版权说明：本文档由用户提供并上传，收益归属内容提供方，若内容存在侵权，请进行举报或认领
文档简介
FracturesoftheFemoralNeckandIntertrochantericFracturesKnutStrömsöe,MDPhD,OrthopaedicDepartment,AkerUniversityHospital,Oslo,NorwayClassificationoffracturesintheproximalfemurTheComprehensiveAO/ASIFClassification(Mülleretal.1990)offracturesintheproximalfemurThecomprehensiveclassificationofneckfracturesoftheproximalfemurPauwel’sclassificationofneckfractures(1965)(basedontheanglethefracturelinewiththeresultantofforces(R))Garden’sclassification
(basedontherelationshipofthemedialtrabeculaeintheheadandpelvis)Reportedannualincidenceofhipfracturesper100000ofpopulation(ParkerandPryor1993)Sweden 165Canada 103Finland 91UK 86USA 80Malayasia 70Israel 59Korea 34
population40000001979:68001989:99001999:11800(290per100000)NumberofhipfracturesinNorway1979-1999:
Wehavetodefineourproblem
Aging219001930196019901997200020202050CooperC,CampionG,MeltonLJ(1992)OsteoporosisInt;2:285-2896.25millionisanestimatednumberofhipfracturesworldwideby2050Increasingworldpopulationandincreasinglifeexpectancyseemstobethemostimportantreasonforthisincrease
Whydoweexperienceanincreasethenumberoffractures?
FallingfrequencyincreaseswithagePorosityofboneincreaseswithageCooperC,CampionG,MeltonLJ(1992)OsteoporosisInt;2:285-289Determinantsoffracturerisk-Neuromuscularfunction-Environmentalhazards-TimespentatriskTypeoffallProtectiveresponsesEnergyabsorptionGeometryofboneBonemineralmassQualityofboneRiskoffallForceofimpactStrengthofboneRiskoffracture
ChoiceofTreatmentpolicyGradeofdislocation(Garden1972,Thorngren1991)Sizeofheadfragment(Benterudetal.ActaOrthScand1994)Posteriorcomminution(Benterudetal.1997)Osteoporosis(Bentley1972,Riska1969,Anderson1969,Thorngren1995)
Fracturerelatedpatternoffemoralneckfracturesrepresentingriskforosteofixationfailure,non-unionandavascularnecrosisImpactedfracturesarereportedtohavelessincidenceofnon-unions(BentleyG,JBJS;50B:551,1968,Raymakers,1993)Impactedfracturesdeveloplesssegmentalcollapseinavascularnecrosisofthehead?
Fracturerelatedpatternoffemoralneckfracturesleadingtoa“treatmentpolicy”..Crawfordreported12%ofavascularnecrosisin50impactedfracturesoutof339femoralneckfractureswithanoverallincidenceofavascularnecrosisin37%(CrawfordH,JBJS;47A:830,1965)Preservationofthefemoralhead
orhemi(total)arthroplasty?JuliusNicolaysen(1831-1909),fromBergen,workedasaProfessorinOslo.Henailedamedialfemoralneckfracturein1893,2yearsbeforeWilhelmKonradRøntgendiscoveredtheX-rayOsteoporosisisfrequentnotthemainproblemFracturepatternisoftendifferentastotheolderpatientProstheticreplacementasaprimarytreatmentalternativehastobechosenwithgreatercarethanintheolderpatient
Femoralneckfracturesintheyoungor“younggeriatric”patienthavedifferentaspectsastotheolderpatient..
Transcervicalandsubcapitalfemoralneckfracture(31Band31-C3)inthe“younggeriatric”patientHipreplacement(hemiortotalarthroplasty)representsaninternalamputationwithallitsimplicationsPreservationofthejoint(asinalljointfractures)shouldbewhatweaimatinthetreatmentSecondaryfailureslikesecondaryosteofixationfailureaswellassegmentalcollapsemaybehandledbysecondaryarthroplasty
“PrimaryandsecondaryCharmley-Hastingshemiarthroplastyindisplacedfemoralneckfracturesandtheirsequelae”BenterudJG,KokWL,AlhoA.In:AnnChirGynaecol1996;85(1):72-6Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?Functionallytreated:No.ofPatients Age Instable59 15-69 2=3%73 70-94 16=22%Raaymakers1993Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?Intheliteraturewefind:Instability:Afterearlymobilisationwithoutweightbearing:8-19%Afterimmediatefullweightbearing:32-65%Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?Mortalityinimpactedfemoralneckfractures:Operativetreatment>10%Conservativetreatment1.8-3.3.%(Raaymakers1993)Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?
Retroversionisnotanimportantreasonforhigherinstability(Raaymakers1993)“Itisimpossibleatthetimethepatientpresentshimselftopredictwhichfractureswillundergodesimpaction”(Bentley,Crawford,Judet,Asser,Hansen,Famos,Jeannaret)Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?
Conclusionmaybeasfollows:Agelessthan70:
Internalfixationin situAgemorethan70:Conservativetreatment.If secondarydislocationor AVN:ArhroplastyTimingofSurgeryIndislocatedfemoralneckfractures..
Aspreservationofthefemoralheadisthemaingoalofourtreatmentsurgeryshouldbeperformedassoonaspossibleandlatestwithin6hoursThevalueofdecompressionoftheintracapsularhaematomastillisunknownTimingofSurgery.Ifnotimmediate?Indislocatedfemoralneckfractures..
