外科学课件：骨折总论

一、古代骨科简述周朝（BC1100～770）

伤骨科（疡医科：折、疡之分）春秋战国时期（皇帝内经）

截肢术（脱痈）汉代华佗（AC147～207）

骨折复位、夹板固定，清创术，“麻沸散”：手术无痛原则晋代葛洪（AC261～347）

竹夹板外固定骨折隋代巢元方（AC581～618）

骨折内固定：线连接碎骨唐代蔺道人“仙授理伤续断秘方”：

骨折治疗四大原则：

复位、固定、内外用药、功能锻炼明代杨清叟

止血带：绢袋清代江考鲫

骨移植：以别骨填接古希腊Hippocrates（Bc460～377）

骨折脱位等的治疗古罗马Galen（Ac130～200）

人体解剖16世纪Azeecs人

骨不连内固定治疗：木片Orthopaedicsnamedin1741NicholasAndrycoinedtheword.Orthos:correct,straight.Paedion:childJean-AndreVenel(1740-1791):Venevese,becalledtheFatherofOrthopaedicsPlastercastofParis1751Movementsystem(Orthopaedics)iscomposedwithspine,extremities,bone,joint,muscles,vessels,nerves,lymph,fascia,synovium,etc.现代骨科及相关组织AASOS骨科

需要创造性

相关学科的发展Creative,InnovationMultiidiciplinesdevelopmentOrthopaedicsINTRODUCTIONOFFRACTUREDefinitionClassificationTreatmentPrognosisHealingprocessandtheaffectingfactorsClinicalfindingsandimageologyexaminationCausesEmergencycareBoneFracture1.DEFINITIONOFFRACTUREAfractureisabreakinthecontinuityofabone2.CausesoffracturesTraumaDirectforceDirectforcecausesthefracture2.CausesoffracturesTraumaDirectforceIndirectforceIndirectforcecausesthefractureMuscularcontractionforce2.CausesoffracturesTraumaDirectforceIndirectforcefracturecausedbymuscularcontractionCyclicforce–--fatiguefractureMuscularcontractionforce2.CausesoffracturesTraumaDirectforceIndirectforceBonediseasesLocalized

diseasesGeneralizeddiseasesCyclicforceMuscularcontractionforce2.CausesoffracturesTraumaDirectforceIndirectforce—tubercularosteomyelitis,osteosarcoma,localizedmetastaticcarcinoma,etc.—osteoporosis,multiplemyeloma,diffusemetaststiccarcinoma,etc.3.ClassificationoffracturesOnthebasisofetiologyTraumaticfracturePathologicalfractureTraumaticfracturePathologicalfractureOnthebasisofrelationshipwithexternalenvironmentClosedfractureOpenfracture3.ClassificationoffracturesOnthebasisofetiologyOpenfractureOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyOnthebasisofdisplacementsUndisplacedfractureOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyNosignificantdisplacementfracturesDisplacedfractureDifferentsortsofdisplacedfracturesFactorsresponsiblefordisplacementsThefracturingforceThemusclepullonthefracturefragmentsThegravityIncorrectmedicalcareOnthebasisofdisplacementsOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyOnthebasisoftimefreshfractureoldfractureWithin3wksover3wksOnthebasisofdisplacementsOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyOnthebasisoftimestablefractureunstablefractureOnthebasisofstabilityAO/ASIFCLASSIFICATIONAO(ArbeitsgemeinschaftfurOsteosynthesefragen)ASIF(AssociationfortheStudyofInternalFixation)Location+type+subtype+group12-A14.EmergencycareoffracturesRescuethelifeABCDEFstepsABCDEFAirwayandbreathingBleedingandcirculationCentralnervesystemDigestivesystemExcretionFracture(McMurtry1980)Managethewound4.EmergencycareoffracturesPreservethelifeImmobilizethefractureManagethewound4.EmergencycareoffracturesPreservethelifeTransferthepatientImmobilizethefractureManagethewound4.EmergencycareoffracturesPreservethelifeTwomethodstotransportthespinefracturerollingliftingFalsemethodtotransportthespinefractureDefinitionClassificationTreatmentPrognosisHealingProcessandtheaffectingfactorsClinicalfindingsandimagingstudiesCausesEmergencycareFractureCLINICAL&RADIOLOGICALFEATURESSystemicManifestations

PrimaryShock(NeurogenicShock)SecondaryShockHaemorrhageNotice:excludetocerebralinjuryandrespiratoryembarrassment

CLINICAL&RADIOLOGICALFEATURES

LocalManifestation

SwellingTraumaticInflammationPainImpairmentoffunction

Deformity

SpecificSigns

AbnormalMotion

BonyCrepitusorGratingCLINICAL&RADIOLOGICALFEATURESCLINICAL&RADIOLOGICALFEATURESImageologyExaminationFractureyesorno?PatternoffractureDecidetheTreatmentMethodsCOMPLICATIONOFFRACTURE

EarlyComplicationsShockFatembolismInjurytoImportantOrganandTissueOsteofascialCompartmentSyndromeCOMPLICATIONOFFRACTURE

LateComplicationsSystemicComplicationPressureSores(bedsore)PneumoniaInfectionoftheUrinarytractCOMPLICATIONOFFRACTURE

