骨科处_方案Orthopaedic Care and Protocol课件PPT

Orthopaedic Care and Orthopaedic Care and ProtocolProtocol 骨科处理骨科处理方案 K S Leung K S Leung 梁梁国穗国穗 TP Lam TP Lam 林子平林子平 Fragility FracturesFragility Fractures Case Scenario Case Scenario 病例病例 A 85 years old lady, who lives alone in a public housing estate, slipped in the toilet at home and landed on her right side one day before the admission. She complained pain and inability to move the right hip. 85岁女 性，独居于公屋，入院前一日上厕所时滑倒，右侧 着地，其后右髋部疼痛，活动受限。 She has history of ischaemic heart disease and diabetes mellitus on hypoglycaemic drug. 既往有缺血性心脏病和糖 尿病病史，使用降糖药 Laboratory Investigations Haemoglobin 9.2 gm/dl WBC 12.8 10^9/L Fasting sugar 15.7 mmol/L Sodium 142 mmol/L Potassium 5.2 mmol/L Creatinine 92 umol/L Urea 5.1 mmol/L LDH 245 U/L Physical examination 体检: Conscious. Temperature 38.5Conscious. Temperature 38.5oo C, BP: 170/100 mm Hg, C, BP: 170/100 mm Hg, pulse: 90/min. Dehydrated. Chest: mild coarse basal pulse: 90/min. Dehydrated. Chest: mild coarse basal crepitations. crepitations. 神志清楚，体温神志清楚，体温38.538.5，血压，血压170/100mmHg170/100mmHg，脉，脉 搏搏9090次次//分，脱水貌，听诊肺底部轻微粗糙的捻发音分，脱水貌，听诊肺底部轻微粗糙的捻发音 4 Common QuestionCommon Question：： 问：问题： When can we operate on the patient?When can we operate on the patient? 甚麽时候可以做手术？甚麽时候可以做手术？ Geriatric Hip Fractures Geriatric Hip Fractures 老年髋部骨折老年髋部骨折 Commonest in-patient fractures 老年人最常见的骨折 Commonest operation performed 通常采用手术治疗 Two major groups 两组 „ Femoral neck fractures 股骨颈 „ Trochanteric fractures 转子 Osteoporotic fractures 骨质疏松性骨折 Fall injuries 跌倒损伤 Deterioration in mobilities and increase in mortality 活动能力降低，死亡率增高 Geriatric Hip FracturesGeriatric Hip Fractures ProblemsProblems-- 存在的問題存在的問題 „„ Increasing incidence Increasing incidence 發生率增加發生率增加 „„Social and family ProblemsSocial and family Problems 社會家庭問題社會家庭問題 „„Multiple medical ProblemsMultiple medical Problems 多重醫療問題多重醫療問題 „„Poor bone quality (osteoporosis)Poor bone quality (osteoporosis) 骨質疏骨質疏鬆鬆 „„Prolonged rehabilitationProlonged rehabilitation 康復時間長康復時間長 Aims of Treatment Aims of Treatment 治治疗目的疗目的 Pain relief 减轻疼痛 Early regain of independence 早期获得独立 能力 „ Self care 自理 „ Walking and sitting 行走和坐 „ ADL 日常生活能力 Early mobilisation 早期活动 Prevent deformities and complications 避免畸形和并 发症 Facilitate fracture healing 促进骨折愈合 Concept of Concept of Early Operative FixationEarly Operative Fixation 早期手术固定的概念早期手术固定的概念 Fittest at the time Fittest at the time of admissionof admission 入院时状态最佳入院时状态最佳 Early mobility & Early mobility & independenceindependence 有利有利早期活动和独立早期活动和独立 O perative M ortality O perative M ortality Days after InjuryDays after Injury Management Protocol Management Protocol 处理方案处理方案 Medical and social History Basic investigations: CBP, RFT, ECG, CXR Medical social workerMedical social worker Medical conditions UnstableUnstable Stable Geri-orthopaedic joint consultation and stabilisations Operation D1 or as soon as possible Operation D2 or later+/- Anaesthetic consult Rehabilitation Discharge Community Community ProgramProgram Femoral Neck FracturesFemoral Neck Fractures 股骨颈骨折股骨颈骨折 Internal FixationInternal Fixation内固定内固定 Joint preservation 保留关节 Minimally invasive surgery 微创手术 Long lasting painless movements 长期无痛的活动 „„ Longevity Longevity 寿命长寿命长 „„ Better function Better function 更好的功能更好的功能 Less expensive 价格低 Salvage possible 保救的可能 Time factor 时间因素 „ <72 hours 解剖解剖 Anatomy of Anatomy of femoral neck !femoral neck ! NonNon--union union 不愈合不愈合 Avascular necrosis Avascular necrosis 缺血性坏死缺血性坏死 Revision rate Revision rate 翻修率翻修率: 15: 15--30%30% Hips saved Hips saved 保全髋关节保全髋关节：： 8585--70%70%！！ Femoral Neck Fractures Femoral Neck Fractures 股骨颈骨折股骨颈骨折 ArthroplastyArthroplasty 关节置换关节置换 Hemi or Total Hemi or Total 半髋或全髋半髋或全髋 “Simple” operation 简单手术 Early mobilisation 早期活动 Time factor 时间因素 Complications Complications 并发症并发症 „„ Periprosthetic fractures Periprosthetic fractures 假体周围骨折假体周围骨折 „„ Protrusio Protrusio 假体脱出假体脱出 „„ Infection Infection 感染感染 „„ Surgical trauma Surgical trauma 手术创伤手术创伤 Trochanteric Fractures 转子部骨折 Prevention of Fragility FracturesPrevention of Fragility Fractures 脆性骨折的预防脆性骨折的预防 Improving bone quality 增加骨质量 „ Osteoporosis 骨质疏松 Preventing falls-预防跌倒 „ www.no-fall.hk „ Decreasing the incidence 降低发生率 „ Minimising the impact Preventing second fracture 避免二次骨折 „ Drug - antiresorption 抗骨吸收药物 „ Fall prevention 预防跌倒 Hip Protector Hip Protector 髋关节保护垫髋关节保护垫 0.15 ml Clinical ProblemsClinical Problems Large patient loadLarge patient load Medical and anesthetic Medical and anesthetic complexitiescomplexities Fracture characteristics Fracture characteristics Choice of methodsChoice of methods Choice of implantsChoice of implants Geriatric Fragility FracturesGeriatric Fragility Fractures 老年脆性骨折老年脆性骨折 Hip fractures Hip fractures 髋部骨折髋部骨折 „„ Femoral neck Femoral neck -- younger younger 股骨颈股骨颈 较年轻较年轻 „„ Trochanteric Trochanteric –– more common, older age, more common, older age, poorer health poorer health 转子区转子区 更常见，年长，健康状况差更常见，年长，健康状况差 „„ MedicoMedico--social problems social problems 医疗、社会负担医疗、社会负担 „„ Major clinical problem Major clinical problem 巨大的临床问题巨大的临床问题 Distal radial fractures Distal radial fractures 桡骨远端骨折桡骨远端骨折 „„ Commonest outpatient fractures Commonest outpatient fractures 门诊最常见的骨折门诊最常见的骨折 Vertebral fractures Vertebral fractures 椎体骨折椎体骨折 „„ Compression fracture Compression fracture 压缩骨折压缩骨折 „„ May be silent May be silent 症状可能症状可能不明显不明显 Dinner fork deformity 原因－跌倒风险的增加原因－跌倒风险的增加 20032003年调查了年调查了1414间急诊室：间急诊室： 创伤病例总数创伤病例总数 5804058040因跌倒引致创因跌倒引致创 伤：伤： 3882038820（（6565％）％） 髋部骨折髋部骨折 20032003--20042004 Surgical ManagementSurgical Management Advancement in TechnologiesAdvancement in Technologies Understanding of PathologiesUnderstanding of Pathologies ✦✦Distal radial fractureDistal radial fracture ✦✦Proximal humeral Proximal humeral fracturefracture ✦✦Elbow fracturesElbow fractures ✦✦Proximal femoral Proximal femoral fracturesfractures ✦✦Distal femoral fracturesDistal femoral fractures ✦✦Periprosthetic fracturePeriprosthetic fracture ✦✦Vertebral fracturesVertebral fractures Locked PlatesLocked Plates To enhance fracture To enhance fracture healinghealing „ By providing biological environment for secondary fracture healing • Minimal compression • Bridging plate • Minimally invasive procedure • Bio-mechanical stability „„ By providing mechanical By providing mechanical stability for early stability for early mobilisationmobilisation • Osteoporotic bone • Fracture comminution Locked plate is Locked plate is specially indicated in:specially indicated in: ✦✦Osteoporotic fractures. Osteoporotic fractures. ✦✦Major comminutions in Major comminutions in diaphyseal fractures of diaphyseal fractures of the lower limb.the lower limb. ✦✦MIS: Internal fixation MIS: Internal fixation of the closely reduced of the closely reduced fractures that fractures that anatomical reduction anatomical reduction is not required.is not required. ✦✦Periprosthetic Periprosthetic fractures.fractures. 