pfna粗隆間骨折治療PPT學(xué)習(xí)教案

1、會計學(xué)1pfna粗隆間骨折治療粗隆間骨折治療股骨粗隆間骨折是老年人的常見病股骨粗隆間骨折是老年人的常見病 美國發(fā)病率為美國發(fā)病率為0.034% 瑞典發(fā)病率為瑞典發(fā)病率為0.035% 中國老齡化，發(fā)病率不低于以上數(shù)字中國老齡化，發(fā)病率不低于以上數(shù)字 Reference:雍宜民雍宜民. 實用骨科臨床實用骨科臨床M . 北京北京: 科學(xué)技術(shù)文獻出版社科學(xué)技術(shù)文獻出版社, 1999: 188-198.Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartmen

2、t of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第1頁/共36頁病死率較高，大約病死率較高，大約10%20%在骨折后在骨折后1年內(nèi)死亡年內(nèi)死亡主要死因為臥床后出現(xiàn)的內(nèi)科并發(fā)癥主要死因為臥床后出現(xiàn)的內(nèi)科并發(fā)癥有心血管疾病和高齡患者的病死率比其他人高一倍有心血管疾病和高齡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

3、, 1998: 2182-2199.張慶明張慶明, 沈惠良沈惠良, 雍宜民雍宜民, 等等. 經(jīng)皮鈦合金空心釘治療高齡老年人粗隆間骨折經(jīng)皮鈦合金空心釘治療高齡老年人粗隆間骨折. 骨與關(guān)節(jié)損傷雜志骨與關(guān)節(jié)損傷雜志, 2002, 17(5) : 332-334. Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of M

4、edical Sciences 第2頁/共36頁Classification31 - A 3232：股骨干：股骨干 3131：股骨近端：股骨近端3131：股骨遠端：股骨遠端31 B31 B：關(guān)節(jié)囊內(nèi)的股骨頸骨折：關(guān)節(jié)囊內(nèi)的股骨頸骨折31 A31 A：關(guān)節(jié)囊外的轉(zhuǎn)子間骨折：關(guān)節(jié)囊外的轉(zhuǎn)子間骨折31 A31 A：關(guān)節(jié)囊內(nèi)的股骨頭骨折：關(guān)節(jié)囊內(nèi)的股骨頭骨折AOAODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics ,

5、 Guangdong General Hospital, Guangdong Academy of Medical Sciences 第3頁/共36頁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 Classificati

6、on - AOA1：順粗隆間簡單的兩部分骨折，內(nèi)側(cè)有良好的骨皮質(zhì)支撐：順粗隆間簡單的兩部分骨折，內(nèi)側(cè)有良好的骨皮質(zhì)支撐A2：粗隆間粉碎性骨折，內(nèi)側(cè)和后方破裂，外側(cè)骨皮質(zhì)完好：粗隆間粉碎性骨折，內(nèi)側(cè)和后方破裂，外側(cè)骨皮質(zhì)完好A3：外側(cè)骨皮質(zhì)破裂，逆轉(zhuǎn)之間骨折：外側(cè)骨皮質(zhì)破裂，逆轉(zhuǎn)之間骨折第4頁/共36頁Classification - AODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong

7、 General Hospital, Guangdong Academy of Medical Sciences A1A1A2A2A3A3第5頁/共36頁31 A2/331 A 131 A 1穩(wěn)定的骨折穩(wěn)定的骨折不穩(wěn)定的骨折不穩(wěn)定的骨折第6頁/共36頁 Background 手手 術(shù)術(shù) 治治 療療保守治療保守治療牽引牽引保守治療保守治療防旋鞋防旋鞋Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guan

