Fractures of Extremities (Upper Limbs) Dr. Zhong gang. Department of Orthopaedic Surgery West China Hospital of Sichuan University

Transcription

1 Fractures of Extremities (Upper Limbs) Dr. Zhong gang Department of Orthopaedic Surgery West China Hospital of Sichuan University

2 七 上肢骨折和手外伤 (Upper Limbs Fracture and Hand Injury) 一. 知识点与教学要求掌握 : 1. 肱骨干骨折, 肱骨髁上 髁间骨折, 桡骨远端骨折, 前臂双骨折的临床表现及治疗原则 ; 肱骨髁上 髁间骨折的常见并发症 ; 2. 开放性手外伤的治疗原则熟悉 : 1. 肱骨干骨折, 肱骨髁上 髁间骨折, 桡骨远端骨折, 前臂双骨折的病因 分类及发病机制 ; 锁骨骨折, 肱骨近端骨折的病因 分类 发病机制及治疗原则 ; 2. 手部骨折的病因 检查 诊断方法 ; 手部周围神经 血管 肌腱损伤的病因和诊断 ; 断肢 ( 指 ) 的分类 急救处理及再植的适应症和禁忌症 了解 : 手部功能重建的原则, 腕骨脱位的诊治原则

3 Consists of upper limb bone Scapular bone 1 Clavicle bone 1 Humuer 1 Radial 1 Ular 1 Carpals 8 Metacarpals 5 Phalanges 14

4 1 Clavicle bone fracture

5 Clavicle Fractures Clinical manifestation and diagnosis Deformity Abnormal movement Bone crepitus The elbow of the injured side is usually held by the other hand and the head leans to the injured side. May be complicated by the brachial plexus injury and the injury of subclavicular vessels.

6 Clavicle Fractures Treatment Greenstick fractures in the children and non-displaced fractures in the adult Held in branches for 3~6 weeks Displaced fractures Closed reduction + Stabilization with transverse figure 8 bandages

7 Open reduction and internal fixation could be adopted when necessary Intolerant to the bandage stabilization; Recurrent displacement after reduction and affect the appearance; Complicated by vascular or nervous injury; Open fractures; Nonunion of the old fractures; Distal end fractures of clavicle and accompanied by the disruption of the coracoclavicular ligament.

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11 2 Scapular bone fracture 1. Standard AP View 2. Standard lateral view

12 3. Axillary view

13 CT scan and 3D reconstruction MRI Aniography and electromyography

14 The Ada-Miller fracture classification of scapular fracture Type I : acromion (IA), spine (IB), and coracoid (IC) fractures. Type II : extend to the spinoglenoid notch and suprascapular notch (IIA); extend superiorly, involving the spine and superior scapular border (IIB); running horizontally and located just inferior to the spine and glenoid (IIC); Type III: glenoid fractures Type IV: scapular body fractures 14

15 Classification of the scapular neck fracture Type I : anatomical neck fracture Type II: surgical neck fracture Type III: inferior part fracture and extend medially

16 Type I: Anatomical neck fracture

17 Type II: surgical neck fracture

18 Type III: inferior part fracture and extend medially

19 Goss-Ideberg classification of glenoid fracture Ia-anterior border of glenoid fracture Ib-posterior border of glenoid fracture Ⅰ 型 盂缘

