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UNIVERSITATEAOVIDIUSCONSTANTA
FACULTATEA DE MEDICINA SI STOMATOLOGIE
REFERAT BIOSTATISTICA
FRACTURA DESCHISA.DATE STATISTICE.POSIBILITATITERAPEUTICE.
Conducator stiintific,
Conf.Univ.Dr.TEREN O.
Doctorand,
Dr.CORNELIA PANCHICI
CONSTANTA !!"
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Fractura deschsa este c!"sderata #ractura a care #!car c!$u"ca cu e%ter!ru&
'r"tr(! '&a)a de d$e"su" *ara+&e.Marea $a,!rtate a aut!r&!r c!"sdera #racturadeschsa s #ractura a& care #!car se deschde "tr(u" !r)a" ca*tar-*eca/rect/*a)"0.
Ter$e"u& de #ractura c!$'&cata se atr+ue ace&!r #ractur deschse as!cate cu &eu"
*ascu&!("er*!ase sau *scera&e.A&.Radu&escu c!"sdera ca d" 'u"ct de *edere 'at!&!)c
/!rce #ractura "ta& "chsa/care a #!st su'usa u"u act chrur)ca& 'e"tru !ste!s"tea sau
!ste!t!$e este ech*a&e"ta cu ! #ractura deschsa cu t!ate ca 'erc!&u& u"e c!$'&cat
$edate este $u&t $a redus.Orce #ractura deschsa tre+ue c!"sderata de te$ut de!arcec
c!$'&cat&e secu"dare-"#ecta cu 'seud!artr!a su'urata/!steta0 a'ar #rec*e"t $a a&es "
cau& u"u trata$e"t de ur)e"ta "c!rect sau "c!$'ete"t.As'ectu& 'artcu&ar a& #ractur&!rdeschse c!"sta " "t"derea s 'r!#u"$ea &eu"&!r tesutur&!r $! ce re're"ta atat
e&e$e"te de )ra*tate dar s u" crteru de c&as#care a& #ractur&!r deschse.
Fractur&e deschse c!"sttue " e'!ca $!der"a ! caua #rec*e"ta de s'ta&are
"de&u")ata/de "ca'actate te$'!rara de $u"ca/" u"e&e caur duca"d &a "*a&dtate
'er$a"e"ta/&a care se adau)a c!stur $atera&e $'res!"a"te.Dat!rta acest!r as'ecte
&e)ate de et!'at!)e"a/c&"ca s trata$e"tu& #ractur&!r deschse s(au e#ectuat 'r!)rese
tera'eutce u$t!are &e)ate de acest d!$e"u.Daca " 'r$u& ra+! $!"da& 23 d"tre
#ractur&e deschse se c!$'&cau cu ! !steta '!st#racturara/" a& d!&ea ra+! $!"da&dat!rta a'&car trata$e"tu&u de ur)e"ta s #!&!sr a"t+!tce&!r/'r!ce"tu& a scaut &a
d!ar 453.
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CAPITOLUL I. DEFINITIE
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Fractura deschsa a e%stat d" t!tdeau"a " st!ra !$e"r/$a a&es ca ! c!"sec"ta a
ra+!ae&!r/ ca"d c!$'&cat&e se'tce duceau " $!d #rec*e"t &a e%tus.
Ma&)a)"e-1640 a#r$a ca sutura 'r$t*a " cau& #ractur&!r deschsa era cu"!scuta s
'ractcata "ca d" sec!&u& a& 7III(&ea.I" sec!&u& a& 7VI(&ea chrur)u& A$+r!se Pare trata
#ractura deschsa du'a 'r"c'&e ese"ta&e8 de+rdare/reducere
sa")era"da/esch&ect!$e/e*acuarea he$at!$u&u.T!t &u a'art" 'r$a descrere a'r!a'e
st"t#ca a u"e #ractur deschse/*a&a+&a s " ua de asta ca s 'r$a te"tat*a de
reducere chrur)ca&a a acest!r #ractur.
Mar&e desc!'err a&e &u L.Pasteur-144(1950 s :.Dster-14;(19140 au 'r!dus !
ade*arata re*!&ute " chrur)a )e"era&a s " )e"era& " chrur)a #ractur&!r deschse.Ca
ur$are a scaut se$"#cat* $!rta&tatea 'r" c!$'&cat&e #ractur&!r deschse/a crescut
"u$aru& $e$+re&!r sa&*ate/ar 'r!)"!stcu& #u"ct!"a& a de*e"t d" ce " ce $a !'t$st.
I" cursu& 'r$u&u ra+! $!"da& ! c!"duta de trata$e"t )e"era&a a'&cata de chrur)
aceste e'!c c!"sta "8 e%'&!rarea ate"ta s de+rdare &ar)a a '&a)&!r/esch&ect!$e/'&a)a&asata
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Oste!s"tea a #!st "tre*auta "ca d" 195/ ca"d Th. I!"escu a 'ree"tat
c!$u"car "teresa"te &a ce& de a& 7(&ea C!")res de Chrur)e de &a Pars. Du'a e&/ ! sere de
chrur) *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/ Chrstde/ A. :a"u/ Fa)arasa"u/ @ut!a"u s St!a"/ Tataru s Gr)!rescu/
P!'escu etc.
La s#arstu& sec!&u&u trecut/ :u*ara s @a&acescu -19;0 #!&!seau )re#a
der$!e'der$ca du'a Thersch/ 'e"tru ac!'errea de#ecte&!r te)u$e"tare. Ne $a"dr$
cu c!"tr+uta adusa de :u*ara &a desc!'errea s "tre+u"tarea #%at!ru&u e%ter".
I. :a"u -19150 #ace c!"sderat "teresa"te asu'ra chrur)e de ra+!. I" 191/ Th.
&!"escu 'u+&ca ! a$'&a $!"!)ra#e " care #ace ! 'ree"tare c!$'&eta a trata$e"tu&u
ra"&!r de ra+! 'r" $et!da DaB"(Carre&
@reea"u -19440 aduce c!"tr+ute s su+&"aa *a&!area #%at!ru&u e%ter" "
!ste!s"tea #ractur&!r da#are. Trata$e"tu& #ractur&!r deschse de t+e a c!"sttut s
te$a u"!r tee de d!ct!rat e&a+!rate " 'er!ada "ter+e&ca -Pascu&escu T. 194/ P!'escu
S. 19?60.
La C&u,/ Des&u -19?50 e%'u"e e%'ere"ta acu$u&ata de c!&ect*u& C&"cchrur)ca&e d" C&u,/ c!"dus de A&. P!'/ " 'er!ada 1946(19?5/ "tr(! sere de caur.
La Ias/ Pa&a)hta -19?0 aduce " dscute trata$e"tu& #ractur&!r deschse " &e)atura cu
statstca C&"c chrur)ca&e c!"dusa de P. A")he&.
I" cursu& ce&u de a& d!&ea ra+! $!"da&/ chrur) r!$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
deschse " 'artcu&ar/ ar d"tre acesta 'ute$ a$"t 'e P&atarea"u/ Fa)arasa"u/ @ercea"u/
Mar"/ Ghe!r)hu/ O*a"e.
I" 1951/ &a C!"#er"ta Nat!"a&a de Ort!'ede de &a T$s!ara/ se rec!$e"da
"chderea #!caru&u de #ractura su+ 'r!tecta a"t+!tce&!r s $!+&area " a'arat )'sat.I" 192/ &a C!"#er"ta de &a Oradea/ s(a "sstat asu'ra $'!rta"te re!&*ar
'r!+&e$e&!r ac!'err te)u$e"tare/ cat s asu'ra '!s+&tat de a se recur)e &a
!ste!s"tea/ " u"e&e caur de #ractur deschse.
I" 19;1 a a*ut &!c u" s$'!!" !r)a"at de U.S.S.M./ #&a&a @ucurest c!"sacrat
#ractur&!r deschse de )a$+a.
