医学精品课件：01.general principles of fracture 标准

General

PrinciplesoftheDiagnosisAndManagement

ofFRACTURETheFirstAffiliatedHospital,ChongqingUniversityofMedicalSciencesDepartmentofOrthopedicsHuangweiEpidemiology

theUnitedStates

Traumacausesmorethan140,000deathsperyearleadingcauseofdeathforthoseaged1-34yearsmorethancoronaryarterydisease,cancer,andstrokecombinedbeforeage65yearsIn2000,morethan50millionAmericansunderwentmedicaltreatmentforaninjury.Theestimatedlifetimecostoftheseinjuriesisbelievedtobe$406billion.DEFINITIONofFRACTUREThecontinuityandcompletenessof

bonehavebroken

Afractureisacompleteorincompletebreakinthecontinuityofabone

TerminologyAnatomy:Thefractureisdescribedwithrelationtothebonesinvolvedandthelocationwithinthebone(diaphysis,metaphysis,physis,epiphysis).Articularsurfaceinvolvement:Doesthefracturehaveintra-articularinvolvement?Isthereintra-articulardisplacementorgapping?Displacement:Isthedistalfracturefragmentdisplacedcomparedwiththeproximalfragment?Towhatdegreeorpercentageisthefracturedisplaced?Angulation:Theangulardeformityisdefinedindegreesintermsofthedistalfragmentinrelationtotheproximalfragmentorwithrespecttotheproximalapexofthedistalfragment.Rotation:Rotationaldeformityisdescribedbothclinicallyandradiographically.Shortening:Hasthefracturecausedshorteningoftheinvolvedbone?Towhatextenthasshorteningoccurred?TerminologyFragmentation:TheMullerAO(ArbeitsgemeinschaftfürOsteosynthesefragen[AssociationforOsteosynthesis])ComprehensiveClassificationofFracturesprovidesastandardizeddescriptionoffracturepatterns,makingcommunicationregardingsuchinjuriesmorepreciseandunderstandable.Amultifragmentaryfractureisonethathasseveralbreaksinthebone,creatingmorethan2fragments.Wedgefracturesareeitherspiral(lowenergy)orbending(highenergy)andallowtheproximalanddistalfracturefragmentstocontacteachother.Thecomplexmultifragmentaryfractureisasegmentalfractureoroneinwhichthereisnocontactbetweentheproximalanddistalfragmentswithouttheboneshortening.Simplefracturesarespiral,oblique,ortransverse.FactorsResponsibleforFractures

Directviolence

appliedtothebonealsodamagessurroundingsofttissueAtappingforceappliedtotheboneproducesanobliquefractureAcrushinginjuryresultsinafragmentedfractureoftheboneApenetratingdirectinjuryfromahigh-velocitygunshotblastdestroysboneandsofttissueFactorsResponsibleforFracturesIndirectviolence

appliedtotheboneproducessignificantlylessdamagetosoftandhardtissuesAnabductionorverticalormusclepullforcecausesacompressionoravulseorobliqueorspiralfractureFactorsResponsibleforFracturesManydiseasesofbonemaycausedestructionofboneormayweakentheboneproducesapathologicfractureinflammationtumorortumor-likediseasesosteogenesisimperfectametabolicdiseasesetalFactorsResponsibleforFracturesInrepeatedstresses,whichcausefatiguefracturesthesestressfracturearemostfrequentlyencounteredinboneofthelowerextremity:theneckofthesecondorthirdmetatarsalbonetheshaftofthetibiaorfibulartheneckofthefemurCLASSIFICATIONSFracturesmaybecausedby

ViolencedirectindirectInjuryfractureMusclepullAvulsionfractureFatigueStressfractureDiseasePathologicalfractureclassificationsFromWhetherHaveDirectorindirectCommunicationBetweentheFractureandWoundoftheSkinandMucosaFromWithinOpenFracture

FromWithoutClosedFractureDirectViolenceIndirectViolenceMusclepullAvulsionfractureOpenFractureOpenComminutedFracture车祸致左小腿开放性毁损OpenandComminutedfractureclassificationsFromStability

