Femurfrakturer - AO Danmarkao-danmark.dk/wp-content/uploads/2020/02/Femurfrakturer...Retrograd...
Transcript of Femurfrakturer - AO Danmarkao-danmark.dk/wp-content/uploads/2020/02/Femurfrakturer...Retrograd...
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Femurfrakturer Frakturtyper, behandling og kirurgiske adgange
LBI
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Incidens
• 10/100.000/år
• Yngre mænd og ældre kvinder
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Klassifikation
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Primær behandling
• ATLS
• Åben skade?
• NV forhold
• Rtg i 2 plan incl hofte og knæ
• Stræk
• Øvrige skader?
• ETC vs DCO
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Mål med operation
• Diafysær fraktur:
Længde, akse, rotation
• Stabil osteosyntese
• Hurtig mobilisering
• Ingen komplikationer
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Behandlingsmuligheder
• Konservativ???
• Ekstern fixation
• Skinneosteosyntese
• Marvsømning
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Ekstern fixation
• Damage kontrol • Bro til definitiv kirurgi, feks:
• Pt for syg • Åbne og kontaminerede • Bløddelshåndtering • Rette kirurg, udstyr mm
• Færdigbehandling (sjældent) • Infektion • Børn • (Transport)
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Skinneosteosyntese
• Blokeret marvkanal • Knæ/hofteprotese eller traumeimplantat
• Lukket marvkanal efter tidligere fraktur
• Deformitet mm
• Epi-/metafysær + diafysær fraktur
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Marvsømning
• Load-sharing (ikke bearing)
• Biomekanisk dejligt med et tykt, langt søm
• Heler med callus
• Minimalt invasivt
• Indsættes fra hoften eller fra knæet
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Retrograd sømning
• Indikationer, feks: • Floating knee • Ipsilateral collum femoris • Svært adipøse • Distale skaftfrakturer • Acetabulum, ryg frx mm
• Cons: • Intraartikulært entrypoint • Låsning prox tæt ved kar/nerve strukturer • Korsbånd • Knæsmerter
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Antegrad sømning
• Golden standard
• Extraartikulært entrypoint
• Hurtigere helingstid end retrograd
• Cons: • Hoftesmerter • Obs gluteus medius -> trendelenburg • Blow-out ved forkert entrypoint • Svært adipøse
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Lejring
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Længde, akse og rotation
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Længde, akse og rotation
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Ream vs unream
• Reamet søm: • Bedre fit diafysært • Tykkere søm • Hurtige heling • Færre non- og delayed unions • Færre havarier • Reamer debris – osteogenese?
• Pas på med samtidigt svært thorax traume pga lungekomplikationer
• Skarpe reamere, ikke over-ream (varme nekrose, FES, ARDS)
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Sømtyper
• Lige, kurveret, anatomisk..
• Alle (nu om dage) kanyleret
• Alle med unikt design, entrypoint og kurvatur
• RTFM!
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Kirurgisk adgang
• 3-5 cm adgang prox for troch major
• Palper toppen af troch major
• Identificer entrypoint
• Obs gluteus medius ved reamning
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Operativ teknik
• Frakturen reponeret (!)
• Entrypoint (!)
• Guidewire centralt/centralt
• Ream 1 - 1½ mm diafysært
• Isæt søm
• Lås statisk distalt
• Luk frakturen, indstil rotation
• Lås statisk proximalt
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Hvor langt er langt??
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Konklusion
• Reamet antegrad søm er golden standard
• Længde, akse, rotation og relativ stabilitet
• Tykt søm til patellas overkant
• Husk de andre muligheder
• Kend dit/dine søm (og RTFM)
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Længde
• Mål sømlængde på raske ben præ-op
• Luk frakturspalten intra-op
• Lås sømmet i begge ender
• Bilat frx -> simple først
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Akse
• Reponer akserne i begge plan
• Bedre med moderne (anatomiske) søm
• Stræk, Schanz, PORD, Poller/blocking skruer mm
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Rotation
• Frakturen matcher
• Trochanter minor størrelse
• Marv og cortextykkelse matcher
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Ipsilateral collum femoris
• Kig efter dem på traumescanningen
• Varierende incidens 1-9 % i litteratur
• Collum femoris frx tager prioritet
• Recon søm eller DHS + retrograd
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Poller/blocking
• Saggital og coronal fejlstilling • Intraoperativt
• Forhindrer sek. skred
• Altid på den konkave side af frx
• ”Reverse thumbs rule”