" 19;/ a a*ut &!c C!"s#aturea de &a Cra!*a cu te$a Trata$e"tu& #ractur&!r
deschse s a c!$'&cat&!r &!r. C!"c&u&e au c!"s#"tt "ecestatea "chder #!caru&u
de #ractura 'r" d*erse $et!de/ 'recu$ s su'er!rtatea reu&tate&!r !+t"ute 'r"
!ste!s"tea ce"tr!$edu&ara/ asu'ra ce&!r !+t"ute 'r" s"tee&e cu '&ac $eta&ce.
I" 19;;/ &a a V&(a Sesu"e a chrur)&!r d" M!&d!*a -Patra Nea$t0 a #!st dscutata
s #ractura deschsa/ c!"c&u&e #"d s$&are ce&!r de &a Cra!*a.
A& V(&ea C!")res Nat!"a& de Ort!'ede(Trau$at!&!)e -Ias 19940 a c!"s#"tt
"ecestatea c!&a+!rar !rt!'ed('&astca" " *ederea ac!'err 'rec!ce a #!caru&u #racturar/
ar " 'r*"ta !ste!s"tee/ $a,!rtatea 'arer&!r au #!st " #a*!area #%at!ru&u e%ter".
La C!"s#aturea Nat!"a&a de &a T$s!ara -1990/ " 'r*"ta sta+&ar #!caru&u/
'!"derea 'r"c'a&a "ce'e sa ! ca'ete !ste!s"tea ce"tr!$edu&ara.
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Orce c&as#care este de #a't ! u"ea&ta " $a"a s " )a"drea chrur)u&u/ ar 'e"tru
a # acce'tata ea tre+ue sa #e "u "u$a #u"ct!"a&a/ dar s ut&a. C&as#car&e s$'&e/ des
us!r de $a"e*rat -#u"ct!"a&e0/ "u su"t ut&e " trau$ats$e&e se*ere. Pe de a&ta 'arte/
c&as#car&e c!$'&e%e su"t d#c& de $a"e*rat/ dar ut&e " s'eca& " aceste trau$ats$e
se*ere.
Pr$a c&as#care $!der"a a'art"e &u Cauc#oi$ -1950/ care e*a&ueaa
gravitatea fracturii deschise in functie de marimea pierderii cutanate. Aceasta
c&as#care a re*!&ut!"at $!du& de a+!rdare a #ractur&!r deschse s a stat &a +aa sste$e&!r
de c&as#care u&ter!ara 8
( tip 1 ( '&a)a te)u$e"tara 'u"ct#!r$a/ as!cata cu &eu" su+ace"te $"!re
( tip 2 - &eu"e $a e%t"sa a 'e&/ e%sta"d rscu& a'arte u"e "ecr!e
te)u$e"tare secu"dare- tip 3 -'ree"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!)"!stcu& #ractur
du'agradul de lezare apartilor moi8
-tip 1 ( 'er#!rare 'u"ct#!""a a 'e&/ 'r!dusa d"au"tru "a#ara
-tip 4 ( '&a)a c!"tua 'r!dusa 'r" $eca"s$ d"a#ara("au"tru
-tip 3 - #ractura se as!caa cu &eu" 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&ueaa
nivelul de contaminare a focarului fracturar 8- tip 1 -'&a)a te)u$e"tara de d$e"su" $c/ as!cata cu &eu" $"$e a&e
tesutur&!r $!
-tip 2 ( 'erder $a $ar de su+sta"ta cuta"ata/ as!cata cu &eu" 'ut" "t"se a&e
tesutur&!r $! sau cu "*e& de c!"ta$"are redus a& '&a)
- tip 3 - &eu" $!derate sau e%t"se a&e 'art&!r $!/ de*ta&ate sau
c!"ta$"ate $as*
)usti%o *i And(rson -19;0 au 'us &a 'u"ct ! c&as#care ada'tata u&ter!r de
!rt!'e d" "trea)a &u$e/ care are &a +aa marimea deschiderii cutanate, gradul de lezare
sau de contaminare a tesuturilor moi si tipul de fractura. I" 196/ Gust&! s c!&a+!rat!rau subdivizat tipul III in functie de gradul de contaminare / extinderea decolarii periostale
si necesitatea interventiilor de reconstructie vasculara 8
( TipI - #r. deschse cu '&a)a cuta"ata curata/ su+ 1 c$ &u")$e
( Tip II ( #r. deschse cu 'erdere te)u$e"tara $a $are de 1 c$/ dar #ara &eu"
e%t"se a&e 'art&!r $! su+ace"te s #ara a*u&s sau &a$+!ur de 'art $!
( Tip III ( #r. deschse cu d&acerar/ &eu" sau 'erder e%t"se a&e 'art&!r $!
( !rce #r. deschsa se)$e"ta&a
5
CAPITOLUL III. CLASIFICAREA FRACTURILOR
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( !rce a$'utate '!sttrau$atca
( &eu" de e"er)e $are 'r!duse 'r" ar$e de #!c
( #r. deschse care "ecesta rec!"structe *ascu&ara
( #r. deschse $a *ech de + !re
( IIIA ( ac!'erre 'er!sta&a sats#acat!are a #!caru&u/ " cuda
&eu"&!r e%t"se a&e 'art&!r $!
( #r. 'r!duse 'r" trau$ats$e de e"er)e $are/ care "u au
c!res'!"de"ta drecta cu $ar$ea &eu"&!r cuta"ate
( B ( 'erder e%t"se de tesutur $!/ cu dec!&are 'er!sta&a/
duca"d &a e%'u"erea !su&u su+ace"t ( as!cere #rec*e"ta cu
! c!"ta$"are +actera"a $as*a
( C ( #r. deschse as!cate cu &eu" artera&e -"ecesta"d
rec!"structe *ascu&ara0/ #ara c!res'!"de"ta drecta cu
)radu& de &eare a tesutur&!r $!
I" 196/ O(st(rn si Tsc#(rn( au "tr!dus ! c&as#care 'e +aa gradului de lezare a
tesuturilor moi si extinderii contuziei musculare, e*a&uate "u$a du'a e%'&!rarea$"ut!asa a '&a) " sa&a de !'erate 8
( Grad I- c!"tue $"$a a 'e& s c!"ta$"are +actera"a "e)&,a+&a= a+se"ta
c!$"ute.
( Grad II ( &eu" c!"tue a&e 'e& s tesutur&!r $!= c!"ta$"are +actera"a
$!derata.
( Grad III ( c!"ta$"are $as*a/ dstruct "t"se a&e 'art&!r $!/ &eu"
*ascu&are s "er*!ase.
( GradI- a$'utate '!sttrau$atca t!ta&asu+t!ta&a.
I" 191/ Brd si co%a-oratorii au $!d#cat c&as#carea Gust&!/ "ssta"d 'eimportanta vascularizatiei osoase 8
( TipI ( trau$ats$ de e"er)e us!ara / #ractura cu traect !+&c sau s'r!d/
d&acerare te)u$e"tara 4 c$/ '&a)a re&at* curata/ crcu&ate e"d!sta&a
'er!sta&a "tacte.
( Tip II ( trau$ats$ de e"er)e $ede/ #r. cu de'&asare sau c!$"ut*a/
d&acerare cuta"ata 4 c$/ c!"tue $!derata a 'e& s $uscu&atur
adace"te/ #ara de*ta&area $uscu&atur/ crcu&ate e"d!sta&a
"treru'ta.
( Tip!I ( trau$ats$ cu e"er)e "a&ta/ #r. cu de'&asare $'!rta"ta s c!$"utese*era/ 'erdere te)u$e"tara "t"sa cu de*ta&area $uscu&atur &!ca&e/
crcu&ate e"d!sta&a s 'er!sta&a "treru'te.
( TipI ( trau$ats$ #. *!&e"t/ '&a)a )ra*a 'r!dusa 'r" e%'&!e sau str*re/
&eu"e *ascu&ara care "ecesta rec!"structe.
