医学精品课件：03.DengFractue introduction2016f.ppt

1、骨骨 科科 学学Orthopaedics古代骨科简述古代骨科简述周朝（周朝（BC1100770）伤骨科（疡医科：折、疡之分）伤骨科（疡医科：折、疡之分）春秋战国时期（皇帝内经）春秋战国时期（皇帝内经）截肢术（脱痈）截肢术（脱痈）汉代华佗（汉代华佗（AC147207）骨折复位、夹板固定，清创术，骨折复位、夹板固定，清创术，“麻沸散麻沸散”：手术无痛原则：手术无痛原则晋代葛洪（晋代葛洪（AC261347）竹夹板外固定骨折竹夹板外固定骨折隋代巢元方（隋代巢元方（AC581618）骨折内固定：线连接碎骨骨折内固定：线连接碎骨唐代蔺道人唐代蔺道人“仙授理伤续断秘方仙授理伤续断秘方”骨折治疗四大原则：骨折

2、治疗四大原则：复位、固定、内外用药、功能锻炼复位、固定、内外用药、功能锻炼明代杨清叟明代杨清叟 止血带：绢袋止血带：绢袋清代江考鲫清代江考鲫 骨移植：以别骨填接骨移植：以别骨填接古希腊古希腊Hippocrates（Bc460377）骨折脱位等的治疗骨折脱位等的治疗古罗马古罗马Galen（Ac130200）人体解剖人体解剖16世纪世纪Azeecs 人人 骨不连内固定治疗：木片骨不连内固定治疗：木片Jean-Andre Venel(1740-1791):Venevese,be called the Father of Orthopaedics Julius Wolff（1836-1902）：Wol

3、ffs lawhttps:/en.wikipedia.org/wiki/Julius_Wolff_(surgeon)Plaster cast of Paris 1751骨科学命名及研究内容骨科学命名及研究内容Orthopaedics named in 1741 by Nicholas Andry He coined the word:Orthos-:correct,straight -paedion:childMovement system(Orthopaedics)is composed with spine,extremities,bone,joint,muscles,vessels,ne

4、rves,lymph,fascia,synovium,etc.现代骨科及相关组织现代骨科及相关组织AASOS骨科未来的发展和前进方向 需要创造性（Creative,Innovation）相关学科的发展和多学科的互相交融 （Multiidiciplines development）Plane+rocket+Vheicle monocycle+motor OrthopaedicsOrthopaedicsINTRODUCTION OF FRACTUREZhong-Liang Deng Prof.,MD,Ph.D 邓忠良邓忠良 Department of Orthopaedics Second Aff

5、iliated Hospital Chongqing Medical University Definition ClassificationTreatmentPrognosisHealing process and the affecting factorsClinical findings and image checkCausesEmergency care Bone FractureContent：1.DEFINITION OF FRACTUREA fracture is a break in the continuity of a bone2.CAUSES OF FRACTUREST

6、raumaDirect forceDirect force causes the fractureTraumaDirect forceIndirect force Indirect force causes the fracture2.CAUSES OF FRACTURESMuscular contraction forceTraumaDirect forceIndirect force fracture caused by muscular contraction2.CAUSES OF FRACTURESCyclic forceMuscular contraction forceTrauma

7、Direct forceIndirect force Fatigue fracture2.CAUSES OF FRACTURESBone diseasesLocalized diseasesSystemic diseasesCyclic forceMuscular contraction forceTraumaDirect forceIndirect force tubercular osteomyelitis,osteosarcoma,localized metastatic carcinoma,etc.osteoporosis,multiple myeloma,diffuse metast

8、stic carcinoma,etc.2.CAUSES OF FRACTURES3.CLASSIFICATION OF RACTURESOn the basis of etiology Traumatic fracturePathological fractureTraumatic fracturePathological fractureOn the basis of relationship with external environment Closed fractureOpen fractureOn the basis of etiology Open fracture3.CLASSI

9、FICATION OF RACTURESOn the basis of patternOn the basis of relationship with external environment On the basis of aetiology 3.CLASSIFICATION OF RACTURESOn the basis of displacementsUndisplaced fractureOn the basis of patternOn the basis of relationship with external environment On the basis of aetio

