pfna粗隆间骨折治疗实用教案

1、Background股骨粗隆间骨折是老年人的常见病 美国发病率为0.034% 瑞典发病率为0.035% 中国老龄化，发病率不低于以上数字 Reference:雍宜民雍宜民. 实用骨科临床实用骨科临床M . 北京北京(bi jn): 科学技术文献出版社科学技术文献出版社, 1999: 188-198.Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, G

2、uangdong Academy of Medical Sciences 第1页/共36页第一页，共37页。Background 病死率较高，大约10%20%在骨折(gzh)后1年内死亡主要死因为卧床后出现的内科并发症有心血管疾病和高龄患者的病死率比其他人高一倍 References:Canale ST, Beaty JH. Campbells Operative Orthopaedics M. 9th ed. Harcourt: Mosby, 1998: 2182-2199.张庆明张庆明, 沈惠良沈惠良, 雍宜民雍宜民, 等等. 经皮钛合金空心钉治疗经皮钛合金空心钉治疗(zhlio)高龄老年

3、人粗隆间骨折高龄老年人粗隆间骨折. 骨与关节损伤杂志骨与关节损伤杂志, 2002, 17(5) : 332-334. Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第2页/共36页第二页，共37页。Classification31 - A 3232：股骨干 3131：股骨

4、近端3131：股骨远端31 B31 B：关节囊内的股骨颈骨折：关节囊内的股骨颈骨折31 A31 A：关节囊外的转子间骨折：关节囊外的转子间骨折31 A31 A：关节囊内的股骨头骨折：关节囊内的股骨头骨折AOAODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第3页/共36页

5、第三页，共37页。A 1A 1A 2A 2A 3A 331-A31-ADepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Classification - AOA1：顺粗隆间简单的两部分骨折，内侧有良好的骨皮质支撑：顺粗隆间简单的两部分骨折，内侧有良好的骨皮质支撑A2：粗隆间粉

6、碎性骨折，内侧和后方破裂，外侧骨皮质完好：粗隆间粉碎性骨折，内侧和后方破裂，外侧骨皮质完好(wnho)A3：外侧骨皮质破裂，逆转之间骨折：外侧骨皮质破裂，逆转之间骨折第4页/共36页第四页，共37页。Classification - AODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sci

7、ences A1A1A2A2A3A3第5页/共36页第五页，共37页。31 A2/331 A 131 A 1稳定(wndng)的骨折不稳定(wndng)的骨折第6页/共36页第六页，共37页。 Background 手 术 治 疗保守(boshu)治疗牵引保守(boshu)治疗防旋鞋Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong

8、 Academy of Medical Sciences 第7页/共36页第七页，共37页。l年龄、健康状况l骨的质量(zhling)l骨折的几何力学影响(yngxing)治疗的因素l 复位复位l 内植物内植物(zhw)(zhw)的选择的选择l 内植物内植物(zhw)(zhw)的准确的准确放置放置不可控制因素不可控制因素可控制因素可控制因素第8页/共36页第八页，共37页。4早期完全负重早期完全负重在骨质疏松骨有很好的抓持力在骨质疏松骨有很好的抓持力操作简单操作简单对骨折能进行动力加压对骨折能进行动力加压置置入内植物时避免造成医源性骨折入内植物时避免造成医源性骨折保护骨的血供保护骨的血供216

9、345Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 理想(lxing)的内植物所需的条件第9页/共36页第九页，共37页。1854Langenbeck1878Trendelenburg1907Delbet1925Smith-Petersen1932Johannsen/Je

10、rusalem1934Moore1937Thorton1940Kntscher: fem.neck nail1942Brittain1950Lezius1952Jewett1954Kntscher: Y-nail1955Pohl1955Pugh-Massie1955Ender1965AO: angled blade plates1967Kntscher1967Simon-Weidner/Ender1967Zickel1970Teubner: double T plate1980AO: DHS1988Kempf : Gamma-Nail1996Friedl: gliding nail1996 A

11、O: PFN股骨(gg)近端骨折内植物使用的历史Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第10页/共36页第十页，共37页。Department of Orthopedics , Guangdong General Hospital, Guangdong Acade

12、my of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 髓内固定(gdng)髓外固定(gdng)l Proximal Femoral Nail ( PFN )l Gamma - Naill Intramedullary Hip Screwl ACE - Naill 股骨(g(gg g) )髁角钢板l DHS, CHS, DCS DHS, CHS, DCS股骨近端骨折内植物分类第11页/共36页第十一页，共37页。股骨(g

13、g)近端骨折生物力学正常正常(zhngchng)情况情况下下Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第12页/共36页第十二页，共37页。ddm = F x d m = F x d 股骨(gg)近端骨折生物力学Department of Orthopedics ,

14、Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第13页/共36页第十三页，共37页。1. DHS是最具代表性的髓外钉板系统2. 适合于大多数股骨粗隆间骨折 3. 静力加压与动力加压双重功能4. 使骨折紧密结合，促进骨折愈合 Department of Orthopedics , Guangdong General Hospit