D" 'u"ct de *eder a& chrur)u&u '&astca"/ S'ar -Sar s Mears/ 1950 #ace !
c&as#care a '&a)&!r de )a$+a/ 'e +aa carea se '!ate a&e)e teh"ca de rec!"structe
a de#ecte&!r de tesutur. C&as#carea Sar este " tre tre'te 8
Defecte de tesuturi tip I Swarz. Aceasta )ru'a c!"t"e #ractur&e deschse care
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3. "odificarea leziunilor de parti %oi su'te$u%entare "contuzii musculo-
tendinoase, rupturi sau striviri musculare si sindromul de compartiment& '
J &eu"e $uscu&ara $a $ca de 16 d" crcu$#er"ta...................... 1 'ct.
J &eu"e $uscu&ara 'a"a &a 14 d" crcu$#er"taKKKKKKKK4 'ct.
J &eu"e $uscu&ara 'a"a &a ?6 d" crcu$#er"ta.............................. ? 'ct.
J &eu"e $uscu&ara $a $are de ?6 d" crcu$#er"ta.........................6 'ct.
J a$'utate 'arta&a 'r" sect!"are "c!$'&eta..................................5 'ct.
J a$'utate 'arta&a 'r" str*re "c!$'&eta........................................ 'ct.
J a$'utate 'arta&a 'r" sect!"are.....................................................; 'ct.
J a$'utate t!ta&a 'r" str*re............................................................. 'ct.
Daca su"t 'ree"te s &eu" *ascu&are/ &a 'u"cta,u& a"ter!r !+t"ut se $a
adau)a8
J 'e"tru sche$e tra"t!re..............................................................1 'ct.J 'e"tru sche$e c!$'&ete $a $ca de 6 !re..................................4 'ct.
J 'e"tru sche$e c!$'&eta $a $ca de !re..................................? 'ct.
J 'e"tru sche$e c!$'&eta $a $are de !re..................................5 'ct.
Daca su"t 'ree"te s &eu"&e "eur!&!)ce/ &a 'u"cta,u& !+t"ut a"ter!r se
adau)a8
J tu&+urar de se"s+&tate &a "*e&u& 'a&$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"ttate $ca............................................................1 'ct.J c!r' stra" " ca"ttate $are............................................................4 'ct.
Pe"tru c!"ta$"area +actera"a/ &a 'u"cta,u& !+t"ut a"ter!r se $a adau)a 8
J 'ree"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!cate cu ! s'ece a"aer!+a.....................................6 'ct.
3. "odificarea leziunilor asociate&
J #ractur $u&t'&e.................................................................................1 'ct
J &eu" a+d!$"a&e............................................................................4 'ct.
J &eu" t!racce..................................................................................? 'ct.J &eu" 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& (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. deschse de t' I Tsche$e
J U" sc!r #"a& de (19 'ct. c!res'u"de u"e #r. deschse de t' II Tscher"e
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J U" sc!r #"a& de 42 ( ?2 'ct. c!res'u"de u"e #r. deschse de t' III Tscher"e
J U" sc!r #"a& ?2 'ct. c!res'u"de u"e #r. deschse de t' IV Tscher"e
I" 1992/ a #!st 'r!'usa c&as#carea )ru'u&uAO -Mu&&er s c!&a+!rat!r0/ care "c&ude
u" sste$ se'arat de a'recere a &eu"&!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 ( deschderea 'e& 'r" $eca"s$ d"au"tru ( "a#ara
J IO4 ( deschderea 'e& 'r" $eca"s$ d"a#ara ( "au"tru/ 5 c$/ cu
$ar)" c!"tue
J IO? ( deschdere cuta"ata 5 c$/ c!"tue "t"sa a 'e& s $ar)"
de*ta&ateJ IO6 ( c!"tue te)u$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 &eu" $uscu&are
J MT4 ( &eu" $uscu&are crcu$scrse/ dar u"c!$'art$e"ta&e
J MT? ( &eu" $uscu&are a'reca+&e/ stuate &a "*e&u& a 4 c!$'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 S"dr!$ de str*re
!eziuni neuro-vasculare ,/J NV1 ( #ara &eu" "eur!(*ascu&are
J NV4 ( &eu"e "er*!asa !&ata
J NV? ( &eu"e *ascu&ara strct !&ata
J NV6 ( &eu"e *ascu&ara se)$e"ta&a e%t"sa
J NV5 ( &eu"e "eur!(*ascu&ara c!$+"ata/ "c&ua"d a$'utate
'!sttrau$atca su+t!ta&a t!ta&a
(eziuni osoase ( c!d#ca &!cu& s as'ectu& traectu&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 ( da#a
? ( e'#a s $eta#a dsta&a
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( daca #ractura de t+e se "s!teste de #ractura de 'er!"eu
1 ( 'er!"eu "tact
4 ( 'er!"eu #racturat &a a&t "*e& decat #!caru& t+a&
? ( 'er!"eu #racturat &a ace&as "*e& cu #!caru& t+a&
J As'ect traect #racturar
A ( #r. s$'&e ( A& ( traect s$'&u s'r!d
( A4 ( traect s$'&u !+&c $a $are de ?2
( A? ( traect s$'&u/ tra"s*ersa& sau !+&c su+ ?2
@ ( #r. cu a& tre&ea #ra)$e"t cc" #&uture -c!$"ute $ca0. Caracterstc este ca du'a
reducere/ #ra)$e"te&e 'r"c'a&e *" " c!"tact drect.
( @& ( traect s'r!d -c!"u& de t!rsu"e0
( @4 ( traect !+&c -c!"u& de #&e%u"e0
( @? ( traectu& 63 #&uture e as!cat cu #racturarea #&uture&u6
C ( #r. c!$'&e%e -c!$"ute $are0= du'a reducere/ #ra)$e"te&e 'r"c'a&e "u
*" " c!"tact.
( C& ( traect c!$"ut* s'r!d
( C4 ( traect cc" du+&u eta, cu #ra)$e"t "ter$edar -#ractura
se)$e"ta&a0
( C? ( traect c!$'&e%/ "ere)u&at -#ra)$e"t "ter$edar
c!$"ut*0
E%e$'&u 8 #ractura de t+e " 1? $ede cu dsta&a/ as!cata cu ! #ractura de c!&
'er!"er ( 64A14. Pr$a c#ra -60/ a d!ua -40 s u&t$a -40 "e arata u"de este #ractura/
res'ect* #ractura t+e/ !"a da#ara/ as!cata cu #ractura 'er!"eu &a a&t "*e&= A& aratacu$ este #!caru& de #ractura/ res'ect* s'r!d s$'&u.
C&as#carea AO 'er$te u" da)"!stc 'recs a& &eu"&!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$t Se*ert Sc!re0 care 'er$te !re"tarea
chrur)u&u " ad!'tarea u"e dec ,a%putatie versus reconstructie7
)ru1 Ti1 Carac8
t(ristici
D(finir(a %(iuni%or Puncta9
A: In9urii a%( ; E"er)e
,!asa
P&a) 'r" ",u")here/ #ractur s$'&e "chse/ '&a)
'r!duse 'r" ar$e de #!e de ca&+ru $c.
1
sc#(%(tu%ui
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0oi ? Str*r
$as*e
Accde"te " $edu "a*a&/ accde"te de tre" sau d"
"dustra 'etr!&era.
6
B. Star( d(
soc
; N!r$!(
te"s*
Te"su"e artera&a sst!&ca sta+&a " tere" " sa&a
de !'erate cu *a&!are 92$$H).
2
H'!(
te"su"e
tra"(
t!re
T. A. s ta+&a " tere"/ dar care ras'u"de &a
ad$"strarea "tra*e"!asa de #&ude.
1
> H'!(
te"su"e
're&u"(
)ta
T.A. sst!&ca 92$$H) " tere"/ dar care ras'u"de
&a ad$"strarea "tra*e"!asa de #&ude d!ar " sa&a de
!'erate.
4
C. Isc#(0ia
($tr(0itati%or
; Nu
e%sta
Me$+ru& "#er!r cu 'u&s/ #ara se$"e de sche$e
'er#erca.
2
U!ara Pu&s d$"uat #ara se$"e de sche$e. 1
> M!de(
rataL'sa 'u&su&u &a ECHO ( D!''&er/ u$'&ere &e"ta a
'atu&u ca'&ar/ 'areste/ act. $!t!re d$"uata.
