Yakavharwa kuvhiyiwa kwekutapudza kwekutyoka kwepazasi.

Yakavharwa kuderedzwa ndiyo nzira shoma inopindira inogona kushandiswa kune yakagadzikana kuputsika kwemagumo pasina kurasikirwa kwekuyerera kweropa, pasina njodzi yehutachiona, kukurumidza kushanda kupora, kuderedzwa zvakanyanya mari yekurapa, uye inogona kushandiswa kuvharwa kuderedzwa kwembambo mbambo uye intramedullary pini kugadzirisa kurapwa kweakasiyana asina kugadzikana fractures, senge femoral neck fractures, femoral fractures, femoral fractures. humeral stem fractures, nezvimwewo, kubvisa kuparadzwa kwekuyerera kweropa nekuderedza kuderedzwa.

Kuputsika kwemutsipa wefemur

(I) Kudhonza

Murwere anoiswa pamubhedha, uye tibial tuberosity traction inoitwa nemakumbo akabatwa munzvimbo isina kwaakarerekera nekunyorovesa kutenderera kwemukati. Huremu hwekudhonza hunosiyana kubva kumunhu kuenda kumunhu, kazhinji 6-9 kg, uye nguva yekudhonza haifanirwe kudarika maawa gumi nemaviri. 90% yevarwere vanogona kuwana repositioning nekudhonza.

(B) yakavharwa manipulative repositioning

Kana traction ikatadza kuzadzisa zvinodiwa repositioning, manual repositioning inogona kuwedzerwa, pasi pe epidural anesthesia:

1. MC Elvenny nzira

Chinangwa ndechekugadzirisa chiuno, kunze kutenderedza nhengo yakakanganiswa uye kuwedzera simba rekukwevera, uye wozotenderera mukati uye mukati kudzorera chikamu chakakanganisika kuti uwane chinangwa chekugadzirisa zvakare.

2. Leadbetter nzira

Murwere anorara pasi, anokotamisa hudyu uye mabvi akabatwa ne 90 °, kukwevera pamwe chete neaxis yevakadzi yegumbo rakakanganiswa nokuda kwe2 kusvika kumaminitsi e3, ipapo mukati tenderera nhengo yakakanganiswa uye zvishoma nezvishoma kuishandura, mushure mekugadzirisa zvakare, zvinyoronyoro kuderedza nhengo yakakanganiswa, uye kana rutsoka rwakakanganiswa rusingaratidziki kutenderera kunze, rinonyanya kuratidza kubudirira zvakare. Asati aita kugadzirisa kwemukati, C-arm muchina wakashandiswa kuona.

(C) Percutaneous tsono prying unyanzvi

Kana repositioning isingawanikwe nenzira dziri pamusoro apa, inowanzoratidza kana kuti musoro wechikadzi wakaputsika kana kuti pane kupatsanurwa kunotenderera pakati pemusoro nemutsipa (Mufananidzo 1A), kana kuti pane kuiswa pane imwe nzvimbo pakati pemusoro nemutsipa. (Izvi zvinogona kuitika mune chero yeBindu II, III, kana IV mhando). Muchiitiko ichi, kutenderedza nhengo yakakanganisika kuti ipinde mumusoro nemutsipa kutyoka hazvichashandi. Kuti udzivise incision uye kuisazve, percutaneous tsono prying nzira inogona kushandiswa kugadzirisa zvakare kuputsika.

• A 3.0- kusvika 3.5-mm-diameter bone denderedzwa tsono inoiswa vertically kuburikidza neganda 1 kusvika 2 masendimita pazasi pekubatana kwe inguinal ligament uye femoral artery kumberi kwemusoro wemukadzi, uye tsono inotenderedzwa zvakadzika kusvika pakati pemusoro wemukadzi pasi pekutariswa kweC-arm 1

• Kuti usimbise simba rekutsvaga, pfupa rechipiri denderedzwa tsono inogona kuiswa 4-5 mm parallel kune iyi tsono, nekuguma kwetsono yakasara kunze kweganda.

• Kuburikidza netrochanter yakakura, maviri 3.5 mm dhayamita bhonzo denderedzwa tsono dzinoboorwa percutaneously maererano nekona yecervical stem uye kona yeanterior tilt, inosvika kure kure kwekuparara kwemutsipa wemukadzi (usapfuure nekuputsika) uye kusiya kuguma kwetsono kunze kweganda.

• Mushandi anobata maseti maviri emuswe wetsono nemaoko maviri uye anogadzirisa zvikamu zvemusoro nemutsipa zvakatsemuka kuti zvienderane pamwe chete nekubatana kwemubatsiri (Mufananidzo 1C-E).

