5.1 membrul superior
DESCRIPTION
OrtopedieTRANSCRIPT
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V.FRACTURILE MEMBRULUI SUPERIOR
1.FRACTURILE CENTURII SCAPULARE1.A.Fracturile de clavicula
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• INCIDENTA: 11% Locul II in frecventa
fracturilor
• CONDITII FAVORIZANTE:
-Pozitia superficiala a claviculei
• -Rolul de “tampon” intre membrul toracic si trunchi
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MECANISMUL DE PRODUCERE
• DIRECT (rar) • INDIRECT (frecvent)Caderea pe umar sau
mana –Accentuarea curburilor
claviculei ( “S” italic)Fractura claviculei
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Forme clinice
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FORME CLINICEI.Fractura de 1/3 externa
• Rara• Mecanism directA.FARA DEPLASAREPRIN ligamentele coraco-claviculare
(care sunt integre)- Neer IB.CU DEPLASAREINAFARA ligamentelor coraco-
clavicularePRIN ligamentele coraco-claviculare
(care sunt rupte)- Neer IISimptome: -deformare in “treapta de
scara” -semnul “clapei de pian”Tratament : bandaj compresiv tip Robert
Jones
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II.Fractura de 1/3 interna
• Rara• Deplasari variabile ( in
functie de pozitia fata de SCM )
• Tratament :Bandaj Desault 2-3 sapt.
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III.Fractura de 1/3 medie
• Frecventa mare• Traect : - transversal - oblic (scurt – lung)• Focar : - unic - cominutiv• Fragment intermediar – leziuni vasculo-
nervoase
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• Deplasari : -fragm. intern –
cranial (SCM) -fragm. extern –
caudal (deltoid, pectoral)
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• Inspectie:-pozitie antalgica
(“atitudine umila”)-umar coborit-deformarea regiunii-echimoza tardiva• Palpare :-durere punct fix-mobilitate anormala-crepitatii osoase
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TRATAMENTI.Ortopedic
• FARA DEPLASARE-bandaj DESAULT-aparat gipsatDESAULT-GERDY Durata imobilizarii:-copii : 7-14 zile-adulti : 21 zile
• CU DEPLASAREA.Reducere ortopedica
B.Imobilizare
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a.Reducere ortopedica
• Tractiune umeri : -cranial -posterior -extern• Contraextensie
genunchi intre omoplati
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b.Imobilizare
• bandaj DESAULT 21-28 zile
• Bandaj incrucisat in “8” (WATSON-JONES) 21-28 zile
• Metoda COUTEAU (politraumatizati,
tarati)
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II.Chirurgical
• INDICATII: -Fracturi complicate -Fracturi ireductibile -Scurtare sau angulare mare
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• METODE -Fracturi oblice lungi : -Cerclaje sirma -Suruburi -Fracturi transversale si
oblice scurte : -Placa cu suruburi -Brosa Kirschner• IMOBILIZARE Bandaj Desault 14-
21 zile
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COMPLICATIII.Imediate
• Fractura deschisa• Leziuni vasculare (vase subclaviculare)• Leziuni nervoase (directe , indirecte)• Leziuni viscerale (domul pleural)
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COMPLICATIIII.Tardive
• Calus vicios
• Pseudartroza• Osteita• Redori articulare (PSH)
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Fracturile de omoplatfrecv.≈ 1%
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► mec. producere:■ direct: politraumatisme■ indirect: contracţii musculare
► forme clinice: → fr. corp omoplat; → fr. unghiuri – intern – extern – inferior
→ fr. apofizare – coracoida – acromion
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A. Fractura corpului→ traiect: orizontal, vertical→ fracturi cu/fără deplasare→ fracturi simple sau cominutive
► clinic: durere, tumefacţie, echimoze, impotenţă funcţională parţială umăr
► tratament: bandaj Desault 10-20 zile► evoluţie: consolidare în 30-60 zile
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• Fractura unghi intern• Fractura unghi inferior
■ Fractura unghi extern
→ fr. col anatomic (intra-articulară)→ fr. col chirurgical (extra-articulară)
Bandaj Desault
10-15 zile
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Fracturile colului anatomic► se pot asocia cu fracturi ale glenei (factor