4
? A*a"(sata
L'sa 'u&su&u/ e%tre$tate rece/ 'ara&ata a$!rtta/ #ara u$'&erea 'atu&u ca'&ar.
?
@arsta
1aci(ntu%ui
; ?2a" 2
?2(52a" 1
> 52a" 4
sc!r du+&u daca sche$a dureaa de 'este !re
Ta'el I
U" sc!r MESS ; c!"sttue u" su'!rt ,ust#cat 'e"tru deca de a$'utate.
C&as#care Stoc/ -St!cB s Her"er/ 19960 se re#era d!ar &a #ractur&e de )a$+a s este !
c&as#care 'e +aa carea/ du'a 'arerea aut!r&!r/ se '!atepune indicatia dereconstructie adefectelor de tesuturi.
Aut!r e*de"taa $'!rta"ta de!se+ta a ac!'err #!caru&u de #ractura cu $usch
sau cu 'er!st *a+&. D" acest 'u"ct de *edere e c!"sdera ca #!caru& se '!ate a#&a8
J "tr(u" &!c !ste!)e"c/ dec +"e ac!'ert
J "tr(u" &!c 'arta& !ste!)e"c/ dec 'arta& ac!'ert
J "tr(u" &!c "e!ste!)e"c/ dec "eac!'ert
De ase$e"ea/ e descru &a )a$+a tre !"e de $"$a reste"ta/ !"e " care 'e"tru
ac!'errea de#ecte&!r "u se rec!$a"da #!&!srea )re#e de 'e&e &+era des'cata8
J in treimea superioara ( e'#a 'r!%$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 crcu$#er"ta
C&as#carea 'r!'ru(sa $'arte de#ecte&e ce '!t # "ta&"te "tr(! #ractura deschsa
de )a$+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
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a&te 'art $!0
J defecte de tesuturi tip C *toc+ ( de#ecte de 'art $! as!cate cu de#ecte de
OS
Pe +aa aceste c&as#car aut!r sta+&esc "dcat d#erte de rec!"structe 'e"tru
de#ecte de t' d#ert. I" #ractur&e deschse de )a$+a cu de#ecte de t' A sau de t' @/ du'a
#%area #!caru&u de #ractura cu $,&!ace ce"tr!$edu&are/ rec!"structa de#ectu&u de tesutur
se #ace cu 8
J grefa de piele libera despicata daca de#ectu& este " a#ara !"e&!r de $ca
reste"ta
J lambouri locale -#asc!cuta"e sau $!cuta"e0 sau lambouri libere
-$cr!*ascu&are0 daca de#ectu& este "tr(! !"a de $ca reste"ta
I" #ractur&e deschse de )a$+a cu de#ecte de t' C/ du'a #%area !su&u 'r" $,&!ace
e%ter"e/ rec!"structa de#ectu&u de tesutur se #ace ast#e&8
J Intr-o singura etapa chirurgicala -!s Q 'art $!0 daca de#ectu& este "tr(u"
&!c !ste!)e"c -#ra)$e"te de !s +"e ac!'erte as!cate cu de#ect $c de
'art $!0. Rec!"structa "tr(! s")ura eta'a se #ace 'r" &a$+!u c!$'!t
!ste!($!(cuta" &+er -$cr!*ascu&ar0.
J In mai multe etape chirurgicale daca de#ectu& este "tr(u" &!c 'arta&
!ste!)e"c sau "e!ste!)e"c -#ra)$e"te de !s "eac!'erte as!cate cu
de#ect $are de 'art $!0. Rec!"structa 'resu'u"e ! 'r$a eta'a de )re#are
cu u" $usch +"e *ascu&arat/ care *a tra"s#+r$a &!cu& "e!ste!)e"c "tr(u"
&!c !ste!)e"c. I" eta'a ur$at!are se *a 'ractca )re#area !s!asa/ ar )re#a *a #
'&asata " &!cu& !ste!)e"c "!u creat.
Aut!r c!d#ca de ase$e"ea teh"ca de )re#a, " #u"cte de d$e"su"&e
de#ectu&u !s!s8
J defecte de os sub 3 cm ( )re#a de !s s'!")!s
J defecte de os intre 3 si 1 cm - )re#a de creasta &aca *ascu&arata
-$cr!*ascu&ar0
J defecte de o speste 1 cm- )re#a #+u&ara *ascu&arata
Des c&as#carea St!cB "u este ! c&as#care 'r!'ru(sa a #ractur&!r deschse/ are !
$'!rta"ta de!se+ta " sta+&rea crter&!r de rec!"structe.
Nu$aru& $are de 'ace"t '!&trau$atat cu #ractur deschse a&e )a$+e rdca
'r!+&e$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 'ace"t&!r
'!&trau$atat/ c!e#ce"t care de'"de de ur$at!r #act!r8
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 ( ? '
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( #r. deschse ( t' I -Gust&!(A"ders!"0 (1 '
( t' II ( 4 '
( t' $ ( ? '
( " cau& as!cer cu ! #ractura artcu&ara ( 1 ' " '&us
+0 Leu" as!cate #ractur
( &eu" $uscu&are "t"se ( 4 '
( &eu" *ascu&are ( artere $c s $ed (1 '
( *e"e $ar ( 4 '
( artere $ar ( 4 '
( &eu" "er*!ase ( a&u")rec!$'resu"e de "er* 'r"c'a& ( 4 '
( sectu"e de "er* 'r"c'a& ( 4 '
Per!ada de t$' de &a accde"t -" cau& #r. deschse0 8
( h ( & '
( ( 1 4 h ( 4 '
( 1 4 h ( ? '
@0 A&te a#ectu" as!cate #ractur&!r deschse 8a0 S!c ( 'resu"e sa")u"a sst!&ca &OO$$H) ( 4 '
( 'resu"e sa")u"a sst!&ca 2$$H) ( ? '
+0 Leu" $a,!re as!cate ( s$'&e ( ? '
( c!$'&e%e ( 5 '
Su$a 'u"cte&!r !+t"ute re're"ta c!e#ce"tu& de )ra*tate 'e care aut!r 1(au
c&as#cat " 6 )ru'e 8
J coeficient de gravitate I "1- p& ( #r. s$'&e 'r!duse de u" trau$ats$ cu
e"er)e $ca=
coeficient de gravitate II "-1 p& ( trau$ats$ cu e"er)e $are cu c!$"ute
sau #r. deschse de )rad $c=
coeficient de gravitate III "1-1 p& ( trau$ats$ cu e"er)e $are= &eu" a&e
!r)a"e&!r "ter"e=
coeficient de gravitate I " 1 p& ( trau$ats$ cu e"er)e #!arte $are cu
&eu" s$u&ta"e &!c!$!t!r/ t!rac!'u&$!"are sau cra"e"e.
Nc u"u& d" sste$e&e de c&as#care a #ractur&!r deschse "u este 'er#ect/ e&e
tre+u"d ada'tate #ecaru ca " 'arte. C&as#carea &u Gust&!/ +aata 'e studu&
retr!s'ect* s 'r!s'ect* a 1245 caur de #ractur deschse a&e !ase&!r &u")/ tratate
ur$arte " 'er!ada 1955(19;?/ este cea $a #!&!sta c&as#care 'e '&a" "ter"at!"a&/
dat!rta a'&ca+&tat sa&e $edate " 'ractca trau$at!&!)ca.
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;.Dina0ica 0or-iditatii 1rin fracturi d(sc#is(.
Cresterea c!"t"ua a "u$aru&u de accde"te " t!ate tar&e a #acut ca &eu"&e
trau$atce sa !cu'e &!cu& tre s char d! " cadru& $!r+dtat )e"era&e ast#e& "cat a a,u"s
sa c!"sttue ! 'r!+&e$a s!ca&a de "teres $a,!r.I$e"sa $a,!rtate a accde"te&!r s!&date
cu #ractur deschse au dre't caue 'r"c'a&e "eres'ectarea dsc'&"e&!r rutere s "!r$e&!r
de 'r!tecta $u"c.
