UNIVERSITATEAOVIDIUSCONSTANTA FACULTATEA DE MEDICINA SI STOMATOLOGIE

REFERAT BIOSTATISTICA

FRACTURA DESCHISA.DATE STATISTICE.POSIBILITATI TERAPEUTICE.

Conducator stiintific, Conf.Univ.Dr.TEREN O. Doctorand, Dr.CORNELIA PANCHICI

CONSTANTA !!"

CAPITOLUL I.

DEFINITIE

Fractura desch sa este c!"s derata #ractura a care #!car c!$u" ca cu e%ter !ru& 'r "tr(! '&a)a de d $e"s u" *ar a+ &e.Marea $a,!r tate a aut!r &!r c!"s dera #ractura desch sa s #ractura a& care #!car se desch de "tr(u" !r)a" ca* tar-*e. ca/rect/*a) "0. Ter$e"u& de #ractura c!$'& cata se atr +u e ace&!r #ractur desch se as!c ate cu &e. u" *ascu&!("er*!ase sau * scera&e.A&.Radu&escu c!"s dera ca d " 'u"ct de *edere 'at!&!) c /!r ce #ractura " t a& "ch sa/care a #!st su'usa u"u act ch rur) ca& 'e"tru !ste!s "te.a sau !ste!t!$ e este ech *a&e"ta cu ! #ractura desch sa cu t!ate ca 'er c!&u& u"e c!$'& cat $ed ate este $u&t $a redus.Or ce #ractura desch sa tre+u e c!"s derata de te$ut de!arcec c!$'& cat &e secu"dare- "#ect a cu 'seud!artr!.a su'urata/!ste ta0 a'ar #rec*e"t $a a&es " ca.u& u"u trata$e"t de ur)e"ta "c!rect sau "c!$'ete"t.As'ectu& 'art cu&ar a& #ractur &!r desch se c!"sta " "t "derea s 'r!#u". $ea &e. u" &!r tesutur &!r $! ce re're. "ta atat e&e$e"te de )ra* tate dar s u" cr ter u de c&as # care a& #ractur &!r desch se. Fractur &e desch se c!"st tu e " e'!ca $!der"a ! cau.a #rec*e"ta de s' ta& .are "de&u")ata/de "ca'ac tate te$'!rara de $u"ca/ " u"e&e ca.ur duca"d &a "*a& d tate 'er$a"e"ta/&a care se adau)a c!stur $ater a&e $'res !"a"te.Dat!r ta acest!r as'ecte &e)ate de et !'at!)e" a/c& " ca s trata$e"tu& #ractur &!r desch se s(au e#ectuat 'r!)rese tera'eut ce u $ t!are &e)ate de acest d!$e" u.Daca " 'r $u& ra.+! $!"d a& 123 d "tre #ractur &e desch se se c!$'& cau cu ! !ste ta '!st#racturara/ " a& d! &ea ra.+! $!"d a& dat!r ta a'& car trata$e"tu&u de ur)e"ta s #!&!s r a"t + !t ce&!r/'r!ce"tu& a sca.ut &a d!ar 453.

CAPITOLUL II.

ISTORIC

Fractura desch sa a e% stat d " t!tdeau"a " st!r a !$e" r /$a a&es ca ! c!"sec "ta a ra.+!a e&!r/ ca"d c!$'& cat &e se't ce duceau " $!d #rec*e"t &a e% tus. Ma&)a )"e-11640 a# r$a ca sutura 'r $ t *a " ca.u& #ractur &!r desch sa era cu"!scuta s 'ract cata "ca d " sec!&u& a& 7III(&ea.I" sec!&u& a& 7VI(&ea ch rur)u& A$+r! se Pare trata #ractura desch sa du'a 'r "c ' &e ese"t a&e8 de+r dare/reducere sa")era"da/esch &ect!$ e/e*acuarea he$at!$u&u .T!t &u a'art " 'r $a descr ere a'r!a'e st "t # ca a u"e #ractur desch se/*a&a+ &a s " . ua de asta. ca s 'r $a te"tat *a de reducere ch rur) ca&a a acest!r #ractur . Mar &e desc!'er r a&e &u L.Pasteur-1144(11950 s :.D ster-114;(19140 au 'r!dus ! ade*arata re*!&ut e " ch rur) a )e"era&a s " )e"era& " ch rur) a #ractur &!r desch se.Ca ur$are a sca.ut se$" # cat * $!rta& tatea 'r " c!$'& cat &e #ractur &!r desch se/a crescut "u$aru& $e$+re&!r sa&*ate/ ar 'r!)"!st cu& #u"ct !"a& a de*e" t d " ce " ce $a !'t $ st. I" cursu& 'r $u&u ra.+! $!"d a& ! c!"du ta de trata$e"t )e"era&a a'& cata de ch rur) aceste e'!c c!"sta "8 e%'&!rarea ate"ta s de+r dare &ar)a a '&a) &!r/esch &ect!$ e/'&a)a &asata <a '&at/'a"sa$e"t cu !&eu )!$e"!&at 423.Cu t!ate ca e*!&ut a #!care&!r de #ractura a #!st #a*!ra+ &a " $area $a,!r tate a ca.ur &!r/s(a c!"statat ca "c de"ta !ste te '!st#racturara era $a,!r tara. Du'a ce& de(a& d! &ea ra.+! $!"d a& se des'r "d "et d!ua 'r "c ' tera'eut ce8 ( t!a&eta r )ur!asa a '&a) = ( $!+ & .are #er$a a #!caru&u de #ractura. I" 1954 M ra &&e a# r$a ca #ractura desch satre+u e redusa s "ch sa cu !r ce 'ret / tre+u e sa recur)e$ &a )ra#a cuta"ata #ara a e. ta/ch ar " ur)e"ta s sa $!+ & .a$ #!caru& de #ractura. I" aceasta 'er !ada !rt!'ed c!('&ast ca -du'a 19;20 care se "t "de 'a"a " 're.e"t s(a cr sta& .at c!"ce'tu& de +a.a c!"#!r$ caru a $et!de ce&e $a "d cate de sta+ & .are !s!asa tre+u e sa se as!c e.e s u" '!cedeu de ac!'er re a #!caru&u de #ractura " #u"ct e de 'art cu&ar tat &e # ecaru ca. " 'arte/succesu& tera'eut c de' ".a"d " $are $asura de c!&a+!rarea d "tre !rt!'ed > ch ru) '&ast c a".
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Oste!s "te.a a #!st "tre*a.uta "ca d " 1195/ ca"d Th. I!"escu a 're.e"tat c!$u" car "teresa"te &a ce& de a& 7(&ea C!")res de Ch rur) e de &a Par s. Du'a e&/ ! ser e de ch rur) *a&!r!s au a'& cat s de.*!&tat aceasta $et!da de trata$e"t8 A")he&/ Nasta/ :u*ara/ Iac!+!* c / Le!"te/ Chr st de/ A. : a"u/ Fa)arasa"u/ @ut! a"u s St! a"/ Tataru s Gr )!rescu/ P!'escu etc. La s#ars tu& sec!&u&u trecut/ :u*ara s @a&acescu -119;0 #!&!seau )re#a der$!e' der$ ca du'a Th ersch/ 'e"tru ac!'er rea de#ecte&!r te)u$e"tare. Ne $a"dr $ cu c!"tr +ut a adusa de :u*ara &a desc!'er rea s "tre+u "tarea # %at!ru&u e%ter". I. : a"u -19150 #ace c!"s derat "teresa"te asu'ra ch rur) e de ra.+! . I" 191A/ Th. &!"escu 'u+& ca ! a$'&a $!"!)ra# e " care #ace ! 're.e"tare c!$'&eta a trata$e"tu&u ra" &!r de ra.+! 'r " $et!da DaB "(Carre& @re.ea"u -19440 aduce c!"tr +ut e s su+& " a.a *a&!area # %at!ru&u e%ter" " !ste!s "te.a #ractur &!r d a# .are. Trata$e"tu& #ractur &!r desch se de t + e a c!"st tu t s te$a u"!r te.e de d!ct!rat e&a+!rate " 'er !ada "ter+e& ca -Pascu&escu T. 1941/ P!'escu S. 19?60. La C&u,/ Des& u -19?50 e%'u"e e%'er e"ta acu$u&ata de c!&ect *u& C& " c ch rur) ca&e d " C&u,/ c!"dus de A&. P!'/ " 'er !ada 1946(19?5/ "tr(! ser e de 1A ca.ur . La Ias / Pa&a)h ta -19?A0 aduce " d scut e trata$e"tu& #ractur &!r desch se " &e)atura cu stat st ca C& " c ch rur) ca&e c!"dusa de P. A")he&. I" cursu& ce&u de a& d! &ea ra.+! $!"d a&/ ch rur) r!$a" re* " $ereu asu'ra tutur!r as'ecte&!r &e)ate de trata$e"tu& '&a) &!r de ra.+! " )e"era&/ s a& #ractur &!r desch se " 'art cu&ar/ ar d "tre acest a 'ute$ a$ "t 'e P&atarea"u/ Fa)arasa"u/ @ercea"u/ Mar "/ Ghe!r)h u/ O*a"e.. I" 1951/ &a C!"#er "ta Nat !"a&a de Ort!'ed e de &a T $ s!ara/ se rec!$e"da "ch derea #!caru&u de #ractura su+ 'r!tect a a"t + !t ce&!r s $!+ & .area " a'arat ) 'sat. I" 19A2/ &a C!"#er "ta de &a Oradea/ s(a "s stat asu'ra $'!rta"te re.!&*ar 'r!+&e$e&!r ac!'er r te)u$e"tare/ cat s asu'ra '!s + & tat de a se recur)e &a !ste!s "te.a/ " u"e&e ca.ur de #ractur desch se. I" 19;1 a a*ut &!c u" s $'!. !" !r)a" .at de U.S.S.M./ # & a&a @ucurest c!"sacrat #ractur &!r desch se de )a$+a. " 19;A/ a a*ut &!c C!"s#atu rea de &a Cra !*a cu te$a CTrata$e"tu& #ractur &!r desch se s a c!$'& cat &!r &!rC. C!"c&u. &e au c!"s# "t t "eces tatea "ch der #!caru&u de #ractura 'r " d *erse $et!de/ 'recu$ s su'er !r tatea re.u&tate&!r !+t "ute 'r " !ste!s "te.a ce"tr!$edu&ara/ asu'ra ce&!r !+t "ute 'r " s "te.e&e cu '&ac $eta& ce. I" 19;;/ &a a V&(a Ses u"e a ch rur) &!r d " M!&d!*a -P atra Nea$t0 a #!st d scutata s #ractura desch sa/ c!"c&u. &e # "d s $ &are ce&!r de &a Cra !*a. A& V(&ea C!")res Nat !"a& de Ort!'ed e(Trau$at!&!) e -Ias 19940 a c!"s# "t t "eces tatea c!&a+!rar !rt!'ed('&ast c a" " *ederea ac!'er r 'rec!ce a #!caru&u #racturar/ ar " 'r * "ta !ste!s "te.e / $a,!r tatea 'arer &!r au #!st " #a*!area # %at!ru&u e%ter". La C!"s#atu rea Nat !"a&a de &a T $ s!ara -19910/ " 'r * "ta sta+ & .ar #!caru&u / '!"derea 'r "c 'a&a "ce'e sa ! ca'ete !ste!s "te.a ce"tr!$edu&ara.
6

