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中医骨伤科下肢骨折Fractureofthelowerextremity1林江豪LIMCHIANGHOU22/8/2013Newwordsextremity[iks’tremiti]肢体,末端,极端trabeculae[trə’bekjuli:]小梁,柱trochanter[trəu’kæntə]转子,粗隆tensile[‘tensail]抗张的,拉力的circumflex[‘sə:kəmfleks]旋绕的,卷曲的ambulate[’æmbuleit]行走Acetabulum[æsi’tæbjuləm]髋臼2下肢功能是负重和行走,需要良好的稳定。Stable对下肢骨折的整复,不仅要与健肢的长度相等,而且要对位对线良好。Goodalignment患肢成角畸形,影响肢体的承重力;患肢短缩在2cm以上,出现跛行。Length3下肢骨折整复后,常需配合持续牵引,固定时间也长,防止过早负重而发生畸形或再骨折。现多采用内固定的方法,以求达到解剖复位,坚强固定,早期功能活动。ORIFoftenneededinordertomakeanatomicalreductionandrigidfixationsoearlyexercisecanbeperformed.4髋部骨折hipfractures5SummaryHipfracturesintheUnitedStateshaveanincidenceofgreaterthan250,000peryear,withtotalcostsestimatedtoexceed8billiondollarsayear.Thesenumbersareexpectedtotriplebytheyear2050.Thesefracturesoccurprimarilyintheelderly,havemultipleassociatedmedicalrisks,andareusuallytheresultofasimplefall.6Surgicaltreatmentandrapidmobilizationaretheprimaryfactorsinreturningpatientstoaprefractureleveloffunction.能尽快恢复活动。Multiplesurgicaltreatmentsareavailable,andthetimingandchoiceoftreatmentmustbeindividualizedineachcase.治疗个体化。7股骨颈骨折fractureoffemoralneck颈干角Neckshaftangle:正常值在110°~140°之间。颈干角随年龄增加而减小,儿童平均151°,而成人男性132°,女性127°。82020/5/3192020/5/3110颈干角大于正常值为髋外翻,小于正常值为髋内翻。股骨颈的中轴线与股骨两髁中点间的联线形成的角度,称前倾角或扭转角,正常为12°~15°。在治疗股骨颈骨折时,必须保持正常的颈干角和前倾角,特别是前倾角。相关解剖relatedanatomy11Thebonyanatomyofthefemoralheadandneckisclassicallydividedintofivetrabeculargroups.Thatis,principalcompressivegroup,secondarycompressivegroup,principaltensilegroup,secondarytensilegroupandgreatertrochantergroup.12股骨头、颈部的血运主要来自三个途径Therearemainlythreesourcesofbloodsupplytotheheadandneckoffemoralbone:关节囊的小动脉来源于旋股内侧动脉、旋股外侧动脉、臀下动脉和闭孔动脉的吻合部到关节囊附着部,分为骺外动脉、上干骺动脉和下干骺动脉,进入股骨颈,供应股骨颈和大部分股骨头的血运。Thearteriolesofjointcapsulewhichoriginatefromtheanastomosisofmedialcircumflexfemoralartery(旋股内侧动脉),lateralcircumflexfemoralartery(旋股外侧动脉),glutealartery(臀下动脉)andobturatorartery(闭孔动脉)totheattachmentofthejointcapsule,canbedividedintoepiphysealexternalcarotidartery(骺外动脉),superiormetaphysealartery(上干骺动脉)andinferiormetaphysealartery(下干骺动脉),inwhichtheyenteringtheneckofthefemoralbone,andsupplythebloodcirculationtotheneckofthefemoralboneandmostlytheheadofthefemoralbone.2020/5/3113股骨干滋养动脉仅达股骨颈基底部,小部分与关节囊的小动脉有吻合枝。Thenutrientarteriesofthefemoralshaftonlyuptothebaseofthefemoralbone,thereisananastomosisbranchofthesmallportionofthenutrientarterieswiththearteriolesofjointcapsule.圆韧带的小动脉较细,仅供应股骨头内下部分的血运,与关节囊小动脉直接有吻合枝Thearteriolesoftheroundligamentaresmaller,whichonlysupplythebloodcirculationtotheinteriorlyinferiorportionoftheheadofthefemoralbone.Ithasadirectanastomosisbranchwiththearteriolesofthejointcapsule.。