Acest &ucru se ra'!rteaa s " &teratura $!"da&a de e%e$'&u8 daca " 195 " Tu&!use este
a"a&ata ! statstca de 46 de #ractur d"tre care ?23 su"t #ractur deschse/ " 1992 sera'!rteaa ! 'r!'rte de 623.La "! " tara/ C&"ca de Ort!'ede s Trau$at!&!)e @ucurest
e#ectua"d u" studu 'e ! 'er!ada de 16 a"-19?(19;0 c!"stata ! crestere $arcata a "cde"te
acest!r &eu" trau$atce ca"d s(au "re)strat 543 d" caue.
I" C!"sta"ta " 'er!ada 4222(4224 " C&"ca de Ort!'ede s Trau$at!&!)e au #!st "ter"at
1;12 'ace"t d"tre care 4;2 'ace"t au 'ree"tat #ractur de )a$+a.D" acest "u$ar t!ta&
de 'ace"t cu #ractur de )a$+a 192 au 'ree"tat #ractur "chse ar 2 au #!st cu #ractur
deschse re'ree"ta"d 493.
Anul Nr. cazuri
1963 145
1964 157
1965 152
1966 158
1967 66
1968 1441969 64
1970 125
1971 182
1972 257
1973 214
1974 304
1975 234
1976 298
Total 2 500
16
CAPITOLUL I@. STATISTICA
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Ta+e& II ( C&"ca de Ort!'ede s Trau$at!&!)e @ucurest-Studu Statstc 19(19;0
Ta'el III -Clinica de Ortopedie si Traumatologie Constanta(Studiu Statistic 2000-2002)
.Structura 0or-iditatii 1( &ru1( d( varsta si s($(.
D" a"a&a date&!r d" &teratura de s'eca&tate reu&ta ca "cde"ta
$a%$a a #ractur&!r deschse se su'ra'u"e 'este 'er!ada cea $a act*a a
*et-15(6 de a"0.Aceasta c!"statare este a+s!&ut "!r$a&a de!arece #ractur&edeschse sur*" " s'eca& &a !a$e" *a&/$a,!rtatea "te)rat " 'r!cesu&
'r!duct*/&a 'ers!"ae care se de'&aseaa d"tr(u" &!c " a&tu& #!&!s"d " $!d
#rec*e"t $,&!ace&e rutere.
Tota% 1aci(nti
int(rnati
Paci(nti cu fr.
d(sc#isa d( &a0-a
Paci(nti cu fr. inc#isa
d( )a$+a
1;12 +! 192
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/$B)(0( I ( REPARTIAREA CAURILOR PE GRUPE DE VARSTA SI SE7E
U" studu e#ectuat de G!ru" s Tr!a"escu -19;9(@ucurest0arata ca
#rec*e"ta #ractur&!r deschse este de tre !r $a $are &a se%u& $ascu&"-;6.30 c!$'arat* cu se%u& #e$"" -45.430.Acest ra'!rt de #rec*e"ta ? M1F
este "!r$a& de!arece su"t $a $u&t +ar+at a")re"at " $u"c #ce )re&e/
$a,!rtatea aut!*ehcu&e&!r su"t c!"duse de +ar+at/#e$e&e #"d $u&t $a
ate"te atat &a *!&a" cat s ca 'et!".
Gru'a de *rsta Nr. caur
-a"0 M ' T!ta&
2(16 ? 9 2/6
15(46 4;9 ;5 ?56 16/445(?6 ?95 94 6; 19/5
?5(66 6?; 1?6 5;1 44/65(56 ?94 119 511 42/6
55(A6 4?6 9 ??4 1?/?A5(;6 94 ;1 1? /5
;5 s 'este ? ?; ;? 4/9
T!ta& 1;1 49 4 522
-;6/30 -45/430 122/2
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R(1artitia cauisticii in functi( d( s($
+;
;6@ar+at
Fe$e
/arsta (1(?2 a" ( 43 -44 'ace"t0
( ?1(52 a" ( 693 -? 'ace"t0
( 52 a" ( 4? 3 -1 'ace"t0
Fi&83 R(1artitia cauisticii 1(
&ru1( d( varsta
?6
+
;+8>! ani
>; 83! ani
53!ani
LOT 2PACIENTI(SPITALUL CLINIC :UDETEAN CONSTANTA -4222(42240
>
2-1 1-2 2-3 3- - - -
1;
22
522
622
?22
422
122
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STUDIU STATISTIC CLINICA DE ORTOPEDIE @UCURESTI -19(19;0
>.Structura 0or-iditatii in functi( d( s(on si ora 1roduc(rii.
Re'artarea caur&!r cu #ractur deschse 'e a"!t$'ur arata ! "cde"ta
$a%$a " &u"&e de *ara s t!a$"a/ c"d s(au "re)strat/ &a u" &!c/ 1 2; caur
-;4/630/ #ata de &u"&e de 'r$a*ara s ar"a/ c"d s(au "re)strat 9? de caur
-4;/30. - D" acest )ra#c reu&ta cu c&artate ca " &u"&e de ar"a/ " cuda a'e/
)het s '!&eu&u/ dec a 'erc!&u&u $a $are de a&u"ecare s cadere/ se "re)streaa
t!tus ce& $a $c "u$ar de #ractur deschse. D" acest studu/ 'ute$ tra)e c!"c&uaca #rec*e"ta rdcata a "u$aru&u #ractur&!r deschse d" &u"&e de *ara s t!a$"a
tre+ue 'usa $a a&es 'e sea$a "$u&tr $'res!"a"te a $,&!ace&!r 'ers!"ate s
c!&ect*e de tra"s'!rt/ crcu&ata #"d $u&t $a redusa " &u"&e de ar"a.
IARNA PKIMAVARA YARA TOAMNA
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Fi$. 3
Stractura $!r+dtat 'r" #racturdeschse " #u"c,c de se!".
I" #u"cte de !ra 'r!ducer accde"tu&u.-G!ru" sTr!a"escu(19;90
1227000 -
51
6
600 -
200
12 7
1 7
600
eoo
400
2
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?.Structura 0or-iditatii in functi( d( (tio%o&i(
Accde"te&e de crcu&ate se a#&a 'e 'r$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 deschse/ " *re$e ceaccde"te&e de $u"ca se stueaa 'e &!cu& a& d!&ea.Pe &!cu& tre se c&aseaa accde"te&e
d*erse s "e'recate ur$ate de accde"te&e cas"ce s accde"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(ciat(
Studiu statistic S1ita%u% Cinic ud(t(an Constanta !!!8!!%ot 8+! 1aci(nti
3.Structura 0or-iditatii in ra1ort cu s(diu% fracturii si ti1u% d(sc#id(rii
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t(&u0(ntar(
Se re$arca #a'tu& ca #ractur&e deschse de )a$+a c!"sderate )&!+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&uractur&!r deschse -55.63 ra'!rtat de G!ru"0.Pe +aa statstc ce"tru&u de
trau$at!&!)e d" @!rdeau% 195 Pate& s c!&a+!rat!r ra'!rteaa ?.?3 'r!ce"tu&
#ractur&!r deschse.Pr!ce"te&e *araa "sa s " #u"cte de s'ec#cu& ser*cu&u
res'ect*-ser*cu& de ur)e"ta sau de +!&"a* cr!"c/chrur)e )e"era&a sau
trau$at!&!)e0.Pe &!cur&e ur$at!are se stueaa #ractur&e deschse a&e
a"te+ratu&u/#a&a")e&!r 'c!ru&u/#e$uru&/hu$erusu&/etc.
