股骨干粉碎性骨折蝶形骨折块伴“大

块皮质骨分离移位”——必须捆绑吗？
——Strategy、Pitfalls&Tips

刘洋
四川大学华西医院骨科
2016年7月
How to do it?
How to do it?
Case1: 72Y,Female,Fall.

No-union!!
Next?
Case1: 72Y,Female,Fall.

Bone 5 Mons
Graft Later
Case2: 40Y,Male,Accident Crash.

Union?
Really?
Case2: 40Y,Male,Accident Crash.

Re-fracture

Re-fixation
Case2: 40Y,Male,Accident Crash.
Dynamitic

4-Years
Later
Case3: 20Y,Male,Traffic Accident.

What’s
Next?
Case3: 20Y,Male,Traffic Accident.
Delay-Union

Dynamitic
Bone-graft
Case3: 20Y,Male,Traffic Accident.

Healed!
Removal
Nail
Case4: 35Y,Male,Traffic Accident.

Healing?
No-Union?
Case4: 35Y,Male,Traffic Accident.
Case5: 23Y,Male,Car Accident.
Case5: 23Y,Male,Car Accident.
PO.2 weeks
Case5: 23Y,Male,Car Accident.
Case5: 23Y,Male,Car Accident.

Raise your hands!

Case5: 23Y,Male,Car Accident.

PO.2mons
Case5: 23Y,Male,Car Accident.

PO.3mons
PO.7mons
 Extreme Conditions?

>10cm

Ref.Hinsche AF(1), Giannoudis PV, Matthews SE, Smith RM. Spontaneous healing of large femoral
cortical bone defects: does genetic predisposition play a role? Acta Orthop Belg. 2003;69:441-6.
 Length

3 Pitfalls Displacement

Reverse
OTA classification：
Type 1：At least 50% of cortical
circumference remains for contact.
Type 2：Less than 50% of cortical
circumference remains.
Type 3：Complete segmental loss is
present, with absent cortical contact
unless shaft is shortened.
OTA classification：
There is little controversy that types 1 and 2 defects
associated with femoral fractures can usually be managed
by standard techniques of reamed IM nailing anticipating a
high rate of primary union.
 Length:10cm
骨折块长度<10cm:

扩髓时缓慢推进，以免骨折块扭转

保护残留软组织鞘血供

避免延迟愈合和不愈合。
Ref. Wiss DA(1), Brien WW, Stetson WB. Interlocked nailing for treatment of segmental fractures
of the femur.J Bone Joint Surg Am. 1990;72:724-8.
 Displacement:1-2cm (1994)
How far is too far?
1、骨折块距离股骨髓腔>2cm 可能影响骨折愈合；

2、常规使用静态锁定;

Ref. Choo,S., Kim,B.,Ko, H.,Lim,Y.,Seo,J.,Jung,W.:The Fate of

the Comminuted Fragments in Interlocked Femoral Fractures.
Presented at the 4th Conference of the International Society for
Fracture Repair;September 30,1994;Kobe,Japan.
. P.1855
 Displacement:1-2cm (2002)
How far is too far ?

How to measure?

从股骨干皮质连线向骨折块中点
做垂线，该距离为骨折移位距离

Ref. Lee KB, Chung JY, Moon ES, et al.The Fate of Large Butterfly Fragments in Femoral
Shaft Comminuted Fractures Treated with Closed Interlocking Intramedullary Nailing.
J Korean Soc Fract. 2002;15(4):504-510.
 Displacement:1-2cm (2002)
3 Solutions 不必对骨折块切开复位内固定
1、术中不加重骨折块移位；
2、术后通过主动锻炼和大腿肌肉静水压维持骨折块位置；
3、骨折块的移位和成角逐渐减小，即使骨折块翻转或明显移位
或成角也可以获得愈合；

Ref. Lee KB, Chung JY, Moon ES, et al.The Fate of Large Butterfly Fragments in Femoral
Shaft Comminuted Fractures Treated with Closed Interlocking Intramedullary Nailing. J Korean
Soc Fract. 2002;15(4):504-510.
 Displacement:1-2cm (2012)

Key notes:
1、骨折块分离< 2cm；
2、植入髓内钉时尽量避免骨折块移位或成角
Ref. Lee KB, Chung JY, Moon ES, et al.The Fate of Large Butterfly Fragments in
Femoral Shaft Comminuted Fractures Treated with Closed Interlocking Intramedullary
Nailing. J Korean Soc Fract. 2002;15(4):504-510.
Displacement:1-2cm (2012)
影响骨折愈合
的因素

解剖位置因素
术后负重程度

初始复位后骨
折块移位程度
Ref. An KC, Kim YJ, Choi JS, Seo SS, et al.The Fate of Butterfly Fragments
in Extremity Shaft Comminuted Fractures Treated with Closed Interlocking
Intramedullary Nailing. J Korean Fract Soc. 2012 ;25(1):46-51.
 Displacement:1-2cm (2014)

Ref. Lin SJ, Chen CL, Peng KT, et al . Effect of fragmentary displacement
and morphology in the treatment of comminuted femoral shaft fractures
with an intramedullary nail. Injury. 2014 ;45(4):752-6.

Conclusion:
骨折块分离< 1cm不影响骨折愈合；
Displacement:1-2cm (2014)
Equation：Displacement=Dprox+Ddist-Bd

Dprox
Correct?
Bd Ddist
Displacement:1-2cm (2014)

3-D?
Angulation?
Dprox

Ddist
Bd
 Reverse: Reduction (2014)

VS
NO! YES!
1.进一步损伤血管床 1.软组织嵌顿
2.骨痂桥接骨折断端 2.轴向承重能力降低
缝隙困难； 3.骨折块过度活动造
成骨痂矿化困难
 Reverse: Reduction (2014)

Rate: 90%!! 结论:

翻转骨折块造成骨折延
迟愈合或不愈合，导致
患者翻修手术次数增加

Yes!!!
 Our Strategy

Length Displacement Reverse

>10cm <10cm small Incision

>2cm 1-2cm

Clamp Reduction
Clamp during ream Reduction
 Peals &Tips

切开复位 ? 经皮器械辅助复位? 小切口?

Open Reduction: NO (2007)

Disadvantage:
额外的骨膜剥离、
钝性扩髓造成骨坏死
阻塞Haversian管
丢失骨泥
潜在的感染。
 Percutaneous : Yes (2009)
“napkin ring” 样骨折块：
扩髓时用经皮植入克氏针或复位钳固定

避免：骨折块与周围软组织发生扭转、剥脱
。
 Small Incision : Yes (2010)
对于节段性骨折，可以采取有限切口结合复位钳
临时固定，将复杂骨折转变为简单骨折。
 Four Tips (1987)

1.“蝶形” 骨块较大或长斜形骨折的对侧皮质不扩髓；
2. 用直径较小的主钉，避免加重骨折块粉碎程度；
3. 近端和中间骨折块过扩髓0.5mm，避免植入主钉困难
4.骨钩平行于肌纤维方向植入，导针经过后取出；
Messages for Take Home!

1、周径：50%；
2、长度：10cm；
3、宽度：2 cm;
4、经皮临时固定；
5、骨块翻转：切开复位。
Case6: 39Y,Male,Car Accident.
Case6: 39Y,Male,Car Accident.
PO.1mon
Case6: 39Y,Male,Car Accident.
PO.4mons PO.2mons PO.12mons