髕骨骨折（英文版）課件

1evalufullytoimportantisItIt

is

important

to

fully

evaluate

patella

fractures

on

the

AP

x-ray

as

well

asthe

lateral

x-ray.The

AP

x-ray

demonstrates

the

number

of

fragments

andvertical

splits

in

the

sagittal

plane

that

are

not

visible

on

the

lateral

x-ray.2evalufullytoimportantisItIt

is

important

to

fully

evaluate

patella

fractures

on

the

AP

x-ray

as

well

asthe

lateral

x-ray.The

AP

x-ray

demonstrates

the

number

of

fragments

andvertical

splits

in

the

sagittal

plane

that

are

not

visible

on

the

lateral

x-ray.3Lateral

radiograph

demonstrating

complete

separationofthe

patella

with

loss

of

extensor

mechanism.4demonstratiradiographLateralA

vertical

midline

incision

is

performed

over

the

patella.5isincisionmidlineverticalAAfter

coming

through

subcutaneous

tissue,

the

patellafracture

is

immediately

evident. The

clot

andcancellousbone

edges

are

cleaned.subcutanethroughcomingAfter6A

lamina

spreader

demonstrates

the

fracture

site.7demonstratesspreaderlaminaAPATELLA

ARTICULARSURFACE8TROCHLEARGROOVEPROXIMALDISTALThe

articular

surface

of

the

patella

and

trochlear

groove

areevident

upon

flexion

of

the

knee.TROCSURFACEARTICULARPATELLARETINACULAR

TEAR9With

displaced

patella

fractures

there

are

concomitantretinacular

tears

medially

and

laterally.displaceWithTEARRETINACULARPATELLA

ARTICULARSURFACETROCHLEAAfter

complete

debridement

and

cleaning

of

the

fractures,

acannulated

screw

guidewire

can

be

placed

retrograde

throughthe

fracture

site,

close

and

parallel

to

the

articular

surface.TROCSURFACEARTICULARPATELLA10The

drill

is

then

used

also

in

a

retrograde

fashion.inalsousedthenisdrillThe11The

saggital

plane

split

is

seen

when

the

distal

fragment

isflexed.This

fracture

is

fixed

with

a

transverse

lag

screw

that

will

notinterfere

with

the

cannulated

screws.seissplitplanesaggitalThe12Using

a

clamp,

the

fracture

is

reduced.13isfracturetheclamp,

a

UsingFRACTUREREDUCTION14Using

a

clamp,

the

fracture

isreduced.cla

a

UsingREDUCTIONFRACTUREA

second

clamp

is

necessary

in

thiscase

to

maintain

thereduction.15innecessaryisclampsecondACloseup

of

the

complete

reduction,using

several

clamps.16reductcompletetheofCloseupAfter

the

reduction

is

complete,

the

K-wires

are

visualized

in

thelateral

and

AP

planes,

which

are

used

to

evaluate

not

only

theguidewire

placement

but

also

the

reduction.17completisreductiontheAfterLateral

and

AP

views. Notice

that

the

lag

screw

is

placedbetween

the

inferior

lateral

and

inferior

central

fragment,but

does

not

extend

into

the

fragment

on

the

medial

side,

asthis

would

interfere

with

the

placement

of

the

K-wire.18Notice

views.APandLateralThe

two

cannulated

screws

are

placed

over

the

guidewires.

Thesescrews

must

be

large

enough

to

enable

the

tension

band

to

be

placedthrough

them.19arescrewscannulatedtwoTheEach

manufacturer

is

different;

the

surgeon

must

be

confidentthatthe

cannulation

of

the

screw

will

accommodate

the

cable

or

wire

system.20differentismanufacturerEachThe

screw

should

be

placed

such

that

it

is

short

of

the

end

of

thebone. This

is

to

avoid

the

cable

or

wire

system

from

being

injuredby

the

sharp

threaded

end

of

the

screw.21sucplacedbeshouldscrewTheThe

cable

system

is

introduced

through

one

screw

looped

aroundanteriorly,

then

placed

in

the

same

direction

through

the

secondscrew.22introducedissystemcableTheThe

two

ends

are

pulled

through

a

connector

and

underneaththe

clamp,

which

remains

in

place

during

the

tightening.23througpulledareendstwoTheIn

this

case

theDahl-Miles

system

is

used

and

thetighteneris

connected

to

the

two

free

ends

after

a

fastener

is

attached.24syDahl-MilesthecasethisInLateral X-Ray25X-Ray

LateralAP

x-ray

demonstrating

the

tighteningof

the

cable

gripsystem.26tigthedemonstratingx-rayAPAfter

the

wire

is

sufficiently

tightened

and

crimpedin

place,

it

is

trimmed

very

close

to

thesleeve.27sufficientlyiswiretheAfterThe

retinaculum

is

then

carefully

repaired

on

both

themedial

and

lateral

sides

to

afford

stability

and

additionalsupport

to

thereconstruction.28carefuthenisretinaculumTheCloseup

of

the

final

reconstruction.29reconstrufinaltheofCloseupLateral

radiograph

demonstrating

the

reduction.

Notice

thatthescrew

tips

are

shy

of

the

cartilage

on

the

patella.

The

cable

gripsystem

wraps

around

the

bone

and

is

not

making

a

sharpangleat

the

tip

of

thescrew.demonstratiradiographLateral30AP

x-ray

demonstrating

the

reconstruction

using

the

cannulatedscrews

to

fix

the

central

distal

fragment

and

the

medial

distalfragmentback