CAPITOLUL III.

CLASIFICAREA FRACTURILOR

Or ce c&as # care este de #a't ! Cu"ea&taC " $a"a s " )a"d rea ch rur)u&u / ar 'e"tru a # acce'tata ea tre+u e sa # e "u "u$a #u"ct !"a&a/ dar s ut &a. C&as # car &e s $'&e/ des us!r de $a"e*rat -#u"ct !"a&e0/ "u su"t ut &e " trau$at s$e&e se*ere. Pe de a&ta 'arte/ c&as # car &e c!$'&e%e su"t d # c & de $a"e*rat/ dar ut &e " s'ec a& " aceste trau$at s$e se*ere. Pr $a c&as # care $!der"a a'art "e &u Cauc#oi$ -19A50/ care e*a&uea.a gravitatea fracturii deschise in functie de marimea pierderii cutanate. Aceasta c&as # care a re*!&ut !"at $!du& de a+!rdare a #ractur &!r desch se s a stat &a +a.a s ste$e&!r de c&as # care u&ter !ara 8 ( tip 1 ( '&a)a te)u$e"tara 'u"ct #!r$a/ as!c ata cu &e. u" su+ ace"te $ "!re ( tip 2 - &e. u"e $a e%t "sa a ' e& / e% sta"d r scu& a'ar t e u"e "ecr!.e te)u$e"tare secu"dare - tip 3 - 're.e"ta u"e ' erder $'!rta"te de su+sta"ta cuta"ata s tesutur $! su+ ace"te A%&o'(r -19;10 a e&a+!rat ! c&as # care s $ &ara/ a'rec "d 'r!)"!st cu& #ractur du'a gradul de lezare apartilor moi 8 -tip 1 ( 'er#!rare 'u"ct #!""a a ' e& / 'r!dusa d "au"tru "a#ara -tip 4 ( '&a)a c!"tu.a 'r!dusa 'r " $eca" s$ d "a#ara( "au"tru -tip 3 - #ractura se as!c a.a cu &e. u" e%t "se a&e 'art &!r $! And(rson -19;10 a #!st 'r $u& care a "tr!dus ! c&as # care " care e*a&uea.a D nivelul de contaminare a focarului fracturar 8 - tip 1 - '&a)a te)u$e"tara de d $e"s u" $ c / as!c ata cu &e. u" $ " $e a&e tesutur &!r $! -tip 2 ( ' erder $a $ar de su+sta"ta cuta"ata/ as!c ata cu &e. u" 'ut " "t "se a&e tesutur &!r $! sau cu " *e& de c!"ta$ "are redus a& '&a) - tip 3 - &e. u" $!derate sau e%t "se a&e 'art &!r $! / de* ta& .ate sau c!"ta$ "ate $as * )usti%o *i And(rson -19;A0 au 'us &a 'u"ct ! c&as # care ada'tata u&ter !r de !rt!'e. d " "trea)a &u$e/ care are &a +a.a marimea deschiderii cutanate, gradul de lezare sau de contaminare a tesuturilor moi si tipul de fractura. I" 1916/ Gust &! s c!&a+!rat!r au subdivizat tipul III in functie de gradul de contaminare / extinderea decolarii periostale si necesitatea interventiilor de reconstructie vasculara 8 ( Tip I - #r. desch se cu '&a)a cuta"ata curata/ su+ 1 c$ &u") $e ( Tip II ( #r. desch se cu ' erdere te)u$e"tara $a $are de 1 c$/ dar #ara &e. u" e%t "se a&e 'art &!r $! su+ ace"te s #ara a*u&s sau &a$+!ur de 'art $! ( Tip III ( #r. desch se cu d &acerar / &e. u" sau ' erder e%t "se a&e 'art &!r $! ( !r ce #r. desch sa se)$e"ta&a
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( !r ce a$'utat e '!sttrau$at ca ( &e. u" de e"er) e $are 'r!duse 'r " ar$e de #!c ( #r. desch se care "eces ta rec!"struct e *ascu&ara ( #r. desch se $a *ech de + !re ( IIIA ( ac!'er re 'er !sta&a sat s#acat!are a #!caru&u / " c uda &e. u" &!r e%t "se a&e 'art &!r $! ( #r. 'r!duse 'r " trau$at s$e de e"er) e $are/ care "u au c!res'!"de"ta d recta cu $ar $ea &e. u" &!r cuta"ate ( EEE B ( ' erder e%t "se de tesutur $! / cu dec!&are 'er !sta&a/ duca"d &a e%'u"erea !su&u su+ ace"t ( as!c ere #rec*e"ta cu ! c!"ta$ "are +acter a"a $as *a ( EEE C ( #r. desch se as!c ate cu &e. u" arter a&e -"eces ta"d rec!"struct e *ascu&ara0/ #ara c!res'!"de"ta d recta cu )radu& de &e.are a tesutur &!r $! I" 1916/ O(st(rn si Tsc#(rn( au "tr!dus ! c&as # care 'e +a.a gradului de lezare a tesuturilor moi si extinderii contuziei musculare, e*a&uate "u$a du'a e%'&!rarea $ "ut !asa a '&a) " sa&a de !'erat e 8 ( Grad I- c!"tu. e $ " $a a ' e& s c!"ta$ "are +acter a"a "e)& ,a+ &a= a+se"ta c!$ "ut e . ( Grad II ( &e. u" c!"tu.e a&e ' e& s tesutur &!r $! = c!"ta$ "are +acter a"a $!derata. ( Grad III ( c!"ta$ "are $as *a/ d struct "t "se a&e 'art &!r $! / &e. u" *ascu&are s "er*!ase. ( Grad I - a$'utat e '!sttrau$at ca t!ta&aEsu+t!ta&a. I" 1911/ B,rd si co%a-oratorii au $!d # cat c&as # carea Gust &!/ "s sta"d 'e importanta vascularizatiei osoase 8 ( Tip I ( trau$at s$ de e"er) e us!ara / #ractura cu tra ect !+& c sau s' r! d/ d &acerare te)u$e"tara F4 c$/ '&a)a re&at * curata/ c rcu&at e e"d!sta&a D 'er !sta&a "tacte. ( Tip II ( trau$at s$ de e"er) e $ed e/ #r. cu de'&asare sau c!$ "ut *a/ d &acerare cuta"ata G4 c$/ c!"tu. e $!derata a ' e& s $uscu&atur ad ace"te/ #ara de* ta& .area $uscu&atur / c rcu&at e e"d!sta&a "treru'ta. ( Tip !I ( trau$at s$ cu e"er) e "a&ta/ #r. cu de'&asare $'!rta"ta s c!$ "ut e se*era/ ' erdere te)u$e"tara "t "sa cu de* ta& .area $uscu&atur &!ca&e/ c rcu&at e e"d!sta&a s 'er !sta&a "treru'te. ( Tip I ( trau$at s$ #. * !&e"t/ '&a)a )ra*a 'r!dusa 'r " e%'&!. e sau str * re/ &e. u"e *ascu&ara care "eces ta rec!"struct e. D " 'u"ct de *eder a& ch rur)u&u '&ast c a"/ S'ar. -SHar. s Mears/ 19150 #ace ! c&as # care a C'&a) &!rC de )a$+a/ 'e +a.a care a se '!ate a&e)e teh" ca de rec!"struct e a de#ecte&!r de tesutur . C&as # carea SHar. este " tre tre'te 8 I Defecte de tesuturi tip I Swarz. Aceasta )ru'a c!"t "e #ractur &e desch se care
A