Re'ree"tarea ce&!r $a #rec*e"te &!ca&ar a&e #ractur&!r deschseGORUN (19;9
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D" 'u"ct de *edere a& $eca"s$u&u &eu"&!r te)u$e"tare d!$"a de de'arte
a)e"tu& *u&"era"t drect/&eu"&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 *ara+&e s u"e!r str*r )ra*e de
$e$+re.I" t$' ce ! '&a)a 'u"ct#!r$a "u rdca "c ! d#cu&tate tera'eutca-sutura
'r$ara du'a t!a&eta chrur)ca&a0dec!&ar&e te)u$e"tare "t"se s dr!+r&e de
tesutur $! rdca 'r!+&e$e c!$'&e%e atat d" 'u"ct de *edere a& trata$e"tu&u cat s
a& 'r!)"!stcu&u.I"tre aceste d!ua e%tre$e se "ta&"esc #!arte $u&te as'ecte
"ter$edare cu '&a) &"are sau ste&ate cu sau #ara dec!&ar /cu &eu" d*erse a&e
tesutur&!r $! su+cuta"ate.
Tr!a"escu s c!&a+.ra'!rteaa ca d" 1?6de #ractur deschse de
Ga$+a -55/63d" t!ta&u& #ractur&!r deschse0/ 11?5 "tereseaa a$+e&e !ase/-cu122
deschder " #!caru& t+a&/6 de deschder " a$+e&e #!care s 65 de deschder "#!caru& #+u&ar0/41#ractur deschse de t+e s?? de #racture deschse de #+u&a.
As!cer&e &e!"are su"t "u$er!ase s *arate/c!"tr+u"d &a a)ra*area e*!&ute
#ractur deschse "tr(u" 'r!ce"t $c de caur.Ast#e& #ractura deschsa trece 'e '&a"u&
secu"d sau 'e u&t$u& &!c " c!"te%tu& c&"c a& u"!r '!&trau$ats$e.
".Princi1ii d( trata0(nt a% fracturii d(sc#is(.
P&a"u& tera'eutc a'&cat este $'us de )ra*tatea &eu" &!ca&e s a &eu"&!r as!cate
" c!"te%tu& s!cu&u s a& '!&trau$ats$e&!r.Sche$atc se eta'eaa ast#e&8
( re!&*area &eu"&!r &!ca&e > trata$e"tu& &eu"&!r 'art&!r $!
sta+&area #!caru&u de #ractura
( trata$e"tu& de des!care c!"sta"d "8
reech&+rare he$!hdr!e&ectr!&tca
'r!#&a%a deech&+ru&u #&ud!c!a)u&a"t
( trata$e"tu& &eu"&!r ass!cate " c!"te%tu& '!&trau$ats$u&u
( 'r!#&a%a "#ecte '&a) #racturare -a"t+!tc!tera'a0/a "#ecte teta"ce/a
)a")re"e )a!ase.
( trata$e"tu& a#ectu"&!r 'ree%ste"te-da+et/+!& card!*ascu&are/seche&e
"eur!&!)ce/etc.0
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.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 deschse8
( e%ca tesutur&!r de*ta&ate=
( c!"ser*area !rcaru e&e$e"t a"at!$c &eat/'e cat $a $u&t '!s+&=
( !rce ra'!rt a"at!$c sch$+at tre+ue resta+&t.
Du'a G!ru" $a,!rtatea "ter*e"t&!r 'ractcate -5.?30 au #!st !'erat
$"$e dar cu e#ce"ta $a%$a c!"sta"d "8
( t!a&eta ch$ca s $eca"ca r)ur!asa=
( e%ca 'e&/tesutu&u su+cuta"at dr!+t/#ra",ur&!r a'!"e*r!tce s$uscu&are=
( reducerea !rt!'edca a #!caru&u de #ractura=
( $!+&area se)$e"tu&u " a'arat )'sat sau e%te"se c!"t"ua
tra"ssche&etca.
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W Structura $!r+dtat 'r" #ractur deschse " ra'!rt cu t'u& "ter*e"te 'ractcate.
Trata0(nt a1%icat Tota%
Toa%(ta G sutura fara i0o-i%iar(
Toa%(ta 8 sutura G i0o-i%iar( ;?!" 3",>Toa%(ta G ost(osint(a 1ri0ara G sutura 1ri0ara +3 >;,?
Toa%(ta 8f ($cii( %ar&a fara sutura G i0o-i%iar( ;!+ ?,3A01utatii si r(tusari d( -onturi trau0atic( ;!? ?,
P%astii cutanat( in ur&(nta "; ,?R((ctii osoas( >! ;,
T(norafii ?> ;Li&aturi art(ria%( ;3 !,"R(duc(ri orto1(dic( d( %u$atii d(sc#is( 6 ;,R(duc(ri orto1(dic( d( fracturi d(sc#is( 6!+ >",>E$tra&(ri d( unii 6 ;,
E$t(nsii transosoas( 6+ ;;,6
/ratamentul leziunilor asociate
Ost(osint(( 0(ta%ic( o%(cran, ant(-rat, 0(tacar1i(n(, f(0ur,
1at(%a, &a0-a, 0(tatarsi(n( (tc. 6+
Suturi d( 1%a&i div(rs( ;!R(duc(ri orto1(dic( in fracturi div(rs( ;!+
R(duc(ri d( %u$atii div(rs( 6"E$t(nsii transosoas( 3+
Punctii d( #(0atoa0( si #(0artro( vo%u0inoas( >6
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REPARTIAREA FRACTUIOLOR DESCHISE DIN SERIA NOASTRA IN FUNCTIE DE TRATAMENTU L A PLIC AT
C!"dta dea&a este ac!'errea #!caru&u de #ractura 'r"tr(u" '&a" $uscu&ar s a&tu&
te)u$e"tar.Nu se *!r e#ectua sutur " te"su"e/" cau& 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!$'&eta #e cu )re#e de 'e&e/#e cu as!cerea &a$+!ur&!r
$uscu&are-&!ca&e sau de &a dstata as!cata cu )re#area de 'e&e.Sta+&area #!caru&u
de #ractura este ! a d!ua c!"dte !+&)at!re s're e*!&uta de *"decare s a #!caru&u
de #ractura s " ace&as t$' 'e"tru ! +u"a ccatrare a &eu"&!r $uscu&!(
te)u$e"tare.
Oste!s"tea '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)ate sa")u"e atat a !su&u cat
s a'art&!r $!.Du'a G!ru" " ;5 de caur s(au e#ectuat8
( 49 !ste!s"tee $"$e=
( 69 !ste!s"tee #er$e cu +r!se Xrscher/t,e Xu"tscher/suru+ur/'&a)
"suru+ate/t,e E"der/#%at!r e%ter" E&ar!*.
Mar&e dstru)er te)u$e"tare au $'us u" trata$e"t de aste'tare8t!a&eta s
e%ca &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 $!+&are " a'arat )'sat cu #ereastra.
I" statstca e#ectuata &a C&"ca de Ort!'ede s Trau$at!&!)e @ucurest se re$arcau" "u$ar re&at* $are - 6.430 de a$'utat s retusar de +!"tur trau$atce.
Pe &!tu& de 2 de +!&"a* "*est)at " C&"ca de Ort!'ede a S'ta&u&u C&"c
:udetea" C!"sta"ta trata$e"tu& de#"t* a c!"stat "8
. Trata%entul definitiv al fracturilor desc+ise ,sinteza pe 01 de fracturiTip Metode c+irur$icale de
rezolvare aparfilor %oi
Nr. Metode de sta'ilizare a
fracturii ,steosinteza
r. Metode de
sta'ilizare
ortopedica
r.
I
( #ara sutura -'&a)
'u"ct#!r$e0
( sutura 'r$ara
1;
14
OS "t ce"tr!$ed " #!car
1
4
?
1
( a'arat )'sat
6
"chs
( t,e e&astce t' E"der
( t,a Xu"tscher #ara a&ea,
( t,a Xu"tscher cu a&ea,
OS "t. " #!car deschs
( '&aca cu uru+ur Q )re#a
c!rtc!s'!")!asa
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II ( sutura 'r$ara
( sutura secu"dara -46h0
( sutura eta'ata -;(12
&e0
( sutura Q PPLD
(a$'utate de "ecestatecu +!"t deschs s
sutura tard*a
1
12
4
4
1
OS "t. ce"tr!$ed. " #!car
11
?
?
4
4
;
( a'arat )'sat ?
