1、骨盆骨折和下肢骨折pelvic fractures and fractures of the lower extremity中南大學湘雅二醫院骨科倪江東 ContentsPelvic FracturesFractures of Femoral NeckIntertrochanteric FracturesFractures of the Shaft of the FemurFractures of the Tibia and Fibula Pelvic FracturesAnatomyPelvic FracturesAnatomy髂腰韌帶骶棘韌帶骶結節韌帶骶髂關節恥骨聯合Pelvic Frac

2、turesClassificationLocation of FractureAvulsion fracturesSacrum and coccyx fracturesSingle breaks in the pelvic ringPelvic ring disruptions two or more breaks in the pelvic ringPelvic FracturesSacrum and Coccyx fracturesPelvic FracturesAvulsion fractures髂前上棘撕脫骨折Pelvic Fractures Single breaks in the

3、pelvic ringPelvic Fractures Pelvic ring disruptions two or more breaks in the pelvic ringAO分型A型A-1 Fracture of innominate bone; avulsionA-2 Fracture of innominate bone; direct blowA-3 Transverse fracture of sacrum and coccyx B型B-1 Unilateral partial disruption of posterior arch, external rotation (“

4、open book” injury)B-2 Unilateral, partial disruption of posterior arch, internal rotation (lateral compression injury)B-3 Bilateral, partial lesion of posterior archC型C-1 Unilateral, complete disruption of posterior archC-2 Bilateral, ipsilateral complete, contralateral incompleteC 3 Bilateral, comp

5、lete disruptionPelvic Fractures臨床特點（1）劇烈暴力外傷史（2）合并多發傷（3）大部分病人有休克Pelvic Fractures Physical Examination 骨盆擠壓分離試驗陽性 肢體長度不對稱 會陰部瘀斑Pelvic FracturesRadiological EvaluationX rays of pelvic ring 1 AP Pelvis 2 Inlet View 3 Outlet ViewPelvic FracturesCT scan and 3-D reconstructionComplications41235Extraperito

6、neal hematomaIntraperitoneal viscera injuryBladder or Urethral InjuryNerve injuryRectum injuryPelvic Fractures處理步驟1 監測血壓2 建立靜脈通道3 視病人情況及早完成X線和CT檢查4 檢查有無合并損傷，尿液檢查排除泌尿系損傷，肛查排除直腸損傷，腹腔診斷性穿刺排除腹腔內臟器損傷Pelvic FracturesTreatment of general condition（1）根據受傷特點及全身情況制定治療步驟（2）合并多發損傷積極處理（3）積極輸血補液抗休克治療（4）固定骨盆（5）止血（

7、血管造影、栓塞和手術）Pelvic Fractures 固定骨盆 血管栓塞Management of the FracturesPelvic FracturesConservative treatment骨盆邊緣撕脫骨折骶尾骨骨折骨盆環單處骨折輕微的恥骨聯合分離Surgical treatment骨盆環多處骨折骨盆不穩定Surgical treatmentPelvic FracturesSurgical treatmentPelvic FracturesFRACTURE OF FEMORAL NECK AnatomyFRACTURE OF FEMORAL NECKAnatomyNeck-sha

8、ft angle 110 140Anteversion angle 10 15Anatomy Blood surpply of the femoral head1小凹動脈 2旋股內外側動脈的分支 3股骨干滋養動脈升支FRACTURE OF FEMORAL NECK Classification Location of the fracture line1 Subcapital2 Transcervical3 Base NeckFRACTURE OF FEMORAL NECKPauwels1965FRACTURE OF FEMORAL NECK Classification外展型 內收型FRAC

9、TURE OF FEMORAL NECK ClassificationGarden 1964I Valgus impacted or incompleteII Complete Non-displacedIII Complete Partial displacementIV Complete Full displacementClinical manifestation 外傷史 髖部疼痛 活動障礙FRACTURE OF FEMORAL NECKClinical sign 髖部腫脹、皮下瘀斑 患肢短縮、外旋畸形，一般在4560之間 壓痛，患肢縱向叩擊痛FRACTURE OF FEMORAL NE

