2035090100股骨头骨折.ppt
Femoral Head Fractures股骨头骨折,Femoral Head Fractures Mechanism骨折机制,Fracture occurs by shear as femoral head dislocates.With less hip flexion,femoral head fracture tends to be larger.,股骨头脱位时的切应力关节屈曲度小骨折块较大,History and Physical Examination病史及物理检查,Similar to patient with hip dislocation.Patient posture may be less extreme due to femoral head fracture.,髋关节脱位检查患者姿势不太夸张,Classification髋关节脱位分型,Thomas and Epstein Type VHip dislocation with femoral head fracture,Thomas and Epstein V 型脱位伴股骨头骨折,AO/OTA Classification,Pipkin ClassificationPipkin 分型,I Fracture inferior to foveaII Fracture superior to foveaIII Fracture of femoral head with fracture of femoral neckIV Fracture of femoral head with acetabulum fracture,头中心凹之下骨折头中心凹之上骨折伴有股骨颈骨折伴有髋臼骨折,Pipkin,JBJS,1957,Pipkin IAO/OTA 31-C1.2,Pipkin IIAO/OTA 31-C1.3,Pipkin III,Femoral head fracture with femoral neck fracture.,股骨头骨折伴股骨颈骨折,Pipkin IV,Femoral head fracture with acetabulum fracture.High incidence of post-traumatic AVN.,股骨头骨折伴髋臼骨折创伤后股骨头坏死几率高,Radiographic Evaluation放射学检查,AP Pelvis X-RayLateral Hip X-RayJudet viewsPost-reduction CT Scan,正位侧位闭孔位/髂翼位复位后CT,Judet views闭孔位/髂翼位,CT Scan,Essential to evaluate quality of reduction of femoral head fracture(congruence),as well as intra-articular fragments.,对于股骨头骨折复位后形态评估和关节内碎块存在的判断,刘XX，髋关节脱位后三月，关节内游离体，前路手术取出关节内游离骨块,Pipkin I非手术治疗：头凹下骨折并且复位良好的骨折,Pipkin I手术治疗：头凹下骨折/移位,复位、固定或者切除如果可能，ORIF 最好常用前入路,Pipkin II 手术治疗：涉及头凹上骨折,开放复位内固定前路后路后路+Ganz 粗隆截骨骨块切除会造成关节不稳定,Reconstruct Head Whenever Possible,尽可能重塑股骨头,Pipkin III Fractures手术治疗：股骨头/股骨颈骨折,股骨头坏死发生率高老年患者股骨头置换的相对适应症如果股骨头骨折没有移位，不要试图在股骨颈骨折固定前手法复位,股骨头骨折脱位伴股骨颈骨折有移位,闭合复位徒劳年轻人ORIF:手术固定股骨颈复位评价股骨头中老年患者考虑关节置换,股骨头骨折脱位伴股骨颈骨折无移位,股骨颈固定后才能考虑关节复位,Pipkin IV Fractures手术治疗：股骨头/髋臼骨折,入路选择解决双重骨折复位固定的问题需要良好的复位稳定的固定术后创伤性关节炎发生率高,Many Options for Approach:,Posterior vs Anterior Approach,Support for Posterior ApproachSarmiento,CORR 1973Epstein,JBJS 1974(0 good results with ant.approach)Support for Anterior ApproachSwiontkowski,Thorpe,Seiler,Hansen,J Orthop Trauma 1992:12 anterior,12 posterior.Less blood loss and operative time with anterior approach.Improved visualization anteriorly.Increased H.O.anteriorly.67%good and excellent in each group.Nork,Routt et al,OTA 2001:21 cases,?one AVN,Femoral Head Fracture with Acetabulum FracturesKregor,AAOS,2004,10 cases followed 28 monthsAll had ORIF of both femoral head and acetabulum6 Ganz trochanteric flip osteotomy,3 anterior+posterior,1 posterior.Results:3 excellent,6 good,1 poor.“The Ganz Trochanteric Flip Osteotomy combined with surgical dislocation of the hip allows for optimal visualization and fixation of both injuries,controlled reduction of the hip,and thorough debridement of the hip joint.”,My Options for Approach:,Smith-PetersonPipkin IPipkin III(two incision/easier for femoral neck Fx reduction)Legen-beckGanz Surgical DislocationPipkin II(better view of the joint)Pipkin IV(one approach for both Fx reduction&fixation),Case 1,男性，41岁，车祸伤左侧股骨头骨折脱位右肩关节骨折脱位/胫骨骨折治疗原则、方法体位、顺序入路、内固定,Case 2,男性，42岁，车祸伤左侧股骨头/髋臼后壁骨折脱位左侧胫腓骨粉碎开放骨折（Gastilo IIIB)治疗原则、方法体位、顺序入路、内固定,Surgical Dislocation of the Hip for Fractures of the Femoral HeadHelfet,Lorich et al,J Orthop Trauma,2005,谢 谢,
