上肢骨折(医学课件9)

UpperextremityfracturesOrthorpeadicdepartmentofthesecondaffiliatedhospitalofChongqingMedicalUniversityDr.LiangmaincontentClavicularfracture（锁骨骨折）fractureoftheproximalhumerus（肱骨近端骨折）Humeralshaftfracture（肱骨干骨折）

supracondylarfractureofhumerus（肱骨髁上骨折）fractureofradiusandulna（尺桡骨骨折）distal

radiusfracture（桡骨远端骨折）Section1fractureofclavicle解剖概要（anatomyreview）function：connectthearmtothetrunk(躯干)shape：“S”shapeandirregular(不规则)Lateral1/3part:flat；middle1/3part:cylindrical，weak；medial1/3part:prismatic(陵柱状)

shapejoint：lateral-acromioclavicular

joint肩锁关节；medial-sternoclavicular

joint胸锁关节ligament韧带：acromioclavicularligament肩锁韧带，Coracoclavicularligament喙锁韧带:trapezoidligament(斜方韧带)conoidligament锥状韧带

adjacent

structure毗邻结构：Subclavianvessels锁骨下血管，brachial

plexus臂丛神经adjacent

structure毗邻结构毗邻结构

mechanism

of

injuryandfracturedisplacement

受伤机制及骨折移位IndirectViolence间接暴力Fallwiththeshoulderhittingtheground侧方摔倒，肩部着地Resultintransverseorobliquefracture多导致横行骨折或斜行骨折IndirectViolence直接暴力Hitdirectly直接击打

Comminutedfracture可导致粉碎骨折（中1/3）骨折移位（fracturedisplacementinthemiddlethird）：proximalfragmentdisplacedproximallyandposteriorly近端向上、后移位（drawbythesternocleidomastoid胸锁乳突肌牵拉），thedistalfragmentdisplacedinferiorlyandanteriorly(causedbygravityandthetractionofthedeltoid)远端向前下移位（三角肌锁骨部牵拉及重力）。fractureclassification

（骨折分类）Accordingtothefracturesite解剖部位：lateral外侧，middle中段，medial内侧Fracturemorphology骨折形状：横行(transverse)，斜行(oblique)，粉碎(comminuted)外1/3骨折分型：typeⅠ型：fracturelocatesbetweentheacromioclavicularlig.andtheCoracoclavicularlig.Withminimumdisplacement位于肩锁韧带与喙锁韧带之间，移位不明显。typeⅡ型：withdamageoftheCoracoclavicularlig.Theproximalfragmentdisplacedsuperiorly.合并喙锁韧带损伤，骨折近端向上移位。TypeTypeⅢ型：theacromioclavicular

jointinvolved骨折累及肩锁关节Ⅱ型A.BClinicalmanifestationsanddiagnosis

临床表现及诊断Clinicalmanifestationsclinicalsign(症状)：pain疼痛，limitationofmotion活动受限physicalsign(体征)：deformity畸形，ecchymosis皮下瘀斑，bonycrepitus骨擦感diagnosis（诊断）XrayCTscanImagingstudytreatment

治疗conservativetreatment(保守治疗)indication适应征：greenstickfractureinchildren青枝骨折，non-displacementfractureinadult成人无移位骨折。treatment方法：closedreduction手法复位，figureof“8”bandagefor3-6weeks八字绷带固定3-6周。surgicaltreatment(手术治疗)：openreductionandinternalfixation,ORIF（切开复位内固定）surgicalindication(手术指征)：Significantdisplacement明显移位Re-displacementafterclosedreduction复位后再次移位Combinedwithneuralandvasculardamagement合并神经血管损伤Openfracture开放骨折ChronicfractureandFracturenonunion陈旧骨折不愈合DistalfracturewithCoracoclavicularlig.rupture合并喙锁韧带断裂的外端骨折Combinedwithscapularneckfracture合并肩胛颈骨折Conservativetreatment

保守治疗SurgicaltreatmentSurgicaltreatment

手术治疗SurgicaltreatmentSection2proximalhumerusfracture

第二节肱骨近端骨折Anatomyreview解剖概要Collodiaphysealangleabout140(neck-shaftangle颈干角)anatomicalneck(解剖颈)surgicalneck(外科颈)Bloodsupply

血供Posteriorhumeralcircumflexartery旋肱后动脉anteriorhumeralcircumflexartery旋肱前动脉Anatomyreview

(bloodsupply)Kinematicmechanicsoftheshoulder

关节运动力学Pathogenesisandclassification

病因及分类Mechanismofinjury受伤机制Indirectviolence间接暴力Directviolence直接暴力classification分型Traditionalclassification传统分型（1）non-displacementfracture无移位骨折（2）abductivefracture外展型（3）adductivefracture内收型AOclassification(AO分型)TypeA型：extra-articularsimplefracture关节外简单TypeB型：extra-articularcomplexfracture关节外复杂TypeC型：intra-articularfracture关节内Neerclassification分型1,2,3,4partfractureandfracture-dislocation(Ⅰ部分、Ⅱ部分、