骨科团队可以做什么？骨科团队可以做什么？ ✦✦所有的脆性骨折患者所有的脆性骨折患者，，都应考虑骨质都应考虑骨质 疏松的可能性。疏松的可能性。 ✦✦建议患者进行相关检查并进行一定的建议患者进行相关检查并进行一定的 治疗，可以降低再次骨折风险治疗，可以降低再次骨折风险 ✦✦开始或建议开始检查和评估开始或建议开始检查和评估 ✦✦参与参与//领导预防计划领导预防计划 ““仅仅治疗骨折并不够！仅仅治疗骨折并不够！””Joseph LaneJoseph Lane ““我们从事的是骨科，而不仅仅是骨科手术！我们从事的是骨科，而不仅仅是骨科手术！”” David MarshDavid Marsh Modified from: Kanis JA & Johnell O, J Endo Investigation, 22: 583-288. 1999 Fracture is the First Chance Fracture is the First Chance to Manage Osteoporosisto Manage Osteoporosis 50 60 70 80 90 Distal radial fractures Vertebral fractures Hip fractures Comprehensive Care for Elderly Comprehensive Care for Elderly with Fragility Fractureswith Fragility Fractures 老年脆性骨折的综合处理老年脆性骨折的综合处理 Acute Acute 急性期急性期 OrthoOrtho--GeriatricGeriatric Anaesthetic CareAnaesthetic Care 骨科骨科--老年科老年科--麻醉科麻醉科 Standardisation of Standardisation of Management Management Protocols, Surgical Protocols, Surgical ProceduresProcedures 手术操作标准化手术操作标准化 Postoperative Postoperative AssessmentsAssessments 术后评估术后评估 R ehabilitation H ospital R ehabilitation H ospital 康 复 中 心 康 复 中 心 Rehabilitation Rehabilitation 康复康复 GeriGeri-- Orthopaedic/rehabilitaOrthopaedic/rehabilita tion. PT, OT , Nurse , tion. PT, OT , Nurse , MSW , NutritionistMSW , Nutritionist 老年老年--骨科骨科//骨科骨科--康复康复.. 理理 疗师疗师,,职业疗师职业疗师, , 护士护士,,专专 业社工业社工,,营养师营养师 Secondary Prevention Program 二级预防计划 Fragility Fracture Fragility Fracture Clinic Clinic 脆性骨折门诊脆性骨折门诊 Discharge HomeDischarge Home 出院回家出院回家 Community Care Community Care Program Program 社区护理社区护理Fall and Fracture Prevention C entres Fall and Fracture Prevention C entres 骨 折 后 护 理 骨 折 后 护 理 Tertiary Prevention Program 三级预防计划 Primary Prevention Program 一级预防计划 Community centers 社区中心 Family Physicians 家庭医生 Osteoporosis research centre 骨质疏松预防及治疗中心 DeliverablesDeliverables ✦✦ Improved patient careImproved patient care •• Quick and complete recoveryQuick and complete recovery •• Enhancing sustainable rehabilitationEnhancing sustainable rehabilitation •• Preventing secondary fracturesPreventing secondary fractures ✦✦ Promotion of bone health and fracture Promotion of bone health and fracture prevention in the communityprevention in the community ✦✦ Primary and Specialist care collaborationPrimary and Specialist care collaboration •• Enhancing primary bone health care Enhancing primary bone health care ✦✦ MultiMulti--disciplinary collaborationdisciplinary collaboration ✦✦ An integral part of Fall and FractureAn integral part of Fall and Fracture Prevention Program in the CommunityPrevention Program in the Community Community Fall and Fragility Community Fall and Fragility Fracture CentresFracture Centres Shatin & MaOn ShanShatin & MaOn Shan † 3 centres: Jan. 1, 20083 centres: Jan. 1, 2008 „„ LekYuen Estate LekYuen Estate -- ELCHKELCHK „„ ShaKok Estate ShaKok Estate -- TWGTWG „„ KamTai Estate KamTai Estate -- ELCHKELCHK †† 378 fragility fractures378 fragility fractures „„ 70 referred (20%)70 referred (20%) „„ PT compliance 79%PT compliance 79% „„ VT compliance 100%VT compliance 100% „„ Drop out : 9Drop out : 9 †† Actively extending to Actively extending to other sitesother sites PWHPWH KTCC LYCC SKCC A Brief SummaryA Brief SummaryA Brief Summary ✦✦DXA done: 45 DXA done: 45 ✤✤ Hip av.Hip av.