骨折概论.docx

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骨折概论.docx

骨折概论

骨折概论

PrinciplesofFractures

北京大学第三医院骨科周方

定义:

骨的连续性和完整性的中断

Definition:

Afractureisabreakinthestructuralcontinuityofbone

I.病因Etiology

A.创伤性Traumatic:

1.直接外力Directforce:

骨折位于外力直接作用的部位

Thebonebreakatthepointofimpact

2.间接外力Indirectforce:

骨折远离外力作用部位

Thebonebreaksatadistancefromwheretheforceisapplied

B.疲劳或应力性:

长期反复的轻微外力造成的骨折Fatigueorstress:

repetitivestress

C.病理性Pathological:

轻微外力作用于病变的骨组织所造成的骨折

Trivialforceonweakenedbone

II.骨折类型TypesofFractures

1.根据骨折开放与否:

Dependson#exposureornot

闭合骨折Closed#:

骨折部位的皮肤及粘膜完整

skinandmembraneintact

开放骨折open/compound#:

骨折与外界直接相通

skinorbodycavitybreached

2.根据骨折的形态:

Dependsonmorphologyof#

完全骨折:

骨组织完全断裂成两块或两块以上

complete#:

completebreakintotwoormorefragments

a.横骨折Transverse

b.斜骨折Oblique

c.螺旋骨折Spiral

d.粉碎骨折Comminuted

e.嵌插骨折Impacted

f.骨骺损伤Splitofepiphysis

g.节段性骨折segmental

不完全骨折:

骨组织不完全断裂且骨膜连续

boneisincompletedividedandtheperiosteoumremainsincontinuity

a.线性骨折Hairline

b.青枝骨折Greenstick

c.压缩骨折Compression

3.稳定与不稳定骨折Stableandunstable

III.骨折的移位Displacementof#

most#usuallybecomedisplacedby:

因素:

1.外力及其作用方向theforceanditsdirection

2.地心引力thegravity

3.附着肌肉的拉力

thepullofmusclesattachedtothebone

4.搬运或治疗不当

unpropertransportandtreatment

移位通常被描述为Displacementusuallyisdescribedintermsof:

1.对位Apposition

2.对线Alignment

3.旋转Rotation

4.重叠或短缩Alteredlength

IV.临床表现ClinicalFeatures:

1.病史:

外伤史及肢体活动障碍

Injury+inabilitytousetheinjuredlimb

其它病史Generalmedicalhistory

2.一般体征Generalsigns:

a.休克及出血shockorhaemorrhage

b.伴有颅脑、脊髓或脏器损伤

associateddamagetobrain,spinalcordorviscera

c.伴随疾病的体征apredisposingcause

3.局部体征Localsigns:

一般体征commonsigns:

肿胀青紫压痛活动受限

swelling,bruising,tenderness,restrictedrangeofmotion

骨折专有体征#signs:

畸形,异常活动,骨擦音/感

deformity,abnormalmovement,crepitus

4.影像学检查

X-rays:

常规检查,需从五个方面考虑

mandatory,maytakenin5aspects

a.两张片子twoviews:

a#maynotbeseenonasignalpicture

b.两个关节twojoints:

inthelongbone#,jointsbelowandabovethe#mustbeincluded

c.两个肢体twolimbs:

inchildren’s#,normalepiphysismayconfusethediagnoses

d.两种损伤twoinjuries:

severeforcemaycauseinjuryatmorethanonelevel

f.两种情况twooccasions:

#maynotseensoonafterinjury

CT:

关节内骨折及脊柱骨折

MRI:

脊柱骨折时神经损伤情况

骨折的描述Descriptionof#:

1.开放或闭合openorclosed?

2.骨折部位whichboneisbrokenandwhere?

3.是否累及关节jointsurfaceinvolved?

4.骨折的形态shapeofthe#?

V.骨折并发症Complicationsof#

1.休克,弥漫性凝血障碍,呼吸功能障碍

Shock,Diffusecoagulopathy,Respiratorydysfunction

2.内脏损伤Visceralinjury

3.血管损伤ArteryorVascularinjury

4.脊髓损伤Spinalcordinjury

5.神经损伤Nerveinjury

6.脂肪栓塞Fatembolism

7.挤压综合征Crushsyndrome

8.伤口感染Woundinfection

9.骨筋膜室综合征/缺血性肌挛缩

Compartmentsyndrome/Volkmann’scontracture

10.肺炎Pneumonia

11.褥疮Bedsore

12.骨化性肌炎Myositisossificans

13.创伤性关节炎HaemoarthritisorTraumaticarthritis

14.关节僵硬Jointstiffness

15.缺血性坏死Avascularnecrosis

16.废用性骨质疏松Disuseosteoporosis

17.深静脉血拴及肺栓塞D.V.T(deepvenousthrombosis)andP.E(pulmonaryembolism)

18.其它:

延迟愈合、不愈合、畸形愈合,骨骺发育障碍等delayedunion,nonunion,malunion,growthdisturbanceetc.

VI.骨折愈合程

Processoffracturehealing

骨折愈合过程取决于:

Theprocessof#repairvariesaccordingtothe:

a.骨的类型typeofboneinvolved

b.骨折部位活动度theamountofmovementatthe#site.