"chs
( t,e e&astce t' E"der
( t,a Xu"tscher #ara a&ea,
( t,a Xu"tscher cu a&ea,OS "t. " #!car deschs
>;
( '&aca cu uru+ur (
uru+ 'ercuta" !&at
OS e%ter"a
( #%at!r e%ter"
IIIA ( sutura 'r$ara ( suturaeta'ata -;(12 &e0
(PPLD
6
6
?
OS "t. ce"tr!$ed. " #!car
?
4
W W
;;
"chs
( t,e e&astce t' E"der
OS "t. " #!car deschs
( ? +r!e 'ercuta"e OS
e%ter"a
( #%at!r e%ter"
IIIB
( sutura eta'ata -;(12
&e0
( sutura Q PPLD
(PPLD
( PPLD Q &a$+!u #asc!(
cuta"
1
1
?
1
OS e%ter"a
( #%at!r e%ter"
W W
IIIC4
( a$'utate de "ecestate
cu +!"t deschs s sutura
tard*a
4
+. Anti-ioticot(ra1ia
Ut&area a"t+!tce&!r cu s'ectru &ar) " sc!' 'r!#&actc este "ecesara dat!rta
rscu&u rdcat de "#ecte creeat 'r" e%ste"ta s!&ute de c!"t"utatea cu $edu&
e%ter!r.Daca &a "ce'ut "stturea trata$e"tu&u se #ace 'e crteru& de 'r!+a+&tate-a"t+!tce cu s'ectru &ar)('e"c&"a/)e"ta$c"a/$etr!"da!&0 u&ter!r c!"t"uarea
sa se e#ectueaa 'e +aa a"a&e&!r de &a+!rat!r ce ra'!rteaa se"s!+&tatea )er$e"&!r
&a a"t+!tce.
I.Infectia fracturii ,aspecte statistice co%parative
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Clinica de %rtopedie, 8ac. de
#edicina - Constanta, 9omania
Clinica de %rtopedie 0niv. de
#edicina - :itasato, ;aponia
T'#r. I"#ecta '&a) T'#r. I"#ecta '&a)
Nr. 3 Nr. caur 3
I8(49#r. 2 23 I(64#r. 2 23II(?1#r. 9 49.2?3 II(12;#r. 6 ?.;?3
IIIA(11#r. ; ?.?3 IIIA(6?#r. ? .9;3III@(#r.. 5 ?.??3 III@(64#r. 14 4.5;3IIIC ( 4 #r. 4 1223 IIIC(11#r. 4 1.13
6.Trata0(nu% Socu%ui 2i$t
Reech&+rarea he$!hdr!e&ectr!&tca este a'&cata atat &a "*e&u& ca$ere deresusctare cat s/" sa&a de !'erate 'receda"d trata$e"tu& &!c!re)!"a& s c!"t"uata
" STI daca starea )e"era&a ! $'u"e.
I" caustca C&"c de Ort!'ede S'ta& C&"c :udetea" C!"sta"ta 'e u" &!t de 2 de
+!&"a* s(a c!"statat 8
I" caustca a"a&ata/ "u au #!st c!"statate &eu" as!cate '!&trau$ats$u&u care sa
r. cazuri
Trata%entul 2ocului %it Reech&+rarehe$!(hdr!(e&ectr!&tca
-sa")e !)ra'/ ! Rh/ ser/
)&uc!a/ '&as$a/ NaC&/ XC10
Reech&+rare hdr!(e&ectr!&tca
-ser/ )&uc!a/ '&as$a/ NaC&/5
Seroprofilaia AT Vacc"are ATPA -1 #!&a ( 2/5 $&0 SerAT -?222 UI ( dese"s+&are &e"ta0 ;
4rofilaia 'olii Fara $edcate 44
tro%'oe%'olice C&e%a"e ?2
C&*ar" 15
Fra%'ar" 5
C&e%a"e/ He'ar"a/ Ca&c'ar"a ?
C&e%a"e/ C&*ar" 4
He'ar"a/ C&*ar"/ Ca&c'ar"a 1
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$'u"a u" trata$e"t "eur!chrur)ca& sau chrur)ca&/ t!rac!('u&$!"ar/a+d!$"a& etc.
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 impunfracturilor 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.
CAPITOLUL @. CONCLUII
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.Caracteristicile focarului de fractura vor fi consecinta intensitatii si modului de
aplicare al mecanismului traumatic. $spectul de focar simplu, cominutiv
(plurieschilos poate sugera nivelul energiei traumatice..
. /ipul lezional fracturar trebuie evaluat pe baza criteriilor clinice si
prognostice continute de clasificarea Cauchoix-
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41(4? Oct 199
. Bora Iconia 89ezultatele tratamentului chirurgical amdnat in fracturile deschise,
C!"#er"ta Nat!"a&a de Ort!'ede Trau$at!&!)e/ 9/ T$s!ara/ 41(4? Oct./ 199
;. Bra'n C.YHe"ders!" S./ M!!re S. = *urgical treatment of patients Aith open tibial
fractures. Re*e ?1 re#s8 AORN :!ur"a&/ ?-50/ ;5(/ 5(9/ 99(92/ 199 Ma
. C#in(u R. 89ezultatele tratamentului de reconstructie in fracturile de gamba deschisede tip !I B, C!"#er"ta Nat!"a&a de Ort!'ede Trau$at!&!)e/ 12/ T$!ara/ 41(4?
Oct./ 199
9. Co%( D., A"se& L:./ Schart+er) R. 8$ seuential protocol for management of severe
open tibial fractures, C&"ca& Orth!'aedcs Z Re&ated Research/ -?150/ 6(12?/ 1995 :u"
12.Cor-u V./ Mc&e L/ Fara)! Gh./ S$ara"descu D. 8)ste fixatorul extern indicatia ideala
in tratamentul fracturilor deschise de gamba, C!"#er"ta Nat!"a&a de Ort!'ede
Trau$at!&!)e/ 11/ T$!ara/ 41(4? Oct./ 199
11.Cor-u V./ Mc&e L/ Fara)! Gh./ S$ara"descu D. 8(ambourile musculare pediculate in
tratamentul fracturilor deschise de gamba, C!"#er"ta Nat!"a&a de Ort!'ede
Trau$at!&!)e/ 14/ T$s!ara/ 41(4? Oct./ 19914.Co0a T. 8 *tabilization of the bone in open fractures, 4"d@a&Ba" Z thSOROT
C!")ress !# Orth!'aedcs/ 44/ Ia/ R!$a"a/ 42(44 Oct. 1999
1?.Co0a T., Cuc!s V./ Murarasu Ha&!&!r/ T!caru I 8 $titudinea noastra in tratamentul
fracturilor deschise tip !ide gamba, C!"#er"ta Nat!"a&s de Ort!'ede Trau$at!&!)e/
11/ T$s!ara/ 41(4? Oct./ 199
16.Co0a T., Ia"cu C/ Tra"da+at C/ A&e%a O./ Sar+u P./ C!rcac R./ Ge!r)escu N. 8 %ur
)xperience in the #anagement of *evere %pen /ibial *haft 8ractures, 4"d@a&Ba" Z th
SOROT C!")ress !# Orth!'aedcs/ 5/ Ia/ R!$a"a/ 42(44 Oct. 1999
15.David A., Oster$a"" PA./ M!&&e"h!## G/ He+e+ra"d D./ Muhr G. 8 Changes intherapeutic principles in fractures of the extremities Aith severe soft tissue in=uries
exemplified b? tibial fracture. Re*e 5?re#s/ e"tra&+&att #ur Chrur)e/ 144-0/ 1(9/
199;
1.Dic/son J.F., H!##$a" [\./ De&)ad! ED./ C!"treras DM. 8 0nreamed rod Aith earl?