're. "ta de#ecte de 'art $! / dar #ara de#ect de !s. Aut!ru& rec!$a"da ac!'er rea !su&u 'r " &a$+!ur $ !cuta"e &!ca&e sau 'r " tra"s#er $uscu&ar & +er -&at ss $us d!rs 0. Defecte de tesuturi tip II Swarz. Aceasta )ru'a cu'r "de #ractur &e desch se cu de#ecte c!$+ "ate de 'art $! s de !s/ dar $a 'ut " de 1 c$. Este rec!$a"data rec!"struct a 'r " tra"s#er & +er de )re#a c!$'!. ta -!s '&us 'art $! 0. 3. Defecte de tesuturi tip III Swarz. I" aceasta )ru'a "tra #ractur &e desch se cu de#ecte de 'art $! as!c ate cu de#ect de !s $a $are de 1 c$. SHar. rec!$a"da rec!"struct a " d!ua eta'e. I" t a& se rec!$a"da ac!'er rea de#ectu&u de !s 'r " tra"s#er $uscu&ar & +er/ ar a'! rec!"struct a sche&etu&u 'r " 'r!cedee !ste!'&ast ce sau 'r " tra"s'!rt se)$e"tar -$et!da I& .ar!*0. C&as # carea SHar. este *a&!r!asa 'r " "d cat *e 'rec se de rec!"struct e 'e care &e sta+ &este. Este u" cr ter u de a&e)ere a "d cat e de rec!"struct e. Sud/a01, Haas, Tsc#(rn( si B(r&as -19190 au e&a+!rat cea $a c!$'&e%a sca&a de c&as # care s de a'rec ere a se*er tat #ractur &!r desch se. Scala Hanovra c&as # ca #ractur &e desch se 'e +a.a u"u sc!r ce re.u&ta d " su$area 'u"cte&!r care se ac!rda 'e"tru # ecare t ' de &e. u"e. Pu"cta,u& ac!rdat este " #u"ct e de )ra* tatea &e. u" res'ect *e. Dat!r ta "u$aru&u $are de 'ara$etr #!&!s t / sca&a Ha"!*ra aduce u" '&us de 'rec . e/ " s'ec a& 'e"tru a'rec erea 'r!)"!st cu&u s este u" ade*arat "d cat!r de se*er tate. Ea "tr!duce e&e$e"tu& "!u de a'rec ere c rcu$#ere"t a&a/ re$ "ta"du(se &a c!d # carea " #u"ct e de d $e"s u" &e &e. u" $asurate " ce"t $etr . La "! " tara/ 2i#ai Po1(scu 'r!'u"e ur$at!are&e $!d # car / !#er "d ! sca&a $a acces + &a {Modified Hannover Fracture Scale . C!"#!r$ cu 'r!'u"er &e &u / 'u"cta,u& se ac!rda " #e&u& ur$at!r 8 ! "odificarea focarului de fractura "dupa #iiller - $%& ' J #!car de t ' A........................................................................1 'ct. J #!car de t ' @........................................................................4 'ct. J #!car de t ' C #ara de#ect de !s.............................................6 'ct. J #!car cu de#ect de !s $a $ c de 4 c$..................................A 'ct. J #!car cu de#ect de !s $a $are de 4c$.................................1 'ct. #. "odificarea leziunilor te$u%entare& J '&a)a $a $ ca de 1E6 d " c rcu$#er "ta................................1 'ct. J '&a)a 'a"a &a 1E4 d " c rcu$#er "taKKKKKKKKKK4 'ct. J '&a)a 'a"a &a ?E6 d " c rcu$#er "taKKKKKKKKKK? 'ct. J '&a)a $a $are de ?E6 d " c rcu$#er "taKKKKKKKK6 'ct. Daca '&a)a 're. "ta s de#ect te)u$e"tar/ &a 'u"cta,u& !+t "ut a"ter !r se $a adau)a 8 J de#ect te)u$e"tar $a $ c de 1E6 d " c rcu$#er "ta..................... 1 'ct. J de#ect te)u$e"tar 'a"a &a 1E4 d " c rcu$#er "ta............................ 4 ' c t J de#ect te)u$e"tar 'a"a &a ?E6 d " c rcu$#er "taKKKKKK ? 'ct. J de#ect te)u$e"tar $a $are de ?E6 d " c rcu$#er "taKKKKK. 6'ct.
;

3. "odificarea leziunilor de parti %oi su'te$u%entare "contuzii musculotendinoase, rupturi sau striviri musculare si sindromul de compartiment& '

J &e. u"e $uscu&ara $a $ ca de 1E6 d " c rcu$#er "ta...................... 1 'ct. J &e. u"e $uscu&ara 'a"a &a 1E4 d " c rcu$#er "taKKKKKKKK4 'ct. J &e. u"e $uscu&ara 'a"a &a ?E6 d " c rcu$#er "ta.............................. ? 'ct. J &e. u"e $uscu&ara $a $are de ?E6 d " c rcu$#er "ta.........................6 'ct. J a$'utat e 'art a&a 'r " sect !"are "c!$'&eta..................................5 'ct. J a$'utat e 'art a&a 'r " str * re "c!$'&eta........................................A 'ct. J a$'utat e 'art a&a 'r " sect !"are.....................................................; 'ct. J a$'utat e t!ta&a 'r " str * re.............................................................1 'ct. Daca su"t 're.e"te s &e. u" *ascu&are/ &a 'u"cta,u& a"ter !r !+t "ut se $a adau)a8 J 'e"tru sche$ e tra". t!r e..............................................................1 'ct. J 'e"tru sche$ e c!$'&ete $a $ ca de 6 !re..................................4 'ct. J 'e"tru sche$ e c!$'&eta $a $ ca de 1 !re..................................? 'ct. J 'e"tru sche$ e c!$'&eta $a $are de 1 !re..................................5 'ct. Daca su"t 're.e"te s &e. u" &e "eur!&!) ce/ &a 'u"cta,u& !+t "ut a"ter !r se adau)a8 J tu&+urar de se"s + & tate &a " *e&u& 'a&$e sau a& '&a"te ....................1 'ct. J tu&+urar a&e $!t & tat de)ete&!r......................................................4 'ct. (. "odificarea nivelului de conta%inare& J c!r' stra " " ca"t tate $ ca............................................................1 'ct. J c!r' stra " " ca"t tate $are............................................................4 'ct. Pe"tru c!"ta$ "area +acter a"a/ &a 'u"cta,u& !+t "ut a"ter !r se $a adau)a 8 J 're.e"ta u"e s'ec aer!+e............................................................... 4 'ct. J $a $u&te s'ec aer!+e sau u"a s ")ura a"aer!+a............................? 'ct. J s'ec aer!+e as!c ate cu ! s'ec e a"aer!+a.....................................6 'ct. 3. "odificarea leziunilor asociate& J #ractur $u&t '&e.................................................................................1 'ct J &e. u" a+d!$ "a&e............................................................................4 'ct. J &e. u" t!rac ce..................................................................................? 'ct. J &e. u" cra" !(*erte+ra&e....................................................................6 'ct. ). "odificarea ti%pului in care s-a acordat pri%ul a*utor calificat& J 'r $ a,ut!r ac!rdat " "ter*a&u& A(14 !re..........................................1 'ct. J 'r $ a,ut!r ac!rdat du'a 14 !re........................................................4 'ct. Du1a a1r(ci(r(a autori%or sca%(i Hanovra 8 J U" sc!r # "a& de 4 ( 5 'ct. c!res'u"de u"e #r. desch se de t ' I Tsche$e J U" sc!r # "a& de A (19 'ct. c!res'u"de u"e #r. desch se de t ' II Tscher"e
1

