Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
彰化縣醫師公會醫師繼續教育課程 一、時間:99 年 1 月 24 日(星期日)13:30-18:00 二、地點:彰化縣農會 14 樓會議室(彰化市中山路二段 349 號) 三、主辦單位:彰化縣醫師公會 四、指導單位:彰化縣衛生局 五、協辦單位:台灣諾華股份有限公司 彰化縣防癌協會 六、課 程 表: 時 間 13:30~13:55 報 內 到 13:55~14:00 致 詞 14:00~15:00 骨鬆患者之全方面治療與 預防 15:00~16:00 16:00~17:00 17:00~18:00 容 Female pelvic floor: function, dysfunction and management 如何處理乳癌病人的骨質 健康問題 骨折內固定之選擇與運用 主 持 人 / 講 師 彰化縣醫師公會 蔡明忠 理事長 財團法人彰化基督教醫院骨科 于振東醫師 財團法人彰化基督教醫院婦產部 黃志成醫師 秀傳醫療社團法人秀傳紀念醫院 乳房外科 王馨鎂主任 秀傳醫療社團法人秀傳紀念醫院 榮譽院長暨骨科總監 李土生醫師 于振東醫師學經歷 學歷:國立陽明醫學院醫學系學士 中國醫藥大學臨床醫學研究所碩士 經歷:台北榮民總醫院骨科部住院醫師,總醫師 台北榮民總醫院骨科部主治醫師 花蓮鳳林榮民醫院骨科主任 健保局東區審核委員 彰化基督教醫院二林分院急診室主任 紐約 Beth Israel Medical Center 膝關節重建進修 法國 Clinique d’Argonay 髖關節重建進修 2003-2006 大葉大學機械及自動化工程學系暨研究所兼任助理教授 現任: 財團法人彰化基督教醫院骨科部主治醫師 長榮大學臨床教授 研究:高彎曲型人工膝關節之動作分析,早期膝關節壞死之治療,人工膝關節暨 髖關節手術,骨質疏鬆之治療與防治 骨鬆患者之全方面治療與預防 Providing Effective Therapy across a Broad Spectrum of Osteoporosis Patients Yu chen-tung MD. MSc Changhua Christian Hospital Osteoporosis is a disease characterized by low bone mass and bone structural deterioration, which results in increased bone fragility and fracture susceptibility. Fractures, the most important consequence of osteoporosis, are associated with enormous costs and substantial morbidity and mortality. The most typical sites of fractures related to osteoporosis are the spine, hip, and wrist. In Taiwan, one in three women and one in five men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime. The rate of hip fractures is two to three times higher in women than men; however, the one-year mortality following a hip fracture is much higher in males (15% vs. 22%). A number of therapeutic agents are available to treat osteoporosis; bisphosphonates remain the main stream of them. Several bisphosphonates (BPs) are available; with oral and intravenous modes of administration formulated for varying dosing frequencies Each BP has its unique profile and different indications for osteoporosis. More information about the chemistry, pharmacology, and clinical applications of BPs will be presented and discussed. 黃志成醫師學經歷 學歷:高雄醫學院 經歷:彰化基督教醫院婦產科住院醫師及總醫師 彰化基督教醫院婦產科主治醫師 1996~ 台灣婦產科專科醫師 台北馬偕醫院婦產科研究員 淡水馬偕醫院羊水實驗室研究 中華民國婦產科內視鏡醫學會會員 中華民國婦女泌尿暨骨盆鬆弛醫學會會員 專長:尿動力檢查 婦女尿失禁評估,藥物及治療 子宮,膀胱及直腸脫垂等骨盆鬆弛手術及治療 婦科腫瘤,藥物及腹腔鏡手術治療 一般婦科,更年期,月經異常 一般產科 The Female Pelvic Floor Function, Dysfunction and Management Static anatomy outline Static anatomy Pelvic with organs and connective tissues Pelvic with organs and muscles Relationship of the pelvic muscles to organ, ligament and fascia Dynamic anatomy outline Functional anatomy Continence and micturition The integral theory Symptoms of stress, urge, and abnormal emptying mainly derive From laxity In the vagina Its supporting ligaments A result of altered connective tissue Endopelvic fasciaViscero-fascial layer Top layer of the pelvic floor Endopelvic fascia Endopelvic fascia attach to the uterus Parametrium Cardinal and uterosacral ligaments Endopelvic fascia attach to the vagina Paracolpium Endopelvic fascia The upper two thirds of the vagina Suspended and attached to the pelvic walls by the paracolpium after hysterectomy Paracolpium has two portion Level I Upper portion Relative long sheet of tissue Suspend the vagina by attaching it to the pelvic wall Endopelvic fascia Level II Mid-portion Attach the vagina laterally and more directly to the pelvic wall Stretches the vaginal transversely between the bladder and rectum Pubocervical fascia A combination of the anterior vaginal wall and its attachments to the pelvic wall Support the bladder Endopelvic fascia Level II Rectovaginal fascia A combination of the posterior vaginal wall and endopelvic fascia Blocking formation of a rectocele Endopelvic fascia Level III The distal vagina Directly attached to surrounding structures without any intervening paracolpium Anterior Fuse with the urethra Posteriorly Fuse with perineal