2022醫(yī)學課件前臂骨折

1、前臂骨折五附院骨二科 第一頁，共一百四十頁。尺橈骨雙骨折尺骨單骨折橈骨單骨折前臂遠端骨折授課內(nèi)容第二頁，共一百四十頁。體表標志第三頁，共一百四十頁。體表標志第四頁，共一百四十頁。前臂前區(qū)第五頁，共一百四十頁。第六頁，共一百四十頁。前臂前區(qū)第七頁，共一百四十頁。前臂前區(qū)第八頁，共一百四十頁。前臂前區(qū)第九頁，共一百四十頁。橈神經(jīng)深支和后側(cè)骨間神經(jīng)：橈神經(jīng)在肘窩外側(cè)，肱骨外上髁前方，分淺、深兩支橈神經(jīng)深支發(fā)出肌支至橈側(cè)腕長、短伸肌和旋后肌，然后穿入旋后肌，在橈骨頭下方57CM出穿出該肌，稱為后側(cè)骨間神經(jīng)，走行與前臂肌后群淺、深兩層之間分短支與長支前臂后區(qū) 深層第十頁，共一百四十頁。前臂后區(qū)第十一頁，

2、共一百四十頁。前臂后區(qū)第十二頁，共一百四十頁。前臂后區(qū)第十三頁，共一百四十頁。前臂后區(qū)第十四頁，共一百四十頁。A型 簡單骨折A1,A2,A3B型 鍥型骨折 (B1,B2,B3)C型 復雜骨折 (C1,C2,C3) 前臂骨折AO分型第十五頁，共一百四十頁。A1.1 斜型骨折第十六頁，共一百四十頁。A1.2 橫型骨折第十七頁，共一百四十頁。A 1.3 伴有橈骨頭脫位孟氏骨折第十八頁，共一百四十頁。A2.1 斜型骨折第十九頁，共一百四十頁。A2.2 橫型骨折第二十頁，共一百四十頁。A2.3 伴頭下尺橈關節(jié)脫位蓋氏骨折第二十一頁，共一百四十頁。A 3 簡單的雙骨折第二十二頁，共一百四十頁。B1.1 完

3、整鍥型第二十三頁，共一百四十頁。B1.2 帶有碎片的鍥型骨折第二十四頁，共一百四十頁。B1.3 伴有橈骨頭脫位孟氏骨折第二十五頁，共一百四十頁。B2.1 完整鍥型第二十六頁，共一百四十頁。B2.2 碎片鍥型第二十七頁，共一百四十頁。B2.3 伴有下尺橈關節(jié)脫位蓋氏骨折第二十八頁，共一百四十頁。B3.1 尺骨鍥型 ，橈骨簡單骨折第二十九頁，共一百四十頁。B3.2 橈骨鍥型，尺骨簡單骨折第三十頁，共一百四十頁。B3.3 尺橈骨鍥型骨折第三十一頁，共一百四十頁。C1.1 兩端，橈骨完整第三十二頁，共一百四十頁。C1.2 兩段 橈骨骨折第三十三頁，共一百四十頁。C1.3 不規(guī)那么第三十四頁，共一百四十

4、頁。C2.1 兩段 ，尺骨完整第三十五頁，共一百四十頁。C2.2 兩段 ，尺骨骨折 第三十六頁，共一百四十頁。C2.3 不規(guī)那么第三十七頁，共一百四十頁。C 3 尺橈骨復雜骨折第三十八頁，共一百四十頁。橈骨干前外側(cè)入路：橈骨干全長 Henry切口橈骨干后側(cè)入路：橈骨干上中部Thompson切口尺骨干后側(cè)入路：尺骨全長 常用手術入路第三十九頁，共一百四十頁。AP and lateral views of the both bones fracture of the forearm,demonstrating significant shortening and relatively simple

5、oblique fracture patterns.第四十頁，共一百四十頁。The patient is positioned supine with the arm prepped anddraped to just above the elbow and a tourniquet in place. This figure demonstrates the arm held in supination. Note theposition of the biceps insertion as well as the palpable tendonof the FCR and radial a