--2.572.57 ✤✤ Spine av. Spine av. --1.801.80 ✦✦Hip protector: 26 Hip protector: 26 ✦✦Bone health medicationBone health medication ✤✤ Calcium: 53 Calcium: 53 ✤✤ AntiAnti--resorption: 43 resorption: 43 ✦✦Days from TPH to Fragility Fracture Days from TPH to Fragility Fracture Clinic (FFC): 46 days (1.5 mths)Clinic (FFC): 46 days (1.5 mths) ✦✦DaysDays from FFC to Community Centre: from FFC to Community Centre: 68 days (2.2 mths)68 days (2.2 mths) ✦✦ FU in FFC: av~ 1.8 appointmentsFU in FFC: av~ 1.8 appointments Encouraging ResponseEncouraging Response ✦✦ 100% acceptance from patients and 100% acceptance from patients and carerscarers ✤✤ BMD BMD -- selfself--financed!financed! ✤✤ AntiAnti--resorption drugs resorption drugs -- selfself--financed!financed! ✦✦ Excellent support from the family Excellent support from the family membersmembers ✦✦ Excellent compliance to Community Excellent compliance to Community Centre activitiesCentre activities ✦✦ Early discharge from Specialist ClinicsEarly discharge from Specialist Clinics ✦✦ Patient and family satisfactionPatient and family satisfaction ✦✦ Team satisfactionTeam satisfaction ✦✦Hip protector Hip protector -- Motion control airbagsMotion control airbags ✦✦ Low magnitude high frequency vibrationLow magnitude high frequency vibration •• Improve muscle functionImprove muscle function ✴✴ PowerPower ✴✴ CoCo--ordinationordination •• Increase bone mineral contentIncrease bone mineral content •• Enhancement of fracture healing in Enhancement of fracture healing in osteoporotic fracturesosteoporotic fractures •• Prevention of fragility fracturesPrevention of fragility fractures ✦✦ Efficacy of fragility fracture preventionEfficacy of fragility fracture prevention Research & DevelopmentResearch & Development High Frequency Low Magnitude VibrationHigh Frequency Low Magnitude Vibration in Treatment & Prevention of in Treatment & Prevention of Fragility FracturesFragility Fractures •• Improve BMDImprove BMD •• Improve muscle powerImprove muscle power •• Improve coImprove co--ordinationordination Cheung WH, Mok HW, Qin L, Sze PC, Lee KM, Leung KS. High-frequency whole-body vibration improves balancing ability in elderly women. Arch Phys Med Rehabil. 88(7): 852-7, 2007. Lee WS, Cheung WH, Qin L, Tang N, Leung KS. Age-associated decrease of type IIA/B human skeletal muscle fibers. Clin Orthop Relat Res. 450:231-237, 2006. CUHKCUHK--prototypeprototype One Stone One Stone -- Two BirdsTwo Birds 一石二鸟一石二鸟 Comprehensive Management Comprehensive Management of of Fragility Fractures among ElderlyFragility Fractures among Elderly 老年脆性骨折的综合处理老年脆性骨折的综合处理 Extended Patient Centred Project Extended Patient Centred Project and its Related Programs and its Related Programs An Initiative from Orthopaedic SurgeonsAn Initiative from