body Laterally Fuse with levator ani muscles The dynamics of urethral opening and closure-urethral perspective Urethral closure or opening is determined by Contraction or relaxation of one muscle Pubococcygeus Stretch and close the proximal urethral cavity to “C” Forward muscles PCM Backward acting muscles LP and LMA Open the urethral cavity to “O” Relaxation of PCM LP and LMA to stretch The dynamics of urethral closure and opening – vaginal perspective During effort Distal vagina Stretched forward by PCM Upper vagina and bladder base Stretched down and back by LP and LMA PCM and LP contract against PUL LMA contracts against USL The dynamics of urethral closure and opening – vaginal perspective During micturition PCM relaxes Stretch receptors activate the micturition reflex The whole system is stretched down and back by LP and LMA Opening out the outflow tract Detrusor contracts to expel urine The biomechanics of the vagina The vagina stretches To transmit muscle forces for urethral opening and closure Counteracts the hydrostatic pressure at the bladder base Prevents displacement of the stretch receptors Which initiate the micturition reflex Pelvic diaphragm Below the viscero-fascial layer Levator ani group of muscles Pelvic diaphragm Together with superior and inferior fasciae of the levator ani and the levator ani muscles Pelvic diaphragm Functional anatomy Pelvic diaphragm Levator ani Pubovisceral muscle (a thick U-shape muscle) Puboccocygeus and puborectalis Sling-like arrangement Iliococcygeus muscle Horizontal sheet A shelf on which the organs may rest Pelvic diaphragm Pubococcygeus muscle Most cephalic portion of the levator Connects tow relatively immovable structures Pubic and coccyx Could not be expected to contribute substantially to supporting the pelvic organs Pelvic diaphragm Puborectalis portion of the pubovisceral m Lateral vaginal walls are attached to it The fibres between the vagina and pubic bone Pubovaginalis muscle Responsible for elevating the urethra during pelvic muscle contraction Continues dorsally Some fibres insert into the rectum between the internal and external sphincter Others pass behind the ano-rectal junction Pelvic diaphragm Urogenital hiatus is bounded Ventrally (anteriorly) by the pubic bones Laterlly by the levator muscles Dorsally (posteriorly) by the perineal body and external anal sphincter Pelvic diaphragm Pelvic floor muscles and the supportive ligaments The interaction is critical to pelvic organ support If the pelvic floor muscles do not close the pelvic floor The connective tissue must carry this load for long periods of time Eventually fail to hold the vaginal in place Perineal membrane and external genital meuscles Perineal membrane (urogenital diaphragm) A dense triangular-shaped membrane In anterior portion of the pelvis Below the pelvic diaphragm Contaning a central opening Lies at the level of the hymenal ring Attches the urethra, vagina, and perineal body to the ischiopubic rami Functional anatomy of the lower urinary tract Conservative treatment Pelvic floor re-education in urogynecology Pelvic floor muscle training Striated urethral rhabdosphincter fibers Mainly: slow-twitch fibers Fast-twitch fibers only in Compressor urethrae Fast contraction of the pelvic floor muscles Elevate the bladder neck Clamping the urethra Pressing it against the pubic symphysis Pelvic floor muscle training Regular training Increase the number of Activated motor unit potentials The frequency (neural adaptation) Volume (hypertrophy) of excitations Pelvic floor muscle training Consensual protocols Three sets of 8 to 12 slow-velocity maximal contractions Sustained for 6 to 8 seconds Three to four times a week Continued for at least 4 to 5 months Pelvic floor muscle training Often supplemented with Biofeedback Intravaginal resistance devices Vaginal cones Electrical stimulation Bladder