6、rtery.BICEPSTENDONRADIALARTERYFLEXOR CARPIRADIALIS (FCR)第四十一頁，共一百四十頁。A useful technique to make the skin incision is to take a bovicord and pull it taught from the radial side of the biceps tendonto the FCR at the level of the wrist. This can then be used as a template for the incision line.第四十二頁，共一

7、百四十頁。第四十三頁，共一百四十頁。The incision is taken down through the skin, identifying the fascial layer with care taken not to damage any superficial veins that may be intact. The FCR tendon is clearly visible throughout the wound, as is the radial artery in the distal extent of the wound.FCRRADIALARTERY第四十四頁，

8、共一百四十頁。A closeup of the distal aspect of the wound demonstratingThe radial artery and its venous commtantes.RADIAL ARTERY ANDVENOUS COMMTANTES第四十五頁，共一百四十頁。FCRRADIALARTERYThe fascia on the radial side of the flexor carpi radialis is released, exposing the deep tissue. The radial artery can be followe

9、d now throughout the entire incision. 第四十六頁，共一百四十頁。The radial artery may be taken in either direction, however, typically it is easier to take the artery to the radial side.FCRRADIALARTERY第四十七頁，共一百四十頁。The deep dissection is now performed between the flexor-pronator mass on the ulnar side and the art

10、ery and the mobile wad on the radial side.第四十八頁，共一百四十頁。PRONATORFor the proximal dissection, the forearm is brought intosupination and the pronator, FDS and FDP are releasedfrom the volar aspect of the radius第四十九頁，共一百四十頁。FDSThe pronator is being released from the radial aspect of the radius in a subp

11、eriosteal manner. This subperiostealdissection continues distally to release the origin of thecommon flexor.第五十頁，共一百四十頁。After exposure of the volar aspect of the radius proximallyand distally, two clamps can be placed on the ends of thebone in order to deliver them for cleaning.第五十一頁，共一百四十頁。FCRRADIA

12、L ARTERYEach side of the fracture is be delivered in order to expose and clean the cortical edges.第五十二頁，共一百四十頁。These figures demonstrate delivery of the distal fragment and acurved curette being used to clean the cortical edge. Nocleaning should be performed within the intramedullary canal,as this i

13、s healthy tissue and can be useful for the healing process.第五十三頁，共一百四十頁。Once the fractures are completely cleaned along their cortical edges such that the fracture reduction can be visualized, the two clamps are used to reduce the fracture. If a butterfly fragment exists, it is necessary to fix this

14、 with a lag screw back to one of the fracture ends in order to realign the fracture.第五十四頁，共一百四十頁。In the current case, the fracture is a simple pattern and is reduced by delivering the bones jointly, accentuating the deformity and then rotating and fitting the bones together with progressive compress

15、ion while pushing the bones back into the wound, obtaining alignment by steric interference of one side against the other.第五十五頁，共一百四十頁。Once the bones are held reduced, as seen in the following sequence, an appropriate dynamic compression plate is placed and held in place with a clamp. It is importan

16、t that this plate must have the appropriate bend for the volar aspect of the forearm so as not to gap open the dorsal side as the plate is fixed to the bone. Thus, it should be slightly underbent with respect to the standard volar concavity.第五十六頁，共一百四十頁。第五十七頁，共一百四十頁。第五十八頁，共一百四十頁。第五十九頁，共一百四十頁。These f

17、igures demonstrate reduction of the fracture with a plateheld in place on the flat, volar aspect of the bone.Once the reduction is confirmed fixation of the plate is performedusing a compressive technique through the plate.第六十頁，共一百四十頁。The following sequence demonstrates using the offset drillguide t

18、o place an eccentrically drilled hole away from thefracture. The screw is placed to the point where it abutsbut is not inserted completely within the plate until it isaffixed on the other side.第六十一頁，共一百四十頁。第六十二頁，共一百四十頁。HOLEECCENTRICALLYILLUSTRATED第六十三頁，共一百四十頁。第六十四頁，共一百四十頁。In a similar fashion to the

19、 first screw, the second screw is placed on the opposite side of the fracture, also eccentrically away from the fracture. By compressing these two screws against the plate the fracture is translated and compressed together as shown inthe following sequence.第六十五頁，共一百四十頁。第六十六頁，共一百四十頁。第六十七頁，共一百四十頁。This