Stable

TransversefractureGreenstickfractureImpactedfractureEpiphysealinjuryTransversefractureofthelefthumerusImpactedfractureoftheneckoftherightfemur

FromStability

Unstable

SpiralfractureObliquefracture

Slopeofmorethan200o0ComminutedfractureAvulsionclassificationsThecomminutedfractureoftherighthumerusThelongspiralfractureoftheleftfemurdistalGreenstickTransverseAngulationObliqueSpiralDoubleComminutedImpactedCrushAvulsionInvolvingajointCompressionFracture-DislocationEpiphysealinjuryclassificationsPatternofDisplacementAngulationRotationLateralSideOverlaporShorteningImpactingMechanismofthedisplacement

ofthefragmentsDirectionoftheviolenceEffectsofgravityMusclepullImproperFirstAid肌肉拉力造成的骨折移位CLINICAL&RADIOLOGICAL

FEATURESOFTHEFRACTURESystemicManifestationsPrimaryShock(NeurogenicShock)SecondaryShock----Haemorrhagia(-ge)Notice:excludetocerebralinjuryandrespiratoryembarrassmentCLINICAL&RADIOLOGICAL

FEATURESOFTHEFRACTURESystemicManifestationsLowFeverorSlightFevertemperature380C

traumareactionhaematoma

absorptionWBC(whitebloodcell)ESR(erythrocytesedimentationrate)CLINICAL&RADIOLOGICAL

FEATURESLocalManifestationTraumaticInflammation:PainLocalSwellingLossorImpairmentofFunctionEcchymosisLocalizedbonetenderness

SpecificSigns

ThefollowingfeaturesarepathognomonicoffractureDeformityAbnormalMobilityCrepitusorGratingCLINICAL&RADIOLOGICAL

FEATURESAbsenceofdysfunctiondoesnotprecludefracturethisisparticularlytrueof:greenstickfacturesimpactedfracturesfatiguefracturesCLINICAL&RADIOLOGICAL

FEATURESRadiologicalExaminationFractureyesorno?Patternoffracture?Anatomicpartofthefracture?SelectingofTreatmentMethods!COMPLICATIONS

OFFRACTUREEarlyPeriodShockFatembolismInjurytoImportantOrganandTissue(nervousandvascular)Osteo-fascialCompartmentSyndrome

骨筋膜室综合征

Osteofascial

CompartmentSyndrome早期并发症晚期PainPainlessPallorParesthesiaParalysisPulselessness早期PainDull-redPassivemotionpainPulsenessOsteofascial

CompartmentSyndrome肱骨髁上骨折致肱动脉损伤、骨筋膜室综合征COMPLICATIONSOFFRACTURE

EarlyPeriodInfection:tetanus;gasgangrene;osteomylitisThromboembolism:deepvenousthrombosisandpulmonaryembolismAcuterespiratorydistresssyndromeMultiple-organdysfunctionsyndromeCOMPLICATIONOFFRACTURELaterPeriodSystemicComplicationPressureSoresPneumoniaInfectionoftheBladderCOMPLICATIONSOFFRACTURELocalComplications

MyositisOssificansPost-traumaticOsteoarthritisJointStiffnessReflexSympatheticDystrophySudeckatrophyAvascularNecrosisofTheBoneIschemicContracture(Volkmann’s)COMPLICATIONSOFFRACTURE

LaterPeriodDelayedunionNonunionMalunionorangulardeformitiesShorteningGrowtharrestGrowthstimulationFRACTUREHEALING