Orthopaedic Surgeons 由骨科医生领导，以患者为中心的拓展计划和相关项目由骨科医生领导，以患者为中心的拓展计划和相关项目 20072007 31 Fracture is the First Opportunity to Fracture is the First Opportunity to Manage OsteoporosisManage Osteoporosis 骨折是骨质疏松处理的第一个机会骨折是骨质疏松处理的第一个机会 Clinical management protocols Clinical management protocols 临床处理原则临床处理原则 nn Surgical managementSurgical management nn Geriatric managementGeriatric management nn Anaesthetic careAnaesthetic care nn RehabilitationRehabilitation nn Fracture clinicFracture clinic nn Community programCommunity program Communications Communications -- Transfer summary forms Transfer summary forms 交流交流 nn Acute to RehabilitationAcute to Rehabilitation nn Rehabilitation to Fracture clinicsRehabilitation to Fracture clinics nn Fracture clinic to CommunityFracture clinic to Community Liaison person and logisticsLiaison person and logistics Communication setCommunication set--upup Research protocolsResearch protocols In service trainingIn service training 31 手术老年科麻 醉康复骨折门 诊社区计划 急性期至康复期康复至骨 折门诊骨折门诊至社区 联系人和安排交流方法科研方案联系人和安排交流方法科研方案 在职培训在职培训 Training Program for Orthopaedic SurgeonsTraining Program for Orthopaedic Surgeons 骨科医生培训计划骨科医生培训计划 Organisation of Fragility Fracture Program Organisation of Fragility Fracture Program 脆性骨折计划的组织脆性骨折计划的组织 Liaison and multidisciplinary approach Liaison and multidisciplinary approach 多学科合作多学科合作 Standardisation of fracture fixationStandardisation of fracture fixation 骨折固定的标准化骨折固定的标准化 •• PreoperativePreoperative •• IntraIntra--operativeoperative •• PostPost--operativeoperative Surgeon led program Surgeon led program 外科医生主导的计划外科医生主导的计划 •• Surgical management Surgical management 手术处理手术处理 •• Prevention and community program Prevention and community program 预防和社预防和社区计划区计划 术前术中术前术中 术后术后 33 Training Program for Nurses and Training Program for Nurses and Paramedical ProfessionsParamedical Professions 护士和医疗辅助人员培训护士和医疗辅助人员培训 Acute management Acute management 紧急处理紧急处理 Rehabilitation Rehabilitation 康复康复 n AcuteAcute nn Rehabilitation hospitalsRehabilitation hospitals nn Fracture clinicsFracture clinics Community program Community program 社区计划社区计划 nn LiaisonLiaison nn Prevention programPrevention program nn Extended and outreach programExtended and outreach program nn Planning strategyPlanning strategy 33 急性期康复急性期康复 医院骨折门医院骨折门 诊诊 联络预防计联络预防计 划拓展计划划拓展计划 计划策略计划策略 Training Program for Community PhysiciansTraining Program for Community Physicians 社区医生培训计划社区医生培训计划 Community program Community program 社区计划社区计划 •• Fracture and Fall Prevention Fracture and Fall Prevention •• PolyPoly--pharmacy screening and modificationpharmacy screening and modification 并并用药筛选和修改用药筛选和修改 ••General geriatric managementGeneral geriatric management CME accredited training programs CME accredited training programs 继继续教育认证课程续教育认证课程 Private and public collaborationPrivate and public collaboration 私立私立和公立医疗机构的合作和公立医疗机构的合作 Set up of Community Fracture and Fall Set up of Community Fracture and Fall prevention program prevention program 成立社区骨折和跌倒预防计划成立社区骨折和跌倒预防计划 ••Sustainability Sustainability ••EfficiencyEfficiency ••EffectivenessEffectiveness ••One stop community clinical serviceOne stop community clinical service 骨折和跌倒的预防老年科处理 可持续性效果效率一可持续性效果效率一 站式社区临床服务站式社区临床服务 35 Training Program for Community