17骨科-骨盆骨折与下肢骨折

中南大学湘雅二医院骨科CentralSouthUniversity骨盆骨折和下肢骨折pelvicfracturesandfracturesofthelowerextremity中南大学湘雅二医院骨科倪江东中南大学湘雅二医院骨科CentralSouthUniversityContentsPelvicFracturesFracturesofFemoralNeckIntertrochantericFracturesFracturesoftheShaftoftheFemurFracturesoftheTibiaandFibula中南大学湘雅二医院骨科CentralSouthUniversityPelvicFracturesAnatomy中南大学湘雅二医院骨科CentralSouthUniversityPelvicFracturesAnatomy髂腰韧带骶棘韧带骶结节韧带骶髂关节耻骨联合中南大学湘雅二医院骨科CentralSouthUniversityPelvicFracturesClassificationLocationofFractureAvulsionfracturesSacrumandcoccyxfracturesSinglebreaksinthepelvicringPelvicringdisruptions——twoormorebreaksinthepelvicring中南大学湘雅二医院骨科CentralSouthUniversityPelvicFracturesSacrumandCoccyxfractures中南大学湘雅二医院骨科CentralSouthUniversityPelvicFracturesAvulsionfractures髂前上棘撕脱骨折中南大学湘雅二医院骨科CentralSouthUniversityPelvicFracturesSinglebreaksinthepelvicring中南大学湘雅二医院骨科CentralSouthUniversityPelvicFracturesPelvicringdisruptions–twoormorebreaksinthepelvicringAO分型•A型A-1–Fractureofinnominatebone;avulsionA-2–Fractureofinnominatebone;directblowA-3–Transversefractureofsacrumandcoccyx•B型B-1–Unilateralpartialdisruptionofposteriorarch,externalrotation(“openbook”injury)B-2–Unilateral,partialdisruptionofposteriorarch,internalrotation(lateralcompressioninjury)B-3–Bilateral,partiallesionofposteriorarch•C型C-1–Unilateral,completedisruptionofposteriorarchC-2–Bilateral,ipsilateralcomplete,contralateralincompleteC–3–Bilateral,completedisruption中南大学湘雅二医院骨科CentralSouthUniversityPelvicFractures中南大学湘雅二医院骨科CentralSouthUniversity临床特点（1）剧烈暴力外伤史（2）合并多发伤（3）大部分病人有休克PelvicFractures中南大学湘雅二医院骨科CentralSouthUniversityPhysicalExamination骨盆挤压分离试验阳性肢体长度不对称会阴部瘀斑PelvicFractures中南大学湘雅二医院骨科CentralSouthUniversityRadiologicalEvaluationXraysofpelvicring1APPelvis2InletView3OutletViewPelvicFractures中南大学湘雅二医院骨科CentralSouthUniversityCTscanand3-Dreconstruction中南大学湘雅二医院骨科CentralSouthUniversityComplications41235ExtraperitonealhematomaIntraperitonealviscerainjuryBladderorUrethralInjuryNerveinjuryRectuminjuryPelvicFractures中南大学湘雅二医院骨科CentralSouthUniversity处理步骤1监测血压2建立静脉通道3视病人情况及早完成X线和CT检查4检查有无合并损伤，尿液检查排除泌尿系损伤，肛查排除直肠损伤，腹腔诊断性穿刺排除腹腔内脏器损伤PelvicFractures中南大学湘雅二医院骨科CentralSouthUniversityTreatmentofgeneralcondition（1）根据受伤特点及全身情况制定治疗步骤（2）合并多发损伤积极处理（3）积极输血补液抗休克治疗（4）固定骨盆（5）止血（血管造影、栓塞和手术）PelvicFractures固定骨盆血管栓塞中南大学湘雅二医院骨科CentralSouthUniversityManagementoftheFracturesPelvicFracturesConservativetreatment骨盆边缘撕脱骨折骶尾骨骨折骨盆环单处骨折轻微的耻骨联合分离Surgicaltreatment骨盆环多处骨折骨盆不稳定中南大学湘雅二医院骨科CentralSouthUniversitySurgicaltreatmentPelvicFractures中南大学湘雅二医院骨科CentralSouthUniversitySurgicaltreatmentPelvicFractures中南大学湘雅二医院骨科CentralSouthUniversityFRACTUREOFFEMORALNECKAnatomy中南大学湘雅二医院骨科CentralSouthUniversityFRACTUREOFFEMORALNECKAnatomyNeck-shaftangle110°～140°Anteversionangle10°～15°中南大学湘雅二医院骨科CentralSouthUniversityAnatomyBloodsurpplyofthefemoralhead1小凹动脉2旋股内外侧动脉的分支3股骨干滋养动脉升支FRACTUREOFFEMORALNECK中南大学湘雅二医院骨科CentralSouthUniversityClassificationLocationofthefractureline1Subcapital2Transcervical3BaseNeckFRACTUREOFFEMORALNECK中南大学湘雅二医院骨科CentralSouthUniversityPauwels[1965]FRACTUREOFFEMORALNECKClassification外展型内收型中南大学湘雅二医院骨科CentralSouthUniversityFRACTUREOFFEMORALNECKClassificationGarden[1964]IValgusimpactedorincompleteIICompleteNon-displacedIIICompletePartialdisplacementIVCompleteFulldisplacement中南大学湘雅二医院骨科CentralSouthUniversityClinicalmanifestation外伤史髋部疼痛活动障碍FRACTUREOFFEMORALNECK中南大学湘雅二医院骨科CentralSouthUniversityClinicalsign髋部肿胀、皮下瘀斑患肢短缩、外旋畸形，一般在45°~60°之间压痛，患肢纵向叩击痛FRACTUREOFFEMORALNECK中南大学湘雅二医院骨科CentralSouthUniversityRadiologicalEvaluationFRACTUREOFFEMORALNECKX-raysAPpelvisAPandlateralviewofhipCTscan中南大学湘雅二医院骨科CentralSouthUniversityComplications:NonunionAVNoffemoralheadFRACTUREOFFEMORALNECK中南大学湘雅二医院骨科CentralSouthUniversityConservativetreatmentIndications:无明显移位的骨折外展型或嵌插型骨折手术禁忌Methods:下肢皮牵引丁字鞋长期卧床并发症的防治FRACTUREOFFEMORALNECK中南大学湘雅二医院骨科CentralSouthUniversityFRACTUREOFFEMORALNECKSurgicaltreatmentIndications:移位或不稳定老年患者，无手术禁忌陈旧性骨折不愈合Methods:空心螺钉内固定DHS或解剖钢板半髋关节或全髋关节置换中南大学湘雅二医院骨科CentralSouthUniversityFRACTUREOFFEMORALNECKSurgicaltreatment空心螺钉DHSDHS+空心螺钉中南大学湘雅二医院骨科CentralSouthUniversityFRACTUREOFFEMORALNECKSurgicaltreatment半髋关节置换THA(骨水泥型）THA(生物型）中南大学湘雅二医院骨科CentralSouthUniversityINTERTROCHANTERICFRACTURE中南大学湘雅二医院骨科CentralSouthUniversityINTERTROCHANTERICFRACTUREAnatomyCalcarFemoralePosteromedialdenseplateofbone中南大学湘雅二医院骨科CentralSouthUniversityINTERTROCHANTERICFRACTUREClassificationTronzoevansclassificationAO分型•A1A1.1:转子间线骨折A1.2：经小转子骨折A1.3：小转子下骨折•A2A2.1：转子周一处骨折A2.2：转子周多处骨折A2.3：转子周骨折延伸小转子超1CM•A3A3.1：单纯反向斜行A3.2：单纯横断骨折A3.3：多处粉碎性骨折•A2中南大学湘雅二医院骨科CentralSouthUniversityINTERTROCHANTERICFRACTUREClinicalmanifestation外伤史疼痛，肿胀，瘀斑患肢功能障碍Clinicalsign压痛纵向叩击痛下肢短缩，外旋畸形明显，可达90°RadiologicalEvaluationX-raysCTscan中南大学湘雅二医院骨科CentralSouthUniversityConservativetreatment骨牵引长期卧床并发症的防治INTERTROCHANTERICFRACTURE中南大学湘雅二医院骨科CentralSouthUniversitySurgicaltreatmentDHS,DCS解剖钢板PFN关节置换INTERTROCHANTERICFRACTURE中南大学湘雅二医院骨科CentralSouthUniversitySurgicaltreatmentINTERTROCHANTERICFRACTUREDHSDCS解剖钢板中南大学湘雅二医院骨科CentralSouthUniversitySurgicaltreatmentINTERTROCHANTERICFRACTUREPFN关节置换中南大学湘雅二医院骨科CentralSouthUniversityFRACTU