OrganandTissue

Scar

Repair

Fracture

RegenerationNewBone

Stagesofbonehealing1.Forthefirst2weeks,bonehealingfollowsthesamepattenasthehealingofskinoranyortherwound.Thesiteofthewoundisfilledwithbloodandthebrokenendsofbonebecomenecrotic.2.Thebloodclotisinvadedbymacrophagesandosteoclastswhichremovedeadboneandosteoblastswhichproducebone,insteadofthefibroblastswhichformfibroustissueinsofttissueinjuries.3.Beteen2to6weeksafterinjuryosteoidtissuedevelopsandformsafirmmass,orcallus,aroundthefractureandossificationoftheosteoidbegins.Callusformsbothoutsidetheboneassubperiostealcallus,andinsideasendostealcallus.ThepHofthetissuesinreasesatthisstageandcalciumisdeposited.4.Between6and12weeks,ossificationoccurs,asolidbonybridgecrossesthegapandtheboneregainssomemechanicalstrength.5.Between12and26weeks,thecallusmatures.6.Between6and12months,thegapsbetweenthecorticalendsarebridged.7.Between1and2years,remodellingoccurs,bonyprominencesbecomesmoothandnormalbonearchitectureisrestored.Thetimingisveryvariableandismuchfasterrinchildren,inwhomcalluscanbeseenat2weeks.FRACTUREHEALING

StagesofFractureHealing1.Haematoma→→Fibrosis(2w)↓Fibrinogen＋ReticularFibril→BloodClots↓NewVessels＋MesenchymalCellInflammatoryCell→GranulationTissue

FRACTUREHEALING2.PrimaryCallusFormation(6-8w)OriginoftheCallusCellsDOPC(DeterminedosteogenicPrecursorCells)IOPC(InducibleOsteogenicPrecursorCells)FRACTUREHEALINGOriginoftheCallusMineralDeadBoneOsteoblasts,Chondroblasts↓↓CO2↑Phosphorylase↑↓↓pH↓HydrolyzetoPhosphate(intheHematoma)(inthePlasma)FRACTUREHEALING↓↓CalciumofFragmentPhosphateFreeDissolved↓Heamatoma→CalciumPhosphate→DeposittoBoneMatrix→

Callus(WovenBone)

FRACTUREHEALINGEndo-chondralOssificationIntra-membranousOssificationNewboneformseitherthroughappositionalossificationwithoutinitialcartilageformationorbyenchondralossificationofapreminaryfibrocartilagecallus.Inbothinstances,theossificationprocessisintimatelyrelatedtorevascularization,andtheactiveosteoblastsappeartobederivedfromeitherthewallsofthesmallvesselsorfromcirculatingbloodcells.Bonerepairtakesplaceintheperiosteal,cortical,andmedullaryregions,butmostoftherevasculaizationofafractureisfrommedullarycirculation.Whichoftheseareaspredominateintherepairprocessdependsonthenatureofthebone,thedegreeofinitialinjury,andtheamountoffractureimmobilizationduringhealing.Themostrapidofalltheprocessesofhealingistheexternalorperiostealcallus,whichpredominatesinfracturetreatednonoperativelyandwithearlymusclefunction.Itdependsprimarilyonsurroundingsofttissuebloodsupply.Thiscallusisquitetolerantofcontrolledfracturemotion;infactitismostinevidencewhenfracturemotionoccurs,e.g.,inribfractures.Asecondprocessislatemedullarycallus,whichpredominateswhentheexternalcallushasfailed.Itisassistedbyrigidimmobolizationandisthepredominanthealingprocesswithcompressionplatefixation.Intramedullarycallus,asMcKibbonhaspointedout,isnotanevanescentburstofactivitybutaprocessthatseemstopursueitsgoaloffracturebridgingrelentlessly.Thethirdprocessisthatofprimaryboneunionthatexplainstherarephenomenonofhealingwithoutexternalcallus.Itdependsonthemechanismofboneturnover,whichisoccurringatalltimesandwhichcanrespondtobridgefracturedbonecortices,providedthattheyarerigidlyimmobilized.Bythisprocessthedeadcorticalboneimmediatelyadjacenttothefractureisinvadedbynew,longitudinallyorientedosteonesfromtheneighboringlivebone.Themajordisadvantageofprimaryboneunionisitsgreatslownessanditsdependenceonrigidimmobilization.Inmostinstanceswithcompressionplating,thefracturegapissufficientlylargethatitfillsbyboneformedthroughappositionalgrowthinwardfromtheexternalperiostealsource.Thisprimaryboneformsrapidlyinthe4-6weeksbuthasrelativelypoorattachmenttotheavascularboneends.Thisprimarycallusmustberemodeledandreplacedat6-8weeksbysecondaryosteonesbridgingthefracturegaplongitudinally.Theentireprocessofhealinginboneaswellasinsofttissueisdependentontheprocessofrevascularization.FRACTUREHEALING3.Remodelling(8w---Someyears)ModellingWovenBoneLamellarBone(8---12wClinicalHealing)Remodelling(12w---SomeYears)