retraining Biofeedback Are used to increase The patients’s awareness of The intensity and the frequency of pelvic floor muscle contractions Approach One or two fingers to palpate the levator muscles Special device consisting of a vaginal or anal probe with electromyographic sensors Biofeedback Different perineometer devices are used Surface electromyography electrodes The vaginal surface electrode is now placed 3 cm from the introitus Record of pelvic floor muscle activity during contraction Intravaginal resistance devices Devices (air- or water-inflated balloons or perineometers) Inserted into the vagina Pulled out of the vagina with a pulley system Applies gradually increasing force Vaginal cones Ranging from 20 to 100 gm Inserted into the vagina Once the patient can hold the 20-gm cone for 20 minutes on two occasions The next heaviest cone is used 王馨鎂醫師學經歷 學歷: 台北醫學院醫學系學士 現任: 秀傳醫療社團法人秀傳紀念醫院乳房外科主任 資歷: 馬偕醫院一般外科主治醫師 耕莘醫院乳症特別科主治醫師 專長: 乳房手術、乳癌化學治療及荷爾蒙治療、乳癌篩檢、乳房超音波等。 如何處理乳癌病人的骨質健康問題 抗荷爾蒙治療是預防乳癌再發的重要方式之一. 其中,使用芳香環轉化酶( Aromatase Inhibitor)可以達到良好 的治療效果。 然而女性病人在身體裡雌激素濃度下降之後,會出現骨質流失的 問題,使得骨折的危險性上升. 因此,定期追蹤骨密度,建議病人經常運動,服用鈣片及維生素 D, 或使用雙磷酸鹽藥物都可以讓病患骨折的機會降低,提升生活品質。 李土生醫師學經歷 現任:秀傳紀念醫院 榮譽院長暨骨科總監 經歷:台中榮民總醫院 骨科部 部主任 德國柏林大學醫學博士 台灣骨科創傷醫學會 理事長 國際內固定研究學會 台灣分會會長 台中榮總 骨科 科主任 台北榮總 骨科 主治醫師 專長:人工膝關節置換、人工髖關節置換、肌肉及筋膜之疼痛治療、骨折、外傷 骨折內固定之選擇與應用 彰濱秀傳紀念醫院 骨科部 李土生 Life is movement Movement is life The principles of fracture management and internal fixation w Fracture reduction and fixation to restore anatomical relationships. w Stability by fixation or splintage, as the personality of the fracture and the injury requires. w Preservation of the blood supply to soft tissue and bone by careful handling and gentle reduction technique. w Early and safe mobilization of the part and the patient. Fracture and Blood Supply w Although a fracture is a purely mechanical process, it triggers important biological reactions such as bone resorption and bone (callus) formation w These two processes depend on the blood supply Factors may damage the blood supply w The accident w The transportation w The surgical approach w The implant w Elevated intra-articular pressure reduces the epiphyseal bone circulation, especially in young patients Implants and Materials in Fracture Fixation w General requirement w Special requirement (stiffness, strength, ductility, corrosion, resistence, surface structure …) w Biocompatibility w Near metalic implant material (high strength alloys, shape memory alloys) w Biodegrable implant w Implant materials for filling defect w Glue Implants and materials in fracture fixation w Only metal offer high stiffness and strength, good ductility, and biocompatibility at the same time w Today’s metal implant are made either of stainless steel or tatanium w Osteosynthesis restores bone stiffness temporarily, while fracture healing restores it permanently Reduction Technique (1) w Direct reduction : The fracture area is exposed surgically or is already widely open. w Indirect reduction : The fracture lines are not directly exposed and seen, and that the fracture area remains covered by the surrounding soft tissue. Reduction Technique (2) w Indirect reduction techniques offers enormous advantages because they add minimal surgical damage to tissues already traumatized by the fracture. Surgical Reduction (1) w The aim of reduction is to restore, as precisely as possible, the overall length of the bone, as well as the axial and rotational alignment w Fracture reduction requires a variety of technique and flexibility of approach Surgical Reduction (2) w In the articular segment, to avoid post-traumatic osteoarthritis, anatomical reduction of the joint surface, with elevation of the impacted area, is mandatory. Implants in fracture treatment w Screw w Plate w Wire w Pin w Intramedullary nail w External fixators Implant Function in Internal Fixation Fixation