1、General Principles of the Diagnosis And Management of FRACTURE 骨折骨折The First Affiliated Hospital,Chongqing University of Medical SciencesDepartment of Orthopedics 矫形矫形Huang wei Epidemiology the United States Trauma causes more than 140,000 deaths per year leading cause of death for those aged 1-34 y
2、ears more than coronary artery 冠状动脉冠状动脉 disease,cancer,and stroke combined 总和总和 before age 65 years In 2000,more than 50 million Americans underwent 经历经历 medical treatment for an injury.The estimated lifetime cost of these injuries is believed to be$406 billion.DEFINITION of FRACTUREThe continuity a
3、nd completeness of bone have broken A fracture is a complete or incomplete break in the continuity of a bone Terminology 术语术语Anatomy:The fracture is described with relation to the bones involved and the location within the bone(diaphysis 骨干,metaphysis 干骺端,physis 长骨体生长部,epiphysis 骨骺).Articular surfac
4、e 关节面 involvement:Does the fracture have intra-articular 关节内 involvement?Is there intra-articular displacement 位移 or gapping 接触不紧密?Displacement:Is the distal fracture fragment 远端骨折断片 displaced compared with the proximal 近端 fragment?To what degree or percentage is the fracture displaced?Angulation 测角
5、:The angular deformity 成角畸形 is defined in degrees in terms of 按照 the distal fragment in relation to the proximal fragment or with respect to 关于 the proximal apex of the distal fragment.Rotation 旋转:Rotational deformity 旋转畸形 is described both clinically and radiographically.Shortening:Has the fracture
6、 caused shortening of the involved bone?To what extent 范围 has shortening occurred?TerminologyFragmentation 碎裂:The Muller AO(Arbeitsgemeinschaft fr Osteosynthesefragen Association for Osteosynthesis)Comprehensive Classification of Fractures provides a standardized description of fracture patterns,mak
7、ing communication regarding 关于 such injuries more precise and understandable.A multifragmentary fracture 多发性碎裂性骨折 is one that has several breaks in the bone,creating more than 2 fragments.Wedge fractures 楔形骨折 are either spiral 螺旋(low energy)or bending 弯曲(high energy)and allow the proximal and distal
8、 fracture fragments to contact each other.The complex multifragmentary fracture is a segmental fracture 节段性骨折 or one in which there is no contact between the proximal and distal fragments without the bone shortening.Simple fractures are spiral,oblique 倾斜,or transverse 横断.Factors Responsible for Frac
9、tures Direct violence 直接暴力直接暴力 applied to the bone also damages surrounding soft tissuev A tapping force 攻丝力攻丝力 applied to the bone produces an oblique fracture v A crushing injury 挤压伤挤压伤 results in a fragmented fracture of the bone v A penetrating direct injury 贯通伤贯通伤 from a high-velocity 高速高速 guns
10、hot blast 枪弹爆炸枪弹爆炸 destroys bone and soft tissueFactors Responsible for FracturesIndirect violence 间接暴力间接暴力 applied to the bone produces significantly 显著的显著的 less damage to soft and hard tissues An abduction 外展外展 or vertical 垂直垂直 or muscle pull force causes a compression or avulse 撕脱撕脱 or oblique or
11、 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 imperfecta 成骨不全症成骨不全症v metabolic diseases et al Factors Responsible for FracturesIn re
12、peated stresses 重复应力重复应力,which cause fatigue fractures 疲劳性骨折疲劳性骨折 these stress fracture are most frequently encountered 遭到遭到 in bone of the lower extremity 下肢下肢:the neck of the second or third metatarsal bone 跖骨跖骨 the shaft 轴轴 of the tibia 胫骨胫骨 or fibular 腓骨腓骨 the neck of the femur 股骨股骨CLASSIFICATIO
