上肢骨折..ppt

Upper extremity fractures,Orthorpeadic department of the second affiliated hospital of Chongqing Medical UniversityDr.Liang,main content,Clavicular fracture（锁骨骨折）fracture of the proximal humerus（肱骨近端骨折）Humeral shaft fracture（肱骨干骨折）supracondylar fracture of humerus（肱骨髁上骨折）fracture of radius and ulna（尺桡骨骨折）distalradius fracture（桡骨远端骨折）,Section 1 fracture of clavicle,解剖概要（anatomy review）function：connect the arm to the trunk(躯干)shape：“S”shape and irregular(不规则)Lateral 1/3 part:flat；middle 1/3 part:cylindrical，weak；medial 1/3 part:prismatic(陵柱状)shapejoint：lateral-acromioclavicularjoint肩锁关节；medial-sternoclavicularjoint胸锁关节ligament韧带：acromioclavicular ligament肩锁韧带，Coracoclavicular ligament喙锁韧带:trapezoid ligament(斜方韧带)conoid ligament锥状韧带adjacentstructure毗邻结构：Subclavian vessels锁骨下血管，brachialplexus臂丛神经,adjacentstructure毗邻结构,毗邻结构,mechanismofinjury and fracture displacement受伤机制及骨折移位,Indirect Violence间接暴力Fall with the shoulder hitting the ground侧方摔倒，肩部着地Result in transverse or oblique fracture多导致横行骨折或斜行骨折Indirect Violence直接暴力Hit directly直接击打Comminuted fracture可导致粉碎骨折（中1/3）骨折移位（fracture displacement in the middle third）：proximal fragment displaced proximally and posteriorly 近端向上、后移位（draw by the sternocleidomastoid胸锁乳突肌牵拉），the distal fragment displaced inferiorly and anteriorly(caused by gravity and the traction of the deltoid)远端向前下移位（三角肌锁骨部牵拉及重力）。,fracture classification（骨折分类）,According to the fracture site解剖部位：lateral外侧，middle中段，medial内侧Fracture morphology骨折形状：横行(transverse)，斜行(oblique)，粉碎(comminuted)外1/3骨折分型：type型：fracture locates between the acromioclavicular lig.and the Coracoclavicular lig.With minimum displacement位于肩锁韧带与喙锁韧带之间，移位不明显。type型：with damage of the Coracoclavicular lig.The proximal fragment displaced superiorly.合并喙锁韧带损伤，骨折近端向上移位。Type Type 型：the acromioclavicularjoint involved骨折累及肩锁关节,型 A.B,Clinical manifestations and diagnosis临床表现及诊断,Clinical manifestationsclinical sign(症状)：pain疼痛，limitation of motion活动受限physical sign(体征)：deformity畸形，ecchymosis皮下瘀斑，bony crepitus骨擦感diagnosis（诊断）X ray CT scan,Imaging study,treatment治疗,conservative treatment(保守治疗)indication适应征：greenstick fracture in children青枝骨折，non-displacement fracture in adult成人无移位骨折。treatment方法：closed reduction手法复位，figure of“8”bandage for 3-6 weeks八字绷带固定3-6周。surgical treatment(手术治疗)：open reduction and internal fixation,ORIF（切开复位内固定）surgical indication(手术指征)：Significant displacement 明显移位Re-displacement after closed reduction复位后再次移位Combined with neural and vascular damagement 合并神经血管损伤Open fracture 开放骨折Chronic fracture and Fracture nonunion陈旧骨折不愈合Distal fracture with Coracoclavicular lig.rupture合并喙锁韧带断裂的外端骨折Combined with scapular neck fracture 合并肩胛颈骨折,Conservative treatment保守治疗,Surgical treatment,Surgical treatment手术治疗,Surgical treatment,Section 2 proximal humerus fracture第二节 肱骨近端骨折,Anatomy review解剖概要Collodiaphyseal angle about 140(neck-shaft angle颈干角)anatomical neck(解剖颈)surgical neck(外科颈),Blood