J U" sc!r # "a& de 42 ( ?2 'ct. c!res'u"de u"e #r. desch se de t ' III Tscher"e J U" sc!r # "a& G ?2 'ct. c!res'u"de u"e #r. desch se de t ' IV Tscher"e

I" 1992/ a #!st 'r!'usa c&as # carea )ru'u&u AO -Mu&&er s c!&a+!rat!r 0/ care "c&ude u" s ste$ se'arat de a'rec ere a &e. u" &!r cuta"ate/ a ce&!r $uscu !( te"d "!ase s a ce&!r "eur!*ascu&are s !s!ase 8 45 !eziuni ale pielii in fracturile desc+ise ,I--inte$u%ent open

J IO1 ( desch derea ' e& 'r " $eca" s$ d "au"tru ( "a#ara J IO4 ( desch derea ' e& 'r " $eca" s$ d "a#ara ( "au"tru/ F5 c$/ cu $ar) " c!"tu.e J IO? ( desch dere cuta"ata G5 c$/ c!"tu. e "t "sa a ' e& s $ar) " de* ta& .ate J IO6 ( c!"tu. e te)u$e"tara "t "sa ca su'ra#ata s )r!s $e / sca&'are sau ' erdere e%t "sa de su+sta"ta cuta"ata !eziuni %usculo-tendinoase ,Ml J MT1 ( #ara &e. u" $uscu&are J MT4 ( &e. u" $uscu&are c rcu$scr se/ dar u" c!$'art $e"ta&e J MT? ( &e. u" $uscu&are a'rec a+ &e/ s tuate &a " *e&u& a 4 c!$'art $e"te J MT6 ( c!"tu. $uscu&are "t "se/ de#ect $uscu&ar/ ru'tur te"d "!ase J MT5 ( S "dr!$ de C!$'art $e"t E S "dr!$ de str * re !eziuni neuro-vasculare ,./ J NV1 ( #ara &e. u" "eur!(*ascu&are J NV4 ( &e. u"e "er*!asa .!&ata J NV? ( &e. u"e *ascu&ara str ct .!&ata J NV6 ( &e. u"e *ascu&ara se)$e"ta&a e%t "sa J NV5 ( &e. u"e "eur!(*ascu&ara c!$+ "ata/ "c&u.a"d a$'utat e '!sttrau$at ca su+t!ta&a E t!ta&a (eziuni osoase ( c!d # ca &!cu& s as'ectu& tra ectu&u de #ractura J L!cu& ( 'e"tru !ase&e &u") 8 1 ( hu$eru& 4 ( !ase a"te+rat ? ( #e$ur 6(t+e ( 'e"tru se)$e"te&e !s!ase 8 1 ( e' # .a s $eta# .a 'r!% $a&a 4 ( d a# .a ? ( e' # .a s $eta# .a d sta&a
9

( daca #ractura de t + e se "s!teste de #ractura de 'er!"eu 1 ( 'er!"eu "tact 4 ( 'er!"eu #racturat &a a&t " *e& decat #!caru& t + a& ? ( 'er!"eu #racturat &a ace&as " *e& cu #!caru& t + a& J As'ect tra ect #racturar A ( #r. s $'&e ( A& ( tra ect s $'&u s' r! d ( A4 ( tra ect s $'&u !+& c $a $are de ?2L ( A? ( tra ect s $'&u/ tra"s*ersa& sau !+& c su+ ?2L @ ( #r. cu a& tre &ea #ra)$e"t cc " #&utureC -c!$ "ut e $ caC0. Caracter st c este ca du'a reducere/ #ra)$e"te&e 'r "c 'a&e * " " c!"tact d rect. ( @& ( tra ect s' r! d -c!"u& de t!rs u"e0 ( @4 ( tra ect !+& c -c!"u& de #&e% u"e0 ( @? ( tra ectu& 63 #&utureC e as!c at cu #racturarea C#&uture&u C
6

C ( #r. c!$'&e%e -c!$ "ut e $are0= du'a reducere/ #ra)$e"te&e 'r "c 'a&e "u * " " c!"tact. ( C& ( tra ect c!$ "ut * s' r! d ( C4 ( tra ect cc " du+&u eta,C cu #ra)$e"t "ter$ed ar -#ractura se)$e"ta&a0 ( C? ( tra ect c!$'&e%/ "ere)u&at -#ra)$e"t "ter$ed ar c!$ "ut *0 E%e$'&u 8 #ractura de t + e " 1E? $ed e cu d sta&a/ as!c ata cu ! #ractura de c!& 'er!" er ( 6E4EA1E4. Pr $a c #ra -60/ a d!ua -40 s u&t $a -40 "e arata u"de este #ractura/ res'ect * #ractura t + e/ .!"a d a# .ara/ as!c ata cu #ractura 'er!"eu &a a&t " *e&= A& arata cu$ este #!caru& de #ractura/ res'ect * s' r! d s $'&u. C&as # carea AO 'er$ te u" d a)"!st c 'rec s a& &e. u" &!r s este ! $et!da us!ara de st!care a date&!r " ca&cu&at!r. I" a"u& 1992/ H(%f(t *i co%a-oratorii au e&a+!rat ! sca&a re&at * s $'&a "#.).*.*. ( The Ma")&ed E%tre$ tM Se*er tM Sc!re0 care 'er$ te !r e"tarea ch rur)u&u " ad!'tarea u"e dec . ,a%putatie versus reconstructie 7

)ru1 A: In9urii a%( sc#(%(tu%ui <i a%( =(suturi%or

Ti1 ;

>

Carac8 t(ristici E"er) e ,!asa E"er) e $ed e E"er) e "a&ta

D(finir(a %(.iuni%or P&a) 'r " ",u")h ere/ #ractur s $'&e "ch se/ '&a) 'r!duse 'r " ar$e de #!e de ca& +ru $ c. Fractur desch se sau #ractur T"ch se $u&t '&e/ &u%aN / &e. u" 'r " str * re $!derate ca D )ra* tate. E%'&!. " s'at u "ch s. P&a) 'r!duse 'r " ar$e de #!e cu e"er) e c "et ca $are.
12

Puncta9 1 4 ?

Str * r Acc de"te " $ed u "a*a&/ acc de"te de tre" sau d " $as *e "dustr a 'etr!& era. ; N!r$!( Te"s u"e arter a&a s st!& ca sta+ &a " tere" D " sa&a B. Star( d( te"s * de !'erat e D cu *a&!are G92$$H). H '!( T. A. sta+ &a " tere"/ dar care ras'u"de &a soc te"s u"e ad$ " strarea "tra*e"!asa de #&u de. tra"( . t!r e > H '!( T.A. s st!& ca F92$$H) " tere"/ dar care ras'u"de te"s u"e &a ad$ " strarea "tra*e"!asa de #&u de d!ar " sa&a de 're&u"( !'erat e. ) ta ; Nu Me$+ru& "#er !r cu 'u&s/ #ara se$"e de sche$ e C. Isc#(0ia e% sta 'er #er ca. UD!ara Pu&s d $ "uat #ara se$"e de sche$ e. ($tr(0itati%or M!de( L 'sa 'u&su&u &a ECHO ( D!''&er/ u$'&ere &e"ta a > rata 'atu&u ca' &ar/ 'areste. / act. $!t!r e d $ "uata. ? A*a"( L 'sa 'u&su&u / e%tre$ tate rece/ 'ara& .ata D a$!rt ta/ #ara u$'&erea 'atu&u ca' &ar. sata ; F?2a" @arsta 1aci(ntu%ui ?2(52a" > G52a" OPsc!r du+&u daca sche$ a durea.a de 'este A !re Ta'el I

