骨折总原则-General-Principles-of-Fractures

GeneralPrinciplesofFracturesDepartmentofOrthopaedicSurgeryLiuXueyong(刘学勇）IntroductionDefinitionAfractureindicatesdisruptionofthecontinuityorintegrityofboneEtiologydirecttraumaindirecttraumabytransmissionofstress:e.g.fractureofclaviclebymuscular(quardriceps)contraction:e.g.fractureofpatellacontinuousstress(fatiguefracture):e.g.fractureoflower1/3fibularshaft,fractureofthe2ndand3rdmetatarsalbonepathologicalfracture:becauseofcorticaldesruptionwhichresultedfrombonediseasessuchasosteomyelitisandbenign,malignant,ormetastaticlesionsofbone,thefracturehappenedwithslighttraumaClassificationclosefracture:theendoffracturedidnotcommunicatewiththeenvironmentopenfracture:theendoffracturecommunicatedwiththeenvironment,e.g.pubicfracturewithbladderorurethrainjury,coccyxfracturewithrectalinjuryincompletefracture:crack(fissure)fractureandgreenstickfracture(inchildren)completefractureCompletefracturetransversefractureobliquefracturespiralfracturecomminutedfracture:TorYtypeorbutterflyimpactedfracturecompressionfracture:e.g.vertebralbodyorcalcaneusfracturesunkenfracture:skullfractureepiphysealinjuryStablefracture:crack,greenstick,transverse,compressive,impactedfractureUnstablefracture:easilydisplace,e.g.obliquefracture,spiralfracture,comminutedfractureOTAclassificationoflongbonefracturesTaylorandMartinproposedaclassificationofmetaphysealfractures(SUD)inwhichthemainfractureischaracterizedasstable(S),unstable(U),orwithdiaphysealextension(D).Thesearefurtherdividedintothreesubtypes:0,extraarticular;1,lessthan2mmofdisplacement;and2,morethan2mmofdisplacementClassificationofmetaphysealfractures(SUD)DisplacementoffractureangulardisplacementlateraldisplacementshorteningdisplacementseparateddisplacementrotationaldisplacementClinicalfindingsandRadiologicalfindingsSystemicfeaturesShock:resultingfromlossofbloodinpatientswithpelvic,femoralormultiplefracture,severeopenfractureorfracturecomplicatingwithvitalviscrealinjuryFever:resultingfromabsorptionofhematoma,usually38ºlossofblood(ml)LocalfeaturesSpecificsigns:DeformityAbnormalmotionBonycrepitusorgraftingUnspecificsignspainandtendernessswellingandvisiblebruising(ecchymosis)dysfunctionRadiologicalfindingsA-PandlateralviewX-rayincludingupperorlowjointX-rayfindings:fracturelineIfnecessary,radiologicalexaminationisperformnedagainafter2weeksSomespecialviewsAPandobliqueviewforfracturesofmetacarpusandmetatarsuslateralandaxialviewforcalcaneusfractureAPandbutterflyviewforfracturesofscaphoidComplicationsoffractureEarlyperiodshockvisceralinjurysuchasliver,spleen,lung,bladderandurethra,rectuminjuryvitaltissuesinjurysuchasarteries,spinalcord,peripheralnervesfatembolismsyndrome(FES)CompartmentsyndromeFatembolismsyndrome(FES)FESistheunexpectedoccurrenceofhypoxia,confusion,andpatechiaeafewdaysafterlongbonefracturesTheetiologyofFESThebrokenbonesliberatemarrowfatthatembolizestothelungsandbraininwhichfatdropletsenterthevenouscirculationviatornveinsadjacenttothefracturesiteThebiochemicaltheorysuggeststhatmediatorsfromthefracturesitealterlipidsolubilitycausingcoalescence,sincenormalchylomicronsarelessthan1μmindiameterElevatedserumlipaselevelshydrolyzesneutralfattofreefattyacidsandcauseslocalendothelialdamagesinthelungsandothertissuesCompartmentsyndromeCompartmentsyndromeisaconditioncharacterizedbyraisedpressurewithinaclosedspacewithapotentialtocauseirreversibledamagetothecontentsoftheclosedspaceTheprerequisitesforthedevelopmentofacompartmentsyndromeincludeacauseofraisedpressurewithinaconfinedtissuespacecalledosteofascialcompartmentwhichiscomposedofbone,deepfascia,interosseousmembraneandintermuscularseptum.Anyconditionthatincreasesthecontentsorreducesthevolumeofacompartmentcouldberelatedtothedevelopmentofanacutecompartmentsyndrome.Themostcommoncauseassociatedwithdecreaseinthesizeofthecompartmentistheapplicationofatightcast,constrictivedressings,orpneumaticantishockgarments.Closureoffascialdefectshasbeenshowntobeassociatedwiththedevelopmentofanacutecompartmentsyndrome.Thisconditionmostcommonlyoccursinanteriorcompartmentoftheleg,inpatientswhopresentwithsymptomaticmusclehernias.Anumberofconditionshavebeenshowntoincreasethecompartmentcontentsandleadtocompartmentsyndrome.Theseinvolovehemorragewithinthecompartment,ortoaccumulationoffluid(edema)withinthecompartment.Theformerismostcommonlyassociatedwithfracturesofthetibia,elbow,forearm,orfemur,whereasthelatterismostcommonlyassociatedwithpostischemicswellingafterarterialinjuriesorrestorationofarterialflowafterthromosisofamajorarteryThesymptomofpainoutofproportiontotheknowninjuryandthefindingsofatense,swollencompartmentwithsomedegreeofpassivelyinducedstrenchpainrepresenttheearliestmanifestationsofanacutecompartmentsyndromeBythetimesensorydeficitsisobvious,irreversiblechangestonervesormusclesmayalreadyhaveoccurred.Towaitthedevelopmentoffrankmotorweaknessistoinvitediaster.Paresisisalatefindingand,ifpresent,demandsimmediatedsurgicalinterventionTheonlyeffectivewaytodecompressanacutecompartmentsyndromeisbysurgicalfasciotomy.Lateperiodc