supply血供,Posterior humeral circumflex artery旋肱后动脉anterior humeral circumflex artery旋肱前动脉,Anatomy review(blood supply),Kinematic mechanics of the shoulder关节运动力学,Pathogenesis and classification病因及分类,Mechanism of injury受伤机制Indirect violence间接暴力Direct violence直接暴力classification分型Traditional classification传统分型（1）non-displacement fracture无移位骨折（2）abductive fracture外展型（3）adductive fracture内收型AO classification(AO分型)Type A型：extra-articular simple fracture关节外简单Type B型：extra-articular complex fracture关节外复杂 Type C型：intra-articular fracture关节内Neer classification分型1,2,3,4 part fracture and fracture-dislocation(部分、部分、部分、部分、骨折脱位),AO classificationAO分型,Neerclassification,Diagnosis诊断,X-rayAP,Lateral and axial view of the shoulder肩关节正、侧位片、腋位片CT+three dimensional reconstruction三维重建,X-rayin three direction,treatment,Conservative treatment 保守治疗indication适应征Non-displaced fracture无移位骨折Stable abductive fracture稳定的外展型骨折With absolute surgical contraindications存在绝对手术禁忌征患者method方法Supra-shoulder plaster 超肩石膏外固定Abduction brace外展支架固定（adductive fracture内收型骨折）,Surgical treatment手术治疗,Surgical indications手术指征Unstable fracture不稳定骨折Unsuccessful reduction of closed fracture闭合复位失败Anatomy neck fracture解剖颈骨折Fracture-dislocation骨折脱位Articular fracture累及关节面Combined with rotator cuff injury合并肩袖损伤With neural and(or)vascular injury合并神经血管损伤floating shoulder（浮肩）Chronic fracture陈旧骨折,Surgical treatment,methods方法Kirschner wire plus tension bend fixation（克氏针-张力带固定）Screw fixation螺钉固定（lag screw拉力螺钉、canulated screw空心、absorbable screw 可吸收）Proximal humeral locking plate肱骨近端锁定钢板precautions注意事项The repair of the rotator cuff肩袖的修复Repair of joint capsule关节囊的修复Early functional rehabilitation早期功能锻炼,Kirschner wire fixation克氏针固定,经骨缝线固定,Screw fixation螺钉固定,Proximal humeral locking plate fixation肱骨近端锁定钢板,Locking plate,Intromadurally nail,Intromadurally nail,Shoulder arthroplasty肩关节置换,Section 3 humeral shaft fracture（第三节 肱骨干骨折）,Anatomy review解剖概要range部位：2 cm beneath the surgical neck and 2 cm above the supracondyle 外科颈下2cm到肱骨髁上2cmThe nourishing vessels insert in the middle to lower part of the humerus中下部有滋养血管(nourishing vessel)进入The violence of the nourishing vessels could result in fracture nonunion损伤后易导致骨折不愈合The radial nerve across the junction of the middle and lower third of the humerus laterally and posteriorly 中下1/3后外侧紧贴骨面有桡神经（radial nerve）走行Radial nerve damaged,Radial nerve damaged,Pathogenesis and classification 病因及分类,PathogenesisDirect violence直接暴力Transverse or comminuted fracture横行或者粉碎骨折Indirect violence间接暴力Fracture at the junction of the middle and lower third of the humerus中下1/3骨折Oblique or spiral fracture斜行骨折或者螺旋形骨折AO classificationType A型：simple fracture简单骨折Type B型：wedge fracture楔型骨折Type C型：complicated comminuted fracture复杂粉碎骨折,diagnosis诊断,The patients history病史Traumatic history外伤史Physical sign体征Typical signs for fractures骨折体征(deformity畸形，ecchymosis皮下瘀斑，bony crepitus骨擦感)The characteristics of fracture