小儿骨科的临床基础课件.ppt

1、小儿骨科的临床基础病史 现病史 出生史（产伤骨折、臂丛神经麻痹、脑瘫等）发育史（侏儒、甲低、肌营养不良等）家族史（多指、多发骨软骨瘤病等）体格检查 望（整体外观，冠状面、矢状面、水平面）患儿的面容（痛苦面容，21三体面容等）表皮的色泽和皮肤生长情况 患儿身材比例 肢体对称情况 肢体长短情况 肢体活动情况 肢体畸形情况 躯干部活动情况 躯干部畸形情况 患儿的步态体格检查 触 皮肤弹性 皮肤变色情况 局部肿胀情况，温度变化 包块（位置、大小、质地、界限、温度、皮色、与周边关系、活动度、压缩性）压痛（位置，最大压痛点）反常活动、骨擦音、骨擦感 紧张挛缩感 痉挛感 肌力（05级）肌力 0级：无任何收缩

2、 1级：只可触及收缩，没有任何活动。2级：可于水平方向移动，不能对抗重力。3级：仅能对抗重力，不能对抗阻力。4级：能对抗一定程度的阻力 5级：肌力正常 Lovett and Martins肌力分级法 Texas Scottish Rite Hospital肌力分级法Palmar(hand)grasp reflexPresent in neonates and very young infants;normally disappears between ages 2 and 4 moPlantar(foot)grasp reflexPresent in neonates and infants;

3、usually disappears between ages 9 and 12 moMoros reflexPresent at birth;gradually disappears by ages 3-6 mo：CNSStartle reflexAppears at birth;present throughout lifeVertical suspension positioningReflex normally disappears after age 4 moPlacing reactionNormally present at birth in full-term neonates

4、;upper limb placing usually disappears by ages 2-4 mo and lower limb placing by ages 1-2 mo;both responses may persist up to age 12 mo or olderWalking or stepping reflexNormally present at birth;usually disappears by ages 1-2 moCrossed extension reflexPresent at birth;normally disappears by ages 1-2

5、 moWithdrawal reflexPresent at birth;disappears between ages 1 and 2 moPositive support response/leg-straightening reflexPresent at birth;normally disappears at about 4 moExtensor thrust reflexPresent at birth;normally present up to 2 moGalants reflex(trunk incurvation)Present at birth;disappears at

6、 about 2-2 moRotation reflexTime of disappearance variesTonic neck reflexesAsymmetric reflex present at birth,normally disappears by 4-6 mo;symmetric reflex usually present by 5-8 mo,often diminished or absent by 12 moLandaus reflexNormally present from 6 mo to 24-30 moParachute reactionAppears at a

7、bout 6 mo;remains throughout lifeNeck righting reflexNormally present from birth to about 6 moBody righting reflexAppears around 6 mo;can disappear any time after 5 yr or persist throughout lifeOral reflexesUsually disappear at 3-4 mo;may be present longer during sleep深反射 肱二头肌反射 肱三头肌反射 膝反射 踝反射浅反射 Ba

8、bibski反射 提睾反射 Hoffmann反射 括约肌反射 腹壁反射MuscleSegmental InnervationPeripheral NerveTrapeziusCranial XI;C(2)3-4Spinal accessory nerveLevator anguli scapulaeC3-4Nerves to levator anguli scapulae C4-5Dorsal scapular nerveRhomboideus majorC4-5Dorsal scapular nerveRhomboideus minorC4-5Dorsal scapular nerveSer

9、ratus anteriorC5-7Long thoracic nerveDeltoidC5-6Axillary nerveTeres minorC5-6Axillary nerveSupraspinatusC(4)5-6Suprascapular nerveInfraspinatusC(4)5-6Suprascapular nerveLatissimus dorsiC6-8Thoracodorsal nerve(long subscapular)Pectoralis majorC5-T1Lateral and medial anterior thoracicPectoralis minorC

10、7-T1Medial anterior thoracicSubscapularisC5-7Subscapular nervesTeres majorC5-7Lower subscapular nerveSubclaviusC5-6Nerve to subclaviusCoracobrachialisC6-7Musculocutaneous nerveBiceps brachiiC5-6Musculocutaneous nerveBrachialisC5-6Musculocutaneous nerveBrachioradialisC5-6Radial nerveTriceps brachiiC6

