（参考课件）股骨粗隆骨折.ppt

1、股骨粗隆间骨折教学查房,八区骨科 2018-10-21,1,一、汇报病史,住院医师：肖吉,2,病例,患者：陈志林 男 77岁 八区03床 因“右髋部外伤疼痛、活动受限1小时”于2018-10-10,经急诊收入病房,3,病史：患者1小时前行走时不慎跌倒，右髋部着地受伤，当即感右髋部剧烈疼痛，局部未及明显皮肤破溃出血，无法站立、行走，继而局部肿胀，急至我院就诊，查CT示：右股骨上段粉碎性骨折。为进一步诊治，急诊拟“右股骨粗隆间骨折”收入病房。患者受伤以来无头痛，无发热，大小便正常。,4,既往史：既往有低血压病史，否认糖尿病等其他慢性病史。,5,查体：体温 36.7 ，脉搏 84次/分，呼吸 21次

2、/分，血压 88/61mmHg。视：右髋部未及皮肤破溃伤口及疤痕，右下肢外旋畸形，末梢血运正常。触：右髋部压痛明显，可及骨擦感，右下肢皮肤感觉正常。动：右髋部活动受限，右足、右踝活动可。量：右下肢稍短缩。,6,实验室及器械检查：CT：右股骨上段粉碎性骨折。,7,诊断：右股骨粗隆间骨折（EvansV）,8,诊疗计划,1.患者入院时生命体征平稳，心脑肺肾等重要脏器功能可，内环境稳定，具体情况有待检查结果进一步评估。 2.完善血尿粪三大常规、生化组合、血型、凝血常规、输血八项、心电图、心脏彩超、下肢深静脉彩超、全胸片等检查。 3.监测生命体征，暂予以活血消肿、补液等对症治疗，下肢皮肤牵引，择期手术，

3、Autar评分属于中风险，予以预防性抗凝等治疗。,9,10,11,12,股骨粗隆间骨折定义及分析,主治医师：王震,13,定义：股骨粗隆间骨折是指股骨颈基底至小粗隆下缘之间的骨折。,14,临床表现： 伤后髋部疼痛，不能站立或行走。 下肢短缩及外旋畸形明显。 局部可见肿胀及瘀斑，局部压痛明显。扣击足跟部常引起患处剧烈疼痛。,15,诊断：明显外伤史，患肢疼痛，活动受限。线片可确定骨折部位及移位情况。,16,治疗措施：具体治疗方法应根据骨折类型、移位情况、患者年龄和全身情况，分别采取不同方法。,17,Evans classification,18,AO classification,19,治疗方法选择

4、,副主任医师：张锋,20,治疗方法,牵引疗法 适应所有类型的粗隆间骨折。尤其对无移位的稳定性骨折并有较重内脏疾患不适合手术者。,21,手术治疗,股骨粗隆骨折的内固定分为髓外固定和髓内 固定。髓外固定以 DHS 和股骨近端锁定加压钢板为主； 髓内固定以髓内钉为主，目前应用较多的包 括第 3 代 G a m m a 钉、PFNA）和 InterTan）。,22,？,23,24,内固定物的选择,DHS内固定 标准的手术方式。但随着更新型内固定方式 出现，地位出现动摇，但仍是选择的主要方式。,25,髓内固定方式，更具力学优势 Gamma Nail PFNA InterTan,内固定物的选择,26,Ga

5、mma Nail 为目前各类髓内钉的制作原型与模板,27,PFNA 螺旋刀头，优势明显,28,InterTan近端为 2 枚绞索设计的螺钉,29,髋关节置换THR 早期负重，早期下地活动，减少卧床并发症,内固定物的选择,30,结论,对于老年股骨粗隆骨折患者，稳定型骨折可选用 DHS 或 Gamma 钉；不稳定型股骨粗隆骨折，可根据骨折类型、骨质情况等选用 PFNA、InterTan 等髓内固定系统。高龄粉碎性股骨粗隆骨折建议行髋关节置换术。,31,徐众华科主任点评,32,33,Introduction,The Sliding Hip Screw (DHS) is considered the

6、gold standard device for fixation of stable trochanteric fractures Incase of unstable or reverse obliquity pattern fracture, intramedullary nails seem to be more effective with respect to DHS fixation of stable or minimal unstable trochanteric fractures with PFNa in a population of patients compared

7、 to a control group treated by DHS.,34,Materials and methods,A prospective study was conducted in 71 consecutive patients treated by PFNa (group A), and 69 by a DHS (group B), with a mean age of 81.6 and 83.4 years respectively. Short Form 12 was administered to check postoperative results, and the

8、following parameters were evaluated: range of motion,evaluation of pain, gait ability, X-rays, and Tip Apex Distance Index.,35,36,Materials and methods,About 80.4% of fractures were treated in the first 48 hours after trauma (early timing). Intraoperative data concerning blood loss, operative and ra

9、diological exposure time, and postsurgical onset of complications were registered. assisted passive motion in bed at the first postoperative day. At second postoperative day, patients were allowed to seat in bed performing active knee and ankle exercises. From the third postoperative day in stable p

10、atterns, assisted standing and gait exercises with devices were proposed。,37,Materials and methods,Short Form 12 was administered to check postoperative results, and the following parameters were evaluated: range of motion, evaluation of pain, gait ability, X-rays, and Tip Apex Distance Index.,38,Results,39,40,41,42,Conclusions,PFNa may be considered an useful choice for the treatment of st