中文骨折概论.pptx

Dept.Orthopedics,1st Hospital SUMSGeneral Concept of Fracture 骨科概论骨科概论Weiming LIAO(廖威明廖威明)Dr.Med.Ph.D.Prof.Dept.of Orthopedic SurgeryFirst Affiliated Hospital,Sun Yatsen University中山大学附属第一医院骨科中山大学附属第一医院骨科Dept.Orthopedics,1st Hospital SUMS学习要点学习要点 Key points lDefinition of frac.And causes of fracture 骨折定义，骨折原因骨折定义，骨折原因lClassification of frac.骨折分类骨折分类lStability of frac and factors causing displaced frac 骨折稳定性，引起骨折移位的因素骨折稳定性，引起骨折移位的因素lFactors influencing bone union(healing)影响骨折愈合的因素影响骨折愈合的因素Dept.Orthopedics,1st Hospital SUMSKey pointslSpecific signs of frac 骨折特有体征骨折特有体征lComplication of frac 骨折并发症骨折并发症lPrinciple of fracture treatment 骨折治疗原则骨折治疗原则lEmergent treatment for frac 骨折的急救处理骨折的急救处理Dept.Orthopedics,1st Hospital SUMS骨折定义骨折定义Definitionl骨折骨的连续性中段骨折骨的连续性中段lA fracture is a break in the continuity of a bone.Dept.Orthopedics,1st Hospital SUMS外力引起骨折外力引起骨折Forces fracturelDirect violence(直接暴力直接暴力)lIndirect violence（间接暴力）（间接暴力）lForceful pull of muscles（肌肉拉力引起撕脱骨折）（肌肉拉力引起撕脱骨折）lRepeated stress（重复应力引起疲劳骨折）（重复应力引起疲劳骨折）-cause fatigue fracturelBone disease（骨病变引起病理骨折）（骨病变引起病理骨折）-pathological fracDept.Orthopedics,1st Hospital SUMS直接暴力引起横断骨折，直接暴力引起横断骨折，粉碎性骨折粉碎性骨折Direct violenceDept.Orthopedics,1st Hospital SUMS直接暴力直接暴力直接暴力直接暴力Direct Direct violenceviolence间接暴力引起螺旋型骨折间接暴力引起螺旋型骨折Indirect violence(rotational)(rotational)骨肿瘤容易并骨肿瘤容易并发病理骨折发病理骨折Bone tumorDept.Orthopedics,1st Hospital SUMS直接暴力直接暴力Direct force间接暴力引起骨折和脱位间接暴力引起骨折和脱位Fracture&dislocation caused by Indirect violence车祸车祸车祸车祸 Car Car accidentaccidentDept.Orthopedics,1st Hospital SUMS骨折分类：闭合骨折分类：闭合/开放骨折开放骨折Closed/open fracturel根据骨折断端是否与皮肤或体腔相通，分为开根据骨折断端是否与皮肤或体腔相通，分为开放性和闭合性骨折放性和闭合性骨折lBased on whether there is communication between fracture and skin(body cavities)l闭合骨折闭合骨折 Closed fracturesl开放骨折开放骨折 Open fractures:l伤口容易引致感染，因此，需要急诊手术处理伤口容易引致感染，因此，需要急诊手术处理伤口和骨折伤口和骨折Dept.Orthopedics,1st Hospital SUMSOpen fracDept.Orthopedics,1st Hospital SUMSPatterns of fracture骨折类型骨折类型lIncomplete fracture 不全骨折不全骨折lComplete fracture 完全性骨折完全性骨折Dept.Orthopedics,1st Hospital SUMS不全骨折不全骨折Incomplete fracture:partial breaklCrack fracture（裂纹骨折）（裂纹骨折）Greenstick fractures in children 青枝骨折青枝骨折不完全性骨折容易引起漏诊不完全性骨折容易引起漏诊Dept.Orthopedics,1st Hospital SUMS.