0oi

6 2 1

2O 1O 4O ?O 2 1 4

U" sc!r MESS G ; c!"st tu e u" su'!rt ,ust # cat 'e"tru dec . a de a$'utat e. C&as # care Stoc/ -St!cB s H er"er/ 19960 se re#era d!ar &a #ractur &e de )a$+a s este ! c&as # care 'e +a.a care a/ du'a 'arerea aut!r &!r/ se '!ate pune indicatia de reconstructie a defectelor de tesuturi. Aut!r e* de"t a.a $'!rta"ta de!se+ ta a ac!'er r #!caru&u de #ractura cu $usch sau cu 'er !st * a+ &. D " acest 'u"ct de *edere e c!"s dera ca #!caru& se '!ate a#&a8 J "tr(u" &!c C!ste!)e" cC/ dec + "e ac!'er t J "tr(u" &!c 'art a& C!ste!)e" cC/ dec 'art a& ac!'er t J "tr(u" &!c C"e!ste!)e" cC/ dec "eac!'er t De ase$e"ea/ e descr u &a )a$+a tre C.!"e de $ " $a re. ste"taC/ .!"e " care 'e"tru ac!'er rea de#ecte&!r "u se rec!$a"da #!&!s rea )re#e de ' e&e & +era des' cata8 J in treimea superioara ( e' # .a 'r!% $a&a a t + e s $ar) "ea a"ter !ara a $eta# .e J in treimea medie ( #ata a"ter!( "ter"a a t + e J in treimea inferioara ( "trea)a c rcu$#er "ta C&as # carea 'r!'r u(. sa $'arte de#ecte&e ce '!t # "ta&" te "tr(! #ractura desch sa de )a$+a " tre )ru'e 8 J defecte de tesuturi tip $ *toc+ ( de#ecte #asc !cuta"e J defecte de tesuturi tip B *toc+ ( de#ecte $ %te de 'art $! -' e&e/ $usch s
11

a&te 'art $! 0 J defecte de tesuturi tip C *toc+ ( de#ecte de 'art $! as!c ate cu de#ecte de
OS

Pe +a.a aceste c&as # car aut!r sta+ &esc "d cat d #er te de rec!"struct e 'e"tru de#ecte de t ' d #er t. I" #ractur &e desch se de )a$+a cu de#ecte de t ' A sau de t ' @/ du'a # %area #!caru&u de #ractura cu $ ,&!ace ce"tr!$edu&are/ rec!"struct a de#ectu&u de tesutur se #ace cu 8 J grefa de piele libera despicata daca de#ectu& este " a#ara C.!"e&!r de $ ca re. ste"taC J lambouri locale -#asc !cuta"e sau $ !cuta"e0 sau lambouri libere -$ cr!*ascu&are0 daca de#ectu& este "tr(! C.!"a de $ ca re. ste"taC I" #ractur &e desch se de )a$+a cu de#ecte de t ' C/ du'a # %area !su&u 'r " $ ,&!ace e%ter"e/ rec!"struct a de#ectu&u de tesutur se #ace ast#e&8 J Intr-o singura etapa chirurgicala -!s Q 'art $! 0 daca de#ectu& este "tr(u" &!c C!ste!)e" cC -#ra)$e"te de !s + "e ac!'er te as!c ate cu de#ect $ c de 'art $! 0. Rec!"struct a "tr(! s ")ura eta'a se #ace 'r " &a$+!u c!$'!. t !ste!($ !(cuta" & +er -$ cr!*ascu&ar0. J In mai multe etape chirurgicale daca de#ectu& este "tr(u" &!c C'art a& !ste!)e" cC sau C"e!ste!)e" cC -#ra)$e"te de !s "eac!'er te as!c ate cu de#ect $are de 'art $! 0. Rec!"struct a 'resu'u"e ! 'r $a eta'a de )re#are cu u" $usch + "e *ascu&ar .at/ care *a tra"s#+r$a &!cu& "e!ste!)e" c "tr(u" &!c !ste!)e" c. I" eta'a ur$at!are se *a 'ract ca )re#area !s!asa/ ar )re#a *a # '&asata " &!cu& !ste!)e" c "!u creat. Aut!r c!d # ca de ase$e"ea teh" ca de )re#a, " #u"ct e de d $e"s u" &e de#ectu&u !s!s8 J defecte de os sub 3 cm ( )re#a de !s s'!") !s J defecte de os intre 3 si 1, cm - )re#a de creasta & aca *ascu&ar .ata -$ cr!*ascu&ar0 J defecte de o speste 1, cm- )re#a # +u&ara *ascu&ar .ata Des c&as # carea St!cB "u este ! c&as # care 'r!'r u(. sa a #ractur &!r desch se/ are ! $'!rta"ta de!se+ ta " sta+ & rea cr ter &!r de rec!"struct e. Nu$aru& $are de 'ac e"t '!& trau$at .at cu #ractur desch se a&e )a$+e r d ca 'r!+&e$e " e*a&uarea )ra* tat s trata$e"tu& acest!ra. D " acest $!t */ Ver$esa" s c!&a+!rat!r -19990 'r!'u" u" coeficient de gravitate 'e"tru e*a&uarea 'ac e"t &!r '!& trau$at .at / c!e# c e"t care de' "de de ur$at!r #act!r 8 A0 Fact!r &!ca& a0 Fractur ( #r. s $'&e ( #r. a&e !ase&!r $ c (1 ' ( #r. a&e !ase&!r &u") ( 4 ' ( #r. c!$ "ut *e ( ? '
14

( #r. desch se ( t ' I -Gust &!(A"ders!"0 (1 ' ( t ' II ( 4 ' (t '$(?' ( " ca.u& as!c er cu ! #ractura art cu&ara ( 1 ' " '&us +0 Le. u" as!c ate #ractur ( &e. u" $uscu&are "t "se ( 4 ' ( &e. u" *ascu&are ( artere $ c s $ed (1 ' ( *e"e $ar ( 4 ' ( artere $ar ( 4 ' ( &e. u" "er*!ase ( a&u") reEc!$'res u"e de "er* 'r "c 'a& ( 4 ' ( sect u"e de "er* 'r "c 'a& ( 4 ' Per !ada de t $' de &a acc de"t - " ca.u& #r. desch se0 8 (FAh(&' (A(14h(4' (G14h(?' @0 A&te a#ect u" as!c ate #ractur &!r desch se 8 a0 S!c ( 'res u"e sa")u "a s st!& ca F &OO$$H) ( 4 ' ( 'res u"e sa")u "a s st!& ca F A2$$H) ( ? ' +0 Le. u" $a,!re as!c ate ( s $'&e ( ? ' ( c!$'&e%e ( 5 ' Su$a 'u"cte&!r !+t "ute re're. "ta c!e# c e"tu& de )ra* tate 'e care aut!r c&as # cat " 6 )ru'e 8 J coeficient de gravitate I "1-- p& ( #r. s $'&e 'r!duse de u" trau$at s$ cu e"er) e $ ca=

1(au

I coeficient de gravitate II "--1, p& ( trau$at s$ cu e"er) e $are cu c!$ "ut e sau #r. desch se de )rad $ c= I coeficient de gravitate III "1,-1- p& ( trau$at s$ cu e"er) e $are= &e. u" a&e !r)a"e&!r "ter"e= I coeficient de gravitate I ". 1- p& ( trau$at s$ cu e"er) e #!arte $are cu &e. u" s $u&ta"e &!c!$!t!r / t!rac!'u&$!"are sau cra" e"e. N c u"u& d " s ste$e&e de c&as # care a #ractur &!r desch se "u este 'er#ect/ e&e tre+u "d ada'tate # ecaru ca. " 'arte. C&as # carea &u Gust &!/ +a.ata 'e stud u& retr!s'ect * s 'r!s'ect * a 1245 ca.ur de #ractur desch se a&e !ase&!r &u") / tratate D ur$ar te " 'er !ada 1955(19;?/ este cea $a #!&!s ta c&as # care 'e '&a" "ter"at !"a&/ dat!r ta a'& ca+ & tat sa&e $ed ate " 'ract ca trau$at!&!) ca.

1?

CAPITOLUL I@.

STATISTICA

;.Dina0ica 0or-iditatii 1rin fracturi d(sc#is(.