10、CKRadiological Evaluation FRACTURE OF FEMORAL NECK X-rays AP pelvis AP and lateral view of hip CT scanComplications: Nonunion AVN of femoral headFRACTURE OF FEMORAL NECKConservative treatmentIndications:無明顯移位的骨折外展型或嵌插型骨折手術禁忌Methods:下肢皮牽引丁字鞋長期臥床并發癥的防治FRACTURE OF FEMORAL NECKFRACTURE OF FEMORAL NECKSu

11、rgical treatmentIndications:移位或不穩定老年患者，無手術禁忌陳舊性骨折不愈合Methods:空心螺釘內固定DHS或解剖鋼板半髖關節或全髖關節置換FRACTURE OF FEMORAL NECKSurgical treatment空心螺釘DHSDHS+空心螺釘FRACTURE OF FEMORAL NECKSurgical treatment半髖關節置換THA(骨水泥型）THA(生物型）INTERTROCHANTERIC FRACTUREINTERTROCHANTERIC FRACTUREAnatomyCalcar Femorale Posteromedial den

12、se plate of boneINTERTROCHANTERIC FRACTUREClassificationTronzo evans classificationAO分型A1A1.1:轉子間線骨折A1.2：經小轉子骨折A1.3：小轉子下骨折A2A2.1：轉子周一處骨折A2.2：轉子周多處骨折A2.3：轉子周骨折延伸小轉子超1CMA3A3.1：單純反向斜行A3.2：單純橫斷骨折A3.3：多處粉碎性骨折A2INTERTROCHANTERIC FRACTUREClinical manifestation外傷史疼痛，腫脹，瘀斑患肢功能障礙Clinical sign壓痛縱向叩擊痛下肢短縮，外旋畸形明

13、顯，可達90Radiological Evaluation X-raysCT scan Conservative treatment 骨牽引 長期臥床并發癥的防治INTERTROCHANTERIC FRACTURE Surgical treatment DHS, DCS 解剖鋼板 PFN 關節置換 INTERTROCHANTERIC FRACTURE Surgical treatment INTERTROCHANTERIC FRACTUREDHSDCS解剖鋼板 Surgical treatment INTERTROCHANTERIC FRACTUREPFN關節置換FRACTURE OF THE

14、 SHAFT OF THE FEMURFemoral shaft AnatomyFRACTURE OF THE SHAFT OF THE FEMURMechanism直接暴力重物打擊、車輪碾壓、火器性損傷 易致橫行或粉碎性骨折，廣泛軟組織損傷間接暴力高處墜落傷、機器扭轉易致斜形或螺旋形骨折，軟組織損傷較輕FRACTURE OF THE SHAFT OF THE FEMURClassificationFRACTURE OF THE SHAFT OF THE FEMURComplicationsPopliteal artery and vein, tibial nerve and common p

15、eroneal nerve injuryShockFRACTURE OF THE SHAFT OF THE FEMURConservative treatment 骨牽引 長期臥床并發癥的防治FRACTURE OF THE SHAFT OF THE FEMURSurgical treatment Indication: 非手術療法失敗同一肢體或其他部位有多處骨折合并神經血管損傷老年人的骨折，不宜長期臥床者陳舊骨折不愈合或有功能障礙的畸形愈合無污染或污染很輕的開放性骨折FRACTURE OF THE SHAFT OF THE FEMURSurgical treatment Methods: 鋼板

16、內固定 髓內釘固定 FRACTURE OF THE SHAFT OF THE FEMUR 鎖定鋼板內固定 髓內釘內固定 Surgical treatment FRACTURE OF TIBIA AND FIBULA ANATOMY FRACTURE OF TIBIA AND FIBULA Mechanism 暴力直接暴力橫形、短斜行或粉碎性骨折間接暴力螺旋形、斜形骨折 FRACTURE OF TIBIA AND FIBULA Classification脛腓骨干雙骨折單純脛骨干骨折單純腓骨骨折ComplicationsCompartment syndrome 5P(pain,palor,pulselessness, paresthesia,paralysis)Nonunion and delayed union FRACTURE OF TIBIA AND FIBULA Conservative treatment 跟骨牽引 石膏夾板固定 FRACTURE OF TIBIA AND FIBULA Surgical treatment FRACTURE OF TIBIA AND FIBULA Indication:手法復位失敗嚴重粉碎性骨折或雙段骨折污染不重，受傷時間較短的開放性骨折Therapy: 鋼板內