外科学教学课件：Fracture of Lower Extremities1

FractureofLowerExtremitiesFractureofthefemoralneckIntertrochantericFractureFractureofthefemoralshaftFractureofthefemoralneckMostcasesareoldpeople,therateofwomenisgreaterthanmen.Indirectviolencetransmittofemoralneckandresultinfracturewhenpeoplefalloraffectedlimbturnround.Foroldpeople,slight

violencecancausefracturebecauseofosteoporosis.

Foryoungpatients,fractureoftenresultfromstrongviolence,treatmentismoredifficultforyoungpatientsthanthatforold

patients.IntroductionAnatomyofFemurNeckshaftangle（颈干角）：

Thisangleisbetweenthelongaxisofthefemoralneckandtheaxisofthefemoralshaft,therangis130±7°,ifthisangle>130°,itiscoxavalga（髋外翻）;ifthisangle<130°,itiscoxavara（髋内翻）.

coxavalgacoxavaraAntevertedangle（前倾角）：

insagittalplane,thisangleisbetweenthelongaxisofthefemoralneckandcoronalplaneofthefemoralshaft,therangofitis10±7.

Jointcapsule:

Acetabulum,femoralheadandneckarecoveredbyjointcapsule,butthereisnocapsuleatposterior,lateral,inferiorofthehipjoint.femarolneckfractureisintracapsulefractureintertrochantericfractureisextracapsulefractureBloodsupplyofthefemoralhead（１）Foveolarartery,itlocatein

roundligamentoffemur,itonlysupplyfoveaoffemoralhead

.（2）Medialfemoralcircumflexarteryaremainbloodsupplyoffemoralneck.

（3）Deepbranchofnutrientarteryoffemoralshaft,it’sbloodsupplyislittle.

FoveolararteryFractureoffemerolheadwillcausebloodsupplyinjury,whichisthemaincauseoffemoralheadnecrosis.EtiologicalfactorIndirectviolence:externalrotationviolence,mostcasesareoldpeopleandmiddleagepeople,itrelatetobonequalitydecreaseresultfromosteoporosis,lightexternalrotationviolencecancausefracture.

Classificationclassifiedbysiteoffracture：

1.subcapitalfracture

medialandlateralfemoralcircumflexarteryareinjuriedseverely,--causefemoralheadnecrosisandfracturenonunion.

2.perfemoralneckfracture

3.basilarpartfracture

bloodsupplyinterferenceismild,fractureiseasytounion.

ClassificationClassifiedbyfractureline

Pauwells’angle:Betweenfracturelineandhorizontalline.

TypeI:

Pauwells’angle

>50°abductionfracture，itisstablefracture.

TypeII:

30°<

Pauwells’angle<50°.TypeIII:

Pauwells’angle>50°adductionfracture，it’sunstablefracture..ClassifiedbydisplacementGardenclassification

system

１.incompletefracture

：Garden1

２.completefracture

：structureofboneisbrokencompletely.a.nondisplacedfracture

Garden2b.incompletedisplacedfractureGpletedisplacedfracture

Garden4ClinicalfeatureanddiagnosisHistoryof

trauma,Painanddysfunction(cannotstandandwalk)Deformityofaffectedlimb:Shorten、abduction、extenal

rotation(45--60°)

HiptendernessAxialdirectpercussionsign（+）RadiographyX-rayitcanmakesurethesite,typeanddisplacementoffracture.

GardenIIGardenIIIGardenIVFordoubtfulfracture,CTandMRIisuseful.RadiographyCTXrayFordoubtfulfracture,CTandMRIisuseful.RadiographyMRIXray

Conservativetreatment

Fornondisplacementandstablefracture–continueskintractionandworeshoethatcanpreventaffectedlimbrotatesfor6—8weeks.TreatmentRisk:non-displacement-----displacementstable--------unstableComplicationsfromlying

in

bed

for

long

timeOperativetreatment

Indication：Most

displacedfracture，excluding

those

whoareintoleranceofoperationbecause

of

weekgeneralcondition

Operativemethods（１）closedreductionandinternalfixation.（２）openreductionandinternalfixation.（３）Totalhiparthroplasty(olderthan65yearsold)Closedreductionandinternalfixation.Cancellousscrews(空心螺钉)Thecrucialelementforthechoiceoffracturefixationandimplantisthequalityofbone.Anyfixationmethodusedinosteoporoticfracturesshouldbesafeandeasytoapply.Closedreductionandinternalfixation.DynamicHipScrew(动力髋螺钉)TotalhiparthroplastyTotalhiparthroplastyis

oneofthemostsuccessfulsurgeryof21thcenturyWithover100yearsofoperativehistorySchematicdiagram（示意图）TotalhiparthroplastyTotalhiparthroplastyis

oneofthemostsuccessfulsurgeryof21thcenturyTotalhiparthroplastyTotalhiparthroplastyis