13、NSFractures may be caused by v Violence direct indirect Injury fracture v Muscle pull Avulsion 撕脱 fracturev Fatigue 疲劳 Stress fracturev Disease Pathological fractureclassifications From Whether Have Direct or indirect Communication Between the Fracture and Wound of the Skin and MucosavFrom Within Op
14、en Fracture vFrom Without Closed FractureDirect ViolenceIndirect ViolenceMuscle pullAvulsion fracture 撕脱性骨撕脱性骨折折Open FractureOpen Comminuted Fracture车祸致左小腿开放性毁损 Open and Comminuted fractureclassificationsFrom Stability v Stable Transverse fracture 横骨折横骨折 Greenstick fracture 青枝骨折青枝骨折 Impacted fractur
15、e 嵌入骨折嵌入骨折 Epiphyseal injury 骨骺损伤骨骺损伤Transverse fracture of the left humerus 肱骨肱骨Impacted fracture of the neck of the right femur 股骨股骨 From Stabilityv Unstable Spiral fracture 螺旋形骨折螺旋形骨折 Oblique fracture 斜骨折斜骨折 Slope 倾斜倾斜 of more than 200o0 Comminuted fracture 粉碎性骨折粉碎性骨折 Avulsion 撕脱撕脱classifications
16、The comminuted fracture of the right humerusThe long spiral fracture of the left femur distal 股骨远端股骨远端Greenstick Transverse AngulationOblique Spiral DoubleComminuted Impacted CrushAvulsion Involving a jointCompression Fracture-Dislocation 位错位错Epiphyseal injury 骨骺损伤骨骺损伤classificationsPattern of Displ
17、acementAngulation 成角成角Rotation 旋转旋转Lateral Side 侧边侧边Overlap 重叠重叠 or ShorteningImpacting 冲击冲击 Mechanism of the displacementof the 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 神神经源性休克经源性休克)v Secondary Shock-Haemor
18、rhagia(-ge)出血出血 Notice:exclude to cerebral injuryand respiratory embarrassment 呼吸窘迫呼吸窘迫CLINICAL&RADIOLOGICAL FEATURES OF THE FRACTURE Systemic ManifestationsLow Fever or Slight Fever temperature 380C trauma reaction haematoma 血肿血肿 absorptionWBC(white blood cell)ESR(erythrocyte sedimentation rate红细胞沉
19、降率红细胞沉降率)CLINICAL&RADIOLOGICALFEATURESLocal ManifestationTraumatic Inflammation:Pain Local Swelling Loss or Impairment of Function Ecchymosis 瘀斑瘀斑 Localized bone tenderness Specific Signs The following features are pathognomonic 特异病征性的 of fracturev Deformity 畸形畸形v Abnormal Mobilityv Crepitus 捻发音捻发音
20、or Grating 摩擦音摩擦音CLINICAL&RADIOLOGICALFEATURESAbsence 缺乏缺乏 of dysfunction does not preclude 排除排除 fracture this is particularly true of:greenstick factures impacted fractures fatigue fracturesCLINICAL&RADIOLOGICALFEATURESRadiological Examination Fracture yes or no?Pattern of fracture?Anatomic part of
21、 the fracture?Selecting of Treatment Methods !Early Period Shock Fat embolism Injury to Important Organ and Tissue(nervous and vascular)Osteo-fascial Compartment Syndrome 骨筋膜室综合症骨筋膜室综合症 v 骨筋膜室综合征骨筋膜室综合征 Osteofascial Compartment Syndrome 早期并发症早期并发症晚期晚期Pain PainlessPallor 苍白苍白Paresthesia 感觉异感觉异常常Paral
22、ysis 无力无力Pulselessness 无脉无脉早期早期Pain Dull-redPassive motion painPulseness 少脉少脉Osteofascial 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 破伤风破伤风;gas gangrene 气性坏疽气性坏疽;osteomyelitis 骨髓炎骨髓炎v Thromboembolism 血栓栓塞血栓栓塞:deep venous thrombosis and pulmonary embol
23、ismv Acute respiratory distress syndrome 急性急性呼吸窘迫综合症（呼吸窘迫综合症（ARDS）v Multiple-organ dysfunction syndrome 多器官功能障碍综合症（多器官功能障碍综合症（MODS）COMPLICATIONOF FRACTURELater PeriodSystemic Complicationv Pressure Sores 压疮压疮v Pneumonia 肺炎肺炎v Infection of the Bladder 膀胱膀胱COMPLICATIONS OF FRACTURELocal Complications
24、Myositis Ossificans 骨化性肌炎骨化性肌炎 Post-traumatic Osteoarthritis 创伤后骨关节炎创伤后骨关节炎 Joint Stiffness 关节僵硬关节僵硬 Reflex Sympathetic Dystrophy反射交感性营反射交感性营养不良养不良 Sudeck atrophy 创伤后骨萎缩创伤后骨萎缩 Avascular Necrosis of The Bone 骨无血管骨无血管性坏死性坏死 Ischemic Contracture 缺血性肌挛缩缺血性肌挛缩(Volkmann s)Later Periodv Delayed union 延迟愈合延
25、迟愈合v Nonunion 不愈合不愈合v Malunion 连接不正连接不正 or angular deformities 角畸形角畸形v Shorteningv Growth arrestv Growth stimulation FRACTURE HEALING Organ and Tissue Scar 瘢痕瘢痕 Repair Fracture Regeneration 再生再生 NewBone Stages of bone healing1.For the first 2 weeks,bone healing follows the same patten as the healing