儿童的青枝骨折儿童的青枝骨折Greenstick fracture of distal tibia occurs in childrenDept.Orthopedics,1st Hospital SUMSComplete fracture完全性骨折完全性骨折l大多数的骨折属于完全性骨折大多数的骨折属于完全性骨折lComplete break of the injured bonelMost fracturesDept.Orthopedics,1st Hospital SUMS骨折类型骨折类型 Patterns of fracture根据骨折线、形状和程度可分为根据骨折线、形状和程度可分为Based on fracture line/shape/degrees:lTransverse fracture（横形）（横形）lOblique（斜形）（斜形）lSpiral（螺旋形）（螺旋形）lComminuted(with more than two fragments）（）（splintered)（粉碎性）（粉碎性）lCompress fra./crush fracture（压缩性）（压缩性）lImpacted fracture（嵌插）（嵌插）Dept.Orthopedics,1st Hospital SUMSStability of fracture骨折的稳定性骨折的稳定性l稳定型骨折稳定型骨折 Stable fracture:复位后不容易发生移位的骨折，如横型骨折、嵌复位后不容易发生移位的骨折，如横型骨折、嵌插骨折、青枝骨折等插骨折、青枝骨折等 not easily displace after reduction transverse,compacted,greenstick l不稳定骨折不稳定骨折 Unstable:l复位后容易发生移位，如斜型骨折、螺旋型骨复位后容易发生移位，如斜型骨折、螺旋型骨折，粉碎性骨折等折，粉碎性骨折等l a tendency to redisplace after reduction oblique,spiral and communited fractureDept.Orthopedics,1st Hospital SUMSFactors for fracture displacement骨折移位的因素骨折移位的因素1.Force from the injury（外力）（外力）2.Gravity or weight of distal part of affected limb（重力）（重力）3.Pull of muscles around the fracture（肌肉牵拉力）（肌肉牵拉力）4.Incorrect moving of the patient and unsuitable manipulation（人为因素）（人为因素）Dept.Orthopedics,1st Hospital SUMSType of fracture displacement骨折移位类型骨折移位类型 Angulation 成角成角lLateral displacement 侧方移位侧方移位lOverlap displacement 重叠重叠lSeparate displacement 分离分离lRotational 旋转旋转lComminuted frac.粉碎粉碎lmix together 混合混合l多数骨折为混合型骨折多数骨折为混合型骨折Dept.Orthopedics,1st Hospital SUMS骨折的类型与移位骨折的类型与移位l与治疗选择有关与治疗选择有关l与预后有关与预后有关Dept.Orthopedics,1st Hospital SUMS.l完全完全 Complete fracl横型横型 Transverse frac.l成角成角 Angulation l稳定稳定 Stable frac.Dept.Orthopedics,1st Hospital SUMS.l完全完全 Complete frac.l斜型斜型 Oblique frac.l不稳定不稳定 Unstable frac.l成角成角 Angulation disp.Dept.Orthopedics,1st Hospital SUMS.l完全完全 Complete frac.l螺旋螺旋 Spiral frac.l短缩重叠短缩重叠 Shortening(overlap)l侧方移位侧方移位 Lateral disp.l分离分离 Separate frac.l不稳定不稳定 Unstable frac.Dept.Orthopedics,1st Hospital SUMS.l粉碎粉碎 lComminuted frac.Dept.Orthopedics,1st Hospital SUMS多发骨折多发骨折 Multiple fractureDept.Orthopedics,1st Hospital SUMS.l多发多发lMultiple segmental frac.l粉碎粉碎lComminuted frac.Dept.Orthopedics,1st Hospital SUMS.lCoxa Vara 髋内翻髋内翻 l分离分离 Separatel粉碎粉碎 comminuted Dept.Orthopedics,1st Hospital SUMS.l 请分析骨折类型请分析骨折类型What is the type of fra.?Dept.Orthopedics,1st Hospital SUMSHealing of fracture骨折愈合骨折愈合l骨折愈合时间与众多因素有关，包括年龄，全骨折愈合时间与众多因素有关，包括年龄，全身情况，局部血供，骨折部位和类型身情况，局部血供，骨折部位和类型l骨折愈合通常需要骨折愈合通常需要68周以上周以上lHow long does a fracture take to unite?lDepend on many factors:-age,patient condition,local blood supply,type and site of fractureDept.Orthopedics,1st Hospital SUMS.l骨痂lCallus in fracture healing Dept.Orthopedics,1st Hospital SUMSFactors that influence