11、-8(T1)Radial nerveAnconeusC7-8Radial nerveSupinator brevisC5-7Radial nerveExtensor carpi radialis longusC(5)6-7(8)Radial nerveExtensor carpi radialis brevisC(5)6-7(8)Radial nerveExtensor carpi ulnarisC6-8Radial nerveExtensor digitorum communisC6-8Radial nerveExtensor indicis propriusC6-8Radial nerve

12、Extensor digiti minimi propriusC6-8Radial nerveExtensor pollicis longusC6-8Radial nerveExtensor pollicis brevisC6-8Radial nerveAbductor pollicis longusC6-8Radial nervePronator teresC6-7Median nerveFlexor carpi radialisC6-7(8)Median nervePronator quadratusC7-T1Median nervePalmaris longusC7-T1Median n

13、erveFlexor digitorum sublimisC7-T1Median nerveFlexor digitorum profundus(radial half)C7-T1Median nerveLumbricales 1 and 2C7-T1Median nerveFlexor pollicis longusC8-T1Median nerveFlexor pollicis brevis(lateral head)C8-T1Median nerveAbductor pollicis brevisC8-T1Median nerveOpponens pollicisC8-T1Median

14、nerveFlexor carpi ulnarisC7-T1Ulnar nerveFlexor digitorum profundus(ulnar half)C7-T1Ulnar nerveInterosseiC8-T1Ulnar nerveLumbricales 3 and 4C8-T1Ulnar nerveFlexor pollicis brevis(medial head)C8-T1Ulnar nerveFlexor digiti minimi brevisC8-T1Ulnar nerveAbductor digiti minimiC8-T1Ulnar nerveOpponens dig

15、iti minimiC8-T1Ulnar nervePalmaris brevisC8-T1Ulnar nerveAdductor pollicisC8-T1Ulnar nerveMuscleSegmental InnervationPeripheral NervePsoas majorL(1)2-4Nerve to psoas majorPsoas minorL1-2Nerve to psoas minorIliacusL2-4Femoral nerveQuadriceps femorisL2-4Femoral nerveSartoriusL2-4Femoral nervePectineus

16、L2-4Femoral nerveGluteus maximusL5-S2Inferior gluteal nerveGluteus mediusL4-S1Superior gluteal nerveGluteus minimusL4-S1Superior gluteal nerveTensor fasciae lataeL4-S1Superior gluteal nervePiriformisS1-2Nerve to piriformisAdductor longusL2-4Obturator nerveAdductor brevisL2-4Obturator nerveAdductor m

17、agnusL2-4Obturator nerve L4-5Sciatic nerveGracilisL2-4Obturator nerveObturator externusL2-4Obturator nerveObturator internusL5-S3Nerve to obturator internusGemellus superiorL5-S3Nerve to obturator internusGemellus inferiorL4-S1Nerve to quadratus femorisQuadratus femorisL4-S1Nerve to quadratus femori

18、sBiceps femoris(long head)L5-S1Tibial nerveSemimembranosusL4-S1Tibial nerveSemitendinosusL5-S2Tibial nervePopliteusL5-S1Tibial nerveGastrocnemiusL5-S2Tibial nerveSoleusL5-S2Tibial nervePlantarisL5-S1Tibial nerveTibialis posteriorL5-S1Tibial nerveFlexor digitorum longusL5-S1Tibial nerveFlexor halluci

19、s longusL5-S1Tibial nerveBiceps femoris(short head)L5-S2Common peroneal nerveTibialis anteriorL4-S1Deep peroneal nervePeroneus tertiusL4-S1Deep peroneal nerveExtensor digitorum longusL4-S1Deep peroneal nerveExtensor hallucis longusL4-S1Deep peroneal nerveExtensor digitorum brevisL4-S1Deep peroneal n

20、erveExtensor hallucis brevisL4-S1Deep peroneal nervePeroneus longusL4-S1Superficial peroneal nervePeroneus brevisL4-S1Superficial peroneal nerveFlexor digitorum brevisL4-S1Medial plantar nerveFlexor hallucis brevisL5-S1Medial plantar nerveAbductor hallucisL4-S1Medial plantar nerveLumbricales(medial