• Mushure mekunge kurongeka kwakwana, pini yebhonzo yeraundi inoiswa pane yakakura trochanter inopindirwa mumusoro wemukadzi kuti igadziriswe kwechinguvana, uye akati wandei maburi screws anobva apinzwa mumusoro wemukadzi (Mufananidzo 1F).

Iyo yakavharwa yekudzikisa nzira inotsanangurwa pamusoro apa inogona kuwana kuderedzwa kunodiwa munenge 98% yevakadzi mutsipa fractures. Izvo zviri nani kurongeka kwekuputsika, ingave yakavharwa kana incised, zviri nani kufungidzira. Kazhinji, dhigirii rekutsemuka kwekutsemuka kunoratidzwa paX-ray ishoma pane iyo chaiyo dhigirii rekutsemuka. Sezvo kurongeka kwekuputsika kunokanganisa zvakananga kuporeswa kwekuputsika uye mukana weiyo necrosis yemusoro wemukadzi, zvinodikanwa kuve nekutonga kwakaringana kweiyo X-ray firimu mushure mekurongeka kwekuputsika. Kana iyo S-yakaita curve isiri yakatsetseka kana kukanganiswa, inoratidza kuti femoral mutsipa kuputsika hakuna kusvika anatomical repositioning (Mufananidzo 2).

Mufananidzo 1 Femoral neck fracture yakadzoserwa nepercutaneous tsono prying

Mufananidzo 2 Mutsipa wemukadzi wekutyoka X-rays ine inoenderera yekunze curve mukurongeka kweanatomical uye yakakanganiswa yekunze curve mune isiri-anatomical alignment.

Kutyoka kwetsinde remukadzi

Iyo yakavharwa yekudzikisa nzira inogona kubatsira mukurongeka kweiyo femoral stem fracture pasina kukuvadza chero zvinyoro zvinyoro kana kugovera ropa kusvika kumagumo ekutyoka, uye inogona kushandiswa kugadzirisa mukati ne intramedullary mbambo.

• Pasi pe epidural anesthesia, murwere anenge akarara pamubhedha (ganda regumbo rakakanganiswa harina kuvharwa panguva ino), mumwe mubatsiri anobata mhuru yegumbo rinenge rabatwa, uye mumwe mubatsiri anodhonza midzi yehudyu yemurwere nebhandi rejira kuti agadzirise kukwevera, uye nhengo yakakanganiswa iri munzvimbo isina kwayakarerekera uye patella yegumbo rinotenderera rinowanzotarisa kumusoro. kutamiswa nekukweva kwemhasuru, uye inogona kugadziridzwa otomatiki nekudhonza, saka mushandisi anongoda kugadzirisa anterior-posterior uye lateral displacement yekuputsika kwechidzitiro).

• Mushandi anoshandisa maoko maviri kuti akomberedze nhengo yakabatwa uye anobata maoko pamwe chete (Mufananidzo 3 uye Mufananidzo 4), uye anogadzirisa anterior-posterior and lateral displacement yekuputsika kamwechete nekushandisa oblique clamping simba remaoko maviri.

• Semuenzaniso, kana chikamu chepamusoro chekuputsika kwechikadzi chikabviswa kunze uye nechemberi, imwe forearm inoshandiswa kusvina chikamu chepamusoro chekuputsika mukati uye pasi. Imwe forearm inosvina distal fracture segment kunze uye kumusoro kukwereta simba rekuvhara (chiremba wekugadzirisa anofanirwa kuva nekutonga kwakakodzera kwekuputsika kwekutungamira uye kureba kwekufamba kusati kwatangazve), kuitira kuti kuputsika kunogona kubudirira kugadzirisa panguva imwe chete. Panguva yekugadzirisa, mubatsiri anofanira kuwedzera simba rekudhonza uye kuchengetedza femur kubva pakutenderera.

• Kana kuguma kwekutyoka kuchinge kwakaputirwa, ruzha rwepfupa runyoro runofanira kunzwika, panguva ino, mubatsiri anofanira kuramba achibata, asi kuderedza simba rekukwevera.

• Kana pakatyoka ichinyatsoenderana nemuchina weC-arm (kana pachine kusarongeka kushoma, ita zvimwe zvigadziriso kuti uone kuti kuputsika kunopera kunofanana), chengetedza kudhonza, kuuraya hutachiona nhengo yakabatwa uye kuparadzira tauro, uye wozoita intramedullary chipikiri fixation.

