外科学教学课件：Fracture of Upper Extremities1

FractureofUpperExtremitiesReview

of

last

ClassWhat

‘sfractureAfractureisabreakinthecontinuityofaboneClinical

&

RadiologicalFeaturesSystemicManifestationsLocalManifestationTheprinciplesoftreatmentReduction、Immobilization、Rehabilitation、MedicineKey

point：Marked

with

red

color

AnatomyBonethatcomposeupperlimb:Thegirdleofupperlimb

clavicleandscapularThefreeboneofupperlimb

1humerus(arm)1ulna(forearm)1radius(forearm)8carpals(wrist)19metacarpalandphalanges(hand)FRACTUREOFCLAVICLESectionIAnatomyTheclavicleisweakestatthejunctionofthetwocurvesTherefore,mostbreaksoccurapproximatelyinthemiddleoftheclavicleTheclavicleisthebonethatconnectsthetrunkofthebodytothearmSternoclavicularacromioclavicularDistalClavicleACjoint(肩锁关节)Coracoclavicularligaments（喙锁韧带）“Suspensoryligamentsoftheupperextremity”Twocomponents:Trapezoid（三角韧带）Conoid（斜方韧带）StrongerthanACligamentsProvideverticalstabilitytoACjointAnatomy臂丛神经MechanismFallontoshoulder(87%)Directblowontoclavicle(7%)Fallontooutstretchedhand(6%)Birthinjuryfrompassingthroughthebirthcanal.ClassificationAccordingtofracturesite80%occurinthemedial1/315%distalthirdoccureinthelateralordistal1/35%occurinthemedialorproximal1/3ClassificationFractureoflateralclavicleCoracoclavicularligament（喙锁韧带）Classification

greenstickfractures（青枝骨折）

(childrenusually)DisplacementofmiddlethirdfractureMedial

fragmentwasdisplacedsuperiorlyandposteriorly

bySternocleidomastoidMuscle（胸锁乳突肌）Lateralfragmentwasdisplacedinferiorlyandanteriorlybyweightofarmand

DeltoidMuscle

（三角肌）Historyofatrauma

pain,swellingandcrepitusInabilitytoraiseashoulderDeformityalongthelineoftheclavicleClinicalfeaturesFractureofClavicleClinicalfeaturesSubclavianvesselscompromise:

asymmetricpulseorpulsatilehematomaBrachialplexusinjury:

neurologicalexaminationRadiographicEvaluationX-Ray：Inordertodeterminethefracturetypeandextentofinjury.

Take

bothclaviclebonesforcomparison

AnteroposteriorView30-degreeCephalicTiltViewDiagnosisHistoryoftraumaClinicalmanifestationX-ray TreatmentConservativetreatment:

Nondisplacedorgreenstickfractures

Slingfor3-6weeks;

DisplacedMiddle1/3fractures

Closedmanipulativereduction,Figure-of-8strap

ConservativetreatmentClosedreduction,Figure-of-8straptomaintaintheshoulderinaretractedpositiontoimprovethealignmentoffracture.Surgicaltreatment-ORIFIndicationClosedreductionfailNeurovascularinjurieOpenfractureLateral

fracture

withCoracoclavicularligament

rupture

or

scapularneckfracturesNon-union

fractueOpenReductionandInternalFixationFracture

of

lateralclavicleTypeIIORIFRepairtheCoracoclavicularligament

Double

endobutton

TechniqueTheHookPlatespecificallydesignedfor

thelateralfractureofclavicleTypeIIFRACTUREOFHUMERUSSectionIIPartI:ProximalhumeralfracturePartII:FracturesofhumeralshaftPartIII:SupracondylarFracturesSectionII-PartIPartI:ProximalhumeralfractureProximalHumeralAnatomy4bonyfragmentsLesserTubercleGreaterTubercleHeadShaftNeer,JBJS‘70Surgicalneckofhumerus肱骨外科颈Anatomicalneckofhumerus肱骨解剖颈Inferiortotheanatomicalneckofhumerus2-3cm,justlocateintheintersectionofthecompactboneandspongybone,soitiseasetobefracturedAnatomyRotatorcuff（肩袖）Subscapularis（肩胛下肌）Supraspinatus（冈上肌）Infraspinatus（冈下肌）Teresminor（小圆肌）BloodsupplyofproximalhumerusAnteriorhumeralcircumflexartery;Posteriorhumeralcicumflexartery;Arcuateartery;Thelateralascendingbranch(Arcuateartery)oftheanteriorcircumflexhumeralarterycarriesthemostimportantbloodsupplyofthehumeralheadanddamagemayleadtoavascularnecrosis.MechanismElderlyfallontooutstretchedhanddirectblow-fallbonefragility-osteoporosis（骨质疏松）Younghighenergy

