外科學(xué)課件：骨折總論

一、古代骨科簡(jiǎn)述周朝（BC1100～770）

傷骨科（瘍醫(yī)科：折、瘍之分）春秋戰(zhàn)國(guó)時(shí)期（皇帝內(nèi)經(jīng)）

截肢術(shù)（脫癰）漢代華佗（AC147～207）

骨折復(fù)位、夾板固定，清創(chuàng)術(shù)，“麻沸散”：手術(shù)無(wú)痛原則晉代葛洪（AC261～347）

竹夾板外固定骨折隋代巢元方（AC581～618）

骨折內(nèi)固定：線連接碎骨唐代藺道人“仙授理傷續(xù)斷秘方”：

骨折治療四大原則：

復(fù)位、固定、內(nèi)外用藥、功能鍛煉明代楊清叟

止血帶：絹袋清代江考鯽

骨移植：以別骨填接古希臘Hippocrates（Bc460～377）

骨折脫位等的治療古羅馬Galen（Ac130～200）

人體解剖16世紀(jì)Azeecs人

骨不連內(nèi)固定治療：木片Orthopaedicsnamedin1741NicholasAndrycoinedtheword.Orthos:correct,straight.Paedion:childJean-AndreVenel(1740-1791):Venevese,becalledtheFatherofOrthopaedicsPlastercastofParis1751Movementsystem(Orthopaedics)iscomposedwithspine,extremities,bone,joint,muscles,vessels,nerves,lymph,fascia,synovium,etc.現(xiàn)代骨科及相關(guān)組織AASOS骨科

需要?jiǎng)?chuàng)造性

相關(guān)學(xué)科的發(fā)展Creative,InnovationMultiidiciplinesdevelopmentOrthopaedicsINTRODUCTIONOFFRACTUREDefinitionClassificationTreatmentPrognosisHealingprocessandtheaffectingfactorsClinicalfindingsandimageologyexaminationCausesEmergencycareBoneFracture1.DEFINITIONOFFRACTUREAfractureisabreakinthecontinuityofabone2.CausesoffracturesTraumaDirectforceDirectforcecausesthefracture2.CausesoffracturesTraumaDirectforceIndirectforceIndirectforcecausesthefractureMuscularcontractionforce2.CausesoffracturesTraumaDirectforceIndirectforcefracturecausedbymuscularcontractionCyclicforce–--fatiguefractureMuscularcontractionforce2.CausesoffracturesTraumaDirectforceIndirectforceBonediseasesLocalized

diseasesGeneralizeddiseasesCyclicforceMuscularcontractionforce2.CausesoffracturesTraumaDirectforceIndirectforce—tubercularosteomyelitis,osteosarcoma,localizedmetastaticcarcinoma,etc.—osteoporosis,multiplemyeloma,diffusemetaststiccarcinoma,etc.3.ClassificationoffracturesOnthebasisofetiologyTraumaticfracturePathologicalfractureTraumaticfracturePathologicalfractureOnthebasisofrelationshipwithexternalenvironmentClosedfractureOpenfracture3.ClassificationoffracturesOnthebasisofetiologyOpenfractureOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyOnthebasisofdisplacementsUndisplacedfractureOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyNosignificantdisplacementfracturesDisplacedfractureDifferentsortsofdisplacedfracturesFactorsresponsiblefordisplacementsThefracturingforceThemusclepullonthefracturefragmentsThegravityIncorrectmedicalcareOnthebasisofdisplacementsOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyOnthebasisoftimefreshfractureoldfractureWithin3wksover3wksOnthebasisofdisplacementsOnthebasisofpatternOnthebasisofrelationshipwithexternalenvironment3.ClassificationoffracturesOnthebasisofaetiologyOnthebasisoftimestablefractureunstablefractureOnthebasisofstabilityAO/ASIFCLASSIFICATIONAO(ArbeitsgemeinschaftfurOsteosynthesefragen)ASIF(AssociationfortheStudyofInternalFixation)Location+type+subtype+group12-A14.EmergencycareoffracturesRescuethelifeABCDEFstepsABCDEFAirwayandbreathingBleedingandcirculationCentralnervesystemDigestivesystemExcretionFracture(McMurtry1980)Managethewound4.EmergencycareoffracturesPreservethelifeImmobilizethefractureManagethewound4.EmergencycareoffracturesPreservethelifeTransferthepatientImmobilizethefractureManagethewound4.EmergencycareoffracturesPreservethelifeTwomethodstotransportthespinefracturerollingliftingFalsemethodtotransportthespinefractureDefinitionClassificationTreatmentPrognosisHealingProcessandtheaffectingfactorsClinicalfindingsandimagingstudiesCausesEmergencycareFractureCLINICAL&RADIOLOGICALFEATURESSystemicManifestations

PrimaryShock(NeurogenicShock)SecondaryShockHaemorrhageNotice:excludetocerebralinjuryandrespiratoryembarrassment

CLINICAL&RADIOLOGICALFEATURES

LocalManifestation

SwellingTraumaticInflammationPainImpairmentoffunction

Deformity

SpecificSigns

AbnormalMotion

BonyCrepitusorGratingCLINICAL&RADIOLOGICALFEATURESCLINICAL&RADIOLOGICALFEATURESImageologyExaminationFractureyesorno?PatternoffractureDecidetheTreatmentMethodsCOMPLICATIONOFFRACTURE

EarlyComplicationsShockFatembolismInjurytoImportantOrganandTissueOsteofascialCompartmentSyndromeCOMPLICATIONOFFRACTURE