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Fig. 3 The anterior-posterior and lateral displacement of the fracture inogadziriswa panguva imwe chete nekuputira maoko ose kumativi egumbo rakakanganiswa uye kubatanidza maoko pamwe chete, uchishandisa simba rekuvhara kwemaoko maviri.

Mufananidzo 4 Femoral stem fracture repositioning mechanics schematic

• Kune varwere vane hukuru hwekutyoka, kuvharwa kusingabudiriri kuvharwa kana kuputsika, mubhedha wekuvhiya wekuvhiya unogona kushandiswa kuderedzwa kwakavharwa neimwe simba rekushandisa, iro rinogonawo kunyatsozadzisa kuvharwa kwakavharwa kwekuputsika kwechikadzi.

• Mushure mekuisa nhengo yakakanganiswa pane traction frame for traction uye C-arm kuongorora kunoratidza kuti kupindirana kwekuputika kwekuputika kwakagadziriswa, kuguma kwekupedzisira kwegumbo rakakanganiswa rinogona kugadziriswa mukati kuti riwedzere kudzorera kurongeka uye kurongeka mu orthostatic image yefemoral stem.

• Nekuti kudhonzerana kwemhasuru dzechidya pasi pekukweva kunogona kuita basa rakapfava rekutsemuka kwechikadzi kutsemuka kwedzinde, mazhinji echikadzi stem fractures anogona kuwana kurongeka kunogutsa mune orthogonal x-ray mufananidzo.

• Nekudaro, panguva ino, nekuda kwekushaikwa kwerutsigiro runoshanda kumucheto wekupedzisira kwechikamu chekutyoka pasi pesimba regiravhiti, iyo distal fracture segment yefemoral stem inonyanya kubviswa kumashure, uye panguva ino, iyo isina kuvharwa tauro-yakavharwa brace inogona kuiswa kumashure kweiyo distal fracture segment uye posterior kugadzirwa kweganda uye posterior kugadzirwa. displacement ye distal fracture end inogona kugadziriswa nekugadzirisa kureba kwebrace.

• Kana iyo posterior displacement ye distal fracture segment isati yagadziriswa, mbambo yakadzika inogona kugadziriswa percutaneously kumusoro kwetrochanter yakakura kana pyriform fossa, uye ipapo intramedullary repositioning rod inopinzwa mu medullary cavity ye proximal fracture segment of the handled of the handler inosimudzwa. zvine mwero kumberi kudzvinyirira kuputsika kwechikadzi kumashure nekushandisa lever yetsvimbo yekudzosera, nekudaro kudzoreredza kurongeka neiyo posteriorly displaced distal fracture,

• Mushure mekutyoka kwakarongeka, pini refu yekutungamira inopinzwa mukati me distal fracture cavity kuti ipedze iyo yakavharwa reset. Iro intramedullary repositioning rod inonyanya kushanda pakugadzirisa kushanduka, kubvuta, uye kunze kwekutenderera kwekunze kunowanikwa mukuputsika kweproximal femur (Mufananidzo 5).

• Kune yakasara lateral displacement, kuvhurwa kwekupedzisira kwakakomberedzwa kweiyo intramedullary tsvimbo inogona kugadziridzwa kuti itungamire pini refu rekutungamira mukati me distal fracture cavity kuti ipedze kuderedzwa kwakavharwa.

• Imwe nzira yekudzikisa yakavharwa ndeyekuputira mbambo yeSchanz mubhonzo cortex padivi penzvimbo yakaputsika magumo uye kugadzirisa kupera kwekuputsika nenzira yeSchanz mbambo yekudzikisa yakavharwa (Mufananidzo 6). Mushure mokunge kuputsika kunogadziriswa zvinogutsa, mbambo ye intramedullary inopindirwa mukati me proximal uye distal medullary cavity yekuputsika kuti ipedze kugadziriswa kwemukati (Mufananidzo 7).

  
  

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Mufananidzo 5 Kubata kwechikamu cheproximal fracture yekuvharwa repositioning uchishandisa intramedullary repositioning tsvimbo.

Mufananidzo 6 Yakavharwa kuderedzwa uchishandisa mbambo yeSchanz yakaiswa mune unilateral bone cortex pamagumo ekutyoka.

Mufananidzo 7 Yakavharwa kudzikisa intramedullary mbambo kugadzirisa kwe multisegmental comminuted kutyoka kwechikadzi hunde uchishandisa Schanz chipikiri.

