骨折概论.docx

1、骨折概论 骨折概论Principles of Fractures 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: A fracture is a break in the structural continuity of bone I.病因 EtiologyA.创伤性 Traumatic:1.直接外力 Direct force: 骨折位于外力直接作用的部位The bone break at the point of impact2.间接外力 Indirect force: 骨折远离外力作用部位The bone breaks at a distance from

2、 where the force is appliedB.疲劳或应力性：长期反复的轻微外力造成的骨折 Fatigue or stress: repetitive stressC.病理性 Pathological: 轻微外力作用于病变的骨组织所造成的骨折Trivial force on weakened bone II.骨折类型 Types of Fractures1. 根据骨折开放与否: Depends on # exposure or not闭合骨折 Closed #: 骨折部位的皮肤及粘膜完整 skin and membrane intact开放骨折 open / compound #:

3、骨折与外界直接相通skin or body cavity breached2.根据骨折的形态: Depends on morphology of #完全骨折: 骨组织完全断裂成两块或两块以上complete #: complete break into two or more fragmentsa.横骨折 Transverse b.斜骨折 Obliquec.螺旋骨折 Spirald.粉碎骨折 Comminutede.嵌插骨折 Impacted f.骨骺损伤 Split of epiphysisg.节段性骨折 segmental不完全骨折:骨组织不完全断裂且骨膜连续bone is incompl

4、ete divided and the periosteoum remains in continuity a.线性骨折 Hair line b.青枝骨折 Green stickc.压缩骨折 Compression3.稳定与不稳定骨折 Stable and unstableIII.骨折的移位 Displacement of #most # usually become displaced by:因素:1. 外力及其作用方向 the force and its direction2.地心引力 the gravity3.附着肌肉的拉力 the pull of muscles attached to

5、 the bone4.搬运或治疗不当 unproper transport and treatment移位通常被描述为 Displacement usually is described in terms of：1.对位 Apposition 2.对线 Alignment 3.旋转 Rotation 4.重叠或短缩 Altered lengthIV.临床表现 Clinical Features:1.病史:外伤史及肢体活动障碍Injury + inability to use the injured limb其它病史 General medical history2.一般体征 General s

6、igns: a.休克及出血 shock or haemorrhageb.伴有颅脑、脊髓或脏器损伤associated damage to brain, spinal cord or viscerac.伴随疾病的体征 a predisposing cause3.局部体征 Local signs：一般体征 common signs: 肿胀 青紫 压痛 活动受限swelling, bruising, tenderness, restricted range of motion 骨折专有体征 # signs: 畸形，异常活动，骨擦音/感deformity, abnormal movement, cre

7、pitus4. 影像学检查X-rays: 常规检查，需从五个方面考虑mandatory, may taken in 5 aspectsa.两张片子 two views: a # may not be seen on a signal pictureb.两个关节 two joints : in the long bone #, joints below and above the # must be included c.两个肢体 two limbs: in childrens #, normal epiphysis may confuse the diagnosesd.两种损伤 two inj

8、uries: severe force may cause injury at more than one levelf.两种情况 two occasions: # may not seen soon after injuryCT: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 Description of #: 1.开放或闭合 open or closed？2.骨折部位 which bone is broken and where?3.是否累及关节 joint surface involved？4.骨折的形态 shape of the #?V.骨折并发症 Complicati

9、ons of #1. 休克，弥漫性凝血障碍，呼吸功能障碍Shock, Diffuse coagulopathy, Respiratory dysfunction2.内脏损伤 Visceral injury3.血管损伤 Artery or Vascular injury4.脊髓损伤 Spinal cord injury5.神经损伤 Nerve injury6.脂肪栓塞 Fat embolism7.挤压综合征 Crush syndrome8.伤口感染 Wound infection9.骨筋膜室综合征/缺血性肌挛缩 Compartment syndrome/Volkmanns contracture

10、10.肺炎 Pneumonia11.褥疮 Bed sore12.骨化性肌炎 Myositis ossificans13.创伤性关节炎 Haemoarthritis or Traumatic arthritis14.关节僵硬 Joint stiffness15.缺血性坏死 Avascular necrosis 16.废用性骨质疏松 Disuse osteoporosis17.深静脉血拴及肺栓塞 D.V.T(deep venous thrombosis)and P.E(pulmonary embolism)18.其它: 延迟愈合、不愈合、畸形愈合，骨骺发育障碍等 delayed union, no