8、gdong General Hospital, Guangdong Academy of Medical Sciences 第7頁/共36頁影響治療的因素l 復(fù)位復(fù)位l 內(nèi)植物的選擇內(nèi)植物的選擇l 內(nèi)植物的準(zhǔn)確放置內(nèi)植物的準(zhǔn)確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頁/共36頁4早期完全負重早期完全負重在骨質(zhì)疏松骨有很好的抓持力在骨質(zhì)疏松骨有很好的抓持力操作簡單操作簡單對骨折能進行動力加壓對骨折能進行動力加壓置置入內(nèi)植物時避免造成醫(yī)源性骨入內(nèi)植物時避免造成醫(yī)源性骨折折保護骨的血供保護骨的血供216345Department of Orthopedics , Guangdong Ge

9、neral Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 理想的內(nèi)植物所需的條件第9頁/共36頁1854Langenbeck1878Trendelenburg1907Delbet1925Smith-Petersen1932Johannsen/Jerusalem1934Moore1937Thorton1940Kntscher: fem.neck nail1942B

10、rittain1950Lezius1952Jewett1954Kntscher: Y-nail1955Pohl1955Pugh-Massie1955Ender1965AO: angled blade plates1967Kntscher1967Simon-Weidner/Ender1967Zickel1970Teubner: double T plate1980AO: DHS1988Kempf : Gamma-Nail1996Friedl: gliding nail1996 AO: PFN股骨近端骨折內(nèi)植物使用的歷史Department of Orthopedics , Guangdong G

11、eneral Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第10頁/共36頁Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hosp

12、ital, Guangdong Academy of Medical Sciences 髓內(nèi)固定髓內(nèi)固定髓外固定髓外固定l Proximal Femoral Nail ( PFN )l Gamma - Naill Intramedullary Hip Screwl ACE - Naill 股骨髁角鋼板股骨髁角鋼板l DHS, CHS, DCSDHS, CHS, DCS股骨近端骨折內(nèi)植物分類第11頁/共36頁股骨近端骨折生物力學(xué)正常情況下正常情況下Department of Orthopedics , Guangdong General Hospital, Guangdong Academy o

13、f Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第12頁/共36頁ddm = F x d m = F x d 股骨近端骨折生物力學(xué)Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital

14、, Guangdong Academy of Medical Sciences 第13頁/共36頁1. DHS是最具代表性的髓外釘板系統(tǒng)是最具代表性的髓外釘板系統(tǒng)2. 適合于大多數(shù)股骨粗隆間骨折適合于大多數(shù)股骨粗隆間骨折 3. 靜力加壓與動力加壓雙重功能靜力加壓與動力加壓雙重功能4. 使骨折緊密結(jié)合，促進骨折愈合使骨折緊密結(jié)合，促進骨折愈合 Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdo

15、ng General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHS第14頁/共36頁Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DH

16、S第15頁/共36頁Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHS第16頁/共36頁股骨頸長度變短，肢體短縮股骨頸長度變短，肢體短縮 1粉碎性不穩(wěn)定骨折，后內(nèi)側(cè)骨質(zhì)缺損粉碎性不穩(wěn)定骨折，后內(nèi)側(cè)骨質(zhì)缺損 2骨折線位于骨折線位于D

17、HS 進針處時也不適用進針處時也不適用 3Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences DHS手術(shù)存在的問題第17頁/共36頁DHS失敗病例Department of Orthopedics , Guangdong General Hospital, Guangdong

18、Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第18頁/共36頁DHS失敗病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Acad

19、emy of Medical Sciences 第19頁/共36頁DHS失敗病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第20頁/共36頁31A131A1：DHSDHS31A231A2：PFNPFN31A331A3：PFNPFNDepartment of Ortho

20、pedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, 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 prospecti

21、ve 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 evaluation 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

22、 intertrochanteric fractures with use of an intramedullary nail or 95 screw- plate. J Bone Joint Surg(Br), 2002, 84: 372- 381.4. 張經(jīng)緯張經(jīng)緯, 等等. 股骨轉(zhuǎn)子間骨折不同手術(shù)方法比較股骨轉(zhuǎn)子間骨折不同手術(shù)方法比較.中華骨科雜志中華骨科雜志, 2005, 25: 7- 11. 5. 盧華定盧華定, 等等. 股骨近端髓內(nèi)釘在股骨轉(zhuǎn)子周圍骨折中的應(yīng)用股骨近端髓內(nèi)釘在股骨轉(zhuǎn)子周圍骨折中的應(yīng)用. 中國骨與關(guān)節(jié)損傷雜志中國骨與關(guān)節(jié)損傷雜志, 2005, 20(4): 246-2