Ⅲ部分、

Ⅳ部分、骨折脱位)AOclassification

AO分型NeerclassificationDiagnosis

诊断X-rayAP,Lateralandaxialviewoftheshoulder肩关节正、侧位片、腋位片CT+threedimensionalreconstruction三维重建X-ray

inthreedirectiontreatmentConservativetreatment保守治疗indication适应征Non-displacedfracture无移位骨折Stableabductivefracture稳定的外展型骨折Withabsolutesurgicalcontraindications存在绝对手术禁忌征患者method方法Supra-shoulderplaster超肩石膏外固定Abductionbrace外展支架固定（adductivefracture内收型骨折）Surgicaltreatment

手术治疗Surgicalindications手术指征Unstablefracture不稳定骨折Unsuccessfulreductionofclosedfracture闭合复位失败Anatomyneckfracture解剖颈骨折Fracture-dislocation骨折脱位Articularfracture累及关节面Combinedwithrotatorcuffinjury合并肩袖损伤Withneuraland(or)vascularinjury合并神经血管损伤floatingshoulder（浮肩）Chronicfracture陈旧骨折Surgicaltreatmentmethods方法Kirschnerwireplustensionbendfixation（克氏针-张力带固定）Screwfixation螺钉固定（lagscrew拉力螺钉、canulatedscrew空心、absorbablescrew可吸收）Proximalhumerallockingplate肱骨近端锁定钢板precautions注意事项Therepairoftherotatorcuff肩袖的修复Repairofjointcapsule关节囊的修复Earlyfunctionalrehabilitation早期功能锻炼Kirschnerwirefixation

克氏针固定经骨缝线固定Screwfixation

螺钉固定Proximalhumerallockingplatefixation

肱骨近端锁定钢板LockingplateIntromadurallynailIntromadurallynailShoulderarthroplasty

肩关节置换Section3humeralshaftfracture

（第三节肱骨干骨折）

Anatomyreview解剖概要range部位：2cmbeneaththesurgicalneckand2cmabovethesupracondyle外科颈下2cm到肱骨髁上2cmThenourishingvesselsinsertinthemiddletolowerpartofthehumerus中下部有滋养血管(nourishingvessel)进入Theviolenceofthenourishingvesselscouldresultinfracturenonunion损伤后易导致骨折不愈合Theradialnerveacrossthejunctionofthemiddleandlowerthirdofthehumeruslaterallyandposteriorly中下1/3后外侧紧贴骨面有桡神经（radialnerve）走行RadialnervedamagedRadialnervedamagedPathogenesisandclassification

病因及分类PathogenesisDirectviolence直接暴力Transverseorcomminutedfracture横行或者粉碎骨折Indirectviolence间接暴力Fractureatthejunctionofthemiddleandlowerthirdofthehumerus中下1/3骨折Obliqueorspiralfracture斜行骨折或者螺旋形骨折AOclassificationTypeA型：simplefracture简单骨折TypeB型：wedgefracture楔型骨折TypeC型：complicatedcomminutedfracture复杂粉碎骨折diagnosis

诊断Thepatient’shistory病史Traumatichistory外伤史Physicalsign体征Typicalsignsforfractures骨折体征(deformity畸形，ecchymosis皮下瘀斑，bonycrepitus骨擦感)Thecharacteristicsoffracturedisplacement骨折移位特点Symptomsofradialnerveinjury桡神经损伤症状Radialsitenumbnessofthedorsumhandandwrist虎口区麻木Wristextensionobstacle伸腕障碍Imagingstudies影像学X-ray：APandlateralview(includingtheshoulderandelbowjoint)肱骨正、侧位片（包含上下关节）CT+threedimensionalreconstruction三维重建treatmentConservativetreatment保守治疗Closedreductionandsupra-shoulderplasterfixation手法复位，超肩石膏外固定Surgicaltreatment

手术治疗Surgicalindication手术指征Repeatedfailureofclosedreduction反复手法复位失败Separativedisplacement,softtissueimpacted分离移位、软组织嵌入Combinedwithneuralor(and)vascularinjury合并神经血管损伤Chronicfractureorfracturenonunion陈旧骨折不愈合malunion骨折畸形愈合Multiplefracture多发骨折Pathologicalfracture病理性骨折Openfracture开放性骨折Unstablefracture不稳定骨折Operativemethods手术治疗方法Internalfixationwithplatesandscrews钢板螺钉内固定Compressionplating加压钢板Locking-compressionplating锁定加压钢板minimalinvasiveplateosteosynthesis（微创接骨板技术）Interlockingintramedullarynailfixation交锁髓内钉固定precautions注意事项Theprotectionoftheradialnerve桡神经的保护Compressionplating

加压钢板Lockingplate

forchronicfracture

锁定钢板LockingplateincisionRadialnerveprotectionRadialnerveprotection交锁髓内钉交锁髓内钉Section3supracondylarfractureofhumerus

