医学精品课件前臂骨折

1、前臂骨折五附院骨二科 2021/7/15 星期四1尺桡骨双骨折尺骨单骨折桡骨单骨折前臂远端骨折授课内容2021/7/15 星期四2体表标志2021/7/15 星期四3体表标志2021/7/15 星期四4前臂前区2021/7/15 星期四52021/7/15 星期四6前臂前区2021/7/15 星期四7前臂前区2021/7/15 星期四8前臂前区2021/7/15 星期四9桡神经深支和后侧骨间神经：桡神经在肘窝外侧，肱骨外上髁前方，分浅、深两支桡神经深支发出肌支至桡侧腕长、短伸肌和旋后肌，然后穿入旋后肌，在桡骨头下方57CM出穿出该肌，称为后侧骨间神经，走行与前臂肌后群浅、深两层之间分短支与长支

2、前臂后区 深层2021/7/15 星期四10前臂后区2021/7/15 星期四11前臂后区2021/7/15 星期四12前臂后区2021/7/15 星期四13前臂后区2021/7/15 星期四14A型 简单骨折（A1,A2,A3）B型 锲型骨折 (B1,B2,B3)C型 复杂骨折 (C1,C2,C3) 前臂骨折AO分型2021/7/15 星期四15A1.1 斜型骨折2021/7/15 星期四16A1.2 横型骨折2021/7/15 星期四17A 1.3 伴有桡骨头脱位（孟氏骨折）2021/7/15 星期四18A2.1 斜型骨折2021/7/15 星期四19A2.2 横型骨折2021/7/15

3、星期四20A2.3 伴头下尺桡关节脱位（盖氏骨折）2021/7/15 星期四21A 3 简单的双骨折2021/7/15 星期四22B1.1 完整锲型2021/7/15 星期四23B1.2 带有碎片的锲型骨折2021/7/15 星期四24B1.3 伴有桡骨头脱位（孟氏骨折）2021/7/15 星期四25B2.1 完整锲型2021/7/15 星期四26B2.2 碎片锲型2021/7/15 星期四27B2.3 伴有下尺桡关节脱位（盖氏骨折）2021/7/15 星期四28B3.1 尺骨锲型 ，桡骨简单骨折2021/7/15 星期四29B3.2 桡骨锲型，尺骨简单骨折2021/7/15 星期四30B3.

4、3 尺桡骨锲型骨折2021/7/15 星期四31C1.1 两端，桡骨完整2021/7/15 星期四32C1.2 两段 桡骨骨折2021/7/15 星期四33C1.3 不规则2021/7/15 星期四34C2.1 两段 ，尺骨完整2021/7/15 星期四35C2.2 两段 ，尺骨骨折 2021/7/15 星期四36C2.3 不规则2021/7/15 星期四37C 3 尺桡骨复杂骨折2021/7/15 星期四38桡骨干前外侧入路：桡骨干全长 （Henry切口）桡骨干后侧入路：桡骨干上中部（Thompson切口）尺骨干后侧入路：尺骨全长 常用手术入路2021/7/15 星期四39AP and la

5、teral views of the both bones fracture of the forearm,demonstrating significant shortening and relatively simpleoblique fracture patterns.2021/7/15 星期四40The patient is positioned supine with the arm prepped anddraped to just above the elbow and a tourniquet in place. This figure demonstrates the arm

6、 held in supination. Note theposition of the biceps insertion as well as the palpable tendonof the FCR and radial artery.BICEPSTENDONRADIALARTERYFLEXOR CARPIRADIALIS (FCR)2021/7/15 星期四41A useful technique to make the skin incision is to take a bovicord and pull it taught from the radial side of the

7、biceps tendonto the FCR at the level of the wrist. This can then be used as a template for the incision line.2021/7/15 星期四422021/7/15 星期四43The incision is taken down through the skin, identifying the fascial layer with care taken not to damage any superficial veins that may be intact. The FCR tendon

8、 is clearly visible throughout the wound, as is the radial artery in the distal extent of the wound.FCRRADIALARTERY2021/7/15 星期四44A closeup of the distal aspect of the wound demonstratingThe radial artery and its venous commtantes.RADIAL ARTERY ANDVENOUS COMMTANTES2021/7/15 星期四45FCRRADIALARTERYThe f

9、ascia on the radial side of the flexor carpi radialis is released, exposing the deep tissue. The radial artery can be followed now throughout the entire incision. 2021/7/15 星期四46The radial artery may be taken in either direction, however, typically it is easier to take the artery to the radial side.

