臨床神經(jīng)病學(xué)課件：3-3 骨折各論

Fracture

Fractureoftheclavicle

FractureoftheclaviclemostcommoninbothchildrenandadultsoccurintheregionofmidthirdandlateralthirdpartClinicalAppearanceDefiniteinjuryhistoryLocalpain,swelling,pressingpain,canpalpatethedisplacedfragmentoffractureandtherubbingsoundX-rayTreatment(1)NonOperativeTreatment

ReductionbyhandExternalfixationby“8”bandage

:

IndicationsofOperativeTreatment

NonunionNerveandVascularInjuryDifficulttomaintainthefracturebyclosereductionSofttissuebetweenfracturesOpenfractureTreatment(2)SurgicalneckFractureofhumerusHappeninanyage,mostcommoninmiddle-ageandelders.ClassificationUndisplacedAbductedAdductedComminuted

ClinicalAppearanceDefiniteinjuryhistoryLocalpain,swelling,deformity,pressingpain,movementdisordersX-rayTreatmentUndisplacedhangbytriangletowelfor3~4weeksAbductedandadductedreductionbyhandexternalfixationComminutedOperativeTreatmentHumeralshaftfracture肱骨外科頸以下1～2cm至肱骨髁上2cm之間的骨折。三角肌止點(diǎn)以上近折端----向內(nèi)、向前遠(yuǎn)折端----向外、向近三角肌止點(diǎn)以下近折端----向前、外遠(yuǎn)折端----向近Easilyinjuryradialnerve

radialnervepassthroughthemiddlethirdandlowerthirdofhumerus.中下1/3骨折易損傷橈神經(jīng)：垂腕,各手指掌指關(guān)節(jié)不能背伸，拇指不能背伸，前臂旋后障礙；手背橈側(cè)皮膚感覺減退或消失。肱骨中下1/3骨折，注意有無橈N損傷。

Non-OperationOperationDifficultreductionbynon-operationRadialnerveinjuryTreatmentSupracondylarFractureoftheHumerusAnatomyAnterior-mediallytothehumeralcondyle----humeralarteryandmediannervepass.Medialtohumeralcondyle----ulnarnerveLateraltohumeralcondyle----radialnerveNormalelbowjointClassificationExtension

FlexionInjuryhistory(handagainsttheground)Sign:elbowswell,painandsubcutaneousgore.Examinationpressingpainbonesoundpseud-jointmovementNormalpost-elbowtrianglerelationNerveandvascularinjuryornot.ExtensionFxeasilyinjurybloodvesselandnerveDiagnosis特別注意－－伸直型骨折近端前下移位損傷肱動(dòng)脈軟組織腫脹影響遠(yuǎn)端肢體血液循環(huán)前臂骨筋膜室綜合征、缺血性肌攣縮FractureoftheshaftofulnaandradiusDiagnosisAttention:bonefascialcompartmentsyndrome

前臂高張力腫脹，劇痛；橈動(dòng)脈搏動(dòng)摸不清；手指皮溫降低，感覺異常，主動(dòng)活動(dòng)障礙，被動(dòng)活動(dòng)劇痛Ischemicmusclecontracture

5Psign(Painlessness,Pulselessness,Pallor,Paresthesia,Paralysis)Monteggia’sFractureUlnaupperthirdfractureaccompaniedwithradialheaddislocationGaleazzi’sFractureRadiallowerthirdfractureaccompaniedwithulnarheaddislocationTreatmentFractureofradiusandulna(bothbonesfracture)MonteggiafractureGaleazzifractureFractureofthedistalradius橈骨遠(yuǎn)端關(guān)節(jié)面