Wolff’sLawStressandPiezoelectricityFRACTUREHEALINGFRACTUREHEALINGFRACTUREHEALING

CriterionofFractureHealing

1.AbsenceTendernessandAxial

PercussionPain2.AbsenceAbnormalMobility3.VisibleContinuedCallushasBridgedFragmentsandFractureLineIndistinctFRACTUREHEALING4.AftertheSplintshasbeenRemoved,A.TheArmisParalleltoGround,andHold1kgPersistin3min.B.TheLegsisWalk30Paceon3min.C.AfterObserve2wContinually,GoodResulthasShowedontheFractureSiteFRACTUREHEALING

CriterionofFractureHealingINFLUENCEDFACTORS

ofFRACTUREHEALINGSystemicFactors1.Age2.SystemicCondition

LocalFactors1.PatternofFracture

INFLUENCEDFACTOR

ofFRACTUREHEALING2.

BloodSupply(Fragment)A.AllgoodBothFragmentsB.OnegoodandOtherBadC.AllBadBothFragmentsD.AbsenceBloodSupplyontheFragmentINFLUENCEDFACTORS

ofFRACTUREHEALING3.Infection4.InjuriesofSoftTissue5.InterpositionofSofttissueintoFractureGap

6.BasicDisease(local)INFLUENCEDFACTORS

ofFRACTUREHEALING

MethodofTreatment?!1.RepeatedReductionbyManipulation2.OverTractionofFragments3.NoCorrectFixation4.NoCorrectDebridement5.InfluenceofOpenReduction6.NoCorrectFunctionalExercisesINFLUENCEDFACTORS

ofFRACTUREHEALING

BiologicalFactors20%MedicinalFactors80%!!

FIRSTAIDofFRACTURE

PurposeofFirstAid1.SavetheLive2.PreserveLimbs3.SafetyQuicklyTransport

SystemicConditionShockComaRespiratoryEmbarrassmentFIRSTAIDofFRACTURETemporaryCareofFracture

OpenClosed

CorrectTransportPRINCIPLESofFRACTURE

TREATMENTReduction

ImmobilizationRehabilitationMedicationREDUCTION

CriterionofReduction1.AnatomicReduction2.FunctionalReduction

(1).NoObserveGapandRotation(2).Shortening＜1~2cmintheLeg(3).Angulation＜15~10(4).AppositionoftheFragments＞

1/3(shaft),or3/4(epiphyseal)REDUCTION

MethodsofReduction1.ByClosedManipulation2.ByMechanicalTractionwithorwithoutManipulation3.ByOpenReductionIMMOBILIZATION

ReasonsofImmobilization1.PreventionofDisplacementorAngulation2.PreventionofMovement3.ReliefofPainIMMOBILIZATIONMethodsofImmobilization1.ByWoodenSplintorPlasterorSplint(other)2.ByContinuousTraction3.ByExternalFixer4.ByInternalFixationREHABILITATION1.ActiveMuscularContraction(AfterInjuryWithin2Weeks)2.ActiveExercisesJointsofAdjacentFracture(AfterInjury2~8w)3.ActiveResistanceExercises(After8w)4.PhysiotherapyMedication

TraditionalMedication

ForbidUsingNonsteroidAnti-InflammatoryDrugs(NSAIDs)TREATMENTofOPEN

FRACTURE

PreventingInfection!!

TREATMENTofOPEN

FRACTURE1.TypeofOpenFractureFromWithinFromWithout

Potential

TREATMENTofOPEN

FRACTURE

2.ConditionsoftheWound

ContaminativeExtentDegreeofSoftTissueInjuryTREATMENTofOPEN

FRACTURE3.DebridementSamePrinciplesofSurgicalDebridementGoldenTime:6~8h(afterinjury)LargerBonyPieceShouldbePreservedSelectingMethodsofFixationRepairofNerve、Tendon、VesselSkinClosureFEATUREofOPENI