displacement骨折移位特点Symptoms of radial nerve injury桡神经损伤症状Radial site numbness of the dorsum hand and wrist虎口区麻木Wrist extension obstacle伸腕障碍Imaging studies影像学X-ray：AP and lateral view(including the shoulder and elbow joint)肱骨正、侧位片（包含上下关节）CT+three dimensional reconstruction三维重建,treatment,Conservative treatment保守治疗Closed reduction and supra-shoulder plaster fixation手法复位，超肩石膏外固定,Surgical treatment手术治疗,Surgical indication手术指征Repeated failure of closed reduction反复手法复位失败Separative displacement,soft tissue impacted分离移位、软组织嵌入Combined with neural or(and)vascular injury合并神经血管损伤Chronic fracture or fracture nonunion陈旧骨折不愈合malunion骨折畸形愈合Multiple fracture多发骨折Pathological fracture病理性骨折Open fracture开放性骨折Unstable fracture不稳定骨折,Operative methods手术治疗方法Internal fixation with plates and screws钢板螺钉内固定Compression plating加压钢板Locking-compression plating锁定加压钢板minimal invasive plate osteosynthesis（微创接骨板技术）Interlocking intramedullary nail fixation交锁髓内钉固定precautions注意事项The protection of the radial nerve桡神经的保护,Compression plating加压钢板,Locking platefor chronic fracture 锁定钢板,Locking plate,incision,Radial nerve protection,Radial nerve protection,交锁髓内钉,交锁髓内钉,Section 3 supracondylar fracture of humerus(第三节 肱骨髁上骨折),definition定义：fracture happens at the junction of the humeral shaft and the supracondyle肱骨干与肱骨髁交界处发生的骨折。Anatomy review解剖概要Anteversion angle前倾角：30-50anatomic factors leading to increased risk of fractures易发生骨折的解剖学基础Adjunction structures毗邻结构：brachial artery肱动脉、median nerve正中神经、ulnar nerve尺神经、radial nerve桡神经,Fracture classification骨折分类,extension-typesupracondylarfractureof humerus伸直型肱骨髁上骨折injurymechanism受伤机制：Elbow hyperextension and land on the palm when falling跌倒时肘关节过着地伸，手掌着地The shearing force directed superiorly to inferiorly剪切暴力由上而下The distal fragment displaced posteriorly and superiorly远折端向后上Physical sign体征：elbow joint swelling肘关节肿胀，with normal posterior elbow triangle肘后三角正常。The neural and vascular injury should be excluded 应特别注意是否合并神经血管损伤flexiontypesupracondylarfracture屈曲型肱骨髁上骨折Landing on flex elbow肘关节屈曲，肘后方着地Fracture line directs anterosuperiorly to posteroinferiorly骨折线前上至后下,Fracture classification,Diagnosis and treatment诊断及治疗,diagnosis诊断morecommoninchildren儿童多见With significant traumatic history外伤史Clinical symptoms and physical signs of fracture临床症及体征Imaging findings影像学表现,treatment治疗Closed reduction手法复位Bone traction牵引-olecroanon bone traction尺骨鹰嘴骨牵引Plaster fixation for flexiontypesupracondylarfracture石膏外固定（屈曲型骨折）Extended elbow fixed for 10 days then fix a 40 degree flexed elbow for 4 to 6 weeks伸直为7-10天，屈肘40位4-6周Open reduction and internal fixation切开复位，内固定Surgical indications手术指征Closed reduction unsuccessful手法复位失败Significant displacement骨折移位严重Combined with neural and vascular damagement合并神经血管损伤Supracondylar fracture in adult成人髁上骨折precautions注意事项：brachial artery injury could result in Forearm ischemic 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,Operative