242702848 fracturi membru superior
DESCRIPTION
fracturi membru superior ortopedie suubTRANSCRIPT
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FRACTURILE MEMBRULUI TORACIC
S.U.U.M.C. “”Carol Davila” BucurestiClinica de Ortopedie – Traumatologie
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Fracturile claviculei
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Fracturile claviculeiFracturile claviculei
• Frecvente la copil (30% dintre fracturi)
• Cadere pe mana ++• Soc direct pe umar
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Palpare– Durere– Fragmente mobile
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1- Coracoida, 2 - acromion, 3 - glena
Radiografie
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Deplasarea tipica
- Fragment interen ascensionat (SCM)
- Umar cazut (greutate, pectoral)
- Fragmentul intern basculat
- Atitudine de traumatism al membrului superior.
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Traiect situat intre insertiile ligamentare
Traiect in afara insertiilor
Un fragment pastreaza legatura cu unul dintre ligamente
Deplasarea variaza in functie de localizarea fracturii
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Complicatiile fracturilor de clavicula
Risc de leziuni neurovasculare
Risc de deschidere cutanata
In caz de deplasare importanta :
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Risc de leziune vasculonervoasa
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Tratament ortopedicTratament ortopedic
• Simpla esarfa pentru sustinerea membrului toracic
• La copil : idem
• Consolidare in 3-5 saptamani
Fractura fara deplasare
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Tratament ortopedicTratament ortopedic
• Bandaj in ‘8’ reglabil
• Consolidare in 3-5 saptamani
• Frecvente calusuri vicioase
Fractura deplasata
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Tratament ortopedicTratament ortopedic
Tip de bandaj pentru copilul mic
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Tratament ortopedicTratament ortopedic
• Frecvent calus vicios
• Inconvenient estetic mai mare decat functional
• Pseudartroza rara (tratamentul chirurgical)
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Tratament chirurgical
Brosa Placa superioara
Placa inferioara
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Tratament chirurgical
Avantaje
Restabilirea anatomiei
Mobilizare precoce
Inconveniente
Deperiostarea
Devascularizarea
Intarzierea in consolidare
Infectie posibila
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Fracturile distale : hobanaj (brose si fir in 8)
Tratament chirurgical
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Fractura deschisa
Tratament posibil prin minifixator extern
Tratament chirurgical
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Fracturile extremitatii superioare a humerusului
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Anatomie
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Fracturile extraarticulare
Brat departat mai putin de 45° : fractura in adductie
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Brat departat mai mult de 45° : Fractura in abductie
Fracturile extraarticulare
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Diagnostic
• Durere la nivelul colului humeral• Deformare mai vizibila in Fr in abductie• Echimoza• Se vor cauta complicatiile
– vasculare (puls)– nervoase : plexul brahial, circumflexa, radialul– cutanate(deschidere rara)– musculare (deltoid, tendonul biceps, interpozitie)
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Radiografie
Se analizeaza traiectele de fractura si se numara fragmentele
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CT uneori necesar
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Clasificare
• Fracturi extraarticulare
– Tuberozitare (trohiter, trohin)– Fracturi subtuberozitare (col chirurgical)
angrenate 70%
• Fracturi articulare
• Fracturi epifizo- metafizare
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Fracturi extraarticulare
Fr trohiter
Fr subtuberozitare
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Fracturi articulare
Angrenate Deplasate Foarte deplasate Fr-luxatie
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Fractura- luxatie
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Fracturile luxatii
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Enucleerea
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Fractura trohiterului
Reducere chirurgicala a fracturilor deplasate
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Osteosinteza cu suruburi sau cerclaj
Fracturi de trohiter deplasate
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Complicatii vasculare
Pulsul +++
Doppler sau angiografie
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Fractura fara deplasare :
Bandaj tip Dessault 30 zile
Dupa 15 zile : mobilizare blanda Z 30 : reeducare
Tratament ortopedic
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Dupa 15 zile : mobilizare blanda Z 30 : reeducare
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Reducerea manuala este urmata de imobilizare in bandaj sau bandaj gipsat
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Gips in rotatie neutra pentru fracturile neangrenate
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Tratament ortopedic
Fracturi deplasate: reducere lenta
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Imaginea 3D uneori utila pentru decizia terapeutica
Tratament chirurgical
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Tratamentul chirurgical al fracturilor extremitate proximala de humerus
• Osteosinteza clasica – Cu brose– Cu suruburi– Placa si suruburi
• Tije elastice
• Tija zavorata
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Instalarea pacientului pentru interventiile pe umar
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Brose simple
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Brose percutane cu focar inchis
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Brose percutane cu focar inchis
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Tratament chirurgical
Suruburi simple
(reeducare precoce : risc de migrare si degradare montaj)
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Tratament chirurgical
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Tratament chirurgical
Osteosinteza solida cu placa si suruburi
Mobilizare precoce (inconvenient- focarul deschis)
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Tratament chirurgical
Brose elastice
(Hacketal)
Realizate sub tractiune si control RX
2-5 brose sunt introduse lateral sau prin orificiu deasupra fosetei olecraniene
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Photo J. chouteau
Incizie sub trohiter Introducerea tijei dupa alezaj Zavorare
