前臂骨折.ppt

前臂骨折前臂骨折 五附院骨二科 五附院骨二科五附院骨二科 尺桡骨双骨折 尺骨单骨折 桡骨单骨折 前臂远端骨折 授课内容 五附院骨二科五附院骨二科 体表标志 五附院骨二科五附院骨二科 体表标志 五附院骨二科五附院骨二科 前臂前区 五附院骨二科五附院骨二科 五附院骨二科五附院骨二科 前臂前区 五附院骨二科五附院骨二科 前臂前区 五附院骨二科五附院骨二科 前臂前区 五附院骨二科五附院骨二科 桡神经深支和后侧骨间神经：桡神经在肘窝外侧，肱骨外上髁前方，分浅、深两支 桡神经深支发出肌支至桡侧腕长、短伸肌和旋后肌，然后穿入旋后肌，在桡骨头下方57CM出穿出该肌，称为后侧骨间神经，走行与前臂肌后群浅、深两层之间 分短支与长支 前臂后区 深层 五附院骨二科五附院骨二科 前臂后区 五附院骨二科五附院骨二科 前臂后区 五附院骨二科五附院骨二科 前臂后区 五附院骨二科五附院骨二科 前臂后区 五附院骨二科五附院骨二科 A型 简单骨折（A1,A2,A3）B型 锲型骨折 (B1,B2,B3)C型 复杂骨折 (C1,C2,C3)前臂骨折AO分型 五附院骨二科五附院骨二科 A1.1 斜型骨折 五附院骨二科五附院骨二科 A1.2 横型骨折 五附院骨二科五附院骨二科 A 1.3 伴有桡骨头脱位（孟氏骨折）五附院骨二科五附院骨二科 A2.1 斜型骨折 五附院骨二科五附院骨二科 A2.2 横型骨折 五附院骨二科五附院骨二科 A2.3 伴头下尺桡关节脱位（盖氏骨折）五附院骨二科五附院骨二科 A 3 简单的双骨折 五附院骨二科五附院骨二科 B1.1 完整锲型 五附院骨二科五附院骨二科 B1.2 带有碎片的锲型骨折 五附院骨二科五附院骨二科 B1.3 伴有桡骨头脱位（孟氏骨折）五附院骨二科五附院骨二科 B2.1 完整锲型 五附院骨二科五附院骨二科 B2.2 碎片锲型 五附院骨二科五附院骨二科 B2.3 伴有下尺桡关节脱位（盖氏骨折）五附院骨二科五附院骨二科 B3.1 尺骨锲型，桡骨简单骨折 五附院骨二科五附院骨二科 B3.2 桡骨锲型，尺骨简单骨折 五附院骨二科五附院骨二科 B3.3 尺桡骨锲型骨折 五附院骨二科五附院骨二科 C1.1 两端，桡骨完整 五附院骨二科五附院骨二科 C1.2 两段 桡骨骨折 五附院骨二科五附院骨二科 C1.3 不规则 五附院骨二科五附院骨二科 C2.1 两段，尺骨完整 五附院骨二科五附院骨二科 C2.2 两段，尺骨骨折 五附院骨二科五附院骨二科 C2.3 不规则 五附院骨二科五附院骨二科 C 3 尺桡骨复杂骨折 五附院骨二科五附院骨二科 桡骨干前外侧入路：桡骨干全长 （Henry切口）桡骨干后侧入路：桡骨干上中部（Thompson切口）尺骨干后侧入路：尺骨全长 常用手术入路 AP and lateral views of the both bones fracture of the forearm,demonstrating significant shortening and relatively simple oblique fracture patterns.The patient is positioned supine with the arm prepped and draped to just above the elbow and a tourniquet in place.This figure demonstrates the arm held in supination.Note the position of the biceps insertion as well as the palpable tendon of the FCR and radial artery.BICEPS TENDON RADIAL ARTERY FLEXOR CARPI RADIALIS (FCR)A useful technique to make the skin incision is to take a bovi cord and pull it taught from the radial side of the biceps tendon to the FCR at the level of the wrist.This can then be used as a template for the incision line.The incision is taken down through the skin,identifying the fascial layer with care taken not to damage any superficial veins that may be intact.The FCR tendon is clearly visible throughout the wound,as is the radial artery in the distal extent of the wound.FCR RADIAL ARTERY A closeup of the distal aspect of the wound demonstrating The radial artery and its venous commtantes.RADIAL ARTERY AND VENOUS COMMTANTES FCR RADIAL ARTERY The fascia on the radial side of the flexor carpi radialis is released,exposing the deep tissue.The radial artery can be followed now throughout the entire incision.The radial artery may be taken in either direction,however,typically it is easier to take the artery to the radial side.FCR RADIAL ARTERY The deep dissection is now performed between the flexor-pronator mass on the ulnar side and the artery and the mobile wad on the radial side.PRONATOR For the proximal dissection,the forearm is brought into supination and the pronator,FDS and FDP are released from the volar aspect of the radius FDS The pronator is being released from the radial aspect of the radius in a subperiosteal manner.This subperiosteal dissection continues distally to release the origin of the common flexor.After exposure of the volar aspect of the radius proximally and distally,two clamps can be placed on the ends of the bone in order to deliver them for cleaning.FCR RADIAL ARTERY Each side of the fracture is be delivered in order to expose and clean the cortical edges.These figures demonstrate delivery of the distal fragment and a curved curette being used to clean the cortical edge.No cleaning should be performed within the intramedullary canal,as this is healthy tissue and can be useful for the healing process.Once the fractures are completely cleaned along their cortical edges such that the fracture reduction can be visualized,the two clamps are used to reduce the fracture.If a butterfly fragment exists,it is necessary to fix this with a lag screw back to one of the fracture ends in order to realign the fracture.In the current case,the fracture is a simple pattern and is reduced by delivering the bones jointly,accentuating the deformity and then rotating and fitting the bones together with progressive compression while pushing the bones back into the wound,obtaining alignment by steric interference of one side against the other.Once the bones are held reduced,as seen in the following sequence,an appropriate dynamic compression plate is placed and held in place with a clamp.It is important that this plate must have the appropriate bend for the volar aspect of the forearm so as not to gap open the dorsal side as the plate is fixed to the bone.Thus,it should be slightly underbent with respect to the standard volar concavity.These figures demonstrate reduction of the fracture with a plate held in place on the flat,volar aspect of the bone.Once the reduction is confirmed fixation of the plate is performed using a compressive technique through the plate.The following sequence demonstrates using the offset drill guide to place an eccentrically drilled hole away from the fracture.The screw is placed to the