Technique w Technique of absolute stability ‧ Lag screw ‧ Plates ‧ Tension band principle w Technique of relative stability ‧ Intramedullary nailing ‧ Bridge plating ‧ External fixation w Internal Fixator : a new technology Technique of absolute stability w Lag screw w Plates w Tension band principle Principles of lag screw: proximal 4.5mm distal 3.2mm drill bit Shaft screw provide better compression Lag screw fixation Lag screw combine buttress plate fixation Lag screws with neutralization plate Different function of plates w Neutralization plate w Buttress plate w Tension band plate w Bridge plate Tension band principle w The tension band convert tensile forces into compression forces w In the diaphysis angular deformity (convexity) indicates the tension side w The opposite cortex should be able to withstand compression forces Tension band plate w A plate under tension is much stronger than under bending forces Cortical defect, plate under bending No cortical defect, plate under tension Tension band principle The application of a tension band will neutralize the forces and even convert them into compression when the joint is flexed Fixation Technique w Technique of absolute stability ‧ Lag screw ‧ Plates ‧ Tension band principle w Technique of relative stability ‧ Intramedullary nailing ‧ Bridge plating ‧ External fixation w Internal Fixator : a new technology Fracture with flexible surgical fixation w Intramedullary nail w External fixators w Bridging plate w Internal fixators (Locked plate screws) Intramedullary nailing w Nailing of disphyseal fractures is standard w Interlocking increases stability of fixation and widens the indication for nailing w A solid nail is less susceptible to infection than a tubular nail w Damage to endosteal blood supply after reaming w In severe trauma may cause respiratory distress Unreamed nail Solid nail Contraindication for intramedullary nailing w Infection w Femoral fractures in the multiply injuried patient with pulmonary trauma, where temporary stabilization by external fixator is advocated w Metaphyseal fractures: malalignment may occur Bridge plating w The plate acts as an extramedullary splint w Biological plating combines adequate stability with uncompromised biology Bridge plate with ext. fixator Comminuted fracture Bridge plate Medial buttress Ext. Fixator Fixation Technique w Technique of absolute stability ‧ Lag screw ‧ Plates ‧ Tension band principle w Technique of relative stability ‧ Intramedullary nailing ‧ Bridge plating ‧ External fixation w Internal Fixator : a new technology w Much of the vascular supply to the callus area derives from the surrounding soft tissue, a reason not to strip any soft tissue! w Internal fixation of fracture alters the biology of fracture healing w Reaming does result in a delayed return of blood flow in cortical bone w The least damage to the blood supply, however,is done by the use of external or internal fixators Biological problems in Conventional Internal Fixation (1) Biological problems in Conventional Internal Fixation (2) w Plating : ‧ Compromise to cortical blood supply w Nailing : ‧ Damage to endosteal blood supply The principle of preserving blood supply to bone, must be addressed in every phase of fracture management. Recent Developments in Internal Fixation Technology (1) w Minimal invasive technique ‧ Nailing : The damage of endosteal blood supply, can be reduced by avoiding reaming ‧ Plating : Conventional plating is been increasing replaced by using internal fixator Recent Developments in Internal Fixation Technology (2) w Unreamed solid nail with locking w Internal fixator (uni- or bi-cortical fixation) ‧ Locked screw-plate ‧ PC-Fix ‧ LISS w Increase stability of fixation & widens the indication of nailing w Limited damage of endosteal blood supply and less susceptable to infection Unreamed nailing with locking Unreamed