骨折概论Word格式文档下载.docx
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骨折概论Word格式文档下载.docx
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闭合骨折Closed#:
骨折部位的皮肤及粘膜完整
skinandmembraneintact
开放骨折open/compound#:
骨折与外界直接相通
skinorbodycavitybreached
2.根据骨折的形态:
Dependsonmorphologyof#
完全骨折:
骨组织完全断裂成两块或两块以上
complete#:
completebreakintotwoormorefragments
a.横骨折Transverse
b.斜骨折Oblique
c.螺旋骨折Spiral
d.粉碎骨折Comminuted
e.嵌插骨折Impacted
f.骨骺损伤Splitofepiphysis
g.节段性骨折segmental
不完全骨折:
骨组织不完全断裂且骨膜连续
boneisincompletedividedandtheperiosteoumremainsincontinuity
a.线性骨折Hairline
b.青枝骨折Greenstick
c.压缩骨折Compression
3.稳定与不稳定骨折Stableandunstable
III.骨折的移位Displacementof#
most#usuallybecomedisplacedby:
因素:
1.外力及其作用方向theforceanditsdirection
2.地心引力thegravity
3.附着肌肉的拉力
thepullofmusclesattachedtothebone
4.搬运或治疗不当
unpropertransportandtreatment
移位通常被描述为Displacementusuallyisdescribedintermsof:
1.对位Apposition
2.对线Alignment
3.旋转Rotation
4.重叠或短缩Alteredlength
IV.临床表现ClinicalFeatures:
1.病史:
外伤史及肢体活动障碍
Injury+inabilitytousetheinjuredlimb
其它病史Generalmedicalhistory
2.一般体征Generalsigns:
a.休克及出血shockorhaemorrhage
b.伴有颅脑、脊髓或脏器损伤
associateddamagetobrain,spinalcordorviscera
c.伴随疾病的体征apredisposingcause
3.局部体征Localsigns:
一般体征commonsigns:
肿胀青紫压痛活动受限
swelling,bruising,tenderness,restrictedrangeofmotion
骨折专有体征#signs:
畸形,异常活动,骨擦音/感
deformity,abnormalmovement,crepitus
4.影像学检查
X-rays:
常规检查,需从五个方面考虑
mandatory,maytakenin5aspects
a.两张片子twoviews:
a#maynotbeseenonasignalpicture
b.两个关节twojoints:
inthelongbone#,jointsbelowandabovethe#mustbeincluded
c.两个肢体twolimbs:
inchildren’s#,normalepiphysismayconfusethediagnoses
d.两种损伤twoinjuries:
severeforcemaycauseinjuryatmorethanonelevel
f.两种情况twooccasions:
#maynotseensoonafterinjury
CT:
关节内骨折及脊柱骨折
MRI:
脊柱骨折时神经损伤情况
骨折的描述Descriptionof#:
1.开放或闭合openorclosed?
2.骨折部位whichboneisbrokenandwhere?
3.是否累及关节jointsurfaceinvolved?
4.骨折的形态shapeofthe#?
V.骨折并发症Complicationsof#
1.休克,弥漫性凝血障碍,呼吸功能障碍
Shock,Diffusecoagulopathy,Respiratorydysfunction
2.内脏损伤Visceralinjury
3.血管损伤ArteryorVascularinjury
4.脊髓损伤Spinalcordinjury
5.神经损伤Nerveinjury
6.脂肪栓塞Fatembolism
7.挤压综合征Crushsyndrome
8.伤口感染Woundinfection
9.骨筋膜室综合征/缺血性肌挛缩
Compartmentsyndrome/Volkmann’scontracture
10.肺炎Pneumonia
11.褥疮Bedsore
12.骨化性肌炎Myositisossificans
13.创伤性关节炎HaemoarthritisorTraumaticarthritis
14.关节僵硬Jointstiffness
15.缺血性坏死Avascularnecrosis
16.废用性骨质疏松Disuseosteoporosis
17.深静脉血拴及肺栓塞D.V.T(deepvenousthrombosis)andP.E(pulmonaryembolism)
18.其它:
延迟愈合、不愈合、畸形愈合,骨骺发育障碍等delayedunion,nonunion,malunion,growthdisturbanceetc.
VI.骨折愈合程
Processoffracturehealing
骨折愈合过程取决于:
Theprocessof#repairvariesaccordingtothe:
a.骨的类型typeofboneinvolved
b.骨折部位活动度theamountofmovementatthe#site.
