1、General Principles of the Diagnosis And Management of FRACTUREThe First Affiliated Hospital,Chongqing University of Medical SciencesDepartment of OrthopedicsHuang wei Epidemiology the United States Trauma causes more than 140,000 deaths per year leading cause of death for those aged 1-34 years more
2、than coronary artery disease,cancer,and stroke combined before age 65 years In 2000,more than 50 million Americans underwent medical treatment for an injury.The estimated lifetime cost of these injuries is believed to be$406 billion.DEFINITION of FRACTUREThe continuity and completeness of bone have
3、broken A fracture is a complete or incomplete break in the continuity of a bone TerminologyAnatomy:The fracture is described with relation to the bones involved and the location within the bone(diaphysis,metaphysis,physis,epiphysis).Articular surface involvement:Does the fracture have intra-articula
4、r involvement?Is there intra-articular displacement or gapping?Displacement:Is the distal fracture fragment displaced compared with the proximal fragment?To what degree or percentage is the fracture displaced?Angulation:The angular deformity is defined in degrees in terms of the distal fragment in r
5、elation to the proximal fragment or with respect to the proximal apex of the distal fragment.Rotation:Rotational deformity is described both clinically and radiographically.Shortening:Has the fracture caused shortening of the involved bone?To what extent has shortening occurred?TerminologyFragmentat
6、ion:The Muller AO(Arbeitsgemeinschaft fr Osteosynthesefragen Association for Osteosynthesis)Comprehensive Classification of Fractures provides a standardized description of fracture patterns,making communication regarding such injuries more precise and understandable.A multifragmentary fracture is o
7、ne that has several breaks in the bone,creating more than 2 fragments.Wedge fractures are either spiral(low energy)or bending(high energy)and allow the proximal and distal fracture fragments to contact each other.The complex multifragmentary fracture is a segmental fracture or one in which there is
8、no contact between the proximal and distal fragments without the bone shortening.Simple fractures are spiral,oblique,or transverse.Factors Responsible for Fractures Direct violence applied to the bone also damages surrounding soft tissuev A tapping force applied to the bone produces an oblique fract
9、ure v A crushing injury results in a fragmented fracture of the bone v A penetrating direct injury from a high-velocity gunshot blast destroys bone and soft tissueFactors Responsible for FracturesIndirect violence applied to the bone produces significantly less damage to soft and hard tissues An abd
10、uction or vertical or muscle pull force causes a compression or avulse or oblique or spiral fractureFactors Responsible for Fractures Many diseases of bone may cause destruction of bone or may weaken the bone produces a pathologic fracturev inflammationv tumor or tumor-like diseasesv osteogenesis im
11、perfectav metabolic diseases et al Factors Responsible for FracturesIn repeated stresses,which cause fatigue fractures these stress fracture are most frequently encountered in bone of the lower extremity:the neck of the second or third metatarsal bone the shaft of the tibia or fibular the neck of th
12、e femur CLASSIFICATIONSFractures may be caused by v Violence direct indirect Injury fracture v Muscle pull Avulsion fracturev Fatigue Stress fracturev Disease Pathological fractureclassifications From Whether Have Direct or indirect Communication Between the Fracture and Wound of the Skin and Mucosa
13、vFrom Within Open Fracture vFrom Without Closed FractureDirect ViolenceIndirect ViolenceMuscle pullAvulsion fractureOpen FractureOpen Comminuted Fracture车祸致左小腿开放性毁损 Open and Comminuted fractureclassificationsFrom Stability v Stable Transverse fracture Greenstick fracture Impacted fracture Epiphyseal