union影响骨折愈合因素影响骨折愈合因素General condition全身情况全身情况lAge 年龄年龄lHealthy condition 健康状况健康状况l疾病情况疾病情况Dept.Orthopedics,1st Hospital SUMS影响骨折愈合的局部因素影响骨折愈合的局部因素Local factor for fracture unionlTypes of bone 骨的类型骨的类型lSites,types,severity of fracture 骨折因素骨折因素l多发骨折、分离骨折、粉碎骨折、股骨颈骨折、多发骨折、分离骨折、粉碎骨折、股骨颈骨折、胫骨远端骨折等影响骨折愈合胫骨远端骨折等影响骨折愈合lunion multiple frac.Separate frac.Comminuted frac.femoral neck frac.distal part of tibiaDept.Orthopedics,1st Hospital SUMS影响骨折愈合的局部因素影响骨折愈合的局部因素Local factor for fracture unionlBlood supply 血供，局部血供与骨折的解剖部血供，局部血供与骨折的解剖部位、骨折类型、严重程度、软组织损伤程度和位、骨折类型、严重程度、软组织损伤程度和感染有关感染有关Related with anatomical site,types,severity of fracture and soft tissue injurelSevere injury of soft tissuelInfection Dept.Orthopedics,1st Hospital SUMS影响骨折愈合的因素影响骨折愈合的因素Factors that influence unionl不恰当的处理不恰当的处理 Unsuitable management:反复多次复位反复多次复位 repeated reduction 过度牵引过度牵引 excessive traction:separation 不恰当的运动不恰当的运动 unsuitable immobility:movement 固定不可靠固定不可靠 unstable fixation Dept.Orthopedics,1st Hospital SUMSClinical manifestation of fracture(骨折临床表现）骨折临床表现）lHistory:injury 外伤史外伤史lGeneral condition 全身情况全身情况:lShock?Hemorrhage?是否有休克、出血是否有休克、出血lDamage to brain?To lungs and heart?To abdomen?To spinal cord?To others?是否有重要器官损伤？是否有重要器官损伤？lIt is important to look for other injuries.重视重要器重视重要器官损伤是重要的官损伤是重要的 Dept.Orthopedics,1st Hospital SUMS骨折的局部表现骨折的局部表现Local manifestationSpecific signs of fracture 骨折特有体征骨折特有体征lDeformity 畸形畸形lAbnormal mobility(movement between the fragments)反常活动反常活动lCrepitus 骨擦感或骨擦音骨擦感或骨擦音l三者中有一可作出诊断，但三者都没有不可以三者中有一可作出诊断，但三者都没有不可以否定骨折否定骨折lOne of them can make diagnosis Caution:none of them is found in some fractures.Dept.Orthopedics,1st Hospital SUMS骨折的其他表现，但没有特异性骨折的其他表现，但没有特异性Other signs of fracturenot specificlSwelling 肿胀肿胀lBruising(ecchymosis)淤斑淤斑lTenderness 压痛压痛lImpairment of function 功能障碍功能障碍l以上表现没有特征性，但可提供参考以上表现没有特征性，但可提供参考All sings above are not specific to fracture.Dept.Orthopedics,1st Hospital SUMS当你处理骨折患者时，需要了解当你处理骨折患者时，需要了解Ask yourself when you deal with a fracturelA wound?Open fracture?是否开放骨折是否开放骨折lAny impairment of circulation?局部血液循环情况局部血液循环情况lAny evidence of nerve injury?是否有神经损伤？是否有神经损伤？lAny evidence of visceral injury?是否有重要器官损是否有重要器官损伤？伤？lCompartment syndromes?