Cresterea c!"t "ua a "u$aru&u de acc de"te " t!ate tar &e a #acut ca &e. u" &e trau$at ce sa !cu'e &!cu& tre s ch ar d! " cadru& $!r+ d tat )e"era&e ast#e& "cat a a,u"s sa c!"st tu e ! 'r!+&e$a s!c a&a de "teres $a,!r.I$e"sa $a,!r tate a acc de"te&!r s!&date cu #ractur desch se au dre't cau.e 'r "c 'a&e "eres'ectarea d sc '& "e&!r rut ere s "!r$e&!r de 'r!tect a $u"c . Acest &ucru se ra'!rtea.a s " & teratura $!"d a&a de e%e$'&u8 daca " 1915 " Tu&!use este a"a& .ata ! stat st ca de 4A6 de #ractur d "tre care ?23 su"t #ractur desch se/ " 1992 se ra'!rtea.a ! 'r!'rt e de 623.La "! " tara/ C& " ca de Ort!'ed e s Trau$at!&!) e @ucurest e#ectua"d u" stud u 'e ! 'er !ada de 16 a" -19A?(19;A0 c!"stata ! crestere $arcata a "c de"te acest!r &e. u" trau$at ce ca"d s(au "re) strat 543 d " cau.e. I" C!"sta"ta " 'er !ada 4222(4224 " C& " ca de Ort!'ed e s Trau$at!&!) e au #!st "ter"at 1;12 'ac e"t d "tre care 4;2 'ac e"t au 're.e"tat #ractur de )a$+a.D " acest "u$ar t!ta& de 'ac e"t cu #ractur de )a$+a 192 au 're.e"tat #ractur "ch se ar 12 au #!st cu #ractur desch se re're.e"ta"d 493.

Anul

Nr. cazuri

1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 Total

145 157 152 158 66 144 64 125 182 257 214 304 234 298 2 500

16

Tota% 1aci(nti int(rnati 1;12

Paci(nti cu fr. d(sc#isa d( &a0-a +!

Paci(nti cu fr. inc#isa d( )a$+a 192

Ta+e& II ( C& " ca de Ort!'ed e s

Trau$at!&!) e @ucurest -Stud u Stat st c 19AA(19;A0

Ta'el III - Clinica de Ortopedie si Traumatologie Constanta(Studiu Statistic 2000-2002)

.Structura 0or-iditatii 1( &ru1( d( varsta si s($(.

D " a"a& .a date&!r d " & teratura de s'ec a& tate re.u&ta ca "c de"ta $a% $a a #ractur &!r desch se se su'ra'u"e 'este 'er !ada cea $a act *a a * et -15(A6 de a" 0.Aceasta c!"statare este a+s!&ut "!r$a&a de!arece #ractur &e desch se sur* " " s'ec a& &a !a$e" *a& . /$a,!r tatea "te)rat " 'r!cesu& 'r!duct */&a 'ers!"ae care se de'&asea.a d "tr(u" &!c " a&tu& #!&!s "d " $!d #rec*e"t $ ,&!ace&e rut ere.

15

/$B)(0( I

( REPARTIRAREA CARURILOR PE GRUPE DE VARSTA SI SE7E

U" stud u e#ectuat de G!ru" s Tr! a"escu -19;9(@ucurest 0arata ca

Gru'a de * rsta -a" 0 M Nr. ca.ur ' T!ta&

2(16 15(46 45(?6 ?5(66 65(56 55(A6 A5(;6 ;5 s 'este T!ta& -;6/130

A 4;9 ?95 6?; ?94 4?6 94 ?A

? ;5 94 1?6 119 91 ;1 ?; A49

9 ?56 61; 5;1 511 ??4 1A? ;?

2/6

16/4 19/5 44/1 42/6 1?/?

A/5 4/9

11;1 -45/430

4 522 122/2

#rec*e"ta #ractur &!r desch se este de tre !r $a $are &a se%u& $ascu& " -;6.130 c!$'arat * cu se%u& #e$ " " -45.430.Acest ra'!rt de #rec*e"ta ? ME1F este "!r$a& de!arece su"t $a $u&t +ar+at a")re"at " $u"c # . ce )re&e/ $a,!r tatea aut!*eh cu&e&!r su"t c!"duse de +ar+at /#e$e &e # "d $u&t $a ate"te atat &a *!&a" cat s ca ' et!" .

1A

R(1artitia ca.uisticii in functi( d( s($

+;A ;6A
@ar+at Fe$ e

/arsta (11(?2 a" ( 413 -44 'ac e"t 0 ( ?1(52 a" ( 693 -?1 'ac e"t 0 G52 a" ( 4? 3 -11 'ac e"t 0
Fi&83 R(1artitia ca.uisticii 1( &ru1( d( varsta
+A
;+8>! ani >; 83! ani 53!ani

>A

?6A

LOT 12PACIENTI(SPITALUL CLINIC :UDETEAN CONSTANTA -4222(42240S

A22

522

622

?22

422

122

1;
2-11 1--21 2--31 3--11 1---1 ---21 2--31 3-G

STUDIU STATISTIC CLINICA DE ORTOPEDIE @UCURESTI -19AA(19;A0

>.Structura 0or-iditatii in functi( d( s(.on si ora 1roduc(rii.

Re'art .area ca.ur &!r cu #ractur desch se 'e a"!t $'ur arata ! "c de"ta $a% $a " &u" &e de *ara s t!a$"a/ c "d s(au "re) strat/ &a u" &!c/ 1 12; ca.ur -;4/630/ #ata de &u" &e de 'r $a*ara s ar"a/ c "d s(au "re) strat A9? de ca.ur -4;/A30. - D " acest )ra# c re.u&ta cu c&ar tate ca " &u" &e de ar"a/ " c uda .a'e. / )het s '!&e u&u / dec a 'er c!&u&u $a $are de a&u"ecare s cadere/ se "re) strea.a t!tus ce& $a $ c "u$ar de #ractur desch se. D " acest stud u/ 'ute$ tra)e c!"c&u. a ca #rec*e"ta r d cata a "u$aru&u #ractur &!r desch se d " &u" &e de *ara s t!a$"a tre+u e 'usa $a a&es 'e sea$a "$u&t r $'res !"a"te a $ ,&!ace&!r 'ers!"ate s c!&ect *e de tra"s'!rt/ c rcu&at a # "d $u&t $a redusa " &u" &e de ar"a.

IARNA

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Stractura $!r+ d tat 'r " #ractur desch se " #u"c, c de se.!".

I" #u"ct e de !ra 'r!ducer Tr! a"escu(19;90

acc de"tu&u .-G!ru" s

19

?.Structura 0or-iditatii in functi( d( (tio%o&i(

Acc de"te&e de c rcu&at e se a#&a 'e 'r $u& &!c " et !&!) a #ractur &!r/e&e # "d res'!"sa+ &e de a'r!a'e ,u$atate d " "u$aru& t!ta& a& #ractur &!r desch se/ " *re$e ce acc de"te&e de $u"ca se s tuea.a 'e &!cu& a& d! &ea.Pe &!cu& tre se c&asea.a acc de"te&e d *erse s "e'rec .ate ur$ate de acc de"te&e cas" ce s acc de"te&e de s'!rt.

Etio%o&ia fracturii d(sc#is( d( &a0-a

Accid(nt( ruti(r( Accid(nt( d( 0unca Accid(nt( casnic( A&r(siuni Accid(nt( n(1r(ci.at(

Studiu statistic S1ita%u% Cinic Cud(t(an Constanta !!!8 !! D%ot 8+! 1aci(ntiE

3.Structura 0or-iditatii in ra1ort cu s(diu% fracturii si ti1u% d(sc#id(rii

t(&u0(ntar(

Se re$arca #a'tu& ca #ractur &e desch se de )a$+a c!"s derate )&!+a&-#ractur a&e a$+e&!r !ase/#ractur de t + e s #ractur de # +u&a0 re're. "ta 'este ,u$atate d " t!ta&u& #ractur &!r desch se -55.63 ra'!rtat de G!ru"0.Pe +a.a stat st c ce"tru&u de trau$at!&!) e d " @!rdeau% 1915 Pate& s c!&a+!rat!r ra'!rtea.a ?A.?3 'r!ce"tu& #ractur &!r desch se.Pr!ce"te&e *ar a.a "sa s " #u"ct e de s'ec # cu& ser* c u&u res'ect *-ser* c u& de ur)e"ta sau de +!&"a* cr!" c /ch rur) e )e"era&a sau trau$at!&!) e0.Pe &!cur &e ur$at!are se s tuea.a #ractur &e desch se a&e a"te+ratu&u /#a&a")e&!r ' c !ru&u /#e$uru&/hu$erusu&/etc.

