1、上肢骨折与关节损伤Mechanism 损伤机制损伤机制vMostly IndirectvCommonly described as “ a fall on outstretched hand “vType of injury depends on position of the upper limb at the time of impact : Flexed屈曲, Extended伸直, Adducted内收, Abducted外展, Pronated旋前 or Supinated旋后Fracture of the Clavicle 锁骨骨折锁骨骨折vCommon especially in
2、 children and elderlyvCommonest site is the middle one thirdvMainly due to indirect injuryvDirect injury leads to comminuted TreatmentvConservative by an arm sling手臂吊带 or eight bandage 八字绷带vOperative fixation is indicated if there is an open fracture, neurovascular injury or Figure of eight Bandage
3、8字固定带字固定带Acromio Clavicular J Disloc 肩锁关节脱位I型：关节囊、韧带未断裂型：关节囊、韧带未断裂II型：关节囊破裂型：关节囊破裂III型：关节囊、韧带完全断裂型：关节囊、韧带完全断裂Hook Plate 钩钢板钩钢板Dislocation of the Shoulder 肩关节脱位肩关节脱位v Mostly Anterior 95 % of dislocationsv Posterior Dislocation occurs 5 %v True Inferior dislocation (luxatio erecta 直举性肱骨脱位) occurs 1%v
4、Habitual 习惯性脱位 Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is PainlessInferiorMechanism 机制机制vUsually Indirect fall on Abducted and extended shouldervMay be direct when there is a blow on the shoulder from behind Anterior Shoulder d
5、islocationvUsually also inferiorvBankarts Lesion 前盂唇损伤前盂唇损伤 Clinical Picturev Patient is in painv Holds the injured limb with other hand close to the trunkv The shoulder is abducted and the elbow is kept flexedv There is loss of the normal contour 轮廓 of the Clinical Picturev Loss of the contour of t
6、he shoulder may appear as a step v Anterior bulge膨胀 of head of humerus may be visible or palpablev A gap can be palpated above the dislocated head of the humerusX Ray of Dislocation of ShoulderAssociated Injuries of Shoulder DislocationvInjury to the neuro vascular bundle in axilla ( rare )vInjury o
7、f the Axillary腋神经腋神经 ( Usually stretching leading to temporary neuropraxia )vAssociated fractureAxillary Nerve Injury 腋神经伤腋神经伤v Also called circumflex nervev It is a branch from posterior cord of Brachial plexusv It hooks close round neck of humerus from posterior to anteriorv It pierces the deep su
8、rface of deltoid 三角肌 and supply it and the part of skin over itManagement of Shoulder DislocationvIs an EmergencyvIt should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerusvFollowing reduction the shoulder should be immobilised strapped to the trunk for 3-4 week
9、s and rested in a collar and cuffMethods of ReductionvHippocrates Method ( Anesthesia麻醉 is required )vStimpsons technique (Sedation镇静 and Analgesia止痛 are used, but No anesthesia)vKochers technique is the method used in hospitals under general anesthesia and muscle relaxation Hippocrates MethodStimps
10、ons techniqueKochers TechniqueComplications of Shoulder Dislocation : EarlyvNeuro vascular injury ( rare )vAxillary nerve injuryvAssociated Fracture of neck of humerus or greater or lesser tuberosities（肱骨结节） Complications of Shoulder Dislocation : Latev Avascular necrosis of the head of the Humerus
11、(high risk with delayed reduction)v Heterotopic calcification ( used to be called Myositis Ossificans )骨化性肌炎v Recurrent dislocationFractures of The HumerusvProximal Humerus: surgical and anatomical neckvShaft of HumerusvDistal humerusFractures of The HumerusFracture Proximal HumerusIntra-medullary K