LateComplicationsSystemicComplicationPressureSores(bedsore)PneumoniaInfectionoftheUrinarytractCOMPLICATIONOFFRACTURE

LocalComplications

InfectionofBoneandJointPost-TraumaticOssificationOsteoarthritisJointStiffnessReflexSympatheticDystrophyAvascularNecrosisofTheBoneIschemicContracture(Volkmann’s)FRACTUREHEALINGOrganandTissueFractureRepairRegeneration

ScarNewBone

FRACTUREHEALINGStagesofFractureHealing1.Haematoma→→Fibrosis(2w)↓Fibrinogen＋ReticularFibril→BloodClots

↓NewVessels＋MesenchymalCell＋I(xiàn)nflammatoryCell→GranulationTissue

CytokinesinvolvedinfracturehealingBMPsBMP2,BMP4,BMP6,BMP7,BMP9TGFbIGFFGFPDGFFRACTUREHEALING2.PrimaryCallusFormation(6-8w)OriginoftheCallusCells

DOPC(DeterminedosteogenicPrecursorCells)

IOPC(InducibleOsteogenicPrecursorCells)FRACTUREHEALINGOriginoftheCallusMineralDeadBoneOsteoblasts,Chondroblasts↓↓CO2↑Phosphorylase↑↓↓pH↓HydrolyzetoPhosphate(intheHematoma)(inthePlasma)Calcium++PhosphateFreeBloodcalciumCalciumPhosphateFractureCallus(WovenBone)CollagenIFRACTUREHEALING

EndochondralOssificationIntramenbranousOssificationFRACTUREHEALING3Remodelling(8w---manyyears)

ModellingWovenBoneLamellarBone(8---12wClinicalHealing)Remodelling(12w---SomeYears)Wolff’sLawStressandPiezoelectricityFRACTUREHEALING

CriteriaofFractureHealing

1.LocalandaxialpercussionproducesnoPain2.Absenceofabnormalmobility3.VisiblecontinuedcallushasBridged,indistinctionoffragmentsandfracturelineFRACTUREHEALING4.Withouttheexternalfixationofsplints

A.TheArmisabletohold1kgstuffhorizontallylastingfor3min.B.TheLegsareabletoWalk30pacesin3min.C.NodeformationappearsonthefracturesiteAftercontinualobservationfor2weeksSystemicFactors1.Age2.SystemicConditionRelatedFactorsInfluencingFractureHealingRelatedFactorsInfluencingFractureHealing

LocalFactors1.PatternofFracture2.

BloodSupply(Fragments)A.Bloodsupplyofbothfragmentsarerich.B.Oneisrichwhiletheotherispoor.C.Bloodsupplyofbothfragmentsarepoor.D.Absenceofbloodsupply.

LocalFactors

3.Infection4.InjuriesofSoftTissue5.InterpositionofSofttissueinto

FractureGap

6.BasicDisease(local)RelatedFactorsInfluencingFractureHealing

MethodofTreatment?!

1.RepeatedReductionbyManipulation2.OverTractionofFragments3.IncorrectFixation4.IncorrectDebridement5.InfluenceofOpenReduction6.IncorrectFunctionalExercisesRelatedFactorsInfluencingFractureHealing

BiologicalFactors20%MedicalFactors80%!!

RelatedFactorsInfluencingFractureHealingPRINCIPLESofFRACTURETREATMENT

Reduction

Immobilization

RehabilitationMedicationREDUCTION

CriterionofReduction1.AnatomicReduction2.FunctionalReduction(1).Novisiblegaporrotation(2).Shortening＜1~2cmintheLeg(3).Angulation＜15~10°

(4).Appositionofthefragments＜

１／３(shaft),or３/４(epiphyseal)REDUCTIONMethodsofReduction1.ByClosedManipulation2.ByMechanicalTractionwithorwithoutManipulation3.ByOpenReductionIMMOBILIZATION

ReasonsforImmobilization1.Preventionofdisplacementorangulation2.Preventionofmovement3.ReliefofpainIMMOBILIZATION

MethodsofImmobilization

1.ByWoodenSplint,PlasterorSplint(other)2.ByContinuousTraction3.ByExternalFixation4.ByInternalFixationREHABILITATION1.ActiveMuscularContraction(AfterInjuryWithin2Weeks)2.ActiveExercisesJointsofAdjacentFracture(AfterInjury2~8w)3.ActiveResistanceExercises(After8w)4.PhysiotherapyMedication

TraditionalMedication

ForbidUsingNonsteroidAnti-InflammatoryDrugs(NSAIDs)TREATMENTofOPENFRACTURE

PreventInfection!!

TREATMENTofOPENFRACTURE1.TypeofOpenFractureFromoutsidetoinnerFrominnertooutsidePotential

TREATMENTofOPENFRACTURE

2.ConditionsoftheWound

ContaminativeExtentDegreeofSoftTissueInjuryTREATMENTofOPENFRACTURE3.DebridementSamePrinciplesofSurgicalDebridementGoldenTime:6~8h(afterinjury)LargerBonyPieceShouldbePreservedSelectingMethodsofFixationRepairofNerve、Tendon、VesselSkinClosureSamePrinciplesofSurgicalDebridement1.KeepArticularCartilageIntact2.NottoLeaveForeignBodiesinJoint3.ForbidtoOpenDraining(CanUseIrrigation)4.RepairofCapsuleandLigamentsTREATMENTofOPENFRACTURE5.InjectAntibioticsintotheJointAfterOperation6.AspirationisEspeciallyImportantinHemarthrosis7.TheJointshouldbeImmobilizedwithTraction,SplintorPlasterCastTREATMENTofOPENFRACTUREDELAYEDUNIONof