23、48.6. 姜磊姜磊, 等等. 閉合復(fù)位閉合復(fù)位PFN治療高齡股骨粗隆間骨折的體會治療高齡股骨粗隆間骨折的體會. 中國骨與關(guān)節(jié)損傷雜志中國骨與關(guān)節(jié)損傷雜志, 2006, 21(1): 59-60.7. 祝敬華祝敬華, 等等. DHS與與PFN在股骨粗隆間骨折中的應(yīng)用在股骨粗隆間骨折中的應(yīng)用. 中國骨與關(guān)節(jié)損傷雜志中國骨與關(guān)節(jié)損傷雜志, 2006, 21: 63-64.8. 范忠明范忠明, 等等. PFNA治療老年股骨粗隆間骨折治療老年股骨粗隆間骨折. 中國骨與關(guān)節(jié)損傷雜志中國骨與關(guān)節(jié)損傷雜志, 2009, 24(2): 151-153.9. 周建華周建華, 等等. PFNA治療老年不穩(wěn)定性股骨

24、轉(zhuǎn)子間骨折治療老年不穩(wěn)定性股骨轉(zhuǎn)子間骨折. 中國骨與關(guān)節(jié)損傷雜志中國骨與關(guān)節(jié)損傷雜志, 2008, 23(12): 1015-1017. 第21頁/共36頁1.一個部件即完成了抗旋轉(zhuǎn)及成角穩(wěn)定性一個部件即完成了抗旋轉(zhuǎn)及成角穩(wěn)定性 2.末端寬大的刀面盡可能多的壓縮周圍骨質(zhì)，尤其是末端寬大的刀面盡可能多的壓縮周圍骨質(zhì)，尤其是在骨質(zhì)疏松的情況下，具有更好的抓持力在骨質(zhì)疏松的情況下，具有更好的抓持力 3.PFNA螺旋刀片和骨質(zhì)貼合緊密，增強了穩(wěn)定性，螺旋刀片和骨質(zhì)貼合緊密，增強了穩(wěn)定性，防止旋轉(zhuǎn)和內(nèi)翻畸形防止旋轉(zhuǎn)和內(nèi)翻畸形 4.生物力學(xué)試驗證明生物力學(xué)試驗證明: 螺旋刀片顯著提高抗切出能力螺旋刀片顯著

25、提高抗切出能力PFNA PFNA 螺旋刀片螺旋刀片Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences PFN-A vs PFN第22頁/共36頁CArm 必不可少Department of Orthopedics , Guangdong General Hospital, Gu

26、angdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第23頁/共36頁骨科牽引床Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdon

27、g Academy of Medical Sciences 第24頁/共36頁骨科牽引床123骨折基本或部分閉合復(fù)位骨折基本或部分閉合復(fù)位向健側(cè)傾斜，掌握前傾角向健側(cè)傾斜，掌握前傾角內(nèi)收、內(nèi)旋患肢，糾正畸形內(nèi)收、內(nèi)旋患肢，糾正畸形Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Science

28、s 第25頁/共36頁Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Intraoperative 第26頁/共36頁52 歲歲，男性，男性12 monthsDepartment of Orthopedics , Guangdong General Hospital, Gu

29、angdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 1第27頁/共36頁鄧鄧X X，F(xiàn)emaleFemale，81Y81YDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong

30、General Hospital, Guangdong Academy of Medical Sciences Case 2第28頁/共36頁丁丁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頁/共36頁Depar

31、tment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，74Y74YCase 5第30頁/共36頁Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，81Y81YCase 8第31頁/共36頁Department of Orthopedics , Guang