WorkersTraining Program for Community Workers 社工培训计划社工培训计划 Community participation Community participation 社区参与社区参与 n FrontFront--line workers line workers 前线工作者前线工作者 nn Concept of Self responsibility of healthConcept of Self responsibility of health 自身自身健康自己负责的概念健康自己负责的概念 nn Self run programs Self run programs 自发开展的计划自发开展的计划 ValueValue--added programs added programs 增值计划增值计划 n SustainabilitySustainability nn Excellent network Excellent network nn Opportunity for collaborationOpportunity for collaboration Planning and resources allocationPlanning and resources allocation 计划和资源配置计划和资源配置 35 可持续性良好的可持续性良好的 网络合作机会网络合作机会 Comprehensive Care for Elderly Comprehensive Care for Elderly with Fragility Fractureswith Fragility Fractures 老年脆性骨折的综合处理老年脆性骨折的综合处理 Acute Acute 急性期急性期 OrthoOrtho--GeriatricGeriatric Anaesthetic CareAnaesthetic Care 骨科骨科--老年科老年科--麻醉科麻醉科 Standardisation of Standardisation of Management Management Protocols, Surgical Protocols, Surgical ProceduresProcedures 手术操作标准化手术操作标准化 Postoperative Postoperative AssessmentsAssessments 术后评估术后评估 R ehabilitation H ospital R ehabilitation H ospital 康 复 中 心 康 复 中 心 Rehabilitation Rehabilitation 康复康复 GeriGeri-- Orthopaedic/rehabilitaOrthopaedic/rehabilita tion. PT, OT , Nurse , tion. PT, OT , Nurse , MSW , NutritionistMSW , Nutritionist 老年老年--骨科骨科//骨科骨科--康复康复.. 理理 疗师疗师,,职业疗师职业疗师, , 护士护士,,专专 业社工业社工,,营养师营养师 Secondary Prevention Program 二级预防计划 Fragility Fracture Fragility Fracture Clinic Clinic 脆性骨折门诊脆性骨折门诊 Discharge HomeDischarge Home 出院回家出院回家 Community Care Community Care Program Program 社区护理社区护理Fall and Fracture Prevention C entres Fall and Fracture Prevention C entres 骨 折 后 护 理 骨 折 后 护 理 Tertiary Prevention Program 三级预防计划 Primary Prevention Program 一级预防计划 Community centers 社区中心 Family Physicians 家庭医生 Osteoporosis research centre 骨质疏松预防及治疗中心 Thank youThank you 谢谢谢谢 Causes Causes –– increased risk of increased risk of FallsFalls Survey on 14 Accident and Emergency departments in 2003:Survey on 14 Accident and Emergency departments in 2003: Total no. trauma cases: 58040Total no. trauma cases: 58040 Injuries due to Falls:Injuries due to Falls:38820 (65%)38820 (65%) Hip fractures 2003Hip fractures 2003--20042004 Case Scenario 病例� Common Question： 问题： Geriatric Hip Fractures �老年髋部骨折� Geriatric Hip Fractures � Aims of Treatment 治疗目的 Concept of �Early Operative Fixation�早期手术固定的概念� Management Protocol �处理方案 Femoral Neck Fractures 股骨颈骨折�Internal Fixation内固定 Non-union 不愈合 Femoral Neck Fractures 股骨颈骨折� �Arthroplasty 关节置换� Hemi or Total 半髋或全髋� Prevention of Fragility Fractures脆性骨折的预防� Clinical Problems Geriatric Fragility Fractures�老年脆性骨折� 原因－跌倒风险的增加� Surgical Management�Advancement in Technologies�Understanding of Pathologies Locked Plates Locked plate is specially indicated in: 骨科团队可以做什么？ Comprehensive Care for Elderly with Fragility Fractures �老年脆性骨折的综合处理 Deliverables Community Fall and Fragility Fracture Centres�Shatin & MaOn Shan A Brief Summary Encouraging Response Research & Development High Frequency Low Magnitude Vibration in Treatment & Prevention of Fragility Fractures Comprehensive Management �of �Fragility Fractures among Elderly�老年脆性骨折的综合处理 Fracture is the First Opportunity to Manage Osteoporosis�骨折是骨质疏松处理的第一个机会� Training Pro