14、 injuryTransverse fracture of the left humerusImpacted fracture of the neck of the right femur From Stabilityv Unstable Spiral fracture Oblique fracture Slope of more than 200o0 Comminuted fracture AvulsionclassificationsThe comminuted fracture of the right humerusThe long spiral fracture of the lef
15、t femur distalGreenstick Transverse AngulationOblique Spiral DoubleComminuted Impacted CrushAvulsion Involving a jointCompression Fracture-DislocationEpiphyseal injuryclassificationsPattern of DisplacementAngulationRotationLateral SideOverlap or ShorteningImpacting Mechanism of the displacementof th
16、e fragments肌肉拉力肌肉拉力造成的骨造成的骨折移位折移位CLINICAL&RADIOLOGICAL FEATURES OF THE FRACTURE Systemic Manifestationsv Primary Shock(Neurogenic Shock)v Secondary Shock-Haemorrhagia(-ge)Notice:exclude to cerebral injury and respiratory embarrassmentCLINICAL&RADIOLOGICAL FEATURES OF THE FRACTURE Systemic Manifestat
17、ionsLow Fever or Slight Fever temperature 380C trauma reaction haematoma absorptionWBC(white blood cell)ESR(erythrocyte sedimentation rate)CLINICAL&RADIOLOGICALFEATURESLocal ManifestationTraumatic Inflammation:Pain Local Swelling Loss or Impairment of Function Ecchymosis Localized bone tenderness Sp
18、ecific Signs The following features are pathognomonic of fracturev Deformityv Abnormal Mobilityv Crepitus or GratingCLINICAL&RADIOLOGICALFEATURESAbsence of dysfunction does not preclude fracture this is particularly true of:greenstick factures impacted fractures fatigue fracturesCLINICAL&RADIOLOGICA
19、LFEATURESRadiological Examination Fracture yes or no?Pattern of fracture?Anatomic part of the fracture?Selecting of Treatment Methods !Early Period Shock Fat embolism Injury to Important Organ and Tissue(nervous and vascular)Osteo-fascial Compartment Syndrome v 骨筋膜室综合征骨筋膜室综合征 Osteofascial Compartmen
20、t Syndrome 早期并发症早期并发症晚期晚期Pain PainlessPallorParesthesiaParalysisPulselessness早期早期Pain Dull-redPassive motion painPulsenessOsteofascial Compartment Syndrome肱骨髁上骨折致肱动脉损伤、骨筋膜室综合征肱骨髁上骨折致肱动脉损伤、骨筋膜室综合征Early Periodv Infection:tetanus;gas gangrene;osteomylitisv Thromboembolism:deep venous thrombosis and pul
21、monary embolismv Acute respiratory distress syndromev Multiple-organ dysfunction syndromeCOMPLICATIONOF FRACTURELater PeriodSystemic Complicationv Pressure Soresv Pneumoniav Infection of the BladderCOMPLICATIONS OF FRACTURELocal Complications Myositis Ossificans Post-traumatic Osteoarthritis Joint S
22、tiffness Reflex Sympathetic Dystrophy Sudeck atrophy Avascular Necrosis of The Bone Ischemic Contracture(Volkmann s)Later Periodv Delayed unionv Nonunionv Malunion or angular deformitiesv Shorteningv Growth arrestv Growth stimulation FRACTURE HEALING Organ and Tissue Scar Repair Fracture Regeneratio
23、n NewBone Stages of bone healing1.For the first 2 weeks,bone healing follows the same patten as the healing of skin or any orther wound.The site of the wound is filled with blood and the broken ends of bone become necrotic.2.The blood clot is invaded by macrophages and osteoclasts which remove dead
24、bone and osteoblasts which produce bone,instead of the fibroblasts which form fibrous tissue in so ft tissue injuries.3.Beteen 2 to 6 weeks after injury osteoid tissue develops and forms a firm mass,or callus,around the fracture and ossification of the osteoidbegins.Callus forms both outside the bon
25、e as subperiosteal callus,and inside as endosteal callus.The pH of the tissues inreases at this stage and calcium is deposited.4.Between 6 and 12 weeks,ossification occurs,a solid bony bridge crosses the gap and the bone regains some mechanical strength.5.Between 12 and 26 weeks,the callus matures.6