在长管状骨,缺乏坚强内固定的情况下,骨折愈合分为五个阶段:
Inatubularbone,andintheabsenceofrigidfixation,healingproceedingin5stages:
1.血肿形成期tissuedestructionandhaematomaformation
2.炎症反应及细胞增生期2W
Inflammationandcellularproliferation
3.原始骨痂形成期callusformation4W
4.骨痂坚固期Consolidation数月
5.骨痂改造塑型期Remodeling
骨折临床愈合的指征:
Indicationforclinical#union:
1.局部无压痛notenderness
2.无异常活动noabnormalmovement
3.X线所见:
骨折线模糊,有连续骨小梁通过骨折端,骨折周围有明显骨痂包绕
#lineobliteratedandcrossedbytrabecularbonewithwelldefinedcallusarounditonXR
4.上肢持重1kg超过1分钟,下肢不扶拐持续行走超过30步
lift1kgfor1min.orcontinuouswalkingmorethan30stepswithoutprotection
5.达到上述要求后,持续观察骨折端两周以上无变化
nochangeson#sitefortwomoreweeksobservation
VII.影响骨折愈合的因素
FactorsonFractureUnion
1.年龄Age
2.局部血运LocalBloodSupply
3.感染Infection
4.软组织损伤程度
DegreeofSoftTissueDamage
5.骨折断端间软组织嵌入
InterpositionofSoftTissueBetweenTwoFragments
6.健康状况GeneralCondition
7.治疗Treatment
VIII.骨折的治疗Treatmentof#
1.急救EmergencyTreatment
1).清除障碍Obtainaccess
2).保持良好通气、换气Airwayandventilation
3).止血Haemorrage
4).抗休克Shock
5).临时固定Splintage
目的thepurpose:
a.防止血管、神经及脏器的进一步损伤preventfurtherdamageton.v.andvisceral
b.减轻疼痛reducepain
c.便于转运easyfortransport
6).包扎伤口wounddressing
7).迅速转运transport
2.闭合骨折的治疗Treatmentofclosed#:
原则:
复位,固定,功能锻炼reduce,hold,exercise
1).复位Reduce
a.闭合复位closedreduction
解剖复位—最理想的复位,关节内骨折及前臂骨折需达到此要求anatomicreduction--theidealreduction,requiredinintraarticular#,forearm#
功能复位—必须达到以下要求:
Functionalreductionmustreach:
i.无旋转及分离移位Norotationandseparation
ii.下肢短缩少于1cm(成人)/2cm(儿童),无侧方成角,可有轻度前后成角inthelowerlimbshorteninglessthen1cm/2cminadults/children,nolateralangulation,minorA.Pangulation
iii.骨干骨折对位大于1/3,干骺端骨折对位大于3/4
b.切开复位openreduction
2).固定Holdreduction
a.小夹板Woodsplintage
b.石膏Castsplintage
c.功能性支具Functionalbrace
d.持续牵引:
Continuoustraction
儿童皮牵引4-5kg
成人骨牵引,重量为体重的1/7
e.外固定架Externalfixation
f.内固定Internalfixation:
钢板,螺钉,髓内钉,椎弓根螺钉等适应征∶
1.无法用手法复位者,
2.不稳定骨折或复位后再移位者,
3.由肌肉牵拉造成的骨折,
4.愈合缓慢或较差的骨折,
5.病理性骨折,
6.多发骨折,
7.护理困难的骨折,
8.关节内骨折,
9.需长期制动的骨折,
10.有移位的骨骺分离
Salter-HarrisTypeIII,IV
11.脊柱骨折不稳定或伴有神经损伤
3).功能锻炼Exercise
目的:
theobjective:
减轻水肿reduceoedema
恢复关节功能preservejointmovement,
恢复肌肉力量restoremusclepower,
逐渐恢复正常活动guidepatientbacktonormalactivity
a.抬高患肢Elevationimmediateafterinjury
b.主动活动Activeexerciseimmediateafterrigidfixation,aftercast--staticmusclecontraction
c.被动活动Assistantmovement
3.开放骨折的治疗:
Treatmentofopen#:
1).治疗前应考虑的四个方面:
4questionstobeansweredwhenseetheopen#:
a.伤口的性质whatisthenatureofthewound
b.皮肤及软组织有无缺损
whatisthestateoftheskinaroundthewound
c.患肢血运isthecirculationsatisfactory
d.有无神经损伤isthenerveintact
Gustilo-Andersonclassificationofopenfracture:
开放骨折分级:
I.清洁伤口,<
1CM
II.伤口大于1CM,但不广泛,可有撕脱皮瓣
IIIA.伤口广泛,但仍有足够皮肤覆盖,或由高能量创伤造成
IIIB.广泛软组织缺损伴骨膜剥脱及骨质外露
IIIC.伴血管损伤并需修复者
2).预防感染Topreventinfection
a.立即包扎伤口immediatewoundcover
b.预防应用抗菌素antibioticprophylaxis
c.早期清创
最好在6-8小时内进行,也可以在8-24小时内进行,但必须:
Earlywounddebridementbestwithin6-8hrs,couldbedonein8-24hrsonlyif:
1.早期应用抗菌素earlyantibioticprophylaxis
2.伤口污染轻lesscontaminatedwound
3.软组织损伤轻lesssofttissuedamage,
如果>
24小时—观察,二期清创,关闭伤口If>
24hrs--observation,secondstageclose
d.稳定骨折stabilizationofthe#
3).伤口闭合:
Woundclosure:
一期:
伤后6-8小时内,局部无张力firststageclose:
within6-8hrs,notension,
二期:
伤后5天,伤口探查清创后直接缝合或植皮secondstageclose:
5dayslater,closewoundorskingraftafterinspection
谢谢!
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