临床神经病学：3-3 骨折各论

1、 Fracture of the clavicle Fracture of the clavicle nmost common in both children and adults noccur in the region of mid third and lateral third part Clinical Appearance nDefinite injury history nLocal pain, swelling, pressing pain, can palpate the displaced fragment of fracture and the rubbing sound

2、 nX-ray Treatment (1) Non Operative Treatment nReduction by hand nExternal fixation by “8” bandage nNonunion nNerve and Vascular Injury nDifficult to maintain the fracture by close reduction nSoft tissue between fractures nOpen fracture Treatment (2) Surgical neck Fracture of humerus nHappen in any

3、age, most common in middle-age and elders. nClassification nUndisplaced nAbducted nAdducted nComminuted Clinical Appearance nDefinite injury history nLocal pain, swelling, deformity, pressing pain, movement disorders nX-ray Treatment nUndisplaced nhang by triangle towel for 34 weeks nAbducted and ad

4、ducted nreduction by hand nexternal fixation nComminuted nOperative Treatment Humeral shaft fracture 肱骨外科颈以下12cm至 肱骨髁上2cm之间的骨折。 n三角肌止点以上 近折端-向内、向前 远折端-向外、向近 n三角肌止点以下 近折端-向前、外 远折端-向近 nEasily injury radial nerve nradial nerve pass through the middle third and lower third of humerus. n中下1/3骨折易损伤桡神经：垂腕,

5、 各手指掌指关节不能背伸，拇指不能背伸， 前臂旋后障碍；手背桡侧皮肤感觉减退或 消失。 肱骨中下1/3骨折， 注意有无桡N损伤。 nNon-Operation nOperation nDifficult reduction by non-operation nRadial nerve injury Treatment Supracondylar Fracture of the Humerus Anatomy nAnterior-medially to the humeral condyle- humeral artery and median nerve pass. nMedial to hu

6、meral condyle-ulnar nerve nLateral to humeral condyle-radial nerve Normal elbow joint Classification nExtension nFlexion nInjury history (hand against the ground) nSign: elbow swell, pain and subcutaneous gore. nExamination npressing pain nbone sound npseud-joint movement nNormal post-elbow triangle

7、 relation nNerve and vascular injury or not. nExtension Fx easily injury blood vessel and nerve Diagnosis 特别注意伸直型骨折伸直型骨折 近端前下移位 损伤肱动脉 软组织肿胀 影响远端肢体血液循环 前臂骨筋膜室综合征、缺血性肌挛缩 Fracture of the shaft of ulna and radius Diagnosis Attention: nbone fascial compartment syndrome 前臂高张力肿胀，剧痛；桡动脉搏动摸不清；手指皮温降低， 感觉异常，主动

8、活动障碍，被动活动剧痛 nIschemic muscle contracture 5P sign (Painlessness, Pulselessness, Pallor, Paresthesia, Paralysis) Monteggias Fracture nUlna upper third fracture naccompanied with radial head dislocation Galeazzis Fracture n Radial lower third fracture n accompanied with ulnar head dislocation Treatment

9、 Fracture of radius and ulna (both bones fracture) Monteggia fracture Galeazzi fracture Fracture of the distal radius n桡骨远端关节面桡骨远端关节面 掌倾掌倾 1015 尺偏尺偏 2025 nColles Fracture -伸直型伸直型 nSmith Fracture -屈曲型屈曲型 nBarton Fracture -关节面骨折伴腕关节脱位关节面骨折伴腕关节脱位 Fracture of distal radius 1. Colles Fracture nradial dis

10、tal fragment moves to radial and dorsal side. n多见于成年人和老人 n典型畸形 n“餐叉”畸形-背侧移位 n“枪刺刀”畸形-桡侧移位 2. Smith Fracture nradial distal fragment moves to radial and palmar side. (Reverse Colles fracture) Smiths FractureColles Fracture 3. Barton Fracture 桡骨远端背侧或掌侧骨折，累及关节面，腕关节随之移位 Treatment: n手法复位外固定手法复位外固定 n切开复位内

11、固定切开复位内固定 n恢复掌倾角、尺偏角恢复掌倾角、尺偏角 损伤桡神经 垂腕 骨筋膜室综合症 损伤肱动脉 缺血性肌挛缩 结节与骨干交界易骨折 骨折并发症 三种畸形 Fracture of the femoral neck 解剖特点 n颈干角颈干角1307(平均127) n前倾角前倾角107(1215) n成人股骨头的血供来源：成人股骨头的血供来源： 旋股内、外侧动脉在股骨颈基底形旋股内、外侧动脉在股骨颈基底形 成的动脉环成的动脉环 以以旋股内侧动脉旋股内侧动脉为主为主 圆韧带内的小凹动脉圆韧带内的小凹动脉 股骨干滋养动脉的升支股骨干滋养动脉的升支 股骨颈骨折会影响股骨头血供，发生股骨头缺血坏死

12、或骨折不愈合。股骨颈骨折会影响股骨头血供，发生股骨头缺血坏死或骨折不愈合。 nMost commonly in the older nIndirection violence Classification According to the displacement degree: nGarden : Incomplete Fracture nGarden : Complete, Non-displaced nGarden : Complete, partly displaced nGarden : Complete, fully displaced According to X-ray: nA

13、dduction nPauwels 50 nUnstable nEasy to diaplace nAbduction nPauwels 30 nStable nuneasy to displace According to the fracture site: nSubcapital femur fracture 对股骨头血供影响很大对股骨头血供影响很大 nTranscervical neck fracture nBaseline neck fracture 对股骨头血供影响较小对股骨头血供影响较小 Clinical appearance nMiddle-aged or elder had

14、fall history nHip pain after injury nLimited lower limb activity nUnable to standing and walking nPatients with stable Fx could walk, but few days later, appeared hip pain and difficult to walk. Clinical appearance nAffected limb in external rotation, usually between 45-60 nLocal pressing pain nAxis

15、 knocking pain nAffected limb is shorten nX-ray : identify fracture site, type and displacement. 大转子上移征：大转子上移征： Treatment Non-operation nUnmarked displaced Fx nAbduction and inserted stable Fx nElder with bad general condition 需长期卧床，现已较少采用需长期卧床，现已较少采用 Treatment Operation nAdduction Fx and displaced

16、Fx nOlder than 65 Yrs with subcapital femoral Fx nTeen-age femoral neck Fx nDated femoral neck Fx Operation method nClosed reduction and internal fixation nOpen reduction and internal fixation nArthroplasty Screws Total hip arthroplasty Complication nAvascular Necrosis (Subcapital fracture) Intertro

17、chanteric fracture 解剖特点： nTrochanteric zone pain nSwelling, lower limb unable to move. Physical examination nTrochanteric zone pressing pain nexternal rotation 90and shortening of lower limb X-ray Clinical appearance Treatment nNon-operation nskeleton traction，尽量少用 nOperation nDHS nPFNA, -nail DHS内固定 闭合复位，PFNA内固定 Femoral neck fracture & Intertrochanteric fracture n相同点：相同点： 常见于老年人，骨质疏松性骨折；常见于老年人，骨质疏松