是否有骨筋膜室综合是否有骨筋膜室综合 骨筋膜室综合征骨筋膜室综合征Dept.Orthopedics,1st Hospital SUMSTest for checking circulation检查患肢血循环检查患肢血循环lColor 皮肤颜色皮肤颜色lWarmth 皮温皮温lArterial pulse 搏动搏动lCapillary return 毛细血管回流毛细血管回流lNerve conductivity 神经功能神经功能lSpecific tests:Doppler ultrasonography or arteriography 特殊检查：超声，血管造影特殊检查：超声，血管造影Dept.Orthopedics,1st Hospital SUMS影像学检查影像学检查Radiographic examinationlX线检查是最基本、最必须的检查线检查是最基本、最必须的检查lX线照片可明确骨折的部位、类型线照片可明确骨折的部位、类型lX-ray(plain film)is important,basic and inevitable for diagnosis and treatment.X-ray can show:l fracturelSite of fracturelType of fractureDept.Orthopedics,1st Hospital SUMSX线检查线检查X-ray examinationl需要对有怀疑骨折的病人进行需要对有怀疑骨折的病人进行X线检查线检查lMust take X-ray film for each suspect fractureDept.Orthopedics,1st Hospital SUMSl股骨粗隆间骨折股骨粗隆间骨折lIntertrochanteric facture of femurDept.Orthopedics,1st Hospital SUMS多发骨折多发骨折 Multiple fracDept.Orthopedics,1st Hospital SUMSA-P view A-P view show normalshow normalLateral view show Lateral view show displacementdisplacement正侧位检查的必要性正侧位检查的必要性Dept.Orthopedics,1st Hospital SUMSA-P viewLateral viewX线检查的正侧位线检查的正侧位Two direction viewsDept.Orthopedics,1st Hospital SUMSCT or MRIl骨盆、脊柱等一些特殊部位需要骨盆、脊柱等一些特殊部位需要CT或或MRI检查检查l意义：骨折移位情况，与周围结构的关系，指导意义：骨折移位情况，与周围结构的关系，指导治疗治疗lNecessary in fractures of spine and pelvis,or in some specific frac.Significance:ldisplacement of fragmentslRelation between fragments and nearby structurelGuide for treatmentDept.Orthopedics,1st Hospital SUMS髋臼骨折髋臼骨折Acetabular frac.Dept.Orthopedics,1st Hospital SUMSComplication of fracture骨折并发症骨折并发症Early complication 早期并发症早期并发症1.Shock 休克休克2.Infection 感染感染3.Viscera injury 内脏损伤内脏损伤l肋骨骨折肋骨骨折 Rib fracture injure to lungs,liver,spleen(rupture)l骨盆骨折骨盆骨折 Pelvic fracture injure to bladder,rectalDept.Orthopedics,1st Hospital SUMSComplication of fracture4.Main artery or vein injury 血管损伤血管损伤5.Spinal cord injury 脊髓损伤脊髓损伤6.Peripheral nerve injury 周围神经损伤周围神经损伤7.Lipoembolization 脂肪栓塞脂肪栓塞partment syndrome 骨筋膜室综合征骨筋膜室综合征Dept.Orthopedics,1st Hospital SUMSMiddle and late stage complication后期并发症后期并发症1.Pneumonia 肺炎肺炎2.Bed sore 褥疮褥疮3.DVT 深静脉血栓形成深静脉血栓形成4.Ossification(ossifying myositis)骨化性肌炎骨化性肌炎Dept.Orthopedics,1st Hospital SUMSComplication of fracture5.Traumatic arthritis 创伤性关节炎创伤性关节炎6.Stiff of joint 关节僵硬关节僵硬7.ischemic necrosis of the affected bone 骨坏死骨坏死8.Ischemic contrature of the affected muscle 缺血缺血性肌挛缩性肌挛缩9.Bone atrophy,Sudecks atrophy 骨萎缩骨萎缩10.感染、骨髓炎感染、骨髓炎Dept.Orthopedics,1st Hospital SUMSTreatment of fracture骨折治疗骨折治疗First aid First aid 急救急救:1.Save lives 抢救生命抢救生命2.dressing of wound and control bleeding(hemostasia)包扎伤口，止血包扎伤口，止血3.temporary immobilization of the fractured limbs 骨折临时固定骨折临时固定4.rapid transportation 迅速送医院迅速送医院Dept.Orthopedics,1st Hospital SUMSPrinceple of Treatment for fracture骨折治疗原则骨折治疗原则lReduction 复位复位lImmobilization 