26、.Between 6 and 12 months,the gaps between the cortical ends are bridged.7.Between 1 and 2 years,remodelling occurs,bony prominences become smooth and normal bone architecture is restored.The timing is very variable and is much fasterr in children,in whom callus can be seen at 2 weeks.FRACTURE HEALIN
27、G Stages of Fracture Healing1.Haematoma Fibrosis (2 w)Fibrinogen Reticular Fibril Blood Clots New Vessels Mesenchymal Cell Inflammatory Cell Granulation Tissue FRACTURE HEALING 2.Primary Callus Formation (6-8 w)Origin of the Callus Cells D O P C (Determined osteogenic Precursor Cells)I O P C (Induci
28、ble Osteogenic Precursor Cells)FRACTURE HEALING Origin of the Callus Mineral Dead Bone Osteoblasts,Chondroblasts CO 2 Phosphorylase pH Hydrolyze to Phosphate (in the Hematoma)(in the Plasma)FRACTURE HEALING Calcium of Fragment Phosphate Free Dissolved Heamatoma Calcium Phosphate Deposit to Bone Matr
29、ix Callus (Woven Bone)FRACTURE HEALING Endo-chondral Ossification Intra-membranous Ossification New bone forms either through appositional ossification without initial cartilage formation or by enchondral ossification of a preminary fibrocartilage callus.In both instances,the ossification process is
30、 intimately related to revascularization,and the active osteoblasts appear to be derived from either the walls of the small vessels or from circulating blood cells.Bone repair takes place in the periosteal,cortical,and medullary regions,but most of the revasculaization of a fracture is from medullar
31、y circulation.Which of these areas predominate in the repair process depends on the nature of the bone,the degree of initial injury,and the amount of fracture immobili zation during healing.The most rapid of all the processes of healing is the external or periosteal callus,which predominates in frac
32、ture treated nonoperatively and with early muscle function.It depends primarily on surrounding soft tissue blood supply.This callus is quite tolerant of controlled fracture motion;in fact it is most in evidence when fracture motion occurs,e.g.,in rib fractures.A second process is late medullary call
33、us,which predominates when the external callus has failed.It is assisted by rigid immobolization and is the predominant healing process with compression plate fixation.Intramedullary callus,as McKibbon has pointed out,is not an evanescent burst of activity but a process that seems to pursue its goal
34、 of fracture bridging relentlessly.The third process is that of primary bone union that explains the rare phenomenon of healing without external callus.It depends on the mechanism of bone turnover,which is occurring at all times and which can respond to bridge fractured bone cortices,provided that t
35、hey are rigidly immobilized.By this process the dead cortical bone immediately adjacent to the fracture is invaded by new,longitudinally oriented osteones from the neighboring live bone.The major disadvantage of primary bone union is its great slowness and its dependence on rigid immobilization.In m
36、ost instances with compression plating,the fracture gap is sufficiently large that it fills by bone formed through appositional growth inward from the external periosteal source.This primary bone forms rapidly in the 4-6weeks but has relatively poor attachment to the avascular bone ends.This primary
37、 callus must be remodeled and replaced at 6-8weeks by secondary osteones bridging the fracture gap longitudinally.The entire process of healing in bone as well as in soft tissue is dependent on the process of revascularization.FRACTURE HEALING 3.Remodelling (8 w-Some years)Modelling Woven Bone Lamel
38、lar Bone (8-12 w Clinical Healing)Remodelling (12 w-Some Years)Wolff s Law Stress and PiezoelectricityFRACTURE HEALINGFRACTURE HEALINGFRACTURE HEALING Criterion of Fracture Healing 1.Absence Tenderness and Axial Percussion Pain 2.Absence Abnormal Mobility 3.Visible Continued Callus has Bridged Fragm