LocalComplications

InfectionofBoneandJointPost-TraumaticOssificationOsteoarthritisJointStiffnessReflexSympatheticDystrophyAvascularNecrosisofTheBoneIschemicContracture(Volkmann’s)FRACTUREHEALINGOrganandTissueFractureRepairRegeneration

ScarNewBone

FRACTUREHEALINGStagesofFractureHealing1.Haematoma→→Fibrosis(2w)↓Fibrinogen＋ReticularFibril→BloodClots

↓NewVessels＋MesenchymalCell＋InflammatoryCell→GranulationTissue

CytokinesinvolvedinfracturehealingBMPsBMP2,BMP4,BMP6,BMP7,BMP9TGFbIGFFGFPDGFFRACTUREHEALING2.PrimaryCallusFormation(6-8w)OriginoftheCallusCells

DOPC(DeterminedosteogenicPrecursorCells)

IOPC(InducibleOsteogenicPrecursorCells)FRACTUREHEALINGOriginoftheCallusMineralDeadBoneOsteoblasts,Chondroblasts↓↓CO2↑Phosphorylase↑↓↓pH↓HydrolyzetoPhosphate(intheHematoma)(inthePlasma)Calcium++PhosphateFreeBloodcalciumCalciumPhosphateFractureCallus(WovenBone)CollagenIFRACTUREHEALING

EndochondralOssificationIntramenbranousOssificationFRACTUREHEALING3Remodelling(8w---manyyears)

ModellingWovenBoneLamellarBone(8---12wClinicalHealing)Remodelling(12w---SomeYears)Wolff’sLawStressandPiezoelectricityFRACTUREHEALING

CriteriaofFractureHealing

1.LocalandaxialpercussionproducesnoPain2.Absenceofabnormalmobility3.VisiblecontinuedcallushasBridged,indistinctionoffragmentsandfracturelineFRACTUREHEALING4.Withouttheexternalfixationofsplints

A.TheArmisabletohold1kgstuffhorizontallylastingfor3min.B.TheLegsareabletoWalk30pacesin3min.C.NodeformationappearsonthefracturesiteAftercontinualobservationfor2weeksSystemicFactors1.Age2.SystemicConditionRelatedFactorsInfluencingFractureHealingRelatedFactorsInfluencingFractureHealing

LocalFactors1.PatternofFracture2.

BloodSupply(Fragments)A.Bloodsupplyofbothfragmentsarerich.B.Oneisrichwhiletheotherispoor.C.Bloodsupplyofbothfragmentsarepoor.D.Absenceofbloodsupply.

LocalFactors

3.Infection4.InjuriesofSoftTissue5.InterpositionofSofttissueinto

FractureGap

6.BasicDisease(local)RelatedFactorsInfluencingFractureHealing

MethodofTreatment?!

1.RepeatedReductionbyManipulation2.OverTractionofFragments3.IncorrectFixation4.IncorrectDebridement5.InfluenceofOpenReduction6.IncorrectFunctionalExercisesRelatedFactorsInfluencingFractureHealing

BiologicalFactors20%MedicalFactors80%!!

RelatedFactorsInfluencingFractureHealingPRINCIPLESofFRACTURETREATMENT

Reduction

Immobilization

RehabilitationMedicationREDUCTION

CriterionofReduction1.AnatomicReduction2.FunctionalReduction(1).Novisiblegaporrotation(2).Shortening＜1~2cmintheLeg(3).Angulation＜15~10°

(4).Appositionofthefragments＜

１／３(shaft),or３/４(epiphyseal)REDUCTIONMethodsofReduction1.ByClosedManipulation2.ByMechanicalTractionwithorwithoutManipulation3.ByOpenReductionIMMOBILIZATION

ReasonsforImmobilization1.Preventionofdisplacementorangulation2.Preventionofmovement3.ReliefofpainIMMOBILIZATION

MethodsofImmobilization

1.ByWoodenSplint,PlasterorSplint(other)2.ByContinuousTraction3.ByExternalFixation4.ByInternalFixationREHABILITATION1.ActiveMuscularContraction(AfterInjuryWithin2Weeks)2.ActiveExercisesJointsofAdjacentFracture(AfterInjury2~8w)3.ActiveResistanceExercises(After8w)4.PhysiotherapyMedication

TraditionalMedication

ForbidUsingNonsteroidAnti-InflammatoryDrugs(NSAIDs)TREATMENTofOPENFRACTURE

PreventInfection!!

TREATMENTofOPENFRACTURE1.TypeofOpenFractureFromoutsidetoinnerFrominnertooutsidePotential

TREATMENTofOPENFRACTURE

2.ConditionsoftheWound

ContaminativeExtentDegreeofSoftTissueInjuryTREATMENTofOPENFRACTURE3.DebridementSamePrinciplesofSurgicalDebridementGoldenTime:6~8h(afterinjury)LargerBonyPieceShouldbePreservedSelectingMethodsofFixationRepairofNerve、Tendon、VesselSkinClosureSamePrinciplesofSurgicalDebridement1.KeepArticularCartilageIntact2.NottoLeaveForeignBodiesinJoint3.ForbidtoOpenDraining(CanUseIrrigation)4.RepairofCapsuleandLigamentsTREATMENTofOPENFRACTURE5.InjectAntibioticsintotheJointAfterOperation6.AspirationisEspeciallyImportantinHemarthrosis7.TheJointshouldbeImmobilizedwithTraction,SplintorPlasterCastTREATMENTofOPENFRACTUREDELAYEDUNIONof