treatment,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,Section 4 ulna and radius fracture第四节 尺桡骨骨折,Anatomy review解剖概要Humeroulnar joint肱尺关节Humeroradial joint肱桡关节Proximal radioulnar joint上尺桡关节Distal radioulnar joint下尺桡关节Triangular fibrocartilage三角纤维软骨盘Interosseous membrane骨间膜Maximum tension at Neutral position中立位时最紧张Contracture cause limited motion骨间膜挛缩后果,Pathogenesis and classification 病因及分类,PathogenesisDirect violence直接暴力Indirect violence间接暴力Twisting force扭转暴力,classification分类AO classificationType A型：simple fracture简单骨折Type B型：wedge fracture楔形骨折Type C型：complicated fracture复杂骨折,Clinical manifestation临床表现,pain疼痛deformity畸形Abnormal activity异常活动Bony crepitus骨擦感Weaken or disappear Bone transduction sound骨传导音减弱或消失Could combine with radial head or ulnar head dislocation可合并桡骨头或尺骨小头脱位Could combined with neural or vascular injury可合并神经血管损伤,diagnosis诊断,Traumatic history外伤史symptom症状Physical sign体征Radiographic manifestation影像学表现X rayCT+3D reconstruction,treanment,Conservative treatment保守治疗Manipulative reduction手法复位Long arm cast or plintlet fixation in neutral position小夹板或石膏托外固定,Operative treatment,Open reduction and internal fixation切开复位内固定（ORIF）Surgical indication手术指征Unstable fracture不稳定骨折Unsuccessful closed reduction闭合复位失败Open fracture with limited contamination within 6 hours开放骨折污染轻、时间短Combined with nerves,vessels or tendon injury合并神经血管及肌腱损伤Multiple injury in unilateral extremity同侧肢体多发损伤Old fracture陈旧骨折Fracture malunion骨折畸形愈合,External fixator stabilization外支架固定Ulnar shaft fracture complicated by distal radial complex comminuted fracture尺骨干骨折合并桡骨远端粉碎骨折Complicated open fractures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,Postoperative treatment术后处理,Improve the circulation of the injured extremity and prevent the development of compartment symdrome改善患肢循环，预防骨筋膜室综合征Functional exercise功能锻炼,Special fracture type特殊骨折,Monteggia fracture（孟氏骨折）,Galeazzi fracture（盖氏骨折）,Monteggia fracture 孟氏骨折,definition定义：ulna proximal third fracture with radial head fracture尺骨近端1/3骨折合并桡骨头脱位Injury mechanism病因：fall with prone forearm and extended elbow肘伸直位，前臂旋前跌倒classification分型伸直型屈曲型内收型特殊型,诊断,外伤史症状特有体征肘前或肘后可扪及桡骨头前臂不能旋转可能损伤桡神经或者正中神经,治疗,保守治疗：闭合复位，石膏外固定肘关节功能位手术治疗（ORIF）闭合复位失败桡骨头复位后再脱位陈旧骨折骨折畸形愈合术后处理：石膏固定12周,环状韧带修复,盖氏骨折,定义：桡骨远1/3骨折伴尺骨小头脱位病因直接暴力间接暴力,分型型：桡骨横行骨折（稳定型）型：桡骨斜行骨折（不稳定型）型：合并尺骨远1/3（特殊型）,诊断,病史、症状及体征影像学必要时做腕关节MRI明确是否存在三角纤维软骨盘损伤,治疗,保守治疗（型）：手法复位，石膏外固定。8-12周。手术治疗：型及型ORIF修复三角纤维软骨盘,第六节 桡骨远端骨折（fracture of the distal end of radius）,定义：距桡骨远端关节面3cm以内的骨折解剖概要：掌倾角10-15尺偏角20-25下尺桡关节三角纤维软骨盘舟桡关节月桡关节,病因及分型,病因：间接暴力AO分型A型：关节外骨折B型：部分关节内骨折C型：完全关节内骨折Colles 骨折Smith 骨折Barton 骨折,Colles 骨折,桡骨远端伸直型骨折受伤机制跌倒时腕背伸、前臂旋前、手掌着地临床表现疼痛、畸形、活动受限银叉畸形抢刺样畸形,治疗,保守治疗闭合复位，石膏托外固定（屈腕位2周，中立位6-8周）闭合复位，克氏针有限内固定，外支架外固定切开复位，钢板螺钉内固定,入路及固定,钢板内支架,Smith 骨折,定义：桡骨远端屈曲型骨折（反colles 骨折）Thomas分型型：关节线横行，背侧成角型：骨折线斜行，远背侧斜向掌近侧型：关节内骨折诊断外伤史、临床表现、影像学治疗保守治疗：手法复位，石膏外固定手术治疗：ORIF,Barton 骨折,定义：桡骨远端冠状面骨折，合并腕关节半脱位受伤机制：剪切暴力跌倒时腕背伸或者掌屈时手掌着地,诊断及治疗,诊断：病史体征影像学：X-ray、CT治疗:ORIF,非常感谢！,