20、 image demonstrates the reduced fracture, viewedfrom the volarly.第六十八頁，共一百四十頁。This image shows that the fracture is also compressed on the oppositeside due to proper contouring of the plate. Once the radius is fixed, the ulna is approached using a standard subcutaneous longitudinal incision with the

21、 arm flexed, as seen in the next image.第六十九頁，共一百四十頁。第七十頁，共一百四十頁。These images demonstrate the superficial dissection downto the fascia directly over the ulna, which is the commonfascia between the flexor carpi ulnaris and the extensor carpi ulnaris. This is divided in line with the muscles directly o

22、ver the subcutaneous border of the ulna.第七十一頁，共一百四十頁。第七十二頁，共一百四十頁。ECUEXTENSORCARPI ULNARISFCUFLEXOR CARPI ULNARIS第七十三頁，共一百四十頁。A periosteal elevator is used to cleanthe external surface of the ulna.第七十四頁，共一百四十頁。This is cleaned, reduced and fixed in exactly the same fashion as the radius was, using a

23、6-hole DCP plate and in compressive mode. These images show the plate in place with screw holes, allowing for compression in the final compressed fracture.第七十五頁，共一百四十頁。第七十六頁，共一百四十頁。第七十七頁，共一百四十頁。Intraoperative fluoroscopic views demonstrate accuratereduction and appropriate length of screws.第七十八頁，共一百

24、四十頁。Postoperative AP and lateral views demonstratinganatomic reduction and alignment of the radius and ulna.第七十九頁，共一百四十頁。第八十頁，共一百四十頁。第八十一頁，共一百四十頁。第八十二頁，共一百四十頁。第八十三頁，共一百四十頁。第八十四頁，共一百四十頁。第八十五頁，共一百四十頁。第八十六頁，共一百四十頁。第八十七頁，共一百四十頁。第八十八頁，共一百四十頁。橈骨干后側(cè)入路 1第八十九頁，共一百四十頁。橈骨干后側(cè)入路 2第九十頁，共一百四十頁。橈骨干后側(cè)入路 3第九十一頁，共一百四十

25、頁。橈骨干后側(cè)入路 4第九十二頁，共一百四十頁。橈骨干后側(cè)入路 5第九十三頁，共一百四十頁。橈骨干后側(cè)入路 6第九十四頁，共一百四十頁。橈骨干后側(cè)入路 7第九十五頁，共一百四十頁。橈骨干后側(cè)入路 8第九十六頁，共一百四十頁。尺骨干后側(cè)入路1第九十七頁，共一百四十頁。尺骨干后側(cè)入路2第九十八頁，共一百四十頁。尺骨干后側(cè)入路3第九十九頁，共一百四十頁。尺骨干后側(cè)入路4第一百頁，共一百四十頁。尺骨干后側(cè)入路5第一百零一頁，共一百四十頁。尺骨干后側(cè)入路6第一百零二頁，共一百四十頁。較為常見，約占全身骨折的6，青少年多見骨折端可發(fā)生側(cè)方、重疊、旋轉(zhuǎn)，成角移位，復位要求高直接暴力：二骨多外在一水平，橫形、

26、粉碎，多節(jié)段骨折，復位要求高傳導暴力：橈骨中1/3骨折橫形，鋸齒形，沿骨間膜傳至尺骨，尺骨低位骨折，多呈短斜形 尺橈骨雙骨折 概述第一百零三頁，共一百四十頁。扭轉(zhuǎn)暴力：手臂極度旋前著地，尺橈骨相互扭轉(zhuǎn)，橈骨多向背側(cè)成角，尺骨多向掌側(cè)成角X線攝片應包括上尺橈關節(jié)，防止遺漏關節(jié)脫位假設僅有單骨折，未發(fā)生骨折的一骨尚完整，會阻礙斷端的靠攏造成別離，從而延遲愈合或不愈合第一百零四頁，共一百四十頁。骨折不愈合多見于橈骨干中、下1/3交界處尺骨干中、上1/3交界處Trojian 復習文獻1636例，發(fā)生率7.3%； 其中采用手法復位外固定的1121例，發(fā)生率3.8%； 切開復位內(nèi)固定515例，發(fā)生率14.

