外科學(xué)教學(xué)課件：Fracture of Upper Extremities1

FractureofUpperExtremitiesReview

of

last

ClassWhat

‘sfractureAfractureisabreakinthecontinuityofaboneClinical

&

RadiologicalFeaturesSystemicManifestationsLocalManifestationTheprinciplesoftreatmentReduction、Immobilization、Rehabilitation、MedicineKey

point：Marked

with

red

color

AnatomyBonethatcomposeupperlimb:Thegirdleofupperlimb

clavicleandscapularThefreeboneofupperlimb

1humerus(arm)1ulna(forearm)1radius(forearm)8carpals(wrist)19metacarpalandphalanges(hand)FRACTUREOFCLAVICLESectionIAnatomyTheclavicleisweakestatthejunctionofthetwocurvesTherefore,mostbreaksoccurapproximatelyinthemiddleoftheclavicleTheclavicleisthebonethatconnectsthetrunkofthebodytothearmSternoclavicularacromioclavicularDistalClavicleACjoint(肩鎖關(guān)節(jié))Coracoclavicularligaments（喙鎖韌帶）“Suspensoryligamentsoftheupperextremity”Twocomponents:Trapezoid（三角韌帶）Conoid（斜方韌帶）StrongerthanACligamentsProvideverticalstabilitytoACjointAnatomy臂叢神經(jīng)MechanismFallontoshoulder(87%)Directblowontoclavicle(7%)Fallontooutstretchedhand(6%)Birthinjuryfrompassingthroughthebirthcanal.ClassificationAccordingtofracturesite80%occurinthemedial1/315%distalthirdoccureinthelateralordistal1/35%occurinthemedialorproximal1/3ClassificationFractureoflateralclavicleCoracoclavicularligament（喙鎖韌帶）Classification

greenstickfractures（青枝骨折）

(childrenusually)DisplacementofmiddlethirdfractureMedial

fragmentwasdisplacedsuperiorlyandposteriorly

bySternocleidomastoidMuscle（胸鎖乳突?。㎜ateralfragmentwasdisplacedinferiorlyandanteriorlybyweightofarmand

DeltoidMuscle

（三角肌）Historyofatrauma

pain,swellingandcrepitusInabilitytoraiseashoulderDeformityalongthelineoftheclavicleClinicalfeaturesFractureofClavicleClinicalfeaturesSubclavianvesselscompromise:

asymmetricpulseorpulsatilehematomaBrachialplexusinjury:

neurologicalexaminationRadiographicEvaluationX-Ray：Inordertodeterminethefracturetypeandextentofinjury.

Take

bothclaviclebonesforcomparison

AnteroposteriorView30-degreeCephalicTiltViewDiagnosisHistoryoftraumaClinicalmanifestationX-ray TreatmentConservativetreatment:

Nondisplacedorgreenstickfractures

Slingfor3-6weeks;

DisplacedMiddle1/3fractures

Closedmanipulativereduction,Figure-of-8strap

ConservativetreatmentClosedreduction,Figure-of-8straptomaintaintheshoulderinaretractedpositiontoimprovethealignmentoffracture.Surgicaltreatment-ORIFIndicationClosedreductionfailNeurovascularinjurieOpenfractureLateral

fracture

withCoracoclavicularligament

rupture

or

scapularneckfracturesNon-union

fractueOpenReductionandInternalFixationFracture

of

lateralclavicleTypeIIORIFRepairtheCoracoclavicularligament

Double

endobutton

TechniqueTheHookPlatespecificallydesignedfor

thelateralfractureofclavicleTypeIIFRACTUREOFHUMERUSSectionIIPartI:ProximalhumeralfracturePartII:FracturesofhumeralshaftPartIII:SupracondylarFracturesSectionII-PartIPartI:ProximalhumeralfractureProximalHumeralAnatomy4bonyfragmentsLesserTubercleGreaterTubercleHeadShaftNeer,JBJS‘70Surgicalneckofhumerus肱骨外科頸Anatomicalneckofhumerus肱骨解剖頸Inferiortotheanatomicalneckofhumerus2-3cm,justlocateintheintersectionofthecompactboneandspongybone,soitiseasetobefracturedAnatomyRotatorcuff（肩袖）Subscapularis（肩胛下?。㏒upraspinatus（岡上肌）Infraspinatus（岡下?。㏕eresminor（小圓?。〣loodsupplyofproximalhumerusAnteriorhumeralcircumflexartery;Posteriorhumeralcicumflexartery;Arcuateartery;Thelateralascendingbranch(Arcuateartery)oftheanteriorcircumflexhumeralarterycarriesthemostimportantbloodsupplyofthehumeralheadanddamagemayleadtoavascularnecrosis.MechanismElderlyfallontooutstretchedhanddirectblow-fallbonefragility-osteoporosis（骨質(zhì)疏松）Younghighenergy