Re're.e"tarea ce&!r $a #rec*e"te &!ca& .ar a&e #ractur &!r desch seUGORUN (19;9V

D " 'u"ct de *edere a& $eca" s$u&u &e. u" &!r te)u$e"tare d!$ "a de de'arte a)e"tu& *u&"era"t d rect/&e. u" &e te)u$e"tare *ar "d de &a '&a) 'u"ct #!r$e s $'&e 'a"a &a dec!&ar te)u$e"tare "t "se/cu sca&'ur *ar a+ &e s u"e!r str * r )ra*e de $e$+re.I" t $' ce ! '&a)a 'u"ct #!r$a "u r d ca " c ! d # cu&tate tera'eut ca-sutura 'r $ara du'a t!a&eta ch rur) ca&a0dec!&ar &e te)u$e"tare "t "se s .dr!+ r &e de tesutur $! r d ca 'r!+&e$e c!$'&e%e atat d " 'u"ct de *edere a& trata$e"tu&u cat s a& 'r!)"!st cu&u .I"tre aceste d!ua e%tre$e se "ta&"esc #!arte $u&te as'ecte "ter$ed are cu '&a) & " are sau ste&ate cu sau #ara dec!&ar /cu &e. u" d *erse a&e tesutur &!r $! su+cuta"ate. Tr! a"escu s c!&a+.ra'!rtea.a ca d " 1?16de #ractur desch se de Ga$+a -55/63d " t!ta&u& #ractur &!r desch se0/ 11?5 "teresea.a a$+e&e !ase/-cu122A desch der " #!caru& t + a&/16 de desch der " a$+e&e #!care s 65 de desch der " #!caru& # +u&ar0/41A#ractur desch se de t + e s ?? de #racture desch se de # +u&a. As!c er &e &e. !"are su"t "u$er!ase s *ar ate/c!"tr +u "d &a a)ra*area e*!&ut e #ractur desch se "tr(u" 'r!ce"t $ c de ca.ur .Ast#e& #ractura desch sa trece 'e '&a"u& secu"d sau 'e u&t $u& &!c " c!"te%tu& c& " c a& u"!r '!& trau$at s$e.

".Princi1ii d( trata0(nt a% fracturii d(sc#is(.

P&a"u& tera'eut c a'& cat este $'us de )ra* tatea &e. u" &!ca&e s a &e. u" &!r as!c ate " c!"te%tu& s!cu&u s a& '!& trau$at s$e&!r.Sche$at c se eta' .ea.a ast#e&8 ( re.!&*area &e. u" &!r &!ca&e > trata$e"tu& &e. u" &!r 'art &!r $! sta+ & .area #!caru&u de #ractura ( trata$e"tu& de des!care c!"sta"d "8 reech & +rare he$!h dr!e&ectr!& t ca 'r!# &a% a de.ech & +ru&u #&u d!c!a)u&a"t ( trata$e"tu& &e. u" &!r ass!c ate " c!"te%tu& '!& trau$at s$u&u ( ( 'r!# &a% a "#ect e '&a) #racturare -a"t + !t c!tera' a0/a "#ect e teta" ce/a )a")re"e )a.!ase. trata$e"tu& a#ect u" &!r 'ree% ste"te-d a+et/+!& card !*ascu&are/seche&e "eur!&!) ce/etc.0

F.Trata0(ntu% %oco8r(&iona% a% fracturi%or d(sc#is(. E% sta tre 'r "c ' $ar " trata$e"tu& de ur)e"ta a& u"e #ractur desch se8 ( e%c . a tesutur &!r de* ta& .ate= ( c!"ser*area !r caru e&e$e"t a"at!$ c &e.at/'e cat $a $u&t '!s + &= ( !r ce ra'!rt a"at!$ c sch $+at tre+u e resta+ & t. Du'a G!ru" $a,!r tatea "ter*e"t &!r 'ract cate -5A.?30 au #!st !'erat $ " $e dar cu e# c e"ta $a% $a c!"sta"d "8 ( t!a&eta ch $ ca s $eca" ca r )ur!asa= ( e%c . a ' e& /tesutu&u su+cuta"at .dr!+ t/#ra",ur &!r a'!"e*r!t ce s $uscu&are= ( reducerea !rt!'ed ca a #!caru&u de #ractura= ( $!+ & .area se)$e"tu&u " a'arat ) 'sat sau e%te"s e c!"t "ua tra"ssche&et ca.

W Structura $!r+ d tat 'r " #ractur desch se " ra'!rt cu t 'u& "ter*e"t e 'ract cate.

Trata0(nt a1%icat

Tota%

Toa%(ta G sutura Dfara i0o-i%i.ar(E Toa%(ta 8 sutura G i0o-i%i.ar( Toa%(ta G ost(osint(.a 1ri0ara G sutura 1ri0ara Toa%(ta 8f ($ci.i( %ar&a Dfara suturaE G i0o-i%i.ar( A01utatii si r(tusari d( -onturi trau0atic( P%astii cutanat( in ur&(nta R(.(ctii osoas( T(norafii Li&aturi art(ria%( R(duc(ri orto1(dic( d( %u$atii d(sc#is( R(duc(ri orto1(dic( d( fracturi d(sc#is( E$tra&(ri d( un&#ii E$t(nsii transosoas( /ratamentul leziunilor asociate Ost(osint(.( 0(ta%ic( Do%(cran, ant(-rat, 0(tacar1i(n(, f(0ur, 1at(%a, &a0-a, 0(tatarsi(n( (tc.E Suturi d( 1%a&i div(rs( R(duc(ri orto1(dic( in fracturi div(rs( R(duc(ri d( %u$atii div(rs( E$t(nsii transosoas( Punctii d( #(0atoa0( si #(0artro.( vo%u0inoas(

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REPARTIRAREA FRACTUIOLOR DESCHISE DIN SERIA NOASTRA IN FUNCTIE DE TRATAMENTUL APLICAT

C!"d t a dea&a este ac!'er rea #!caru&u de #ractura 'r "tr(u" '&a" $uscu&ar s a&tu& te)u$e"tar.Nu se *!r e#ectua sutur " te"s u"e/ " ca.u& s "dr!$u&u de c!$'art $e"t se *!r e#ectua #asc !t!$ &a " *e&u& &!,e&!r $uscu&are te"s !"ate.L 'sa de su+sta"ta te)u$e"tara se *a c!$'&eta # e cu )re#e de ' e&e/# e cu as!c erea &a$+!ur &!r $uscu&are-&!ca&e sau de &a d stata as!c ata cu )re#area de ' e&e.Sta+ & .area #!caru&u de #ractura este ! a d!ua c!"d t e !+& )at!r e s're e*!&ut a de * "decare s a #!caru&u de #ractura s " ace&as t $' 'e"tru ! +u"a c catr .are a &e. u" &!r $uscu&!( te)u$e"tare. Oste!s "te.a 'r $ara c!"sta " a&e)erea $et!de ce&e $a s )ure ce *a as )ura # %area cea $a s!& da a #ra)$e"te&!r !s!ase cu res'ectarea r )at e sa")u "e atat a !su&u cat s a'art &!r $! .Du'a G!ru" " ;15 de ca.ur s(au e#ectuat8 ( 419 !ste!s "te.e $ " $e= ( 69A !ste!s "te.e #er$e cu +r!se X rscher/t ,e Xu"tscher/suru+ur /'&a) "suru+ate/t ,e E"der/# %at!r e%ter" E& .ar!*. Mar &e d stru)er te)u$e"tare au $'us u" trata$e"t de aste'tare8t!a&eta s e%c . a &ar)a 'a"a " tesut sa"at!s "u au $a 'er$ s sutura 'r $ara.De aceea reducerea #ractur a #!st ur$ata de $!+ & .are " a'arat ) 'sat cu #ereastra. I" stat st ca e#ectuata &a C& " ca de Ort!'ed e s Trau$at!&!) e @ucurest se re$arca u" "u$ar re&at * $are - 6.430 de a$'utat s retusar de +!"tur trau$at ce. Pe &!tu& de 12 de +!&"a* "*est )at " C& " ca de Ort!'ed e a S' ta&u&u C& " c :udetea" C!"sta"ta trata$e"tu& de# " t * a c!"stat "8

. Trata%entul definitiv al fracturilor desc+ise ,sinteza pe 01 de fracturi

Tip Metode c+irur$icale de rezolvare aparfilor %oi Nr. Metode de sta'ilizare a fracturii ,-steosinteza
1; 14

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I ( #ara sutura -'&a) 'u"ct #!r$e0 ( sutura 'r $ara

OS "t ce"tr!$ed " #!car "ch s ( t ,e e&ast ce t ' E"der ( t ,a Xu"tscher #ara a&e.a, ( t ,a Xu"tscher cu a&e.a, OS "t. " #!car desch s ( '&aca cu Duru+ur Q )re#a c!rt c!s'!") !asa

Metode de sta'ilizare ortopedica ( a'arat ) 'sat

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11 4 ?