21、1 or 2)L4-S1Medial plantar nerveQuadratus plantaeS1-2Lateral plantar nerveAdductor hallucisL5-S2Lateral plantar nerveAbductor digiti quintiS1-2Lateral plantar nerveFlexor digiti quinti brevisS1-2Lateral plantar nerveLumbricales(lateral 2 or 3)S1-2Lateral plantar nerveInterosseiS1-2Lateral plantar ne

22、rve临床检查 腹壁反射 敲击试验 Barlow试验 Coleman试验（足外翻）Ely试验（股直肌）足前进角 前弯试验 Galeazzi征 Gower试验 髋关节旋转实验 Nelaton线 Ober试验 Ortolani试验 Patrick试验 Phelps股薄肌试验 Thomas试验 腘窝角 Trenderlenburg试验体格检查 动（肢体活动范围）屈：关节弯曲活动，关节向远离中立位的方向活动。伸：关节伸直活动，关节向靠近中立位的方向活动。过伸：关节伸展超过中立位的范围（膝关节和肘关节）内收：肢体向靠近身体的中线的方向移动 外展：肢体向远离身体的中线的方向移动 旋后：前臂或手部的掌面向前

23、或指向身体的前面 旋前：前臂或手部的掌面向后或指向身体的后面 内翻：向内翻转（中立位）外翻：向外翻转（中立位）内旋：向着身体轴线的方向旋转 外旋：远离身体轴线的方向旋转Flexion:Act of bending a joint;a motion away from the zero starting position.Extension:Act of straightening a joint;a return motion to the zero starting position.Hyperextension:When the motion opposite to flexion is

24、an extreme or abnormal extension(as may be seen with the knee or elbow joint),and the joint extends beyond the zero starting position.Abduction:Lateral movement of the limbs away from the median plane of the body,or lateral bending of the head or trunk.Adduction:Movement of a limb toward the median

25、plane of the body.Supination:Act of turning the forearm or hand so that the palm of the hand faces upward or toward the anterior surface of the body.Pronation:Turning of the palm of the hand so that it faces downward or toward the posterior surface of the body.Inversion:An inward turning motion(seen

26、 primarily in the subtalar joint of the foot).Eversion:An outward turning motion.Internal(inward)rotation:Process of turning on an axis toward the body.External(outward)rotation:Process of turning on an axis away from the body(opposite motion of internal rotation).体格检查 颈椎（屈、伸、左侧屈、右侧屈、左环转、右环转）体格检查 腰椎

27、（屈、伸、左侧屈、右侧屈、左旋转、右旋转）体格检查 肩关节（屈、伸、外展、上举、前伸、后伸、左环转、右环转）体格检查 肘关节（屈、伸）前臂（旋前、旋后）体格检查体格检查 腕关节（掌屈、背屈、尺偏、桡偏）60 60 30 20 体格检查 掌指关节和指间关节（屈、伸）-2090（掌指）-30100（近侧指间）-2070（远侧指间）-4060（拇指掌指关节）-3080（拇指指间关节）体格检查 髋关节（屈、伸、内收、外展、内旋、外旋）体格检查 膝关节（屈、伸）体格检查 踝关节（背屈、跖屈）体格检查 量（各种身体轴线长度和关节活动角度）骨科换药操作 带帽子和口罩 洗手 剪开石膏，显露患肢（尽量保持肢体位

28、置不变）去除敷料 切口或创面消毒（污染和非污染创口）敷料包扎（厚度和形状尽可能与去除敷料一致）石膏固定，包扎绷带，固定患肢 洗手 去除帽子和口罩骨科石膏固定要求 普通石膏：跨越骨折处上下关节固定；上肢810层石膏绷带，23层棉花衬垫；下肢1214层石膏绷带，34层棉花衬垫；要注意骨突部位；尽可能不翻转石膏；管形石膏固定时过关节时要走8字；管形石膏固定后要注意患肢血运（5P）；刚刚发生外伤时，骨折移位明显，石膏固定以患儿最舒适的体位（痛苦程度最轻）固定，可随弯就弯，不要求功能位；骨折移位不明显，则尽可能行功能位固定。如何判断血管神经损伤 血管损伤：以动脉搏动为准（桡动脉和足背动脉）；手部和足部的色泽（暗红色或紫色），肢体常伴有难以忍受的疼痛。神经损伤：以神经支配的肌肉活动进行判断。