nail Solid nail Unreamed nailing with locking Internal fixator: a new technology w Prevent the pressure of a plate against bone w Function as a subcutaneous or submuscular external fixator w Use of locked screw and unicortical fixation New design plate w LC-DCP ( Limited contact-DCP) w PC- Fix ( Point contact fixator) & LCP plate w LISS (Less invasive stabilization system) PC-Fix & LCP w The first implant designed to fulfill the new requirements was the small PC-Fix for forearm fracture w Limited application in metaphyseal and epiphyseal area LCP - Locked screws and plate Compare between conventional DCP and LCP plate Compare between DCP and LC-DCP (a) (b) (c) PC-Fix LISS w LISS was designed for the distal femur and proximal tibia, to be inserted by minimal invasive technique New LISS plate Choice of internal fixation w Patient’s condition w Soft tissue condition w Location of fracture: articular, metaphysis, diaphysis w Goal of fixation: absolute stability or flexible fixation Articular fractures: principles w Repair of adult articular cartilage depends on exact reconstruction, rigid fixation, and early motion w Continuous passive motion (CPM) after anatomical reduction and rigid fixation can lead to hyaline cartilage healing w Timing of surgery depends on soft-tissue condition Articular fractures: principles w Perfect anatomical restoration and freedom of joint motion can only be obtained by internal fixation (Sir John Charnley) Intraarticular fracture need lag screw for absolute stability Metaphyseal fracture : principles w Bone defect must be filled with autogenous bone or a substitute w Axial alignment is more important than anatomical reduction w Buttress of the metaphysis can be done by plate or external fixators Intraarticular depression fracture need elevation and buttress plate fixation Technique error Dual plate for medial buttress Medial buttress Tension plate with no medial buttress : implant failure Cortical defect Diaphyseal fractures: principles w Bone quality influences the choice of fixation technique w Fracture type and displacement are good predictors of soft-tissue damage w History of accident indicates the amount of energy involved w Arterial injury dominates decision making Diaphyseal fractures: principles w Exact anatomical reconstruction of the diaphysis is not necessary for normal limb function (humerus) w Radius and ulnar demand anatomical reduction similar to a joint w Joint must be in their original axial relationship Unstable fracture with nonunion Implant selection error Too large gap and unstable fixation Inadequate fixation : plate too short Neutralization plate without lag screw fixation may fail Dynamization of interlocking nail cause bone union Correct alignment Dynamization Static locking screw Varus deformity Tension bend principle External fixator act as tension band Wrong application Unnecessary plating Gap Summary w The pursuit of absolute stability, original proposed for almost all fracture, is mandatory only for joint and certain related fracture recently. w When clinical situation favor, the use of plate, proper planning & the current technique for minmal access and fixation have been designed to minimize any insult to the bloody supply of the bony fragment and soft tissue Summary w Articular fracture - anatomical reduction and rigid fixation (screw, plate, etc) w Fr. of patella, olecranon, avulsion Fr. - tension band principle (pin, wire, plate) w Simple diaphyseal fracture - flexible fixation (plate, nail with locking or without locking, unreamed nail with locking) w Multifragmental fracture - splintage fixation (locking nail or bridging plate) Summary w Fracture of forearm diaphysis - anatomical reduction with fixation (DCP, LC-DCP, PC-Fix) w Femoral supracondylar or proximal tibial fr. - flexible fixation (DCS, DCP, locked screw-plate, LISS) Thanks for your attention !