10、FCRRADIALARTERY2021/7/15 星期四47The deep dissection is now performed between the flexor-pronator mass on the ulnar side and the artery and the mobile wad on the radial side.2021/7/15 星期四48PRONATORFor the proximal dissection, the forearm is brought intosupination and the pronator, FDS and FDP are relea

11、sedfrom the volar aspect of the radius2021/7/15 星期四49FDSThe pronator is being released from the radial aspect of the radius in a subperiosteal manner. This subperiostealdissection continues distally to release the origin of thecommon flexor.2021/7/15 星期四50After exposure of the volar aspect of the ra

12、dius proximallyand distally, two clamps can be placed on the ends of thebone in order to deliver them for cleaning.2021/7/15 星期四51FCRRADIAL ARTERYEach side of the fracture is be delivered in order to expose and clean the cortical edges.2021/7/15 星期四52These figures demonstrate delivery of the distal

13、fragment and acurved curette being used to clean the cortical edge. Nocleaning should be performed within the intramedullary canal,as this is healthy tissue and can be useful for the healing process.2021/7/15 星期四53Once the fractures are completely cleaned along their cortical edges such that the fra

14、cture reduction can be visualized, the two clamps are used to reduce the fracture. If a butterfly fragment exists, it is necessary to fix this with a lag screw back to one of the fracture ends in order to realign the fracture.2021/7/15 星期四54In the current case, the fracture is a simple pattern and i

15、s reduced by delivering the bones jointly, accentuating the deformity and then rotating and fitting the bones together with progressive compression while pushing the bones back into the wound, obtaining alignment by steric interference of one side against the other.2021/7/15 星期四55Once the bones are

16、held reduced, as seen in the following sequence, an appropriate dynamic compression plate is placed and held in place with a clamp. It is important that this plate must have the appropriate bend for the volar aspect of the forearm so as not to gap open the dorsal side as the plate is fixed to the bo

17、ne. Thus, it should be slightly underbent with respect to the standard volar concavity.2021/7/15 星期四562021/7/15 星期四572021/7/15 星期四582021/7/15 星期四59These figures demonstrate reduction of the fracture with a plateheld in place on the flat, volar aspect of the bone.Once the reduction is confirmed fixat

18、ion of the plate is performedusing a compressive technique through the plate.2021/7/15 星期四60The following sequence demonstrates using the offset drillguide to place an eccentrically drilled hole away from thefracture. The screw is placed to the point where it abutsbut is not inserted completely with

19、in the plate until it isaffixed on the other side.2021/7/15 星期四612021/7/15 星期四62HOLEECCENTRICALLYILLUSTRATED2021/7/15 星期四632021/7/15 星期四64In a similar fashion to the first screw, the second screw is placed on the opposite side of the fracture, also eccentrically away from the fracture. By compressin

20、g these two screws against the plate the fracture is translated and compressed together as shown inthe following sequence.2021/7/15 星期四652021/7/15 星期四662021/7/15 星期四67This image demonstrates the reduced fracture, viewedfrom the volarly.2021/7/15 星期四68This image shows that the fracture is also compre

21、ssed on the oppositeside due to proper contouring of the plate. Once the radius is fixed, the ulna is approached using a standard subcutaneous longitudinal incision with the arm flexed, as seen in the next image.2021/7/15 星期四692021/7/15 星期四70These images demonstrate the superficial dissection downto

22、 the fascia directly over the ulna, which is the commonfascia between the flexor carpi ulnaris and the extensor carpi ulnaris. This is divided in line with the muscles directly over the subcutaneous border of the ulna.2021/7/15 星期四712021/7/15 星期四72ECUEXTENSORCARPI ULNARISFCUFLEXOR CARPI ULNARIS2021/

23、7/15 星期四73A periosteal elevator is used to cleanthe external surface of the ulna.2021/7/15 星期四74This is cleaned, reduced and fixed in exactly the same fashion as the radius was, using a 6-hole DCP plate and in compressive mode. These images show the plate in place with screw holes, allowing for comp

24、ression in the final compressed fracture.2021/7/15 星期四752021/7/15 星期四762021/7/15 星期四77Intraoperative fluoroscopic views demonstrate accuratereduction and appropriate length of screws.2021/7/15 星期四78Postoperative AP and lateral views demonstratinganatomic reduction and alignment of the radius and uln

25、a.2021/7/15 星期四792021/7/15 星期四802021/7/15 星期四812021/7/15 星期四822021/7/15 星期四832021/7/15 星期四842021/7/15 星期四852021/7/15 星期四862021/7/15 星期四872021/7/15 星期四88桡骨干后侧入路 （1）2021/7/15 星期四89桡骨干后侧入路 （2）2021/7/15 星期四90桡骨干后侧入路 （3）2021/7/15 星期四91桡骨干后侧入路 （4）2021/7/15 星期四92桡骨干后侧入路 （5）2021/7/15 星期四93桡骨干后侧入路 （6）2021/7/