在长管状骨,缺乏坚强内固定的情况下,骨折愈合分为五个阶段:

Inatubularbone,andintheabsenceofrigidfixation,healingproceedingin5stages:

1.血肿形成期tissuedestructionandhaematomaformation

2.炎症反应及细胞增生期2W

Inflammationandcellularproliferation

3.原始骨痂形成期callusformation4W

4.骨痂坚固期Consolidation数月

5.骨痂改造塑型期Remodeling

骨折临床愈合的指征:

Indicationforclinical#union:

1.局部无压痛notenderness

2.无异常活动noabnormalmovement

3.X线所见:

骨折线模糊,有连续骨小梁通过骨折端,骨折周围有明显骨痂包绕

#lineobliteratedandcrossedbytrabecularbonewithwelldefinedcallusarounditonXR

4.上肢持重1kg超过1分钟,下肢不扶拐持续行走超过30步

lift1kgfor1min.orcontinuouswalkingmorethan30stepswithoutprotection

5.达到上述要求后,持续观察骨折端两周以上无变化

nochangeson#sitefortwomoreweeksobservation

VII.影响骨折愈合的因素

FactorsonFractureUnion

1.年龄Age

2.局部血运LocalBloodSupply

3.感染Infection

4.软组织损伤程度

DegreeofSoftTissueDamage

5.骨折断端间软组织嵌入

InterpositionofSoftTissueBetweenTwoFragments

6.健康状况GeneralCondition

7.治疗Treatment

VIII.骨折的治疗Treatmentof#

1.急救EmergencyTreatment

1).清除障碍Obtainaccess

2).保持良好通气、换气Airwayandventilation

3).止血Haemorrage

4).抗休克Shock

5).临时固定Splintage

目的thepurpose:

a.防止血管、神经及脏器的进一步损伤preventfurtherdamageton.v.andvisceral

b.减轻疼痛reducepain

c.便于转运easyfortransport

6).包扎伤口wounddressing

7).迅速转运transport

2.闭合骨折的治疗Treatmentofclosed#:

原则:

复位,固定,功能锻炼reduce,hold,exercise

1).复位Reduce

a.闭合复位closedreduction

解剖复位—最理想的复位,关节内骨折及前臂骨折需达到此要求anatomicreduction--theidealreduction,requiredinintraarticular#,forearm#

功能复位—必须达到以下要求:

Functionalreductionmustreach:

i.无旋转及分离移位Norotationandseparation

ii.下肢短缩少于1cm(成人)/2cm(儿童),无侧方成角,可有轻度前后成角inthelowerlimbshorteninglessthen1cm/2cminadults/children,nolateralangulation,minorA.Pangulation

iii.骨干骨折对位大于1/3,干骺端骨折对位大于3/4

b.切开复位openreduction

2).固定Holdreduction

a.小夹板Woodsplintage

b.石膏Castsplintage

c.功能性支具Functionalbrace

d.持续牵引:

Continuoustraction

儿童皮牵引4-5kg

成人骨牵引,重量为体重的1/7

e.外固定架Externalfixation

f.内固定Internalfixation:

钢板,螺钉,髓内钉,椎弓根螺钉等适应征∶

1.无法用手法复位者,

2.不稳定骨折或复位后再移位者,

3.由肌肉牵拉造成的骨折,

4.愈合缓慢或较差的骨折,

5.病理性骨折,

6.多发骨折,

7.护理困难的骨折,

8.关节内骨折,

9.需长期制动的骨折,

10.有移位的骨骺分离

Salter-HarrisTypeIII,IV

11.脊柱骨折不稳定或伴有神经损伤

3).功能锻炼Exercise

目的:

theobjective:

减轻水肿reduceoedema

恢复关节功能preservejointmovement,

恢复肌肉力量restoremusclepower,

逐渐恢复正常活动guidepatientbacktonormalactivity

a.抬高患肢Elevationimmediateafterinjury

b.主动活动Activeexerciseimmediateafterrigidfixation,aftercast--staticmusclecontraction

c.被动活动Assistantmovement

3.开放骨折的治疗:

Treatmentofopen#:

1).治疗前应考虑的四个方面:

4questionstobeansweredwhenseetheopen#:

a.伤口的性质whatisthenatureofthewound

b.皮肤及软组织有无缺损

whatisthestateoftheskinaroundthewound

c.患肢血运isthecirculationsatisfactory

d.有无神经损伤isthenerveintact

Gustilo-Andersonclassificationofopenfracture:

开放骨折分级:

I.清洁伤口,<1CM

II.伤口大于1CM,但不广泛,可有撕脱皮瓣

IIIA.伤口广泛,但仍有足够皮肤覆盖,或由高能量创伤造成

IIIB.广泛软组织缺损伴骨膜剥脱及骨质外露

IIIC.伴血管损伤并需修复者

2).预防感染Topreventinfection

a.立即包扎伤口immediatewoundcover

b.预防应用抗菌素antibioticprophylaxis

c.早期清创

最好在6-8小时内进行,也可以在8-24小时内进行,但必须:

Earlywounddebridementbestwithin6-8hrs,couldbedonein8-24hrsonlyif:

1.早期应用抗菌素earlyantibioticprophylaxis

2.伤口污染轻lesscontaminatedwound

3.软组织损伤轻lesssofttissuedamage,

如果>24小时—观察,二期清创,关闭伤口If>24hrs--observation,secondstageclose

d.稳定骨折stabilizationofthe#

3).伤口闭合:

Woundclosure:

一期:

伤后6-8小时内,局部无张力firststageclose:

within6-8hrs,notension,

二期:

伤后5天,伤口探查清创后直接缝合或植皮secondstageclose:

5dayslater,closewoundorskingraftafterinspection

谢谢!

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