10、logy No significant displacement fracturesDisplaced fractureangulation shift overlap gap rotation 3.CLASSIFICATION OF RACTURESFactors which are responsible for displacements The fracturing forceThe muscle pull on the fracture fragmentsThe gravity to the fragmentPhysician activityOn the basis of disp

11、lacementsOn the basis of patternOn the basis of relationship with external environment On the basis of aetiology On the basis of timefresh fractureold fractureWithin 3 wksover 3 wks3.CLASSIFICATION OF RACTURESOn the basis of displacementsOn the basis of patternOn the basis of relationship with exter

12、nal environment On the basis of aetiology On the basis of timestable fractureunstable fractureOn the basis of stability3.CLASSIFICATION OF RACTURESAO/ASIF CLASSIFICATIONAO(Arbeitsgemeinschaft fur Osteosynthesefragen)ASIF(Association for the Study of Internal Fixation)Location +type+subtype +group4.E

13、MERGENCY CARE OF FRACTURESRescue the lifeABCDEF stepsABCDEFAir way and breathingBleeding and circulationCentral nerve systemDigestive systemExcretionFracture(Mc Murtry 1980)Manage the wound Preserve the lifeControl the bleeding and cover the wound properly4.EMERGENCY CARE OF FRACTURESImmobilize the

14、fractureManage the wound Preserve the life4.EMERGENCY CARE OF FRACTURESTransfer the patientImmobilize the fractureManage the wound Preserve the lifeTwo methods to transport the spine fracturerollinglifting4.EMERGENCY CARE OF FRACTURESWrong method to transport the spine fractureDefinition Classificat

15、ionTreatmentPrognosisHealing Process and the affecting factorsClinical findings and imaging studiesCausesEmergency careFractureContent：Systemic Manifestations Primary Shock(Neurogenic Shock)Secondary Shock Haemorrhage Notice:to exclude cerebral injury and expiratory dyspnea Local Manifestation Swell

16、ing Traumatic Inflammation Pain Impairment of function Deformity Unique Signs Abnormal Motion Bony Crepitus or Grating Image check(classic workup)Fracture yes or no?Pattern of fracture Decision making for the Treatment Early Complications Shock Fat embolism Injury to Important Organ and Tissue Osteo

17、fascial Compartment Syndrome Late Complications Systemic Complication Pressure Sores(bedsore)Pneumonia Infection of the Urinary tract Local Complications Infection of Bone and Joint Post-Traumatic Ossification Osteoarthritis Joint Stiffness Reflex Sympathetic Dystrophy Avascular Necrosis of The Bone

18、 Ischemic Contracture(Volkmann contracture)Bone tissue.Bone cells.Woven bone.Laminar bone.TrabeculaeSpongy bone(Cancellous bone).Compact bone(cortical bone).Volkmann canal.Haversian system Tissue Injury Bone Fracture Repair Regeneration Scar NewBone Three major phases 1.Reactive phase 2.Reparative p

19、hase 3.Modeling and Remodeling phase 1.Reactive phase(2 w)Hematoma and inflammation Fibrinogen Reticular Fibril Blood Clots New Vessels Mesenchymal Cell Inflammatory Cell Haematoma Fibrosis Granulation Tissue Formation and Fiberization Cytokines involved in fracture healingBMPs BMP2,BMP4,BMP6,BMP7,B

20、MP9TGFbIGFFGFPDGF2.Reparative phase(Primary Callus Formation)(6-8 w)Oestoid tissue formation Intramenbranous Ossification Cartilage callus formation Endochondral OssificationWoven bone (immature bone)Origin of the Callus Mineral Dead Bone Osteoblasts,Chondroblasts CO 2 Phosphorylase pH Hydrolyze to

21、Phosphate (in the Hematoma)(in the Plasma)Calcium+Phosphate FreeBlood calciumCalcium PhosphateFracture Callus (Woven Bone)Collagen Ionly cyclic loading can induce bone formation 3.Modeling and Remodeling phase (8 w-)Modeling:woven bone to lamellar bone(in trabecular bone)Remodelling:Transformation t

22、o oringinal bone contour(12 w-)Wolff s Law https:/en.wikipedia.org/wiki/Wolff%27s_lawThe law of transformation of the bone Loading Fine motion Blood supplyCyclic ForceCriteria of Clinical Fracture Healing 1.Local and axial percussion produces no pain 2.Absence of abnormal mobility 3.Visible continua