27、8%第一百零五頁，共一百四十頁。手法復位外固定切開復位加壓鋼板內(nèi)固定切開復位髓內(nèi)釘固定 治療第一百零六頁，共一百四十頁。手術指征：1 開放性損傷68小時以內(nèi)，軟組織廣泛挫傷2 多發(fā)性骨折，特別是同側(cè)其他部位伴有骨折的，手法復位外固定困難的3 多段骨折，不穩(wěn)定性骨折，手法復位不滿意或不能維持容易再移位的4 尺橈骨上1/3骨折，肌肉豐富，骨間隙較小，手法復位困難者 切開復位內(nèi)固定第一百零七頁，共一百四十頁。5 對位不良的陳舊性骨折6 骨折不愈合7 病理性骨折8 合并神經(jīng)血管損傷需手術探查者 第一百零八頁，共一百四十頁。目前多運用動力加壓鋼板DCP和有限接觸動力加壓鋼板LC-DCP適應證：主要用于髓

28、內(nèi)釘固定效果不佳的部位，例如橈骨上1/3；橈骨下1/3；尺骨干上1/3的骨折機理：加壓鋼板對骨折端有加壓作用，螺釘和鋼板孔之間可以滑動而自動加壓，防止斷端別離，有利于早期愈合 切復加壓鋼板內(nèi)固定1第一百零九頁，共一百四十頁。 切復加壓鋼板內(nèi)固定 2第一百一十頁，共一百四十頁。切復加壓鋼板內(nèi)固定 3 第一百一十一頁，共一百四十頁。本卷須知：1 首先選擇非粉碎的、形狀穩(wěn)定的先固定，然后操作另一個2 橈骨干在近側(cè)骨折，鋼板置于橈骨背側(cè) 橈骨干在遠側(cè)骨折，鋼板置于橈骨掌側(cè) 3 最后縫合是松松地將深筋膜縫12針，并放置引流，防止前臂筋膜間室綜合征和缺血性肌痙攣的產(chǎn)生切復加壓鋼板內(nèi)固定 4第一百一十二頁，

29、共一百四十頁。術后長臂石膏后托固定，12天拔引流管床邊進行手部、腕部的屈伸活動術后12周，活動肩關節(jié)術后34周，去石膏，活動肘關節(jié)定期復查X線，如果斷端吸收、別離，說明固定不牢靠或活動量太大，減少鍛煉，必要時加強固定切復加壓鋼板內(nèi)固定 5第一百一十三頁，共一百四十頁。男 28歲 車禍后6小時，閉合傷 病例1第一百一十四頁，共一百四十頁。 病例1第一百一十五頁，共一百四十頁?；颊吣校?8歲，被機器絞傷前臂病例2第一百一十六頁，共一百四十頁。病例2第一百一十七頁，共一百四十頁。病例2第一百一十八頁，共一百四十頁。期急診清創(chuàng)手術術后進一步治療創(chuàng)面和傷口愈合中的并發(fā)癥期手術，34個月后。手術步驟第一百

30、一十九頁，共一百四十頁。清創(chuàng)斯氏針固定，預行二期修復病例2第一百二十頁，共一百四十頁?；颊?，男，25歲，6小時前被皮帶纏繞致左尺橈骨骨折，急診入院?；颊呒毙悦嫒?，患肢無破裂創(chuàng)口，肢端感覺血供尚存，無典型感覺減退區(qū)。 病例 3第一百二十一頁，共一百四十頁。病例3？第一百二十二頁，共一百四十頁。適應證：尺骨干髓腔直，可適用任何形式的髓內(nèi)釘；橈骨干彎曲，不能使用擴髓器，一般只用Sage釘；故主張橈骨骨折用鋼板，尺骨骨折用髓內(nèi)釘機理：可以通過閉合穿針，不需剝離骨膜和組織，對血供影響小，軸向抗壓縮、彎曲、旋轉(zhuǎn)性能優(yōu)于鋼板內(nèi)固定 切復交鎖髓內(nèi)釘固定第一百二十三頁，共一百四十頁。女 ，38歲，車禍后3小時入院 病例4第一百二十四頁，共一百四十頁。 病例4第一百二十五頁，共一百四十頁。術后一年 病例4第一百二十六頁，共一百四十頁。男，27歲，車禍6小時入院 病例5第一百二十七