Ankle fracture

(A) Preoperative kugadzirira

• Radiographic diagnosis: Iyo yakajairika ankle imaging evaluation inofanirwa kusanganisira 3 phases: anteroposterior (Mufananidzo 8), ankle point (15 ° yemukati kutenderera) (Mufananidzo 9), uye lateral (Mufananidzo 10).

• Kana chikwama chemakumbo chakuvadzwa zvakanyanya mukati uye kunze kwechidzitiro uye talus ichaendeswa kune 11 madhigirii akasiyana (Mufananidzo 11). Static radiographs hainyatso kuratidza kugadzikana kwechitsiko chetsoka. Kushungurudzika radiographs uye MRI inogona kuvandudza kuongororwa kwekugadzikana kwechidzitiro chemakumbo uye kukuvara kwe ligament (Mufananidzo 12).

• Muchiitiko ichi, rudzi rwekukuvara kwechidzitiro runofanira kunyatsogadziriswa nemaitiro ekukuvadza uye radiological data yegumbo rakakanganiswa kuitira kuti itungamirire zvakanaka kugadzirisa uye kugadzirisa.

• Dzimwe nguva kureruka kwepakati pemakumbo emakumbo kunogona kuva chikamu che 'Maisonneuve fracture' yakaoma, iyo inosanganisirawo kuparara kwefibula uye kusanganiswa kwekukuvara kwegumbo, saka tibiofibula yose inofanira kuongororwa radiographically.

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Mufananidzo 8 Pamberi uye kumashure

Mufananidzo 9 Ankle points (15 ° yemukati kutenderera)

Mufananidzo 10 Lateral position

Mufananidzo 11 Kutyoka kuchinjika sezviri pachena kwakasanganiswa nekubviswa

Mufananidzo 12 Stress radiograph (triangular ligament rupture)

(II) Chiremba

Femoral uye sciatic nerve anesthesia inowanzotorwa.

(C) reset maitiro

Iko shure-kunze kwekutenderera rudzi rwekuvhara repositioning inoitwa mukurongeka kwekunze kwechidzitiro chemukati-chigunwe-posterior ankle-inferior tibiofibular union. Iro posterior rotation-internal rotation type inoitwa muhurongwa hwemukati wemakumbo-kunze kwechidzitiro.

• Muchiitiko chekutenderera-kunze kwekutenderera rudzi IV, murwere anoiswa supine uye mabvi anogadziriswa pa90 ° kuti asunungure mhuru triceps.

• Vabatsiri vaviri vanobata popliteal chikamu chechidya nerutsoka zvakateerana, uye traction inoshandiswa munzira yekutyoka deformity (simba rekukwevera harifanirwe kuve rakawandisa kudzivirira kuwedzera kukuvara).

• Mubatsiri anodhonza tsoka anotenderedza tsoka mukati kuti agadzirise kuremara kwekunze kutenderera (Mufananidzo 13). Paunenge uchisundidzira kumucheto kwakananga kudivi retibial uye uchikwevera iyo distal tibia kudivi refibula, mubatsiri anotendeuka nechomukati uye dorsally anowedzera chidzitiro chegumbo kuti agadzirise kutama kwechidzitiro chekunze uye talus (Mufananidzo 14).

• Chengetedza kutenderera kwemukati-yemukati kutenderera-dorsal yekuwedzera chinzvimbo. Zvadaro chivharo chekuputsika kwechigunwe chemashure chinobatwa nezvigunwe zvose, zvigunwe zvina zvinokomberedza distal tibia, uye zvigunwe zvose zvinosundidzira nekusvina kure, uchikwevera pasi distal tibia kuti udzorere shure kwechidzitiro (Mufananidzo 15).

• Pakupedzisira, mushandisi anosundidzira gumbo remukati kumashure uye pasi nezvigunwe kuti rigadzirise zvakare (Mufananidzo 16). Vabatsiri vaviri vanochengetedza rutsoka nechidzitiro mukati memukati-inotenderera-yemukati-inotenderera-dorsal yekuwedzera nzvimbo mukugadzirira kugadzirisa.

Mufananidzo 13 Kugadziriswa kwekutenderera kwekuremara kwekunze kwekutenderera

Mufananidzo 14 Kugadziriswa kwe lateral displacement yekunze ankle uye talus

Mufananidzo 15 Kugadziriswa kwemashure ekushanduka kwegumbo

Mufananidzo 16 Kugadziriswa kwemukati weankle displacement

Iro post-rotation-internal repositioning process inopesana ne-post-rotation-external repositioning process uye inoitwa mukurongeka kwechidzitiro chemukati-kunze kwechidzitiro.

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