23、l callus has bridged the fragments and fracture line is disappeared 4.Without the external fixation of splints A.The Arm is able to hold 1 kg stuff horizontally lasting for 3 min.B.The Legs are able to Walk 30 paces in 3 min.C.No deformation appears on the fracture site after continual observation f

24、or 2 weeks1.Age 2.Systemic ConditionFactors Influenced Fracture Healing Systemic Factors 1.Pattern of Fracture 2.Blood Supply(Fragments)A.Blood supply of both fragments are rich.B.One is rich while the other is poor.C.Blood supply of both fragments are poor.D.Absence of blood supply.Local Factors Lo

25、cal Factors 3.Infection 4.Injuries of Soft Tissue 5.Soft tissue into the fracture gap 6.Basic Disease(local)Factors Influenced Fracture Healing Methods of Treatment:1.Repeated Reduction by Manipulation 2.Over Traction to Fragments 3.Incorrect Fixation 4.Incorrect Debridement 5.Influence of Open Redu

26、ction 6.Incorrect Functional ExercisesFactors Influenced Fracture Healing Biological Factors 20%Medical Factors 80%!Factors Responsible for Fracture Poor HealingWhat we should do is to facilitate fracture healing Reduction Immobilization Rehabilitation Medication Criteria of Reduction 1.Anatomic Red

27、uction 2.Functional Reduction (1).No Observe Gap and Rotation (2).Shortening 1 2 cm in the Leg (3).Angulation 15 10 (4).Apposition of the Fragments /3(shaft),or /(epiphyseal )1.Closed Manipulation 2.Mechanical Traction with or without Manipulation 3.Open ReductionReasons of Immobilization 1.Prevent

28、from Displacement 2.Prevent from Movement 3.Relief of PainMethods of Immobilization:1.Wooden Splint ,Plaster Cast 2.Continuous Traction 3.External Fixator 4.Internal Fixation 1.Active Muscular Contraction (Within 2 Weeks postfracture)2.Active Motion on Joints Adjacent to Fracture (2 8 w postfracture

29、)3.Active Resistance Exercises (Over 8 ws postfracture)4.Physiotherapy Traditional medicine Avoid to use Nonsteroid Anti-Inflammatory Drugs(NSAIDs)Prevent Infection !1.Types of Open Fracture From outside to inside From inside to outside Potential open fracture 2.Conditions of the Wound Contamination

30、 degree Soft Tissue Injury 3.Debridement Same Principles as Surgical Debridement Golden Time :6 8 h(after injury)Larger Bony Piece Should be Preserved Properly fix the fracture Repair Nerve、Tendon、Vessel Properly Close the wound Same Principles as Surgical Debridement 1).Restore the smooth surface o

31、f joint 2).Not to Leave Foreign Bodies in Joint 3).Forbid to Open Draining(Can Use Irrigation)4).Repair of Capsule and Ligaments 5).Inject Antibiotics into the Joint After operation 6).Aspiration is Especially Important in hemarthrosis 7).The Joint should be Immobilized with traction ,Splint or Plas

32、ter 1.After 8-12 w Fracture 2.Pain of Fracture Site 3.Fracture Line Can be Seen Clearly 4.A Little Callus 5.No Osteosclerosis of the Fragments 6.Fracture has Possibility of Healing Clinical Features Motion without pain(False Joint or Pseudarthrosis)Atrophic Type 1.Sclerosis of the Bone Ends 2.Withou

33、t Callus Formation 3.Closed Marrow Cavity.Roentgenographic Evaluation Hyperplasia Type Excess Callus Formation Around the Fracture Site with a Lucent Interval through the Callus itself and Fragments Causes 1.Infection 2.Inadequate Blood Supply 3.Excessive Shearing Movement 4.Soft Tissue existed betw

34、een fragments Causes 5.Separation Between the Fragments 6.Destruction of Bone 7.Corroding Metal 8.Synovial Nonunion Fracture Healing with unacceptable angulation or rotation原因骨折骨折描述分类时间开放性完整性形态 稳定性移位移位影响因素急救急救诊断诊断治疗治疗愈合愈合转归转归临床表现并发症骨折急救原则专有体征早晚期并发症骨筋膜室综合征原则愈合过程影响愈合因素临床愈合标准不愈合Wolffs law开放性骨折处理THANK YOU FOR YOUR ATTENTION!