(第三节肱骨髁上骨折)definition定义：fracturehappensatthejunctionofthehumeralshaftandthesupracondyle肱骨干与肱骨髁交界处发生的骨折。Anatomyreview解剖概要Anteversionangle前倾角：30-50°—anatomicfactorsleadingtoincreasedriskoffractures易发生骨折的解剖学基础Adjunctionstructures毗邻结构：brachialartery肱动脉、mediannerve正中神经、ulnarnerve尺神经、radialnerve桡神经Fractureclassification

骨折分类extension-type

supracondylar

fracture

ofhumerus伸直型肱骨髁上骨折injury

mechanism受伤机制：Elbowhyperextensionandlandonthepalmwhenfalling跌倒时肘关节过着地伸，手掌着地Theshearingforcedirectedsuperiorlytoinferiorly剪切暴力由上而下Thedistalfragmentdisplacedposteriorlyandsuperiorly远折端向后上Physicalsign体征：elbowjointswelling肘关节肿胀，withnormalposteriorelbowtriangle肘后三角正常。Theneuralandvascularinjuryshouldbeexcluded应特别注意是否合并神经血管损伤flexion

type

supracondylar

fracture屈曲型肱骨髁上骨折Landingonflexelbow肘关节屈曲，肘后方着地Fracturelinedirectsanterosuperiorlytoposteroinferiorly骨折线前上至后下FractureclassificationDiagnosisandtreatment

诊断及治疗diagnosis诊断morecommon

in

children儿童多见Withsignificanttraumatichistory外伤史Clinicalsymptomsandphysicalsignsoffracture临床症及体征Imagingfindings影像学表现treatment治疗Closedreduction手法复位Bonetraction牵引-olecroanonbonetraction尺骨鹰嘴骨牵引Plasterfixationforflexion

type

supracondylar

fracture石膏外固定（屈曲型骨折）Extendedelbowfixedfor10daysthenfixa40degreeflexedelbowfor4to6weeks伸直为7-10天，屈肘40°位4-6周Openreductionandinternalfixation切开复位，内固定Surgicalindications手术指征Closedreductionunsuccessful手法复位失败Significantdisplacement骨折移位严重Combinedwithneuralandvasculardamagement合并神经血管损伤Supracondylarfractureinadult成人髁上骨折precautions注意事项：brachialarteryinjurycouldresultinForearmischemic

myospasm肱动脉损伤影响远端肢体血液循环，可导致前臂缺血性肌痉挛treatment

治疗Operativetreatment鹰嘴截骨切口鹰嘴截骨切口三头肌翻开切口三头肌劈开切口双柱固定复杂关节面骨折Section4ulnaandradiusfracture

第四节尺桡骨骨折Anatomyreview解剖概要Humeroulnarjoint肱尺关节Humeroradialjoint肱桡关节Proximalradioulnarjoint上尺桡关节Distalradioulnarjoint下尺桡关节Triangularfibrocartilage三角纤维软骨盘Interosseousmembrane骨间膜MaximumtensionatNeutralposition中立位时最紧张Contracturecauselimitedmotion骨间膜挛缩后果Pathogenesisandclassification

病因及分类PathogenesisDirectviolence直接暴力Indirectviolence间接暴力Twistingforce扭转暴力classification分类AOclassificationTypeA型：simplefracture简单骨折TypeB型：wedgefracture楔形骨折TypeC型：complicatedfracture复杂骨折Clinicalmanifestation

临床表现pain疼痛deformity畸形Abnormalactivity异常活动Bonycrepitus骨擦感WeakenordisappearBonetransductionsound骨传导音减弱或消失Couldcombinewithradialheadorulnarheaddislocation可合并桡骨头或尺骨小头脱位Couldcombinedwithneuralorvascularinjury可合并神经血管损伤diagnosis

诊断Traumatichistory外伤史symptom症状Physicalsign体征Radiographicmanifestation影像学表现XrayCT+3DreconstructiontreanmentConservativetreatment保守治疗Manipulativereduction手法复位Longarmcastorplintletfixationinneutralposition小夹板或石膏托外固定OperativetreatmentOpenreductionandinternalfixation切开复位内固定（ORIF）Surgicalindication手术指征Unstablefracture不稳定骨折Unsuccessfulclosedreduction闭合复位失败Openfracturewithlimitedcontaminationwithin6hours开放骨折污染轻、时间短Combinedwithnerves,vesselsortendoninjury合并神经血管及肌腱损伤Multipleinjuryinunilateralextremity同侧肢体多发损伤Oldfracture陈旧骨折Fracturemalunion骨折畸形愈合Externalfixatorstabilization外支架固定Ulnarshaftfracturecomplicatedbydistalradialcomplexcomminutedfracture尺骨干骨折合并桡骨远端粉碎骨折Complicatedopenfractures复杂开放骨折前臂双骨折锁定钢板固定锁定及加压髓内固定髓内固定Postoperativetreatment

术后处理Improvethecirculationoftheinjuredextremityandpreventthedevelopmentofcompartmentsymdrome改善患肢循环，预防骨筋膜室综合征Functionalexercise功能锻炼Spe