26、 of skin or any orther wound.The site of the wound is filled with blood and the broken ends of bone become necrotic 坏死的坏死的.2.The blood clot 血凝块血凝块 is invaded by macrophages 巨噬细胞巨噬细胞 and osteoclasts 破骨细胞破骨细胞 which remove dead bone and osteoblasts 成骨细胞成骨细胞 which produce bone,instead of the fibroblasts
27、 which form fibrous tissue in soft tissue injuries.3.Beteen 2 to 6 weeks after injury osteoid tissue 骨样组织骨样组织 develops and forms a firm 牢固的牢固的 mass,or callus 结痂结痂,around the fracture and ossification 成骨成骨 of the osteoid 骨化骨化 begins.Callus forms both outside the bone as subperiosteal 骨膜下骨膜下callus,and
28、 inside as endosteal 骨内骨内 callus.The pH of the tissues increases at this stage and calcium is deposited 储存储存.4.Between 6 and 12 weeks,ossification occurs,a solid bony bridge 骨桥骨桥 crosses the gap and the bone regains 恢复恢复 some mechanical strength.5.Between 12 and 26 weeks,the callus matures.6.Between
29、 6 and 12 months,the gaps between the cortical 皮质的皮质的 ends are bridged.7.Between 1 and 2 years,remodelling 重重塑塑 occurs,bony prominences 凸起物凸起物 become smooth and normal bone architecture is restored.The timing is very variable and is much faster in children,in whom callus can be seen at 2 weeks.FRACT
30、URE HEALING Stages of Fracture Healing1.Haematoma Fibrosis (2 w)Fibrinogen 纤维蛋白原纤维蛋白原 Reticular Fibril 网状网状纤维纤维 Blood Clots New Vessels Mesenchymal Cell 间充质细胞间充质细胞 Inflammatory Cell Granulation Tissue 肉芽组织肉芽组织 FRACTURE HEALING 2.Primary Callus Formation 形成形成 (6-8 w)Origin of the Callus Cells D O P C
31、 (Determined osteogenic Precursor Cells确定成骨前体细胞确定成骨前体细胞)I O P C (Inducible Osteogenic Precursor Cells诱导成骨前体细胞诱导成骨前体细胞)FRACTURE HEALING Origin of the Callus Mineral 矿物矿物 Dead Bone Osteoblasts,Chondroblasts 成软骨细胞成软骨细胞 CO 2 Phosphorylase 磷酸化酶磷酸化酶 pH Hydrolyze 水解水解 to Phosphate 磷酸盐磷酸盐 (in the Hematoma)(
32、in the Plasma)FRACTURE HEALING Calcium of Fragment Phosphate Free Dissolved Heamatoma Calcium Phosphate Deposit 沉积沉积 to Bone Matrix 骨骨基质基质 Callus (Woven Bone 编织骨编织骨)FRACTURE HEALING Endo-chondral Ossification 软骨内成骨软骨内成骨 Intra-membranous Ossification 膜内成骨膜内成骨 New bone forms either through appositiona
33、l 同位的同位的 ossification 骨化骨化 without initial cartilage formation 最初的最初的软骨形成软骨形成 or by enchondral 软骨内的软骨内的 ossification of a preminary 预备的预备的 fibrocartilage callus 纤维性骨痂纤维性骨痂.In both instances 例子例子,the ossification process is intimately related to revascularization 血血管再生管再生,and the active osteoblasts a
34、ppear to be derived from 来源于来源于 either the walls of the small vessels or from circulating blood cells.Bone repair takes place in the periosteal 骨膜骨膜,cortical 皮质皮质,and medullary 髓质髓质 regions,but most of the revascularization 血管再生血管再生 of a fracture is from medullary circulation.Which of these areas pr
35、edominate 支配支配 in the repair process depends on the nature of the bone,the degree of initial injury,and the amount of fracture immobilization 固定固定 during healing.The most rapid of all the processes of healing is the external 外部的外部的 or periosteal 骨膜的骨膜的 callus,which predominates in fracture treated n
36、onoperatively 保守治疗保守治疗 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 明显的明显的 when fracture motion occurs,e.g.,in rib 肋骨肋骨 fractures.A second process is late medulla
37、ry callus,which predominates when the external callus has failed.It is assisted by rigid 坚硬的坚硬的 immobilization and is the predominant healing process with compression plate fixation 压板固定压板固定.Intramedullary callus,as McKibbon has pointed out,is not an evanescent 短暂的短暂的 burst of activity but a process