II

( sutura 'r $ara ( sutura secu"dara -46h0 ( sutura eta' .ata -;(12 . &e0 ( sutura Q PPLD (a$'utat e de "eces tate cu +!"t desch s s sutura tard *a

1A OS "t. ce"tr!$ed. " #!car 12 4 "ch s ( t ,e e&ast ce t ' E"der 4 ( t ,a Xu"tscher #ara a&e.a, 1 ( t ,a Xu"tscher cu a&e.a, OS "t. " #!car desch s ( '&aca cu Duru+ur ( Duru+ 'ercuta" .!&at OS e%ter"a ( # %at!r e%ter" 6 OS "t. ce"tr!$ed. " #!car 6 "ch s ? ( t ,e e&ast ce t ' E"der OS "t. " #!car desch s ( ? +r!De 'ercuta"e OS e%ter"a ( # %at!r e%ter" 1 1 ? 1 4 OS e%ter"a ( # %at!r e%ter"

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( sutura eta' .ata -;(12 . &e0 ( sutura Q PPLD (PPLD ( PPLD Q &a$+!u #asc !( cuta" ( a$'utat e de "eces tate cu +!"t desch s s sutura tard *a

+. Anti-ioticot(ra1ia
Ut & .area a"t + !t ce&!r cu s'ectru &ar) " sc!' 'r!# &act c este "ecesara dat!r ta r scu&u r d cat de "#ect e creeat 'r " e% ste"ta s!&ut e de c!"t "u tatea cu $ed u& e%ter !r.Daca &a "ce'ut "st tu rea trata$e"tu&u se #ace 'e cr ter u& de 'r!+a+ & tate -a"t + !t ce cu s'ectru &ar)('e" c & "a/)e"ta$ c "a/$etr!" da.!&0 u&ter !r c!"t "uarea sa se e#ectuea.a 'e +a.a a"a& .e&!r de &a+!rat!r ce ra'!rtea.a se"s!+ & tatea )er$e" &!r &a a"t + !t ce.

I. Infectia fracturii ,aspecte statistice co%parative

.r. cazuri
1O Trata%entul 2ocului %i3t Reech & +rarehe$!(h dr!(e&ectr!& t ca Clinica de Rh/ %rtopedie Clinica de %rtopedie, 8ac. de -sa")e .!)ra'/ .! ser/ 0niv. de #edicina :itasato, ;aponia #edicina - Constanta, 9omania )&uc!.a/ '&as$a/ NaC&/- XC10 dr!(e&ectr!& t caI"#ect a '&a) I"#ect Reech a '&a) & +rare h T 5 T '#r. '#r. -ser/ )&uc!.a/ '&as$a/ NaC&/ 3 Nr. ca.ur 3 Nr. I(64#r. I8(49#r. Vacc "are ATPA -1 # !&a ( 2/5 $&0 Seroprofila3ia AT 2 ;1 23 2 Ser 23 II(12;#r. + & .are &e"ta0 AT -?222 UI ( dese"s II(?1#r. 9 49.2?3 6 ?.;?3 4rofila3ia Fara $ed cat e IIIA(6?#r. 44 IIIA(11#r. 'olii ; A?.A?3 ? A.9;3 tro%'oe%'olice C&e%a"e ?2 III@(64#r. III@(A#r.. 5 1?.??3 14 41.5;3 C&1223 *ar " 15 IIIC(11#r. IIIC ( 4 #r. 4 4 11.113 Fra% 'ar " 5 C&e%a"e/ He'ar "a/ Ca&c 'ar "a ? C&e%a"e/ C& *ar " 4 He'ar "a/ C& *ar "/ Ca&c 'ar "a 1

6.Trata0(nu% Socu%ui 2i$t Reech & +rarea he$!h dr!e&ectr!& t ca este a'& cata atat &a " *e&u& ca$ere de resusc tare cat s / " sa&a de !'erat e 'receda"d trata$e"tu& &!c!re) !"a& s c!"t "uata " STI daca starea )e"era&a ! $'u"e. I" ca.u st ca C& " c de Ort!'ed e S' ta& C& " c :udetea" C!"sta"ta 'e u" &!t de 12 de +!&"a* s(a c!"statat 8

I" ca.u st ca a"a& .ata/ "u au #!st c!"statate &e. u" as!c ate '!& trau$at s$u&u care sa

$'u"a u" trata$e"t "eur!ch rur) ca& sau ch rur) ca&/ t!rac!('u&$!"ar/ a+d!$ "a& etc.

CAPITOLUL @.

CONCLUHII

1. )ste necesara evaluarea corecta a gradualitatii lezionale, atat la internare,in urgenta, cat si in etapele ulterioare. % interpretare flziopatologica corecta a modificarilor hemodinamice sistemice si loco-regionale, al integritatii structurilor rmicrocirculatorii si al gradului lor de permeabilitate , permite formularea unei strategii terapeutice corespunzatoare. 2. Caracteristicile anatomice, etiologice si fiziopatologice ale gambei impun fracturilor deschise caracteristici lezionale diferentiate, aspecte clinice multiple, dificultati terapeutice si prognostic uneori incert. 3. 8recventa fracturilor deschise de gamba este in crestere datorita traficul rutier si a accidentelor de munca, existand un procent ridicat la categoriile de varsta activa, predominent la sexul masculin.

1.Caracteristicile focarului de fractura vor fi consecinta intensitatii si modului de aplicare al mecanismului traumatic. $spectul de focar simplu, cominutiv ( plurieschilos poate sugera nivelul energiei traumatice.. -. /ipul lezional fracturar trebuie evaluat pe baza criteriilor clinice si prognostice continute de clasificarea Cauchoix-<ustilo-$nderson si de scala!anovra modificata, clasificari care sugereaza si conduita terapeutica. *cala !anovra, spre deosebire de alte cotatii, puncteaza si implicatiile hemodinamice,momentul acordarii primului a=utor calificat si atentioneaza asupra riscului conflictului compartimental 2/ratamentul definitiv al focarului de fractura prin metode ortopedice este rezervat fracturilor stabile, de tip I si contraindicatiilor ma=ore de tratament chirurgical %steosinteza interna poate ft aplicata fracturilor vazute inainte de 2 ore si la care se practica si sutura plagii "fracturi tip I&. >entru fracturile tip II,osteosinteza interna practicata in urgenta prezinta un risc de difuzare a infectiei. *e prefera, in cazul fracturilor tip II si III stabilizarea osoasa prin fixator extern ce asigura o buna imobilizare ? posibilitatea controlului leziunilor cutanate pana la cicatrizare si pregatirea momentului pentru osteosinteza interna ulterioara, in cazul fracturilor tip III.

BIBLIO)RAFIE

1. Aca%ovsc#i L 8 Starile de soc, A")e&escu N./ Pat!&!) e Ch rur) ca&a/ Ed tura Ce&s us/ @ucureDt 199; 4. A%-u L, Ge!r) a R. 8 $natomia topografica, 451(456/ Ed. ALL/ @ucureDt 1996 ?. A%($a DI, Strata" L./ C !"ca D. 8 aloarea antibiogramei in fracturile deschise, C!"#er "#a Nat !"a&a de Ort!'ed e D Trau$at!&!) e/ 6/ T $ s!ara/ 41(4? Oct./ 1991 6. Bar-u D., Lu'escu O& *era/ Ta"ase D./ Trusca T./ P!' "a s / N cu&escu D. 8 @ificultati in tratamentul fracturilor deschise ale membrelor la politraumatizati, C!"#er "ta Nat !"a&a de Ort!'ed e D Trau$at!&!) e/ A/ T $ D!ara/ 41(4? Oct./ 1991 5. B(ttor V./ C!.u+ C/ Murarasu Ha"e&!r / T!caru I. 8 $titudinea noastrd in tratamentul fracturilor deschise tip III de gamba, C!"#er "ta Nat !"a&a de Ort!'.(Trau$./ T $ s!ara/

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