26、15 星期四94桡骨干后侧入路 （7）2021/7/15 星期四95桡骨干后侧入路 （8）2021/7/15 星期四96尺骨干后侧入路（1）2021/7/15 星期四97尺骨干后侧入路（2）2021/7/15 星期四98尺骨干后侧入路（3）2021/7/15 星期四99尺骨干后侧入路（4）2021/7/15 星期四100尺骨干后侧入路（5）2021/7/15 星期四101尺骨干后侧入路（6）2021/7/15 星期四102较为常见，约占全身骨折的6，青少年多见骨折端可发生侧方、重叠、旋转，成角移位，复位要求高直接暴力：二骨多外在一水平，横形、粉碎，多节段骨折，复位要求高传导暴力：桡骨中1/3骨

27、折（横形，锯齿形），沿骨间膜传至尺骨，尺骨低位骨折，多呈短斜形 尺桡骨双骨折 概述2021/7/15 星期四103扭转暴力：手臂极度旋前着地，尺桡骨相互扭转，桡骨多向背侧成角，尺骨多向掌侧成角X线摄片应包括上尺桡关节，防止遗漏关节脱位若仅有单骨折，未发生骨折的一骨尚完整，会阻碍断端的靠拢造成分离，从而延迟愈合或不愈合2021/7/15 星期四104骨折不愈合多见于桡骨干中、下1/3交界处尺骨干中、上1/3交界处Trojian 复习文献1636例，发生率7.3%； 其中采用手法复位外固定的1121例，发生率3.8%； 切开复位内固定515例，发生率14.8%2021/7/15 星期四105手法复

28、位外固定切开复位加压钢板内固定切开复位髓内钉固定 治疗2021/7/15 星期四106手术指征：1 开放性损伤68小时以内，软组织广泛挫伤2 多发性骨折，特别是同侧其他部位伴有骨折的，手法复位外固定困难的3 多段骨折，不稳定性骨折，手法复位不满意或不能维持容易再移位的4 尺桡骨上1/3骨折，肌肉丰富，骨间隙较小，手法复位困难者 切开复位内固定2021/7/15 星期四1075 对位不良的陈旧性骨折6 骨折不愈合7 病理性骨折8 合并神经血管损伤需手术探查者 2021/7/15 星期四108目前多运用动力加压钢板（DCP）和有限接触动力加压钢板（LC-DCP）适应证：主要用于髓内钉固定效果不佳的

29、部位，例如桡骨上1/3；桡骨下1/3；尺骨干上1/3的骨折机理：加压钢板对骨折端有加压作用，螺钉和钢板孔之间可以滑动而自动加压，防止断端分离，有利于早期愈合 切复加压钢板内固定（1）2021/7/15 星期四109 切复加压钢板内固定 （2）2021/7/15 星期四110切复加压钢板内固定 （3） 2021/7/15 星期四111注意事项：1 首先选择非粉碎的、形状稳定的先固定，然后操作另一个2 桡骨干在近侧骨折，钢板置于桡骨背侧 桡骨干在远侧骨折，钢板置于桡骨掌侧 3 最后缝合是松松地将深筋膜缝12针，并放置引流，防止前臂筋膜间室综合征和缺血性肌痉挛的产生切复加压钢板内固定 （4）2021

30、/7/15 星期四112术后长臂石膏后托固定，12天拔引流管床边进行手部、腕部的屈伸活动术后12周，活动肩关节术后34周，去石膏，活动肘关节定期复查X线，如果断端吸收、分离，说明固定不牢靠或活动量太大，减少锻炼，必要时加强固定切复加压钢板内固定 （5）2021/7/15 星期四113男 28岁 车祸后6小时，闭合伤 病例（1）2021/7/15 星期四114 病例（1）2021/7/15 星期四115患者男，18岁，被机器绞伤前臂病例（2）2021/7/15 星期四116病例（2）2021/7/15 星期四117病例（2）2021/7/15 星期四118期急诊清创手术术后进一步治疗创面和伤口愈合中的并发症期手术，34个月后。手术步骤2021/7/15 星期四119清创斯氏针固定，预行二期修复病例（2）2021/7/15 星期四120患者，男，25岁，6小时前被皮带缠绕致左尺桡骨骨折，急诊入院。患者急性面容，患肢无破裂创口，肢端感觉血供尚存，无典型感觉减退区。 病例 （3）2021/7/15 星期四121病例（3）？2021/7/15 星期四122适应证：尺骨干髓腔直，可适用任何形式的髓内钉；桡骨干弯曲，不能使用扩髓器，一般只用Sage钉；故主张桡