固定固定lPreservation of function or functional exercise 功能锻练功能锻练Dept.Orthopedics,1st Hospital SUMSReduction 复位复位lRestore to normal position -Correct deformityl注意骨折的对线和对位注意骨折的对线和对位lAlignment is more important than appositionDept.Orthopedics,1st Hospital SUMSMethods of reduction 复位复位lClose reduction(manual)闭合复位闭合复位lOpen reduction(operation)开放复位开放复位Dept.Orthopedics,1st Hospital SUMSClose reduction(manual)手法复位手法复位Dept.Orthopedics,1st Hospital SUMSImmobilization 固定固定-Maintain position after reductionMethods 固定方法固定方法:l非手术：石膏、小夹板非手术：石膏、小夹板l手术：各种内固定手术：各种内固定Dept.Orthopedics,1st Hospital SUMS牵引牵引 Continuous Traction l具有复位和固定的作用，需要较长时间的卧床具有复位和固定的作用，需要较长时间的卧床lEffect:Reduction and ImmobilizationDept.Orthopedics,1st Hospital SUMS牵引类型牵引类型Types of tractionl 皮肤牵引皮肤牵引 Skin tractionl 骨牵引骨牵引 Skeletal tractionDept.Orthopedics,1st Hospital SUMS外固定支架，用于开放性骨折外固定支架，用于开放性骨折External fixation instrument special use for open fractureDept.Orthopedics,1st Hospital SUMSDept.Orthopedics,1st Hospital SUMS骨折治疗的选择骨折治疗的选择Choice of treatment methodl保守治疗保守治疗 lConservative treatmentl手术治疗手术治疗 loperationDept.Orthopedics,1st Hospital SUMS保守治疗的适应症保守治疗的适应症Indication of Conservative treatmentl多数的闭合稳定型骨折多数的闭合稳定型骨折l不适合手术者不适合手术者Dept.Orthopedics,1st Hospital SUMS手术适应症手术适应症Indication for operation l闭合复位失败闭合复位失败 Close reduction is difficult or faill不稳定骨折不稳定骨折 Unstable fracturel开放骨折开放骨折 Open fracturel关节内骨折关节内骨折 Fracture involve jointl并发神经血管损伤并发神经血管损伤 Complicate blood vessel and nerve injuryl多发骨折多发骨折 multiple fracturesl需要早期活动者需要早期活动者 Need early mobility for some patientsDept.Orthopedics,1st Hospital SUMS手术治疗的优点手术治疗的优点Advantages of operation for fracturel解剖复位解剖复位 Anatomical reductionl早期活动早期活动 Allow Early exercisel避免长期卧床避免长期卧床 Avoid to lie in bed for a long timel避免关节僵硬避免关节僵硬 Avoid joint stiffDept.Orthopedics,1st Hospital SUMS内固定的形式内固定的形式Some Examples of internal fixation Dept.Orthopedics,1st Hospital SUMS.Intramedullary nailSpecial for intertrochantericFrac.&proximal part fracture of femur.Dept.Orthopedics,1st Hospital SUMS手术的缺点手术的缺点Disadvantages and Complications of operationl感染机会感染机会 Infectionl内植物失败内植物失败 Implant failurel手术风险手术风险 Dangerous to some patientsDept.Orthopedics,1st Hospital SUMSExamples of operation.Dept.Orthopedics,1st Hospital SUMSInterlocking medullary nail 交锁髓内钉Dept.Orthopedics,1st Hospital SUMSPlate and screwDept.Orthopedics,1st Hospital SUMSFrac.HealingAfter removing plate and screwDept.Orthopedics,1st Hospital SUMSInterlocking medullary