11、nunion, malunion, growth disturbance etc.VI.骨折愈合程 Process of fracture healing骨折愈合过程取决于：The process of # repair varies according to the：a.骨的类型 type of bone involvedb.骨折部位活动度 the amount of movement at the # 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: In a tubular bone, and in the absence of rigid fixation, hea

12、ling proceeding in 5 stages:1.血肿形成期 tissue destruction and haematoma formation2. 炎症反应及细胞增生期 2W Inflammation and cellular proliferation3.原始骨痂形成期 callus formation 4W4.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: Indication for clinical # union:1.局部无压痛 no tenderness2.无异常活动 no abnormal movement3

13、. 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 # line obliterated and crossed by trabecular bone with well defined callus around it on XR4. 上肢持重1kg 超过1分钟，下肢不扶拐持续行走超过30步lift 1kg for 1 min. or continuous walking more than 30 steps without protection5. 达到上述要求后，持续观察骨折端两周以上无变化 no changes on # site for two more wee

14、ks observationVII.影响骨折愈合的因素Factors on Fracture Union1.年龄Age2.局部血运Local Blood Supply3.感染Infection4.软组织损伤程度Degree of Soft Tissue Damage5.骨折断端间软组织嵌入Interposition of Soft Tissue Between Two Fragments6.健康状况 General Condition7.治疗 TreatmentVIII.骨折的治疗Treatment of #1.急救 Emergency Treatment1).清除障碍 Obtain acce

15、ss2).保持良好通气、换气 Airway and ventilation 3).止血 Haemorrage4).抗休克 Shock5).临时固定 Splintage 目的the purpose: a.防止血管、神经及脏器的进一步损伤 prevent further damage to n. v. and visceralb.减轻疼痛 reduce painc.便于转运 easy for transport6).包扎伤口 wound dressing7).迅速转运 transport2.闭合骨折的治疗Treatment of closed #: 原则：复位，固定，功能锻炼 reduce, ho

16、ld, exercise1).复位 Reduce a.闭合复位 closed reduction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 anatomic reduction - the ideal reduction, required in intraarticular #, forearm #功能复位必须达到以下要求：Functional reduction must reach： i.无旋转及分离移位No rotation and separation 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 in the lower limb sh

17、ortening less then 1 cm/2 cm in adults/children, no lateral angulation, minor A.P angulationiii.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 open reduction2).固定 Hold reductiona.小夹板 Wood splintageb.石膏 Cast splintagec.功能性支具 Functional braced.持续牵引：Continuous traction 儿童 皮牵引4-5kg成人 骨牵引，重量为体重的1/7e.外固定架 External fixat

18、ionf.内固定Internal fixation：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-Harris Type III, IV11.脊柱骨折不稳定或伴有神经损伤3).功能锻炼 Exercise目的: the objective:减轻水肿reduce oedema恢复关节功能preserve joint movement, 恢复肌肉力量restore muscle

19、 power, 逐渐恢复正常活动guide patient back to normal activitya.抬高患肢 Elevation immediate after injury b.主动活动 Active exercise immediate after rigid fixation, after cast-static muscle contraction c.被动活动 Assistant movement3.开放骨折的治疗: Treatment of open #: 1).治疗前应考虑的四个方面：4 questions to be answered when see the ope

20、n #：a.伤口的性质 what is the nature of the wound b.皮肤及软组织有无缺损 what is the state of the skin around the wound c.患肢血运 is the circulation satisfactory d.有无神经损伤 is the nerve intact Gustilo-Anderson classification of open fracture:开放骨折分级:I.清洁伤口，24小时观察，二期清创，关闭伤口If 24hrs - observation, second stage close d.稳定骨折stabilization of the # 3).伤口闭合: Wound closure:一期：伤后6-8小时内，局部无张力first stage close: within 6-8 hrs, no tension,二期：伤后5天，伤口探查清创后直接缝合或植皮second stage close: 5 days later, close wound or skin graft after inspection 谢谢！