12、 wire fixationFractures Shaft of the HumerusvCommonly Indirect vIndirect injury results in Spiral or Oblique fracturesvDirect injuries results in transverse or comminuted fracturevMay be associated with Radial Nerve injuryFracture shaft of the HumerusTreatment : Plating or NailFracture Distal of the
13、 HumerusRadial Nerve Injuryv Results in Wrist dropv Associated with fracture humerus in up to 12% of fracturesv 2/3 ( 8%) of Radial injury are Neuropraxia(神经失用)Management of Radial Nerve InjuryvWhen present in open fractures ; immediate exploration and repairvIn closed injuries treated conservativel
14、y ; initial management is doing Nerve Conduction Studies ( NCS ) and Electromyography ( EMG ) and awaiting for spontaneous recoveryManagement of Radial Nerve injuryvRecovery usually starts after few days but may take up to 9 months for full recoveryvIf No spontaneous recovery occurs in 12 weeks conf
15、irmed by NCS and EMG ;then exploration of the nerve should be carried outManagement of Humerus Shaft FracturevMost of the time is ConservativevClosed Reduction in upright position followed by application of U shaped Slab or Cylinder castvFew weeks later or initially in stable fractures Functional Br
16、ace may be usedU Shaped Slab of POPFunctional Brace 功能支具功能支具Indications for ORIF 切开复位内固定切开复位内固定v Failure to reduce fracture conservatively 保守失败v Bilateral humeral fractures 双侧骨折v Open fracture with radial nerve Injury 开放骨折并神经伤v Unconscious patient 昏迷病人v Delayed-Union 延迟愈合v Non-Union 不愈合v Mal-Union 畸
17、形愈合ORIF：open reduction internal fixationSupra-condylar Fracture of Humerus 肱骨髁上骨折肱骨髁上骨折Pediatric Supra-Condylar Humeral FracturePediatric Supra-condylar fractureReduction of supra-condylar Fracturev Absolute Emergencyv Should be done by experienced doctor as soon as possiblev In the past the arm was
18、 held in flexed elbow position in back-slab POP after reductionv At present time Percutaneous K wire fixation is ALWAYS carried out after reductionComplications Supra-Condylar FracturesA. Early= Compartment syndrome （Volkmanns Ischemia） v Late= Stiffness Volkmanns Ischemic Heterotopic Calcification
19、Mal-Union (Valgus or varus)Supracondylar fractureEblow Dislocation 肘关节脱位肘关节脱位FootballWeightliftingElbow Reduction 肘关节复位肘关节复位v.Fracture Dislocation 骨折脱位骨折脱位Subluxation of Radial Head 桡骨小头半脱位桡骨小头半脱位Subluxation of Radial Head 桡骨小头半脱位桡骨小头半脱位1.拇指按压桡骨小头处；拇指按压桡骨小头处；2.将前臂作旋后或旋活动将前臂作旋后或旋活动Monteggia Fracture-
20、DislocationMonteggia Fracture-DislocationGaleazzi Fracture-DislocationDistal radius fracture伸直型伸直型 屈曲型屈曲型Distal radius fracture：Colles FractureColles Fracture: 枪刺畸形，银叉畸形枪刺畸形，银叉畸形Distal radius fracture：Smith FractureSmith FractureDistal radius fracture：Barton Fracture桡骨远端关节面骨折伴腕关节脱位桡骨远端关节面骨折伴腕关节脱位 Ba
21、rton FractureColles Fracture Reduction 手法复位手法复位Types of treatment2 weeks Types of treatmentScaphoid 舟状骨舟状骨舟状骨血运特点：由远端向近端供血舟状骨血运特点：由远端向近端供血ScaphoidTake Home Messagev肱骨干骨折、桡骨下端骨折的移位特点、肱骨干骨折、桡骨下端骨折的移位特点、诊断和治疗诊断和治疗;vVolkmann缺血性挛缩缺血性挛缩v前臂骨折的移位特点和治疗原则前臂骨折的移位特点和治疗原则;v舟状骨骨折的病因、特点；舟状骨骨折的病因、特点；v桡骨下端骨折的病因、分类、移位特点。桡骨下端骨折的病因、分类、移位特点。
