1、Fracture of Upper ExtremitiesMao Nie,MD,PhD Attending and LecturerDepartment of OrthopaedicsThe 2nd Affiliated Hospital of CQMUSChongqing,ChinaTel&wechat:13678428205 Sports medicine&Arthroscopy Adult Joints ReconstructionReview of last ClassWhat s fracture?A fracture is a break in the continuity of
2、a boneCLINICAL FEATURES临床特征临床特征 Local Manifestation Swelling（肿胀）Traumatic Inflammation Pain（疼痛）Impairment of function （功能障碍）Specific Signs CLINICAL FEATURESLocal ManifestationDeformity(畸形)Deformity(畸形畸形)Abnormal Mobility（反常活动）（反常活动）Crepitus or Grating（骨擦音（骨擦音or骨擦感）骨擦感）Review of last ClassThe princip
3、les of treatment（治疗原则）Reduction、Immobilization、Rehabilitation复位、固定、功能锻炼复位、固定、功能锻炼AnatomyBone that compose upper limb:u The girdle of upper limb clavicle and scapularu The free bone of upper limb 1 humerus(arm)1 ulna(forearm)1 radius(forearm)8 carpals(wrist)19 metacarpal and phalanges(hand)FRACTURE O
4、F CLAVICLE锁骨骨折锁骨骨折Section IAnatomyThe clavicle is weakest at the junction of the two curvesTherefore,most breaks occur approximately in the middle of the clavicleThe clavicle is the bone that connects the trunk of the body to the armSternoclavicular胸锁关节 Acromioclavicular肩锁关节“S”MedialLateral从上面看从前面看横
5、截面AnatomyAnatomy臂丛神经臂丛神经n Mechanism Fall onto shoulder(87%)Direct blow onto clavicle(7%)Fall onto outstretched hand(6%)Birth injury from passing through the birth canal.n Mechanism Birth injury from passing through the birth canal.History of a trauma pain,swelling and crepitus Inability to raise a s
6、houlder Deformity along the line of the clavicleClinical features 患者姿势（头偏向患侧）患者姿势（头偏向患侧）Clinical featuresRadiographic EvaluationX-Ray：In order to determine the fracture type and extent of injury.Take both clavicle bones for comparison Anteroposterior View前后位片30-degree Cephalic Tilt View30度头侧斜位片Green
7、dstick fracture 青枝骨折青枝骨折 (children usually)Radiographic EvaluationCTRadiographic Evaluation Lung injuryComplications Subclavian vessels injury锁骨下血管损伤锁骨下血管损伤asymmetric pulse or pulsatile hematomaComplications Brachial plexus injury（臂丛神经损（臂丛神经损伤）伤）ComplicationsDiagnosis受伤史受伤史症状、体征症状、体征X X线、线、CTCT合并伤的判
8、断合并伤的判断Classification 分型分型According to fracture site（根据骨折部位）l80%occur in the medial 1/3l15%distal third occure in the lateral or distal 1/3l5%occur in the medial or proximal 1/3ClassificationFracture of lateral clavicle 锁骨外端骨折的分型Coracoclavicular ligament（喙锁韧带）TreatmentConservative treatment:保守治疗保守治疗
9、u Nondisplaced or greenstick fractures（非移位或青枝骨折）Sling for 3-6 weeks（悬吊3-6周）TreatmentConservative treatment:uDisplaced Middle 1/3 fractures Closed manipulative reduction,Figure-of-8 strap Surgical treatmentIndication（手术指征）（手术指征）Closed reduction fail（闭合复位失败）Neurovascular injurie（神经血管损伤）Open fracture（开
10、放性骨折）Lateral fracture with Coracoclavicular ligament rupture or scapular neck fractures（合并喙锁韧带断裂或肩胛颈骨折的锁骨外端骨折）Non-union fracture（骨折不愈合）Open Reduction and Internal Fixation切开复位内固定切开复位内固定The Hook Plate（锁锁骨骨钩钢钩钢板）板）specifically designed for the lateral fracture of clavicle Type IIFRACTURE OF HUMERUSSec
11、tion IIPart I:Proximal humeral fracturePart II:Fractures of humeral shaftPart III:Supracondylar FracturesSection II-Part IPart I:Proximal humeral fracture 肱骨近端骨折肱骨近端骨折Proximal Humeral AnatomyNeer,JBJS 70MechanismElderly fall onto outstretched hand direct blow-fall bone fragility-osteoporosis （骨质疏松）Y
12、oung high energy trauma（高能量创伤）Clinical manifestation lHistory of trauma;受伤史lPain;疼痛lSwelling;肿胀lEcchymosis;瘀斑lDysfunction of the shoulder 肩关节功能障碍Radiographic evaluationlX rayAPScapular“Y”Radiographic evaluationlCT scan and 3D reconsrructionDiagnosis History of trauma;受伤史 Clinical manifestation 临床表现
13、Radiographic evaluation 影像学表现ClassificationUnderstanding Fracture Patterns 4 bony fragments Lesser Tub Greater Tub Head ShaftNeer Classification 1 cm displaced 45 degree angulated Excessive rotationClassificationn Neer Classification Four parts Greater and lesser tuberosities,Humeral shaft Humeral h
14、ead A part is displaced if 1 cm displacement or 45 degrees of angulation is seenTreatment Minimally displaced fractures-Sling immobilization,early motion Two-part fractures-Anatomic neck fractures likely require ORIF.High incidence of osteonecrosis Surgical neck fractures that are minimally displace