nailDept.Orthopedics,1st Hospital SUMSA-p positionLateral positionSupracondylar frac.Dept.Orthopedics,1st Hospital SUMS.A-p positionLateral positionFixed by plate and screwDept.Orthopedics,1st Hospital SUMSlFixed by K wireFixed by k-wireDept.Orthopedics,1st Hospital SUMSPlate brokenReplaced by interlocking nailDept.Orthopedics,1st Hospital SUMSBoth conservative and operative method are available Dept.Orthopedics,1st Hospital SUMSA-P viewDept.Orthopedics,1st Hospital SUMS.DCS Dynamic Condylar ScrewComminuted frac.Of Comminuted frac.Of femoral intercondylefemoral intercondyleDept.Orthopedics,1st Hospital SUMS.lMultiple frac.lIndication for opDept.Orthopedics,1st Hospital SUMSDept.Orthopedics,1st Hospital SUMS.lFixed by Special medullar nail and wireDept.Orthopedics,1st Hospital SUMSFrac.In both legsDept.Orthopedics,1st Hospital SUMSInterlocking Intromedullary nailDept.Orthopedics,1st Hospital SUMSlMultiple frac.Dept.Orthopedics,1st Hospital SUMSlFixation by screwsDept.Orthopedics,1st Hospital SUMSDept.Orthopedics,1st Hospital SUMSlFrac.in the neck and shaft of the same femur Dept.Orthopedics,1st Hospital SUMSSpecial screws fix frac.Of neckPlate fix frac.Of shaft Dept.Orthopedics,1st Hospital SUMSAcetabular frac.Use Special plate and pin for fixationDept.Orthopedics,1st Hospital SUMSMultiple frac.Multiple frac.Fixed by k-wire and plateFixed by k-wire and plateTo avoid damage To avoid damage epiphysis in Childrenepiphysis in ChildrenDept.Orthopedics,1st Hospital SUMSExternal fixation 外固定外固定Suitable for open comminuted frac.Dept.Orthopedics,1st Hospital SUMSA-P viewLateral viewSpecial screwDept.Orthopedics,1st Hospital SUMS人工关节人工关节人工关节人工关节Total hip replacementTotal hip replacementsuitable for old people suitable for old people with femoral neck fracwith femoral neck frac.Dept.Orthopedics,1st Hospital SUMSDept.Orthopedics,1st Hospital SUMS总结 Conclusionl骨折的分类有助治疗选择骨折的分类有助治疗选择lClassification of fra.is important for choice of treatmentl骨折特有体征有诊断意义骨折特有体征有诊断意义lSpecial signs of fra.is diagnostic l骨折的稳定性与骨折治疗选择有关骨折的稳定性与骨折治疗选择有关lStability of frac l引起骨折移位的因素对手术是重要的引起骨折移位的因素对手术是重要的lfactors causing displaced frac is important for operation l重视影响骨折愈合的因素重视影响骨折愈合的因素lPay attention to factors influencing bone unionDept.Orthopedics,1st Hospital SUMS总结 Conclusionl预防和处理骨折的并发症预防和处理骨折的并发症lPrevention of complication of frac l掌握骨折治疗原则掌握骨折治疗原则lPrinciple of fracture treatmentl熟悉骨折的紧急处理熟悉骨折的紧急处理lEmergent treatment for frac Dept.Orthopedics,1st Hospital SUMS