20 TypeⅡ: Inferior part of glenoid fossa fracture and extend to the lateral border

21 Tpye Ⅲ:- Superior part of glenoid fossa and coracoid fracture

22 TypeⅣ: Glenoid fracture and extend mediallay

23 Va:Ⅳ+ Ⅱ Vb:Ⅳ+ Ⅲ Vc:Ⅳ+ Ⅱ+ Ⅲ

24 TypeⅥ: Comminuted fracture of glenoid fossa

25 Posterial approach Position: lateral decubitus Incision: transverse, longitudinal Judet L incision

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28 Combined approaches

29 Female, 37 years, complex fracture of scapular and clavicle bone

30 2 weeks postoperation

31 6 months postoperation

32 9 months postoperation

33 3 Proximal humeral fracture NEER classification

34 Neer type I

35 NEER type II NEER type III

36 NEER type IV

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40 Intramedullary nail

41 Case:male,37 years,traffic accident

42 1 year postoperation

43 Special type of proximal humeral frature: Adolescent

44 3 months postoperation

45 Elderly people with osteoporosis

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47 10 months postoperation

48 4 Humeral Shaft Fractures Anatomy Fractures lies between 2cm beneath the surgical neck and 2cm above the epicondyle Radial groove lies at the junction of the middle and lower 1/3 part of the lateroposterior surface of the humeral shaft Etiology and classification Direct forcestransverse or comminuted fractures of the middle shaft Indirect forcesoblique or spiral fractures of the lower part of the shaft The displacement of the fracture is determined by the magnitude, direction of the forces, the location of fracture and the traction of the muscles

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52 Radial nerve anatomy

53 Specific clinical manifestation and diagnosis Radial nerve injury Drop wrist deformity Disabled MP joint extension Disabled extension of thumb Disabled supination of forearm Loss of sense or analgesia of the radial part of the hand dorsum

54 54 5 Distal humeral fracture

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56 Supracondylar Fractures of Humerus Anatomy An anteversion of 30~50 lies between the axes of the humeral shaft and the condyles Common in the children younger than 10yr Humeral a. and median n. lie anteriorly to the humeral condyles Ulnar nerve lies medially Radial nerve lies laterally The injury to the epiphyseal plate of children may lead to the varus or vulgus deformity

57 Supracondylar Fracture of Humerus Etiology and classification Mostly caused by indirect forces Extension type (palm on land): Fracture line extend from lower anterior to the upper posterior Flexion type (elbow on land): Fracture line extend from lower posterior to the upper anterior

58 Stable structure

59 unstable

60 APPROACHES Alonso-Llames( 经三头肌内外侧入路 ) 60

61 61 Campbell( 三头肌正中劈开 )

62 62 Campbell ( 三头肌劈开 V-Y 入路 )

63 63 Bryan-Morrey ( 三头肌自内向外翻转 )

64 64 Olecranon osteotomy( 尺骨鹰嘴截骨 )

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69 Alonso-Llames( 经三头肌内外侧入路 )

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72 72 External fixation

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77 6 Olecroanon fracture

78 A B C Schatzker classification D E F 78

79 79 Mayo classification

80 80 Treatment strategy

81 Tension band

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84 84 Plate fixation

85 85 Intramedullary fixation

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88 7 Forearm fracture Bi-fractures of Forearms Direct forces transverse or comminuted fractures of the same level Indirect forces higher level radial and lower level ulnar oblique fractures Rotation forces higher level unlnar and lower level radial spiral fractures

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91 Monteggia fracture: fracture of the upper 1/3 ulna shaft with the dislocation of radial head type I: extension type-anterior dislocation of the radial head and anterior angulation of the ulna; typeii: flexion type-posterior or posterolateral head dislocation posterior angulation of the ulna; type III: pediatric Monteggia-fracture of ulnar metaphysis and lateral dislocation of the head; type IV : anterior dislocation of the radial head - fracture of the proximal radius at the same level with the ulna

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93 Galeazzi fracture: fracture of the lower 1/3 radius shaft with the dislocation of ulnar head

94 Distal radial fracture Colles fracture. There is fracture of the distal radius with dorsal angulation. The articular surface is not involved.

95 Smiths fracture. The distal radial fracture fragment is angulated and displaced in a volar direction. The articular surface not involved.

96 Barton fracture: A: There is a fracture of the distal radius with extension into the radial articular surface. B: The distal fracture fragment is angled dorsally, the carpus is subluxed posteriorly.

97 Reversed Bartons fracture. It is in fact the volar fracture with volar displacement which occurs more commonly. The fracture fragment varies in size but may involve up to 50% of the articular surface.

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