38、 that seems to pursue 追求追求 its goal of fracture bridging relentlessly 持续地持续地.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 翻转翻转,which is occurring at all times and which can respond to
39、 bridge fractured bone cortices 皮质皮质,provided that they are rigidly immobilized.By this process the dead cortical bone immediately adjacent to 临近临近 the fracture is invaded by new,longitudinally oriented osteons 长度长度调整的骨单位调整的骨单位 from the neighboring live bone.The major disadvantage of primary bone un
40、ion is its great slowness and its dependence on rigid immobilization.In most instances with compression plating 加压固定加压固定,the fracture gap is sufficiently large that it fills by bone formed through appositional growth inward 向内向内 from the external periosteal source.This primary bone forms rapidly in
41、the 4-6weeks but has relatively poor attachment to the avascular 无血管的无血管的 bone ends.This primary callus must be remodeled and replaced at 6-8weeks by secondary osteons bridging the fracture gap longitudinally.The entire process of healing in bone as well as in soft tissue is dependent on the process
42、 of revascularization.FRACTURE HEALING 3.Remodelling (8 w-Some years)Modelling Woven Bone 编织骨编织骨 Lamellar Bone 板层骨板层骨 (8-12 w Clinical Healing)Remodelling (12 w-Some Years)Wolff s Law Stress and Piezoelectricity 压电效应压电效应FRACTURE HEALINGFRACTURE HEALINGFRACTURE HEALING Criterion of Fracture Healing 1
43、.Absence Tenderness and Axial Percussion Pain 叩击痛叩击痛 2.Absence Abnormal Mobility 异常流动异常流动 3.Visible Continued Callus has Bridged Fragments 碎片碎片 and Fracture Line Indistinct 模糊模糊FRACTURE HEALING 4.After the Splints 夹板夹板 has been Removed,A.The Arm is Parallel to Ground,and Hold 1 kg Persist in 3 min.B
44、.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 HealingINFLUENCED FACTORSof FRACTURE HEALING Systemic Factors 1.Age 2.Systemic Condition Local Factors 1.Pattern of Fracture INFLUENCED FACTORof FRACTU
45、RE 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 FragmentINFLUENCED FACTORSof FRACTURE HEALING 3.Infection 4.Injuries of Soft Tissue 5.Interposition 插入插入 of Soft tissue in to Fracture Gap 6.Basic Disease(loca
46、l)INFLUENCED FACTORSof FRACTURE HEALING Method of Treatment?!1.Repeated Reduction by Manipulation 操作操作 2.Over Traction 牵引牵引 of Fragments 3.No Correct Fixation 4.No Correct Debridement 清创清创 5.Influence of Open Reduction 切开复位切开复位 6.No Correct Functional Exercises 功能锻炼功能锻炼INFLUENCED FACTORSof FRACTURE
47、HEALING Biological Factors 20%Medicinal Factors 80%!FIRST AID of FRACTURE Purpose of First Aid 1.Save the Live 2.Preserve Limbs 肢体肢体 3.Safety Quickly Transport 运输运输 Systemic Condition Shock Coma Respiratory Embarrassment 呼吸窘呼吸窘迫迫FIRST AID of FRACTURE Temporary Care of Fracture Open Closed Correct Tr
48、ansportPRINCIPLES of FRACTURETREATMENT Reduction 下降下降 Immobilization 固定固定 Rehabilitation 康复康复 Medication REDUCTION Criterion of Reduction 1.Anatomic Reduction 2.Functional Reduction (1).No Observe Gap and Rotation 循环循环 (2).Shortening 1 2 cm in the Leg (3).Angulation 测角测角 15 10 (4).Apposition 放置放置 of
49、 the Fragments 1/3(shaft 轴轴),or 3/4(epiphyseal 骺的骺的 )REDUCTION Methods of Reduction 1.By Closed Manipulation 2.By Mechanical Traction 机械牵机械牵引引 with or without Manipulation 3.By Open Reduction 切开复位切开复位IMMOBILIZATION Reasons of Immobilization 1.Prevention of Displacement or Angulation 2.Prevention of
50、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 肌肉收肌肉收缩缩 (After Injury Within 2 Weeks)2.Active Exercises Joints of Adjacent