de gravitate)→ luxaţie recidivantă de umăr;► tratament: ■ fr. fără modificarea orientării glenei în
raport cu capul humeral: bandaj Desault 14 zile;
■ fr. cu deplasare ale glenei, fr. cu modificarea orientării glenei în raport cu capul humeral şi fr. asociate cu luxaţie scpulo-humerală: tratam. chirurgical
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Fractură col chirurgical omoplat, operată (placă înşurubată)
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Fracturile colului chirurgical
►fr. fără deplasare: bandaj Desault 10 zile►fr. cu deplasare– clinic: • deformare în "epolet“ a umărului; • deplasare coracoidă la mişcările
braţului; – complicaţii: leziuni plex brahial, n. axilar, vase
axilare
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Fracturile colului chirurgicaltratament
1.Tentativă de reducere ortopedică: – tracţiune braţ în: abducţie 80˚ anteducţie 40˚ flexie cot 90˚ +– gips toraco-brahial de abducţie 4-5 săpt.2. Tratament chirurgical (reducere sângerândă +
osteosinteză cu şuruburi/plăci înşurubate)
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rx iniţialrx post-red. ortop. (eşuată)
rx post-interv. chir. (placă înşurubată)
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Fracturi ale apofizelor omoplatului
►fr. coracoidă►fr. acromion
Tratament: – ortopedic: bandaj Desault 14-21 zile
– chirurgical: şuruburi sau plăci
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FRACTURILE HUMERUSULUI
Din pdv topografic:♦ fract. 1/3 proximale
♦ fract. diafizare
♦ fract. 1/3 distale
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Fracturile 1/3 proximale humerus
-aprox. 5% din totalul fracturilor- tineri: high velocity trauma- virstnici: accidente casnice (osteoporoza)
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Clasificare Neer
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Examen clinic
• Umar tumefiat• Durere intensa• Limitarea mobilitatii umarului• Depresie externa subdeltoidiana (fracturile col
chirurgical)• Echimoza tardiva brahio-toracica• Scurtarea distantei acromio-epicondiliene
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Examen radiografic
Incidenta AP (fata) Incidenta profil Incidenta axilara
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Tratament
• Fracturile in 2 parti, fara deplasare- tratament conservator (bandaj toraco-brahial pt. 3-4 saptamini, urmat de recuperre functionala)
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Tratament chirurgical (osteosinteza) -fract in 2 parti, cu deplasare
-fracturi in 3 sau 4 parti
Brose K percutan Placa LCP Philos Tija zavorata
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Tratament chirurgical(artroplastie) -fracturi in 3 sau 4 parti (osteoporoza)
-fracturi luxatii cominutive
Proteza Neer Proteza reversa
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Complicatii
• Pareze n. axilar• Leziune artera axilara• Pseudartroza • Redoare de umar• Artroza de umar
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Fracturile de diafiza humerala
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Clasificare OTA (Orthopaedic Trauma Association)
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Tratament conservator
-Bandaj Desault-Gips brahio-palmar-Orteze functionale (Sarmiento)
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Tratament chirurgical
Osteosinteza cu placi insurubate
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Tratament chirurgical
Tija anterograda
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Tratament chirurgical
Tije Ender retrograde
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Complicatii
• Fractura deschisa • Pareza nerv radial• Pseudartroza • Redori articulare (umar, cot)
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Fracturile 1/3 distale humerus (paleta humerala)
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Diagnostic
• Cot tumefiat• Durere intensa• Limitare severa mobilitate activa si pasiva cot• Echimoza tardiva• Examen radiografic in 2 incidente (AP+profil)• + CT cot (cu reconstructie 3D)
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