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Zavorarea centromedulara
Tija scurta zavorata
« Telegraph »Reeducare precoce
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Tija zavorata pentru fracturi cominutive metafizodiafizare
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Complicatiile Fr extremitati prox de humerus
• Fractura deschisa este rara• Leziunea vaselor axilare• Necroza capului humeral (1 %)• Pseudartroza- rara• Artroza omo-humerala• Redoarea (rolul chirurgiei si reeducarii)• Calusul vicios :
– Problematic numai daca depaseste 30°
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Necroza capului humeral dupa tratament ortopedic
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Fracturile humerusului
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Deplasarea fragmentelor in functie de localizarea fracturii
Intre pectoral si deltoid
Intre pectoral si subscapular
Sub deltoid
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Mecanism si traiectul de fractura
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Complicatii precoce
• Deschidere cutanata
• Leziunea vaselor
• Leziune de radial
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Tratament ortopedic
Gips toracobrahial
• Imobilizarea articulatiilor supra si subiacente
• Rotatie neutra a umarului
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Tratament ortopedic
Gips de atarnare
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Tratament chirurgical
Tija introdusa din proximal Tija retrograda
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Tija zavorata pentru fractura spiroida de humerus
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Tija zavorata pentru fractura instabila
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Tije elastice
Tija centrala 2 tije laterale
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Osteosinteza cu placa
Placa posterioara Placa externa
Inconveniente :
• Abord chirurgical larg
• Devascularizarea fragmentelor
• Expunerea radialului
• Intarziere de consolidare
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Osteosinteza cu placa zavorata risc de pseudartroza ++
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Fracturi deschise
Pierderi de substanta osoasa
Pseudartrozele infectate
Fixatorul extern
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Evolutia fracturilor de humerus
• Calusul vicios este apanajul tratamentului ortopedic prin deplasare secundara
• Pseudartrozele apar mai ales dupa osteosinteza deschisa
• Paralizia de radial- supraveghere EMG
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Fracturile cotuluiFracturile cotului
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Fracturile distale de humerus
Supracondiliene Supra si intercondiliene
Condil extern Condil intern
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Fractura in hiper extensie
80 %
Cadere pe mana
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Deplasarea
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Examen: Cele 3 repere ale cotului
Aliniament in extensie Triunghi isoscel in flexie
Epicondili, epitrohlee si olecran
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Complicatiile fracturilor supracondiliene
Deschiderea cutanat Lez vasculara Median Cubital
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Tratament ortopedic al fracturilor supracondiliene
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Tratament ortopedic al fracturilor supracondiliene
Reducerea se face in flexie Dar niciodata imobilizarea in flexie
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Prevenirea sindromului Volkmann
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Retractia ischemica a flexorilor
Prevenirea sindromului Volkmann
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Reducere si osteosinteza percutana cu sau fara abord chirurgical
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Tractiunea continua pentru fracturile foarte deplasate :
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Consolidari vicioase
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Fracturi supra si intercondiliene la adult
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Fractura complexa de paleta
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Fractura de paleta humerala
OS cu placa in Y
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Fracturi supra si intercondiliene
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Fixator extern pentru fracturi deschise
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Fractura de epitrohlee
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Fractura condilului intern
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Fracturile olecreanului
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• Soc direct
• Deplasare prin tractiunea tricepsului
• Extensie activa imposibila• Palpare : durerer
: fragmente mobile
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Radiografie
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Tratament
Fara deplasare: imobilizare 3 sapt
Deplasare: OS cu surub, placa sau hobanaj
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Procedeul hobanajului
2 brose
1 fir metalic in 8
Compresia focarului
Mobilizare activa si pasiva
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Procedeul hobanajului
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Fracturile capului radial
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• Cadere pe mana
• Fractura colului radial
• Fr capului radial
Fracturile capului radial
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Fracturile capului radial
Fracturi simple
Brosa transcondiliana
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Fracturile capului radial
Fracturi cominutive
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Fracturile capului radial
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Risc de afectare secundara a pronosupinatiei
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Fracturile antebratului
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Prono-supinatia
Supinatia Pronatia
Pronatia intermediara
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Conditiile prono-supinatiei
• Lungimea oaselor trebuie sa fie intacta
• Curbura pronatorie a radiusului intacta
• Sa nu existe decalaj intre cele 2 oase
• Spatiul interosos liber• Cele 2 articulatii radiocubitale
mobile
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Fracturile antebratului
• Frecvente la copil si adult• Soc direct sau indirect
• La copil fractura in « lemn verde »
• La adult cele mai frecvente in 1/3 medie
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• Cel mai adese ambele oase sunt fracturate