Aound closure for grade III $ and IIIB open tibial fractures' anal?sis of consecutive
patients, Orth!'edcs -Th!r!#are/ N:0/ 41-50/ 5?1(5/199 Ma
1;.E&&%i S., Sch!&& E./ Herte& R. 8 #anagement of IIIB open tibial fractures b? earl?
osteos?nthesis and local muscle flap, U"#a&&chrur)/ 121-90/ ;6(?/ 199 Se'
1.En(scu 2., D!"ca I./ Lu'escu V./ A"dre T./ Ma"da P. 8 #anagementul fracturilor
grave de tibie cu a=utorul fixatorului Ilizarov, C!"#er"ta Nat!"a&s de Ort!'ede
Trau$at!&!)e/ 1;/ T$!ara/ 41(4? Oct./ 19919.)a0-a D., Che*a&&e F.8 /reatment b? external fixator of open
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4?.)orunN.8$ccidentele rutiere in etiopatogenia fracturilor deschise, Re*. Ort!'. Trau$.
-SOROT0/ 4-4(?0/ ;1(;;/ 1994
46.)orunN./ Tr!a"escu O. 88ractura deschisa, Ed. Medca&a/ @ucurest 19;9
45.Has @./ :!*a"!*c S./ !"e ./ T!Ba&c M./ X!'c . 8$nal?sis of results of treatment of
open and unstable grade II and III fractures in the calf, L,ec"cB V,es"B./ 11-?(60/ 5;(
9/ 199 Mar(A'r4.Iovan(scu L., P!' A&./ @a,at A./ @a,at A"ca 8>articularitatile fracturii deschise de
gamba in treimea inferioara, C!"#er"ta Na]!"a&a de Ort!'ede s Trau$at!&!)e/ 42/
T$s!ara/ 41(4? Oct./ 199
4;.Jai @L/ \!B!a$a X./ Sh"d! M./ It!$a" M. 8>roblems of various fixation methods for
open tibia fractures' experience in a ;apanese level I trauma center, A$. :. !# Orth!'.
-Chatha$/ N:0/ 4;-90/ ?1(/ 199 Se'
4.Jindsfat(r J., :!"asse" EA. 8 %steom?elitis in grade II and III open tibia fractures
Aith late debridement, :. !# Orth!'. Trau$a. 9-40/ 141(;/ 1995 A'r
49.Lucaciu D. 8 0pdate on the @rug $dministration in the /reatment of %pen 8ractures,4"d@a&Ba" Z thSOROT C!")ress !# Orth!'aedcs/ 45/ Ias/ R!$a"a/ 42(44 Oct. 1999
?2.Lu1(scu OHv(ra 8 *pecial Characteristics of the /reatment of /?pe III %pen 8ractures,
4"d@a&Ba" Z thSOROT C!")ress !# Orth!'aedcs/ ?2/ Ias/ R!$a"a/ 42(44 Oct. 1999
?1.Lu1(scu O%iv(ra,Na)ea M/ Crstescu I./ Ncu&escu D. 8Internal vs )xternal 8ixation in
III$ - IIIB %pen 8ractures of the #edium /hird of the /ibial *haft, 4"d@a&Ba" Z th
SOROT C!")ress !# Orth!'aedcs/ ?/ Ias/ R!$a"a/ 42(44 Oct. 1999
?4.Lu1(scu O%iv(ra,Na)ea M/ Patru Crst"a 8 /ratamentul profilactic antitrombotic in
fracturile deschise ale gambei utilizdnd enoxaparina sodica "Clexane&, C!"#er"ta
Nat!"a&s de Ort!'ede s Trau$at!&!)e/ 42/ T$s!ara/ 41(4? Oct./ 199
??.Lu1(scu O%iv(ra, Na)ea M/ Patru Crst"a/ @ar+u D./ Ncu&escu D. 8 $titudineaterapeutica in fracturile deschise tip III ale gambei - sinteza centromedulard saufixator
extern , C!"#. Nat!"a&s de Ort!'ede Trau$at!&!)e/ 44/ Tu"s.!ara/ 41(4? Oct./ 199
?6.Lu1(scu @.8 /raumatologie - (uxatiile si fracturile membrelor, V!&.1/ ?(42/ 1(;4/ 4?(
495/ Fac. Medc"a C!"sta"ta/ 199
?5.Lu1(scu @., A"dre T./ E"escu M. 8 #anagement of *everal 8racture of the /ibia.
IlizarovDs )xternal 8ixation, HI C!")ress EFORT/ PO 4/ @arce&!"a 199;
?.2afi P. 8 *oft /issue 9econstruction of the (oAer )xtremities. 12 Eears )xperience in
Far In=ured >atients, SICOT/ Sd"e Austra&a/ 412/ 1(4? A'r& 1999
?;.2atiuta L/ Mercea I./ A"dras E./ H!ra" C/ Dac!"escu S. 8 )xperienta noastrd
privind fractura deschisa de gamba, C!"#er"ta Nat!"a&s de Ort!'ede Trau$at!&!)e/4?/ T$s!ara/ 41(4? Oct./ 199
?.2ar E./ @rau" [./ Ruter A. 8 Fhat are the advantages of 0/4 "unreamed tibial nail&
in open tibial fractures, e"tra&+&att #ur Chrur)e/ 142-90/ ;45(?2/ 1995
?9.2u-ara/ S. 8 /reatment of $cute Compartment *?ndromes, SICOT Sd"e/ 51/ 1(4?
A'r& 1999
62.2u-ara/ S./ Har)e"s A.R. 8$cute Compartment *?ndrome, Sur). C&". N!rth A$erca
?/5?9(55/19?
61.2u-ara/ S./ Oe" CH. 8 Compartmental *?ndrome and Its 9elation to the Crush
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*?ndrome ' $ *pectrum of @isease, C&". Orth!'. a"d Re&ated Research "!.;(9/ 19;5
64.2u-ara/ S.:./ Har)e"s A.R./ Oe" C.A./ Garett! L.P./ ABes!" [.H. 8 /he Fic+
Catether /echniue for #easurement of Intramuscular >ressure, :. @!"eZ:!"t Sur)./
5(A/ 121/ 19;
6?.Natis X./ Tsa")ar!s G./ Ga*r&ds @./ X!u&a&s G=8 %pen tibial fractures treatment Aith
external fixation and secondar? reamed intramedular? nailing, 41stTre""a& [!r&dC!")ress SICOT/ 1(4? a'r&e 1999/ Sd"e Austra&a/ 44?
66.Nico%(scu 2., O,!)a L. 8$dvantages and @isadvantages of )xternal 8ixation for %pen
8ractures, 4"d@a&Ba" Z thSOROT C!")ress !# Orth!'aedcs/ 6/ Ias/ R!$a"a/ 42(44
Oct. 1999
?3. O-adaN. 8 *indroamele de compartimentposttraumatice ale gambei - teza de doctoral/
U.M.F. Car!& Da*&a/ @ucuret 1999
?".O-adaN. 8 *indromul compartimental posttraumatic al gambei ( consideratii clinice,
teoretice si practice, Re*. Ort!'ede Trau$at!&!)e -SOROT0/ 199/ -60/ 42?(411
?.O-ada N., @adarau I/ Or+ea"u V./ O+ada @. 8 /he /ibia %pen 8ractures and the
Compartment *?ndrome. Clinical Consideration. /herapeutic $ttitude., 41st
Tre""a&[!r&d C!")ress SICOT/ 1(4? a'r&e 1999/ Sd"e Austra&a/ 42
?+. O-adaN./ Lu'escu V. 8 Compartmental *?ndromes in the %pen 8ractures of the /ibia,
HI C!")ress !# the Eur!'ea" Federat!" !# Nat!"a& Ass!cat!" !# Orth!'aedcs a"d
Trau$at!&!) -EFORT0 ( @arce&!"a -S'a"a0/ 46(4; a'r&e 199;/ 129
?6.O-adaN./ Lu'escu V./ @adarau I. 8 /herapeutical Consideration in the /reatment of the
%pen /ibia 8ractures, 9unning the 9ise of Copartment *?ndrome, 6thC!")ress !# the
Eur!'ea" Federat!" !# Nat!"a& Ass!cat!" !# Orth!'aedc a"d Trau$at!&!) -EFORT0
@russe&s/ ?( :u"e 1999/ 11;
3!.O-adaN./ Lu'escu V./ @adarau I./ Or+ea"u V./ O+ada @. 8 >robleme terapeutice
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