ThevalueofimmobilisationintractionisquestionableinconcernofdevelopmentofavascularheadnecrosisPositioningofthehipinthemostcomfortablepositiontothepatientprobablyalsoisthepositionwheretheintracapsularpressureisatlowest
Istheviabilityofthefemoralhead
predictable?
Byfractureclassification?Byscintigraphy?MRIIntraoperativebybleeding?Intraoperativebymeasuringofelectricpotentialwithtemporaryimplantedplatineelectrodesandgasinsuflation(H2O2)?Preoperative
IntraoperativeInfemoralneckfractures..
Istheviabilityofthefemoralheadpredictable?MRI
ReductiontechniqueinintracapsularfracturesofthefemoralneckLoosenthefractureby“unpack”itAfterhavingobtainedthereduction“packthefracture”andthenfixitMarkFlynninjury1973ImpactedfractureNondisplacedfracture
DisplacedfractureReductionmanoeuvre(Leadbetter)ImpactedfractureIntracapsularfracturesofthefemoralneckInternalrotationofthefootshouldresultinthefemoralhead,neckandshaftallappearinginastraightlinewithnoresidualanglulationatthefracturesitedorsalventral
ChoiceofImplant
ChoiceofImplant
CannulatedbonescrewsNoncannulatedbonescrewsNailswithhooks(Hansennails)1300AnglebladeplateSlidingScrewPlateSystems(DHS,HCS)
Implantdemands..Theimplantshallprovidestability-preventdislocationinvarus-preventdislocationinretroversion-preventrotationalmicromovementsAllowaxialsinteringalongtheimplantwithoutpenetratingintothejointIncaseofdelayedunionandnonunionmigrationintothejoint/pelvisshouldnotbepossibleChoiceofImplant:
SlidingScrewPlateSystemChoiceofImplantBenterudJG,HusbyT,NordslettenL,AlhoA:“FixationofdisplacedfemoralneckfractureswithaslidingscrewplateandacancellousscrewortwoOlmedscrews.Aprospectivestudyof225elderlypatientswitha3-yearfollowup”.AnnChirGynaecol1997;86(4)338-42ChoiceofImplantAnnChirGynaecol1997;86(4)338-42Conclusions. Bothtreatmentmethods resultedinhighrateofosteofixation failures(18.5%intheSSPgroupand19.5%intheOlmedgroup)andnon-unions(6.2%and8.5% respectively)ChoiceofImplantIn31-B2fracturesofthe“younggeriatric”patienta4holeDHSwithanantirotationalscrew,however,istheimplantofchoice.ThefixationonthetensilesideofthefemurandglidingcylinderforthescrewprovidesstabilityovertimeChoiceofImplantAnglebladeplateandcancellousscrewFemoralneckfractures:
Ifscrews:Twoorthreescrews?Positionofthescrews?Dimensionsofthescrews?
ThreescrewfixationtechniqueinfixationofcervicalfracturesoftheproximalfemurChoiceofImplantScrewswithheadandwasherpreventingaxialmigrationininstabilityScrewswithoutheadandequaldiameterofthreadandshankFateofthemedialneckfractureafterORIFEarlyosteofixationfailurein8-16%Non-unionin8-10%AVNin6-10%
Thismakesanoverallfailurerateof20-30%but-inthefirstyearafteramedialneckfracture25%ofthepatientaredeadtounrelatedfracturedeseaseClassificationoftrochantericfractures(31-A1-3)Bonemassrelatedtoageincancellousboneandcorticalbone100years50yearsBonemassTrochcantericarea
NeckofthefemurAgeFracturesintheproximalFemuratAkerHospital,Oslo,Norway1999
Diagnose No MedianagemalefemaleCervicalFrx 28284(29-104)53229PertrochantericFrx 18688(54-102)75111SubtrochantericFrx37 86(39-95)2017505148357BiomechanichsoftheproximalfemurBiomechanichsoftheproximalfemurBiomechanichsoftheproximalfemurFracturepatternreflectsbiomechanichs
oftheproximalfemurindifferentstagesbyfallingFallingactivatestensileforcesofthemusclesFallinginducesrotationofthefemuronthefixedlegForcesactonthetrochanterbydirectcontactattheendofthefallInunstabletrochantericfracturesintheelderlytheimplantchosenhaveto:respecttheinstabilityofthefractureallowfractureimpactionduringmotionwithoutfixationfailuresecureretentionofthefractureinacceptablepositionduringhealingbuildabiomechanicalconstructwiththeboneallowingearlyweightbearing31-A3.3Fracture.DHSandTSPWeek8Week0slidingscrew-platesystemallowingthefracturesinteringplateonthetensilesiteneutralisingtensionforcesTrochantericSupportingPlatepreventingfemoralshaftmedialisationAdditionalantirotationalscrew31-A3.3Fracture.,The
-nailslidingscrew-nailnailinthecentreofthefemoralaxisreductionoftheleverarmnoneutralisationonthetensilesidesinteringinvaruswith“cuttingthrough”31-A3.3Fracture.The
-nailDay1Day126Day160Inunstabletrochantericfracturesintheelderlytheimplantchosenhaveto:respecttheinstabilityofthefractureallowfractureimpactionduringmotionwithoutfixationfailuresecureretentionofthefractureinacceptablepositionduringhealingbuildabiomechanicalconstructwiththeboneallowingearlyweightbearin
温馨提示
- 1. 本站所有资源如无特殊说明，都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等，如果需要附件，请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸，网页内容里面会有图纸预览，若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间，仅对用户上传内容的表现方式做保护处理，对用户上传分享的文档内容本身不做任何修改或编辑，并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容，请与我们联系，我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
评论
0/150
提交评论