掌傾10~15°

尺偏20~25°CollesFracture----伸直型SmithFracture----屈曲型BartonFracture----關(guān)節(jié)面骨折伴腕關(guān)節(jié)脫位Fractureofdistalradius1.CollesFractureradialdistalfragmentmovestoradialanddorsalside.多見于成年人和老人典型畸形“餐叉”畸形----背側(cè)移位“槍刺刀”畸形----橈側(cè)移位2.SmithFractureradialdistalfragmentmovestoradialandpalmarside.(ReverseCollesfracture)Smith’sFractureColle’sFracture3.BartonFracture橈骨遠(yuǎn)端背側(cè)或掌側(cè)骨折，累及關(guān)節(jié)面，腕關(guān)節(jié)隨之移位Treatment:手法復(fù)位外固定切開復(fù)位內(nèi)固定恢復(fù)掌傾角、尺偏角損傷橈神經(jīng)垂腕骨筋膜室綜合癥損傷肱動(dòng)脈缺血性肌攣縮結(jié)節(jié)與骨干交界易骨折骨折并發(fā)癥三種畸形Fractureofthefemoralneck解剖特點(diǎn) 頸干角130±7°(平均127°)前傾角10±7°(12～15°)成人股骨頭的血供來源：①旋股內(nèi)、外側(cè)動(dòng)脈在股骨頸基底形成的動(dòng)脈環(huán)以旋股內(nèi)側(cè)動(dòng)脈為主②圓韌帶內(nèi)的小凹動(dòng)脈③股骨干滋養(yǎng)動(dòng)脈的升支股骨頸骨折會(huì)影響股骨頭血供，發(fā)生股骨頭缺血壞死或骨折不愈合。MostcommonlyintheolderIndirectionviolenceClassificationAccordingtothedisplacementdegree:GardenⅠ:IncompleteFractureGardenⅡ:Complete,Non-displacedGardenⅢ:Complete,partlydisplacedGardenⅣ:Complete,fullydisplaced

AccordingtoX-ray:AdductionPauwels>50°

UnstableEasytodiaplace

AbductionPauwels<30°Stableuneasytodisplace

Accordingtothefracturesite:Subcapitalfemurfracture

對(duì)股骨頭血供影響很大TranscervicalneckfractureBaselineneckfracture

對(duì)股骨頭血供影響較小ClinicalappearanceMiddle-agedorelderhadfallhistoryHippainafterinjuryLimitedlowerlimbactivityUnabletostandingandwalkingPatientswithstableFxcouldwalk,butfewdayslater,appearedhippainanddifficulttowalk.ClinicalappearanceAffectedlimbinexternalrotation,usuallybetween45-60°LocalpressingpainAxisknockingpainAffectedlimbisshortenX-ray:identifyfracturesite,typeanddisplacement.■

大轉(zhuǎn)子上移征：TreatmentNon-operation

UnmarkeddisplacedFxAbductionandinsertedstableFxElderwithbadgeneralcondition需長(zhǎng)期臥床，現(xiàn)已較少采用TreatmentOperation

AdductionFxanddisplacedFxOlderthan65YrswithsubcapitalfemoralFxTeen-agefemoralneckFxDatedfemoralneckFxOperationmethodClosedreductionandinternalfixationOpenreductionandinternalfixationArthroplastyScrewsTotalhiparthroplastyComplicationAvascularNecrosis

(Subcapitalfracture)Intertrochantericfracture解剖特點(diǎn)：TrochantericzonepainSwelling,lowerlimbunabletomove.PhysicalexaminationTrochantericzonepressingpainexternalrotation90°andshorteningoflowerlimbX-rayClinicalappearanceTreatmentNon-operationskeletontraction，盡量少用OperationDHSPFNA,γ-nailDHS內(nèi)固定閉合復(fù)位，PFNA內(nèi)固定Femoralneckfracture&Intertrochantericfracture相同點(diǎn)：

●

常見于老年人，骨質(zhì)疏松性骨折；

●

外傷后髖部疼痛伴活動(dòng)障礙；

●

常見患肢外旋畸形；

●

髖部有壓痛、叩痛，縱向叩擊痛(+)。不同點(diǎn)：

股骨頸骨折粗隆間骨折

●

解剖關(guān)系：髖關(guān)節(jié)囊內(nèi)囊外

●

局部腫脹：不明