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• Fractura izolata a unui adintre cele doua oase cu sau fara luxatia celuilalt
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Tratamentul fracturilor de antebrat
• Fractura nedeplasata: imobilizare gipsata
• Fracturi in lemn verde: reducere si imobilizare
• Fracturile deplasate– Reducere ortopedica daca este posibil– Deplasarea secundara frecventaq– Reducere si osteosinteza
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Tratamentul fracturilor de antebrat
• Imobilizare cu cotul flectat la 90 grade cu pumnul usor flectatdorsal si pronatie intermediara
• Radiografii de control repetate• Imobilizare gipsata 4-6 saptamani ( dupa varsta)• Rare pseudartroze• Deplasari secundare frecvente
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Fractura in lemn verde
Usoara deplasare : Imobilizare
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Fractura in Fractura in lemn verdelemn verde
Putin deplasata Foarte deplasata
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Reducerea Fr in lemn verde
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Corect calus vicios
Fractura in Fractura in lemn verdelemn verde
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Fracturi ireductibile la copil si cele cu deplasare la adult
Tratament chirurgical
Mobilizare rapida
Consolidare rapida
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Deplasare sub gips osteosinteza cu placi
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Ostéosynthèse des 2 os au tiers distal chez un enfant
Interposition musculaire
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Complicatiile fr de antebrat
• Deschidere cutanata• Ireductibilitate• Sindrom Volkmann• Pseudartroza• Redoarea prono-supinatiei• Sinostoza• Fractura iterativa dupa ablatia placii
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Fractura izolata de radius
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Fractura Essex Lopresti
Fractura de radius si fr de cap radial
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Fractura de cubitus
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Fractura Monteggia
Fractura de cubitus +
Luxatia capului radial
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Fractura Galeazzi
Fractura de radius cu luxatie distala de cubitus
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Tratamentul Fracturii Galeazzi
Dupa reducerea radiusului si cubitusul se reduce
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Tratamentul fracturii Monteggia
- Reducere
- Osteosinteza anatomica a cubitusului
- Radiusul este acum stabilizat
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Fractura Monteggia cominutiva deschisa
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Fracturile de radiocarpiene ( de pumn)
Fracturile extremitatii distale de radius si Fr de scafoid
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Interliniul radiocarpian
Anatomie
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Anatomie
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Fracturile de EDR 9epifiza distala de radius)
• Frecvente la femeile in varsta• Tineri, mai ales sportivi
Cadere pe mana• Hiperextensie (deplasare dorsala)• Hiperflexie ( deplasare palmara)• Inclinatie radiala• Inclinatie ulnara
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Clasificare Clasificare (Castaing)(Castaing)
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Clasificare fracturilor de EDR
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Fracturi articulare
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Fracturi articulare
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Radiografie de pumn
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Fracturi Pouteau-Colles
• Cadere pe palma • Compresie si hiperextensie• Traiect situat la 2.5 cm de articulatie• Adult si varstnic
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Fracturi Pouteau putin deplasata
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Fr Pouteau : deplasata
Deformare in dos de furculita
Inclinatie radiala
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Tratament
• Fracturi fara deplasare- imobilizare 4-6 saptamani
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Fr Pouteau deplasata
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Pouteau: reducere
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Imobilizare dupa reducere
• Flexie- inclinare cubitala
• Radiografie de control
• Pentru 6 saptamani
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Consolidare vicioasa
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Tratament cu brose intrafocale
Si imobilizare
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Tehnica kapandji
2-3 brose prin focar
Mobilizare precoce
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Kapandji
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Tratamentul fracturilor marginale
Placa anterioara
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Tratamentul fracturilor cominutive
Fixator extern cu distractie
Documents M.O
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Fracturi de scafoid carpian
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• Deplasare minima cel mai frecvent
20 % pol superior
70 % col
10 % baza
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• Durere in tabachiera anatomica
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Fr fara deplasare
• Imobilizarea policelui in abductie• Pumn in dorsiflexie in pronatie inclinatie radiala• 6 saptamani
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Tratament chirurgical
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Evolutia fracturilor de scafoid
Consolidare lenta
Frecvent pseudartroza
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Fracturile de metacarpiene
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Deplasarea fracturii de col metacarpian
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Imobilizare in flexie
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Osteosinteza fr de metacarp
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Documents J. Chouteau
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Documents J. Chouteau
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Fractura Benett
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Traitement de la fracture de Benett
Réduction orthopédique et plâtre
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Fracturile de falanga
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Fr de F1 – reducere in flexie
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Imobilizare in flexie
Procédé de la boule de plâtre de Bonvalet
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Osteosinteza
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Va multumesc!