39、ents and Fracture Line IndistinctFRACTURE HEALING 4.After the Splints has been Removed,A.The Arm is Parallel to Ground,and Hold 1 kg Persist in 3 min.B.The Legs is Walk 30 Pace on 3 min.C.After Observe 2 w Continually,Good Result has Showed on the Fracture SiteFRACTURE HEALING Criterion of Fracture
40、HealingINFLUENCED FACTORSof FRACTURE HEALING Systemic Factors 1.Age 2.Systemic Condition Local Factors 1.Pattern of Fracture INFLUENCED FACTORof FRACTURE HEALING 2.Blood Supply(Fragment)A.All good Both Fragments B.One good and Other Bad C.All Bad Both Fragments D.Absence Blood Supply on the Fragment
41、INFLUENCED FACTORSof FRACTURE HEALING 3.Infection 4.Injuries of Soft Tissue 5.Interposition of Soft tissue in to Fracture Gap 6.Basic Disease(local)INFLUENCED FACTORSof FRACTURE HEALING Method of Treatment?!1.Repeated Reduction by Manipulation 2.Over Traction of Fragments 3.No Correct Fixation 4.No
42、Correct Debridement 5.Influence of Open Reduction 6.No Correct Functional ExercisesINFLUENCED FACTORSof FRACTURE HEALING Biological Factors 20%Medicinal Factors 80%!FIRST AID of FRACTURE Purpose of First Aid 1.Save the Live 2.Preserve Limbs 3.Safety Quickly Transport Systemic Condition Shock Coma Re
43、spiratory EmbarrassmentFIRST AID of FRACTURE Temporary Care of Fracture Open Closed Correct TransportPRINCIPLES of FRACTURETREATMENT Reduction Immobilization Rehabilitation Medication REDUCTION Criterion of Reduction 1.Anatomic Reduction 2.Functional Reduction (1).No Observe Gap and Rotation (2).Sho
44、rtening 1 2 cm in the Leg (3).Angulation 15 10 (4).Apposition of the Fragments 1/3(shaft),or 3/4(epiphyseal )REDUCTION Methods of Reduction 1.By Closed Manipulation 2.By Mechanical Traction with or without Manipulation 3.By Open ReductionIMMOBILIZATION Reasons of Immobilization 1.Prevention of Displ
45、acement or Angulation 2.Prevention of Movement 3.Relief of PainIMMOBILIZATION Methods of Immobilization 1.By Wooden Splint or Plaster or Splint(other)2.By Continuous Traction 3.By External Fixer 4.By Internal FixationREHABILITATION 1.Active Muscular Contraction (After Injury Within 2 Weeks)2.Active
46、Exercises Joints of Adjacent Fracture (After Injury 2 8 w)3.Active Resistance Exercises (After 8 w)4.PhysiotherapyMedication Traditional Medication Forbid Using Nonsteroid Anti-Inflammatory Drugs(NSAIDs)TREATMENT of OPENFRACTURE Preventing Infection !TREATMENT of OPENFRACTURE 1.Type of Open Fracture
47、 From Within From Without Potential TREATMENT of OPENFRACTURE 2.Conditions of the Wound Contaminative Extent Degree of Soft Tissue InjuryTREATMENT of OPENFRACTURE 3.Debridement Same Principles of Surgical Debridement Golden Time :6 8 h(after injury)Larger Bony Piece Should be Preserved Selecting Met
48、hods of Fixation Repair of Nerve、Tendon、Vessel Skin Closure FEATURE of OPEN INJURYof JOINTSSame Principles of Surgical Debridement 1.Keep Articular Cartilage Intact 2.Not to Leave Foreign Bodies in Joint 3.Forbid to Open Draining(Can Use Irrigation)4.Repair of Capsule and Ligaments FEATURE of OPEN I
49、NJURYof JOINTS 5.Inject Antibiotics into the Joint After Operation 6.Aspiration is Especially Important in Hemarthrosis 7.The Joint should be Immobilized with Traction or Splint or PlasterDELAYED UNION ofFRACTURE 1.After 8-12 w Fracture 2.Pain of Fracture Site 3.Fracture Line Can be Seen Clearly 4.A
50、 Little Callus 5.No Osteosclerosis of the Fragments 6.Fracture has Possibility of HealingNON UNION of FRACTURE Clinical Features No pain but has abnormal Movement on the Fragments (False Joint or Pseudarthrosis)NONUNION of FRACTURE Roentgenographic Evaluation Atrophic Type 1.Sclerosis of the Bone En