traumaClinicalmanifestationHistoryoftrauma;Pain;Swelling;Ecchymosis;DysfunctionoftheshoulderRadiographicevaluationXrayAPScapular“Y”RadiographicevaluationCTscanand3DreconsrructionDiagnosisHistoryoftrauma;ClinicalmanifestationRadiographicevaluationClassificationUnderstandingFracturePatterns4bonyfragmentsLesserTubGreaterTubHeadShaftNeerClassification1cmdisplaced45degreeangulatedExcessiverotationClassificationNeerClassificationFourpartsGreaterandlessertuberosities,HumeralshaftHumeralheadApartisdisplacedif>1cmdisplacementor>45degreesofangulationisseenTreatmentMinimallydisplacedfractures-Slingimmobilization,earlymotionTwo-partfractures-AnatomicneckfractureslikelyrequireORIF.HighincidenceofosteonecrosisSurgicalneckfracturesthatareminimallydisplacedcanbetreatedconservatively.DisplacementusuallyrequiresORIFThree-partfracturesDuetodisruptionofopposingmuscleforces,theseareunstablesoclosedtreatmentisdifficult.DisplacementrequiresORIF.Four-partfracturesIngeneralfordisplacementorunstableinjuriesORIFintheyoungandhemiarthroplastyintheelderlyandthosewithseverecomminution.HighrateofAVN（avascularnecrosis缺血坏死）

(13-34%)MinimallydisplacedfracturesOpenReductionandInternalFixationLockingCompressionPlateOpenReductionandInternalFixationPre-opXrayPre-opCTIncisionPost-opXrayHumeralheadreplacement

Certainthree-andfour-part

proximal

humerus

fracturesSectionII-PartIIPartII:FracturesofHumeralShaftIntroductionAccountforapproximately3%ofallfractures.Anatomy2cmproximaltosurgicalneck2cmdistaltosupracondyleOnthebackofthemiddlethird,thereisashallowspiralgrooveforradialnerveontheboneDirecttraumaisthemostcommonIndirecttraumasuchasfallonanoutstretchedhandFracturepatterndependsonstressappliedBending-transversefractureoftheshaftTorsional-spiralfractureoftheshaftTorsionandbending-obliquefractureusuallyassociatedwithabutterflyfragment（蝶形骨块）Bending弯屈应力Torsion扭力MechanismClassificationAOclassificationTypeA-SimplefractureType

B-WedgefractureType

C-ComplexfractureDisplacementoffragmentsAfracturebetweentheinsertionofthepectoralismajorandthedeltoid1.The

proximal

fragmentisadductedbythepectoralismajor,teresmajorandlatissimusdorsi.2.The

distalfragmentisshortenedanddisplaced

laterally

bydeltoidDisplacementoffragmentsAfracturebelowthedeltoidinsertionThe

proximalfragmentisdisplacedabductedbydeltoidThe

distal

fragmentisdisplacedproximallybybiceps

and

tricepsClinicalfeatureSymptomPainSwellingDeformityEcchymosisDysfunctionofupperarmClinicalfeaturePEBonycrepitusPseudarthrosisRadialnerve

injuryWrist

dropSensoryRadiographicevaluationAPandlateralviewsofthehumerusIncludingadjacentjoint(shoulderorelbow)A1A3C3DiagnosisHistoryoftrauma;ClinicalmanifestationRadiographicevaluationConservativeTreatmentType

A

and

partial

Type

BClosedmanipulativereductionExternal

Fixation（Splint

or

Plaster

or

Brace）Immobilization：6-8

wks

for

adults，4-6wks

for

childrenTreatmentFracturesofHumeralShaftConservativeTreatmentA,APradiographofthehumerusdemonstratingamidshaftfracture.B,APradiographmadeat3-monthfollow-updemonstratinghealingandcorrectedangulationfollowingmanagementwithaSarmientobrace.C,PhotographofapatientwearingaSarmientobrace.

Type

A2

IndicationClosedreduction

failPolytraumaOpenfractureNeurovascularinjurieUnstalbefractures（Type

B3

and

C）,Non-union

fracturePathologicfractureFloatingelbowAssociatedarticularfractureOperativemanagementFracturesofHumeralShaftMethod

Externalfixation

OpenReductionandInternalFixation

MinimallyInvasivePercutaneousOsteosynthesis

IntramedullaryNailing

(髓内钉)

OperativemanagementFracturesofHumeralShaftThechoiceofimplantsdependsonsurgeonexperience,associatedinjuriesextentandlocationofthesoft-tissueinjury,fracturepattern.Relativeindications:Soft-tissueinjuries(Openfracture);Burns;Fracturesthat