什么是复杂的股骨转子间骨折
股骨转子间骨折复位的要求
good: 正侧位皮质之间的距离均小于一个皮质的厚度 acceptable :正位或侧位皮质之间的距离小于一个皮质的厚度 poor :无论正位侧位,皮质的距离都大于一个皮质的厚度. Youngwoo Kim, et al. Hook leverage technique for reduction ofintertrochanteric fracture. Injury, (2014) 1006–1010 大约有11%左右的转子间骨折,通过闭合复位时很难达到满意的效果的。这个数据各家报道不一,基本上在 3% 到 17% 之间。 Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 ◆ ◆ ◆ 类型一 AO/OTA 31-A1.2 fracture 顺粗隆骨折,骨折线至小粗隆上 Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 不是骨折端间有嵌插,而是近端骨折块“锁”在股骨干的下方,复位近端骨折块非常困难,有时需要切断部分髂腰肌腱。 G.Z. Said, et al. An irreducible variant ofintertrochanteric fractures: a technique for open reduction. Injury, (2005) 36,871—874 AO/OTA 31-A1.3 fracture Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 Supposed chain of causation and effect ofnail breakage after trochanteric fracture: Fixation of a stableintertrochanteric fracture in extreme valgus position (a) results in limitedcranial bone contact of the fragments and leaves a caudal bone defect (b). Lackof bony healing induces permanent full strain on the femoral nail finally leadingto nail breakage, thus resulting in the conversion of an intertrochantericfracture (A1/A2) into a reversed fracture (A3) (c) A1-3型绝对是陷阱 ◆ ◆ ◆ 类型II 矢状位不稳 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 AO/ASIF 分型 31 A1.3 到 31 A2.3 都可能出现矢状位不稳,轴向牵引力和重力只会让近端骨折屈曲、远端骨折向后移动,单纯向上抬大腿对复位没有帮助,如果后内侧或小转子有骨折时尤其难复。 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 如果倾斜的骨折面,在远端骨块上是“面向”后面的,在重力的帮助下,通过牵引和旋转,可能获得满意的复位。 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 相反,如果倾斜的骨折面,在远端骨块上是“面向”前面的,牵引只会加剧移位。 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 Case:孤寡老人,男,82岁,小区滑倒 术前CT片提示转子间粉碎性骨折,骨折线到转子下 术中透视-复位 临时固定、开口 置钉 术后复查 ◆ ◆ ◆ 类型三 AO/OTA 31-A2.2 Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 近端骨折块并没有坎插到股骨干部,有向前向下移位的倾向。并且这种倾向不会因为轴向牵引而停止。 Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 Case:老年女性,75岁,术前X片 术中透视-难以复位 术中透视-克氏针辅助复位 术中透视-辅助复位 术中透视-再次调整-打入导针 术中最后透视
建立骨性通道的时候复位丢失 一期复位丢失 Case:徐某,老年女性,80岁,浴室滑倒 复位、临时固定 主钉插入困难 插入导针处理开口 ------重建骨性隧道 用手指抵住reamer Ioannis Aktselis, et al. Intramedullarynailing of trochanteric fractures—Operative technical tips. Injury, (2012)961–965 在进行以上操作的同时必须将软钻向内折弯,从而可避免软组织将钻头推向外侧。在折弯的作用下,软钻具有变直的反作用力,从而可将钻头推向内侧 Ioannis Aktselis, et al. Intramedullarynailing of trochanteric fractures—Operative technical tips. Injury, (2012)961–965 术中最后透视 近年来,对于股骨转子间骨折合并外侧壁骨折的治疗方法是热点问题
外侧壁的定义 a-b为股骨颈上方切线,c-d为股骨颈下方切线,两条直线与股骨外侧的交界的区域为股骨转子间的外侧壁。 HaqRU Proximal femoral nails compared with reverse distal femoral lockingplates in intertrochanteric fractures with a compromised lateral wall; arandomised controlled trial IntOrthop. 2014 Mar 22. Tip 2: ‘‘No Lateral Wall, No Hip Screw’’ Intertrochanteric Fractures:Ten Tips toImprove Results THE JOURNAL OF BONE & JOINT SURGERY dJBJ S .ORG VOLUME 91-A d NUMBER 3 d MARCH 2009 对于转子间骨折外侧壁的厚度与再次骨折的发生也有关系 d=股骨大转子下无名结节下3cm向上135°至骨折线的距离。 A RELIABLE PREDICTOR OF POST-OPERATIVELATERAL WALL FRACTURE IN INTERTROCHANTERIC FRACTURES。Bone Joint J 2013;95-B:1134–8. 薄壁=外侧壁损伤
外侧壁损伤髓内钉作用 A3.3 unstable intertrochanteric fracture.If sliding hip screw had been chosen as the method of treatment, uncontrollablemedialisation and eventual failure would be likely. The nail acts as a buttress, due to itscentromedullary position and prevents failure 髓内钉可以重建外侧壁阻止股骨近端向外滑移 Evolving concepts of stability andintramedullary fixation of intertrochanteric fractures--a reviewInjury. 2012Jun;43(6):686-93 预测因素
Inadequate ‘three-point’ proximal fixation predicts failure of the Gamma nail.BoneJoint J 2013;95-B:825–30 不稳定型-外侧壁损伤 Treatment of Complex Proximal FemoralFractures With the Proximal Femur Locking Compression Plate Erik A. Hasenboehler, MD; 近端复杂骨折 无论哪种方法固定,复位至关重要! 大量文献都关注于股骨转子间骨折合并外侧壁骨折的固定方法,对于外侧壁粉碎骨折对固定内置物稳定性会有影响。因此矢状位和冠状位的解剖复位会增加稳定,特别是冠状位的复位是十分重要的 Perioperative Lateral Trochanteric WallFractures: Sliding Hip Screw versus Percutaneous Compression Plate forIntertrochanteric Hip Fractures。J Orthop Trauma April 2011 男性,65岁,脊髓灰质炎多年,摔伤 术前CT片2016-06-279 术中透视-复位 术中最后透视 术后复查 术后两个月复查
怎么办? 争议 长钉固定 Treatment of Pertrochanteric Fractures:Long Versus Short Nailing Kaan S Long Versus Short Nailing ForIntertrochanteric Femur Fractures Kelly Carlberg … … 手术时间长 术中失血多 系统并发症多 费用高…… OTA 28th Annual Meeting October3~6,2012 文献 不稳定型-外侧壁损伤-累及转子下 长髓内钉+钢板 一年后 Bone Mass, Structure and Quality Diagnosis of Osteoporosis Pre UrgentSurgery Stability of Reduction 复位第一要素! Blade shaped weightbearing elements PMMA Augmentation 复杂股骨转子间骨折
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