frakturtyper adgange og kirurgisk behandling - ortopaedi.dk€¦ · mccormack rg, brien d, buckley...
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Frakturtyper Adgange og
Kirurgisk behandling
1
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital
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Når foredraget er slut skal du vide noget om: 1. Epidemiologi 2. Konservativ behandling og resultater 3. Indikationer for kirurgisk behandling 4. Adgange til humerus-skaftet 5. Forskellige osteosyntesemetoder
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 2
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14,5 fraktur/100.000 indbygger/år Gns-alder 63 år Kvinder/mænd 61%/39% 8% har radialisparese 8% er patologiske (bryst 26%, myelomer 18%, nyrer 15% , prostata 12%. 2% er åbne frakturer
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 3
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 4
Ca. 30% i proksimale del
Ca. 60% i den centrale del
Ca. 10% i distale del
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Langt de fleste kan behandles konservativt
Dvs. orthose, eks. Sarmeniento
Med eller uden skulder del
Tilpasset orthose
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 5
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Konservativ vs. Operativ behandling: ???? Sammenligning af forskellige operative metoder: få randomiserede
studier Mange case serier med gode resultater Sarmiento A., Latta L. L. Evidengrad IV [Humeral diaphyseal fractures: functional bracing] Unfallchirurg, 2007:(110):824-32 Results: 620 patients Average healing time was 11.5 weeks in 97.5% of patients Operative intervention was required because of a nonunion in 16 patients
(2.5%) Refracture after brace removal occurred in four patients (0.6%) Nerve function did not return in only one of the 67 patient who had radial
nerve palsy
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 6
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20 g. anterior/posterior vinkling 30 g. varus vinkling 15 g. rotationsfejlstilling 3 cm forkortning Når bandagen er anlagt____________ Og stadig bevarer armen normal funktion, pga.
de to led som knoglen er involveret i har store bevægemuligheder
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 7
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Åbne frakturer? Progredierende nervepåvirkning? Karskader Multitraumer, m mange frakturer? Patologiske frakturer? Floating shoulder/elbow? Pt. Ønsker umiddelbar stabilisering Bandage problemer Fejlstilling udover det acceptable Forsinket heling
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 8
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Principielt 3 muligheder
1. ekstern fiksation 2. marvsømning 3. skinneosteosyntese
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 9
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Ekstern fiksation (Sjælden) benyttes ved store bløddelsskader Meget forurenede sår Samtidig lap eller karkirurgi, hvor
skinneosteosyntese er uhensigtsmæssigt Ved damage-control -surgery
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 10
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Marvsømning Kontroversielt, og afhængig af geografi og kirurg Marvsøm, og dermed relativ stabilitet har
principielt 2 indikationer (efter min mening) 1. Damage control surgery 2. Patologiske frakturer
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 11
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 12
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 13
Patologisk humerusfraktur- marvsøm
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Skinne-osteosyntese Guld standard (efter min mening)
Kan håndtere alle frakturtyper Give absolut stabilitet Mulighed for anatomisk reposition Lav risiko for nonunion , failure, og
reoperationsrate
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 14
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1. proksimale 1/3, anterior, anteriolateral 2. midterste 1/3, anterior, posterior 3. distale 1/3 posterior lejring
1. proksimale 1/3: beachchair 2. midterste 1/3: rygleje, sideleje (bugleje) 3. distale 1/3: sideleje (bugleje)
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 15
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 16
Beachchair og deltopectoral-anterolateral, adgang
Sideleje og dorsal adgang
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 17
Forreste adgang
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 18
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 19
Bagerste adgang
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 20
Skinneosteosyntese- incl. Lag screw-absolut stabilitet Skaftfraktur, bagerste adgang
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 21
Hvad vil i foreslå?? Hvilken adgang?? Hvilken osteosyntese
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 22
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 23
Minimal invasiv skinneosteosyntese (MIPO)
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Generelle overvejelser Skinneosteosyntese marvsømning Kan bruges overalt på knoglen Håndterer bedst midtskaftfraktur Mulighed for anatomisk reduktion Akserette repositioner Mulighed for absolut stabilitet Giver relativ stabilitet Giver ingen skuldergener Kan give skuldergener Lav risiko for nonunion og failure større risiko for nonunion /failure
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 24
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1. De fleste frakturer kan behandles konservativt med et godt resultat.
2. Skinneosteosyntese, er velegnet til alle frakturtyper
3. Marvsømning, primært til patologiske frakturer, og damage control surgery
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 25
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 26
Spørgsmål?
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Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH Compression plating versus intramedullary nailing of humeral
shaft fractures--a meta-analysis Acta Orthop, 2006:(77):279-84 Results: N: 155 patients in 3 RCT studies, EVIDENSGRAD I Plate fixation gave a lower relative risk of reoperation than intramedullary nailing
(RR = 0.26, 95% CI 0.007-0.9, p = 0.03) Risk reduction was 74% for reoperation when plate fixation was employed Plate fixation also reduced the risk of shoulder problems in comparison to
intramedullary nails (RR = 0.10, 95% CI 0.03-0.4, p = 0.002)
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 27
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McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH
Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial
J Bone Joint Surg Br, 2000:(82):336-9 EVIDENSGRAD II
Open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.
Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 28
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 29
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 30
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Michael Brix, Traumesektoren Ortopædisk afd. Odense
Universitetshospital 31
“It is perhaps the easiest of the major long bone fractures to treat by conservative methods” Sir John Charnley