oneofthemostsuccessfulsurgeryof21thcenturyCement

prothesis骨水泥型假体Cementlessprothesis非骨水泥型假体Development

of

TotalhiparthroplastyDevelopmentofMaterial：Ceramic（陶瓷），

Tantalum（钽）DevelopmentofProsthesis（假体）design：Big

head，shotstem

Developmentofsugerytechniqe:Minimaly

invasive，

DAA（直接前路)Fasttracksurgery（快速康复外科）ComplicationNecrosisoffemoralheadNon-unionoffractureIntertrochantericFractureGreatertrochanter,minortrochanterandintertrochantericzonearecomposedbyspongybone.Osteoporosis（骨质疏松）iseasytooccurtothesesectionresulttofractureinoldpeople.Thebloodsupplyisabundant,sofractureisinclinetounionandfemoralheadnecrosisisfew.AnatomyCauses

offracture：indirectviolencedirectviolencepathologicviolence

Classification:Tronzo-EvansclassificationStablefracture

unstablefracture

1.Historyoftrauma,affectedhipispain,dysfunctionofaffectedlimb.2.PE：

externalrotationoflowerlimb,angleofexternalrotationis80--90°.affectedhipistenderness.swellingecchymosislowerlimbshorten.axialdirectpercussionsign(+)

Clinicalmanifestationanddiagnosis3.x-ray:makesurethetypeoffractureanddifferentiatewithfemoralneckfracture.Type

IType

IIIDifferentiationbetweenfemoralneckandintertrochanterfracture

FemoralneckfractureintertrochanterfractureSexwomenmenEcchymosisnoyesExternalrotantion45--6090XrayneckoffemurintertrochanterUnunion30%littleFemoralheadnecrosiseasytohappenrareCase

analysisTreatment1.Conservativetreatment:

stablefracture–skeletaltraction2.Operativetreatment:

unstablefracture:openreductionandinternalfixation.

OperativetreatmentDHS(动力髋螺钉)PCCPOperativetreatmentPFNA(ProximalFemoralNailAntirotation)Fractureoffemoralshaft

Femoralshaftisthethickestandlongest

tubiform

bone.Femoralcrestposteriortofemoralshaftis

thesite

ofmuscularattachmentandthelabelofopen

reduction.AntomicaxisMechanicalaxisverticalaxis

AnatomyTherearefourbranchesofdeepfemoralarteryposteriorlateraltofemoralshaft,theyarenutrientarteryforfemoralshaftandeasytobeinjuriedthatresultinmassivebleedingandhemorrhagicshock

Anatomy１directviolence：femoralshaftfractureneedstrongviolence,forexample:directhitofheavyobject,wheelbecking.transverseandcomminutedfracturesaremostcases,softtissueisinjuriedseverelyandextensively.２indirectviolence：fallfromheight,torsionalinjurybymachinecauseobliqueorspiralfracture.

Causesoffracture

Displacement1.Proximal1/3femurfracture

Theproximalfracturepiecedisplacetoanterior,lateralandsupinationbecauseofthetractionofiliopsoas,gluteusmedius,gluteusminimus,hipextortor,

Thedistalfracturepiecedisplacetomedialandposteriorresultfromthetractionofadductoranddisplacetoproximalendbecauseofthetractionofquadricepsfemoris,tensorfasciaelataeandadductor.

２.medial1/3femurfractureFractureislateralangulationbecauseofthetractionofadductors.

３distal1/3femurfracture

Thedistalfracturepiecedisplacetoposteriorbecauseofthetractionofgastrocnemiusandtheweightoflimb,sothepoplitealartery,vein,tibialnerveandcommonperonealnerve

（腓总神经）areeasytobeinjuried.Atthesametime,thedistalfracturedisplacetoupwardresultfromthetractionofmusclesthataroundthefemur.

Clinicalmanifetationanddiagnosis1.Historyoftrauma.2.Thighisswellandecchymosis.3.Angulation,overlapandrotationdeformity.4.Dysfuctionofhipandkneejoint.5.PE：tenderness,abnormalmotion,bonycrepitus.6.Xray：makesurethesiteandtypeoffracture.7.Thedistal1/3fracture:Thedistalfracturepiecedisplacetoposterior,poplitealartery,vein,tibialnerveandperonealnerveinjuryshouldbenoted.ThebloodCirculation,sensationandmotionofdistallimbendshouldbeexaminated.ComplicationHypovolemicshock（低容量性休克）Fatembolismsyndrome（脂肪栓塞综合征）Deepvenousthrombosis（深静脉血栓形成）Traumaticarthritis（创伤性关节炎）ConservativetreatmentSkeletaltractionthroughtibialtubercleorsupracondyleoffemurisapplied.Manipulativereductionandsplintshouldbeappliedatthesametime.Thesetreatmentlast8—10weeks,x-raycanconfirmthe