1、股骨粗隆間骨折教學(xué)查房,八區(qū)骨科 2018-10-21,1,一、匯報病史,住院醫(yī)師：肖吉,2,病例,患者：陳志林 男 77歲 八區(qū)03床 因“右髖部外傷疼痛、活動受限1小時”于2018-10-10,經(jīng)急診收入病房,3,病史：患者1小時前行走時不慎跌倒，右髖部著地受傷，當(dāng)即感右髖部劇烈疼痛，局部未及明顯皮膚破潰出血，無法站立、行走，繼而局部腫脹，急至我院就診，查CT示：右股骨上段粉碎性骨折。為進一步診治，急診擬“右股骨粗隆間骨折”收入病房?；颊呤軅詠頍o頭痛，無發(fā)熱，大小便正常。,4,既往史：既往有低血壓病史，否認糖尿病等其他慢性病史。,5,查體：體溫 36.7 ，脈搏 84次/分，呼吸 21次

2、/分，血壓 88/61mmHg。視：右髖部未及皮膚破潰傷口及疤痕，右下肢外旋畸形，末梢血運正常。觸：右髖部壓痛明顯，可及骨擦感，右下肢皮膚感覺正常。動：右髖部活動受限，右足、右踝活動可。量：右下肢稍短縮。,6,實驗室及器械檢查：CT：右股骨上段粉碎性骨折。,7,診斷：右股骨粗隆間骨折（EvansV）,8,診療計劃,1.患者入院時生命體征平穩(wěn)，心腦肺腎等重要臟器功能可，內(nèi)環(huán)境穩(wěn)定，具體情況有待檢查結(jié)果進一步評估。 2.完善血尿糞三大常規(guī)、生化組合、血型、凝血常規(guī)、輸血八項、心電圖、心臟彩超、下肢深靜脈彩超、全胸片等檢查。 3.監(jiān)測生命體征，暫予以活血消腫、補液等對癥治療，下肢皮膚牽引，擇期手術(shù)，

3、Autar評分屬于中風(fēng)險，予以預(yù)防性抗凝等治療。,9,10,11,12,股骨粗隆間骨折定義及分析,主治醫(yī)師：王震,13,定義：股骨粗隆間骨折是指股骨頸基底至小粗隆下緣之間的骨折。,14,臨床表現(xiàn)： 傷后髖部疼痛，不能站立或行走。 下肢短縮及外旋畸形明顯。 局部可見腫脹及瘀斑，局部壓痛明顯?？蹞糇愀砍Ｒ鸹继巹×姨弁?。,15,診斷：明顯外傷史，患肢疼痛，活動受限。線片可確定骨折部位及移位情況。,16,治療措施：具體治療方法應(yīng)根據(jù)骨折類型、移位情況、患者年齡和全身情況，分別采取不同方法。,17,Evans classification,18,AO classification,19,治療方法選擇

4、,副主任醫(yī)師：張鋒,20,治療方法,牽引療法 適應(yīng)所有類型的粗隆間骨折。尤其對無移位的穩(wěn)定性骨折并有較重內(nèi)臟疾患不適合手術(shù)者。,21,手術(shù)治療,股骨粗隆骨折的內(nèi)固定分為髓外固定和髓內(nèi) 固定。髓外固定以 DHS 和股骨近端鎖定加壓鋼板為主； 髓內(nèi)固定以髓內(nèi)釘為主，目前應(yīng)用較多的包 括第 3 代 G a m m a 釘、PFNA）和 InterTan）。,22,？,23,24,內(nèi)固定物的選擇,DHS內(nèi)固定 標(biāo)準(zhǔn)的手術(shù)方式。但隨著更新型內(nèi)固定方式 出現(xiàn)，地位出現(xiàn)動搖，但仍是選擇的主要方式。,25,髓內(nèi)固定方式，更具力學(xué)優(yōu)勢 Gamma Nail PFNA InterTan,內(nèi)固定物的選擇,26,Ga

5、mma Nail 為目前各類髓內(nèi)釘?shù)闹谱髟团c模板,27,PFNA 螺旋刀頭，優(yōu)勢明顯,28,InterTan近端為 2 枚絞索設(shè)計的螺釘,29,髖關(guān)節(jié)置換THR 早期負重，早期下地活動，減少臥床并發(fā)癥,內(nèi)固定物的選擇,30,結(jié)論,對于老年股骨粗隆骨折患者，穩(wěn)定型骨折可選用 DHS 或 Gamma 釘；不穩(wěn)定型股骨粗隆骨折，可根據(jù)骨折類型、骨質(zhì)情況等選用 PFNA、InterTan 等髓內(nèi)固定系統(tǒng)。高齡粉碎性股骨粗隆骨折建議行髖關(guān)節(jié)置換術(shù)。,31,徐眾華科主任點評,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