15、d can be treated conservatively.Displacement usually requires ORIF Three-part fractures Due to disruption of opposing muscle forces,these are unstable so closed treatment is difficult.Displacement requires ORIF.Four-part fractures In general for displacement or unstable injuries ORIF in the young an
16、d hemiarthroplasty in the elderly and those with severe comminution.High rate of AVN（avascular necrosis 缺血坏死）(13-34%)Case 177岁，老年女性岁，老年女性诊断：肱骨外科颈骨折诊断：肱骨外科颈骨折Neer分型：一部分骨折分型：一部分骨折治疗：保守治疗治疗：保守治疗Case 281岁，老年女性岁，老年女性诊断：肱骨近端骨折（大结节、小结节、诊断：肱骨近端骨折（大结节、小结节、外科颈）外科颈）Neer分型：三部分骨折分型：三部分骨折治疗：切开复位锁定钢板螺钉内固定术治疗：切开复位锁
17、定钢板螺钉内固定术Open Reduction and Internal FixationCase 387岁，老年女性诊断：肱骨近端骨折（大小结节、外科颈、解剖颈）Neer分型：四部分骨折治疗：半肩关节置换术HemiarthroplastySection II-Part IIPart II:Fractures of Humeral ShaftAnatomy2cm proximal to surgical neck2cm distal to supracondyleOn the back of the middle third,there is a shallow spiral groove f
18、or radial nerve（桡神经）桡神经）on the bone Direct trauma is the most common Indirect trauma such as fall on an outstretched hand Fracture pattern depends on stress applied Bending-transverse fracture of the shaft Torsional-spiral fracture of the shaft Torsion and bending-oblique fracture usually associated
19、 with a butterfly fragment（蝶形骨块）Bending 弯屈应力 Torsion 扭力MechanismClinical featureSymptom Pain Swelling Deformity Ecchymosis Dysfunction of upper armPEBony crepitus 骨擦音Pseudarthrosis 假关节Clinical feature Radial nerve injury 桡神经损伤l Check for the neurovascular deficit before and after reduction(especiall
20、y wrist and fingers extension)Wrist drop 垂腕垂腕SensoryRadiographic evaluation AP and lateral views of the humerus Including adjacent joint(shoulder or elbow)A1A3C3Displacement of fragmentsA fracture between the insertion of the pectoralis major and the deltoid1.The proximal fragment is adducted by the
21、 pectoralis major,teres major and latissimus dorsi.2.The distal fragment is shortened and displaced laterally by deltoidDisplacement of fragments A fracture below the deltoid insertion The proximal fragment is displaced abducted by deltoid The distal fragment is displaced proximally by biceps and tr
22、icepsDiagnosis History of trauma;Clinical manifestation Radiographic evaluation Classification AO classification Type A-Simple fracture Type B-Wedge fracture Type C-Complex fractureNon-operative Treatment Type A and partial Type B Closed manipulative reduction External Fixation（Splint or Plaster or
23、Brace）Immobilization：6-8 wks for adults，4-6wks for childrenTreatmentFractures of Humeral Shaft IndicationClosed reduction failPolytraumaOpen fractureNeurovascular injurieUnstalbe fractures（Type B3 and C）,Non-union fracturePathologic fractureFloating elbowAssociated articular fractureOperative manage
24、mentFractures of Humeral Shaft Method Open Reduction and Internal Fixation Minimally Invasive Percutaneous Osteosynthesis Intramedullary Nailing(髓内钉“Rod”)External fixationOperative managementFractures of Humeral Shaft The choice of implants depends on surgeon experience,associated injuries extent an
25、d location of the soft-tissue injury,fracture pattern.Fractures of Humeral ShaftOpen Reduction and Internal FixationCited from Nikolaus Schwarz Locking compression plate(LCP)MIPO technique does not interfere with the fracture site and thus provides improved biological healingMinimally Invasive Percu
26、taneous OsteosynthesisFractures of Humeral ShaftIntramedullary nailing Relative indications:Soft-tissue injuries(Open fracture);Burns;Fractures that require immediate stabilization;External fixationReferenceNeviaser,et al.,Proximal humeral fractures:pin,plate,or replace.Instr Course Lect.2015;64:203
27、-14.Cadet ER,et al.,Hemiarthroplasty for three-and four part proximal humerus fractures.J Am Acad Orthop Surg.2012 Jan;20(1):17-27.Carroll EA,et al.,Management of Humeral Shaft Fractures.J Am Acad Orthop Surg.2012 Jul;20(7):423-33Thanks for Professor Nabil A.Ebraheim from University of Toledo Medical Center for some teaching videos.