此三条血管均比较细小,因此,在临床治疗中存在骨折不愈合和股骨头缺血两个主要问题。2020/5/311415病因病机etiologyandclassification股骨颈骨折常发生于老年人,女略多于男。由于股骨颈部细小,处于疏松骨质和致密骨质交界处,又因老年人骨质疏松,即使受轻微的直接外力或间接外力,便可引起骨折。股骨颈骨折病人,常合并有其他骨折,甚至内脏损伤。16分型方法:按部位不同,分为头下部、颈中部和基底部骨折三种。头下部和颈中部骨折为囊内骨折;基底部骨折又称囊外骨折。移位多的囊内骨折容易发生股骨头缺血性坏死。1718头下颈中基底按X线照片的表现分为外展型和内收型两种。外展型骨折多为头下骨折,骨折端常互相嵌插,骨折线与股骨干纵轴的垂直线(水平线)所形成的倾斜角(林顿氏Linton‘s角),往往小于30°,骨折局部剪力小,较稳定,血运破坏较少,故愈合率高。19内收型骨折常在髋关节内收时发生,骨折线与股骨干纵轴的垂直线所形成的倾斜角,往往在45°左右,颈干角小于正常值。临床上内收型骨折多见,外展型骨折少见。ThePauwelsclassificationdescribestheverticalityofthefracture,withtypeⅠmorehorizontalandtypeⅢmorevertical.20ThemostcommonlyusedclassificationschemeforfemoralneckfracturesisthatproposedbyGarden.Thisclassificationsystemisbasedonthedegreeofdisplacementshownontheanteroposterior(AP)radiograph,withtypesⅠandⅡrepresentingminimallydisplacedfracturesandtypesⅢandⅣrepresentingsignificantlydisplacedfractures.2122诊查要点clinicalfeaturesandinvestigation老年人跌倒后诉髋部疼痛,不敢站立和行走,应首先考虑到股骨颈骨折的可能。Deformity畸形:有移位的骨折伤肢外旋、缩短,髋、膝关节轻度屈曲。Tenderness疼痛:除髋部疼痛外,腹股沟附近有压痛,患肢足跟部或大粗隆部有叩击痛。23Swelling肿胀:局部可有轻度肿胀,囊内骨折肿胀瘀斑常不明显。LimitedR.O.M功能障碍:患髋功能障碍,不能站立行走,但有部分嵌入骨折仍可短时站立或跛行。对这些病人要特别注意,不要因遗漏诊断而使无移位的稳定骨折变为有移位的不稳定骨折。24Theclinicalpresentationofintracapsularhipfracturesisquitevariable.Patientswithfracturesthatareminimallydisplacedorimpactedoftendemonstrateonlyminimalpainandmay,infact,ambulateindependently.Patientswithfracturesthataredisplacedclassicallypresentwithashortenedandexternallyrotatedloverextremityandhavesignificantpainwithflexion,extension,androtation.25Femoralneckfracturesassociatedwithahigh-energyinjuryorinamultiraumasettingcanbeverydifficulttodiagnosisandassess.Inthesecases,theinjurymaybemaskedbyassociatedfracturesinthefemoralshaftoracetabulum.26髋关节正侧位X线照片。HipJointA-P&LateralviewsX-rayForthosepatientsinwhomafractureissuspectedbutplainradiographicfindingsarenegative,theadditionalmethodsofinvestigationusedarebonescanandmagneticresonanceimaging(MRI).27F/3528293031治疗treatment按照骨折的时间、类型和患者的全身情况等决定治疗方案。新鲜无移位骨折或嵌插骨折患肢应制动;移位骨折应尽早给予复位和固定;陈旧性股骨颈骨折可采用髋关节重建术或改变下肢负重力线的切骨术。32Thecurrentrecommendationisthatallidentifiablefemoralneckfracturesbestabilizedinsomefashion.Thetimingofsurgicalinterventionhasbeendebated,andcurrentrecommendationsarethatapatientbebroughttomedicallyoptimalconditionandthentreatedonanurgentbutnotemergencybasis.Theonlyexceptiontothisremainsayoungerpatientwithadisplacedfractures,whoshouldbetreatedon
本文标题:骨伤--下肢骨折1
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