15、al, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHS第14页/共36页第十四页，共37页。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Gu

16、angdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHS第15页/共36页第十五页，共37页。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic

17、 Hip Screw - DHS第16页/共36页第十六页，共37页。股骨颈长度变短，肢体短缩股骨颈长度变短，肢体短缩 1粉碎性不稳定骨折，后内侧骨质缺损粉碎性不稳定骨折，后内侧骨质缺损 2骨折线位于骨折线位于DHS 进针处时也不适用进针处时也不适用 3Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Med

18、ical Sciences DHS手术(shush)存在的问题第17页/共36页第十七页，共37页。DHS失败(shbi)病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第18页/共36页第十八页，共37页。DHS失败(shbi)病例Department of Orth

19、opedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第19页/共36页第十九页，共37页。DHS失败(shbi)病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepart

20、ment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第20页/共36页第二十页，共37页。31A131A1：DHSDHS31A231A2：PFNPFN31A331A3：PFNPFNDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital,

21、 Guangdong Academy of Medical Sciences 1. Boldin C, et al. The proximal femoral nail (PFN)-a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand, 2003, 74: 53-58.2. Flahiff CM, et al. A biomechanical e

22、valuation of an intramedullary fixation device for intertrochanteric fractures. J Trauma, 1993, 35: 23-27.3. Sadowski C, et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or 95 screw- plate. J Bone Joint Surg(Br), 2002, 84: 372- 381.4.

23、张经纬张经纬, 等等. 股骨转子间骨折不同手术方法比较股骨转子间骨折不同手术方法比较.中华骨科杂志中华骨科杂志, 2005, 25: 7- 11. 5. 卢华定卢华定, 等等. 股骨近端髓内钉在股骨转子周围骨折中的应用股骨近端髓内钉在股骨转子周围骨折中的应用. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2005, 20(4): 246-248.6. 姜磊姜磊, 等等. 闭合复位闭合复位PFN治疗高龄股骨粗隆间骨折的体会治疗高龄股骨粗隆间骨折的体会. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2006, 21(1): 59-60.7. 祝敬华祝敬华, 等等. DHS与与PFN在股骨粗隆间骨折

24、中的应用在股骨粗隆间骨折中的应用. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2006, 21: 63-64.8. 范忠明范忠明, 等等. PFNA治疗老年股骨粗隆间骨折治疗老年股骨粗隆间骨折. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2009, 24(2): 151-153.9. 周建华周建华, 等等. PFNA治疗老年不稳定性股骨转子间骨折治疗老年不稳定性股骨转子间骨折. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2008, 23(12): 1015-1017. 第21页/共36页第二十一页，共37页。1. 一个部件即完成了抗旋转及成角稳定性一个部件即完成了抗旋转及成角稳定性 2.

25、 末端宽大的刀面尽可能多的压缩周围骨质，尤其是在末端宽大的刀面尽可能多的压缩周围骨质，尤其是在骨质疏松的情况下，具有更好的抓持力骨质疏松的情况下，具有更好的抓持力 3. PFNA螺旋刀片和骨质贴合紧密，增强了稳定性，防螺旋刀片和骨质贴合紧密，增强了稳定性，防止旋转和内翻畸形止旋转和内翻畸形 4. 生物力学试验证明生物力学试验证明: 螺旋刀片显著提高抗切出能力螺旋刀片显著提高抗切出能力PFNA PFNA 螺旋螺旋(luxun)(luxun)刀片刀片Department of Orthopedics , Guangdong General Hospital, Guangdong Academy o

26、f Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences PFN-A vs PFN第22页/共36页第二十二页，共37页。CArm 必不可少(b b k sho)Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong Gener

27、al Hospital, Guangdong Academy of Medical Sciences 第23页/共36页第二十三页，共37页。骨科( k)牵引床Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第24页/共36页第二十四页，共37页。骨科( k)牵引床123骨

28、折基本或部分闭合复位向健侧倾斜，掌握前倾角内收、内旋患肢，纠正畸形Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第25页/共36页第二十五页，共37页。Department of Orthopedics , Guangdong General Hospital, Guan

29、gdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Intraoperative 第26页/共36页第二十六页，共37页。52 岁岁，男性，男性(nnxng)12 monthsDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orth

30、opedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 1第27页/共36页第二十七页，共37页。邓邓X X，FemaleFemale，81Y81YDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Med

31、ical Sciences Case 2第28页/共36页第二十八页，共37页。丁XXXX，MaleMale，74Y74YDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 3第29页/共36页第二十九页，共37页。Department of Orthopedics

32、, Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，74Y74YCase 5第30页/共36页第三十页，共37页。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepart

33、ment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，81Y81YCase 8第31页/共36页第三十一页，共37页。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，70Y70YCase 9第32页/共36页第三十二页，共37页。Discussion生物力学：髓内系统固定生物力学：髓内系统固定