronator t

21、eres Proximal fragment lies in supination because of unopposed pull of supinator and biceps. Distal fragment is in pronation because of the pull of pronator tere and pronator quadratus,Fractures of radius below level of insertion of pronator teres Proximal fragment:in the neutral position supinator and biceps pronator teres Distal fragment:in the pronation position pronator quadratus,supinator,pronator teres,biceps,Below the insertion of pronator teres,above the insertion of pronator teres,fractures of shaft of radius and ulna,Treatment The