traumaClinicalmanifestationHistoryoftrauma;Pain;Swelling;Ecchymosis;DysfunctionoftheshoulderRadiographicevaluationXrayAPScapular“Y”RadiographicevaluationCTscanand3DreconsrructionDiagnosisHistoryoftrauma;ClinicalmanifestationRadiographicevaluationClassificationUnderstandingFracturePatterns4bonyfragmentsLesserTubGreaterTubHeadShaftNeerClassification1cmdisplaced45degreeangulatedExcessiverotationClassificationNeerClassificationFourpartsGreaterandlessertuberosities,HumeralshaftHumeralheadApartisdisplacedif>1cmdisplacementor>45degreesofangulationisseenTreatmentMinimallydisplacedfractures-Slingimmobilization,earlymotionTwo-partfractures-AnatomicneckfractureslikelyrequireORIF.HighincidenceofosteonecrosisSurgicalneckfracturesthatareminimallydisplacedcanbetreatedconservatively.DisplacementusuallyrequiresORIFThree-partfracturesDuetodisruptionofopposingmuscleforces,theseareunstablesoclosedtreatmentisdifficult.DisplacementrequiresORIF.Four-partfracturesIngeneralfordisplacementorunstableinjuriesORIFintheyoungandhemiarthroplastyintheelderlyandthosewithseverecomminution.HighrateofAVN（avascularnecrosis缺血壞死）

(13-34%)MinimallydisplacedfracturesOpenReductionandInternalFixationLockingCompressionPlateOpenReductionandInternalFixationPre-opXrayPre-opCTIncisionPost-opXrayHumeralheadreplacement

Certainthree-andfour-part

proximal

humerus

fracturesSectionII-PartIIPartII:FracturesofHumeralShaftIntroductionAccountforapproximately3%ofallfractures.Anatomy2cmproximaltosurgicalneck2cmdistaltosupracondyleOnthebackofthemiddlethird,thereisashallowspiralgrooveforradialnerveontheboneDirecttraumaisthemostcommonIndirecttraumasuchasfallonanoutstretchedhandFracturepatterndependsonstressappliedBending-transversefractureoftheshaftTorsional-spiralfractureoftheshaftTorsionandbending-obliquefractureusuallyassociatedwithabutterflyfragment（蝶形骨塊）Bending彎屈應(yīng)力Torsion扭力MechanismClassificationAOclassificationTypeA-SimplefractureType

B-WedgefractureType

C-ComplexfractureDisplacementoffragmentsAfracturebetweentheinsertionofthepectoralismajorandthedeltoid1.The

proximal

fragmentisadductedbythepectoralismajor,teresmajorandlatissimusdorsi.2.The

distalfragmentisshortenedanddisplaced

laterally

bydeltoidDisplacementoffragmentsAfracturebelowthedeltoidinsertionThe

proximalfragmentisdisplacedabductedbydeltoidThe

distal

fragmentisdisplacedproximallybybiceps

and

tricepsClinicalfeatureSymptomPainSwellingDeformityEcchymosisDysfunctionofupperarmClinicalfeaturePEBonycrepitusPseudarthrosisRadialnerve

injuryWrist

dropSensoryRadiographicevaluationAPandlateralviewsofthehumerusIncludingadjacentjoint(shoulderorelbow)A1A3C3DiagnosisHistoryoftrauma;ClinicalmanifestationRadiographicevaluationConservativeTreatmentType

A

and

partial

Type

BClosedmanipulativereductionExternal

Fixation（Splint

or

Plaster

or

Brace）Immobilization：6-8

wks

for

adults，4-6wks

for

childrenTreatmentFracturesofHumeralShaftConservativeTreatmentA,APradiographofthehumerusdemonstratingamidshaftfracture.B,APradiographmadeat3-monthfollow-updemonstratinghealingandcorrectedangulationfollowingmanagementwithaSarmientobrace.C,PhotographofapatientwearingaSarmientobrace.

Type

A2

IndicationClosedreduction

failPolytraumaOpenfractureNeurovascularinjurieUnstalbefractures（Type

B3

and

C）,Non-union

fracturePathologicfractureFloatingelbowAssociatedarticularfractureOperativemanagementFracturesofHumeralShaftMethod

Externalfixation

OpenReductionandInternalFixation

MinimallyInvasivePercutaneousOsteosynthesis

IntramedullaryNailing

(髓內(nèi)釘)

OperativemanagementFracturesofHumeralShaftThechoiceofimplantsdependsonsurgeonexperience,associatedinjuriesextentandlocationofthesoft-tissueinjury,fracturepattern.Relativeindications:Soft-tissueinjuries(Openfracture);Burns;Fracturesthat