INHOUD
Hoofdstuk 1: inleiding .....................................................................................................................................................8
Definities en basisbegrippen traumatologie .............................................................................................................8
Indeling fracturen van lange pijpbeenderen.........................................................................................................8
Hoofdstuk 2: wondheling................................................................................................................................................9
Inleiding .......................................................................................................................................................................9
Fasen van de wondheling ...........................................................................................................................................9
Hemostasefase ........................................................................................................................................................9
Inflammatiefase ......................................................................................................................................................9
Proliferatiefase ..................................................................................................................................................... 10
Remodelleringsfase.............................................................................................................................................. 10
Vertraagde wondheling ........................................................................................................................................... 11
Hoofdstuk 3: fractuurheling ........................................................................................................................................ 12
Inleiding .................................................................................................................................................................... 12
Biologie ..................................................................................................................................................................... 12
Inflammatie .......................................................................................................................................................... 13
Vorming zachte callus .......................................................................................................................................... 13
Vorming harde callus ........................................................................................................................................... 13
Remodellering ...................................................................................................................................................... 13
Belang van bloedvoorziening .................................................................................................................................. 14
Biomechanica en fractuurheling ............................................................................................................................. 14
Niet-operatieve behandeling van fracturen....................................................................................................... 14
Operatieve behandeling van fracturen .............................................................................................................. 14
Methoden van fractuurfixatie................................................................................................................................. 15
Interne fixatie ....................................................................................................................................................... 15
Externe fixatie ...................................................................................................................................................... 16
Basisprincipes van operatieve fractuurbehandeling ............................................................................................. 16
Gewrichtsfracturen .............................................................................................................................................. 16
Schaftfracturen..................................................................................................................................................... 16
Metafysaire fracturen.......................................................................................................................................... 16
Intracapsulaire kop-halsfracturen....................................................................................................................... 16
Avulsiefracturen (tubercula, epicondylen)......................................................................................................... 17
Hoofdstuk 4: polytrauma en de basisprincipes van opvang van de traumapatiënt................................................ 18
Inleiding .................................................................................................................................................................... 18
Opvang...................................................................................................................................................................... 18
Behandeling.............................................................................................................................................................. 18
1
,Hoofdstuk 5: letsels van het bewegingsstelsel: open fracturen ............................................................................... 20
Inleiding .................................................................................................................................................................... 20
Classificatie ............................................................................................................................................................... 20
Behandeling.............................................................................................................................................................. 20
Systemische antibioticaprofylaxe ....................................................................................................................... 20
Fractuurstabilisatie .............................................................................................................................................. 20
Lokale antibiotica ................................................................................................................................................. 20
Wekedelenbedekking .......................................................................................................................................... 20
Hoofdstuk 6: letsels van het bewegingsstelsel: bovenste lidmaat ........................................................................... 21
Claviculafracturen .................................................................................................................................................... 21
Inleiding ................................................................................................................................................................ 21
Diagnose ............................................................................................................................................................... 21
Classificatie ........................................................................................................................................................... 21
Behandeling.......................................................................................................................................................... 21
Nabehandeling ..................................................................................................................................................... 22
Scapulafracturen ...................................................................................................................................................... 22
Inleiding ................................................................................................................................................................ 22
Diagnose ............................................................................................................................................................... 22
Classificatie ........................................................................................................................................................... 23
Behandeling.......................................................................................................................................................... 23
Nabehandeling ..................................................................................................................................................... 23
Proximale humerusfracturen .................................................................................................................................. 24
Inleiding ................................................................................................................................................................ 24
Diagnose ............................................................................................................................................................... 24
Classificatie ........................................................................................................................................................... 24
Behandeling.......................................................................................................................................................... 24
Nabehandeling ..................................................................................................................................................... 25
Humerusschaftfracturen ......................................................................................................................................... 26
Inleiding ................................................................................................................................................................ 26
Diagnose ............................................................................................................................................................... 26
Behandeling.......................................................................................................................................................... 26
Nabehandeling ..................................................................................................................................................... 27
Distale humerusfracturen........................................................................................................................................ 27
Inleiding ................................................................................................................................................................ 27
Diagnose ............................................................................................................................................................... 27
Behandeling.......................................................................................................................................................... 27
Nabehandeling ..................................................................................................................................................... 28
2
, Olecranonfracturen.................................................................................................................................................. 28
Inleiding ................................................................................................................................................................ 28
Diagnose ............................................................................................................................................................... 28
Behandeling.......................................................................................................................................................... 28
Nabehandeling ..................................................................................................................................................... 29
Radiuskopfracturen.................................................................................................................................................. 29
Inleiding ................................................................................................................................................................ 29
Diagnose ............................................................................................................................................................... 29
Behandeling.......................................................................................................................................................... 29
Nabehandeling ..................................................................................................................................................... 30
Distale bicepspeesruptuur....................................................................................................................................... 30
Inleiding ................................................................................................................................................................ 30
Diagnose ............................................................................................................................................................... 30
Behandeling.......................................................................................................................................................... 30
Nabehandeling ..................................................................................................................................................... 30
Fracturen van de radius- en/of ulnaschaft............................................................................................................. 31
Inleiding ................................................................................................................................................................ 31
Diagnose ............................................................................................................................................................... 31
Behandeling.......................................................................................................................................................... 31
Nabehandeling ..................................................................................................................................................... 31
Distale radiusfracturen ............................................................................................................................................ 32
Inleiding ................................................................................................................................................................ 32
Diagnose ............................................................................................................................................................... 32
Behandeling.......................................................................................................................................................... 32
Nabehandeling ..................................................................................................................................................... 32
Hoofdstuk 7: letsels van het bewegingsstelsel: bekkenfracturen ............................................................................ 33
Fracturen van de bekkenring .................................................................................................................................. 33
Inleiding ................................................................................................................................................................ 33
Diagnose ............................................................................................................................................................... 33
Behandeling.......................................................................................................................................................... 33
Fracturen van het acetabulum ................................................................................................................................ 33
Inleiding ................................................................................................................................................................ 33
Diagnose ............................................................................................................................................................... 33
Behandeling.......................................................................................................................................................... 34
Nabehandeling ..................................................................................................................................................... 34
Hoofdstuk 8: letsels van het bewegingsstelsel: onderste lidmaat ........................................................................... 35
Heupfracturen .......................................................................................................................................................... 35
3
, Inleiding ................................................................................................................................................................ 35
Diagnose ............................................................................................................................................................... 35
Classificatie ........................................................................................................................................................... 35
Behandeling.......................................................................................................................................................... 36
Nabehandeling ..................................................................................................................................................... 37
Femurschaftfracturen.............................................................................................................................................. 37
Inleiding ................................................................................................................................................................ 37
Diagnose ............................................................................................................................................................... 37
Behandeling.......................................................................................................................................................... 37
Nabehandeling ..................................................................................................................................................... 38
Distale femurfracturen ............................................................................................................................................ 38
Inleiding ................................................................................................................................................................ 38
Diagnose ............................................................................................................................................................... 38
Behandeling.......................................................................................................................................................... 38
Nabehandeling ..................................................................................................................................................... 38
Quadricepspeesruptuur........................................................................................................................................... 39
Inleiding ................................................................................................................................................................ 39
Diagnose ............................................................................................................................................................... 39
Behandeling.......................................................................................................................................................... 39
Nabehandeling ..................................................................................................................................................... 39
Patellafracturen........................................................................................................................................................ 39
Inleiding ................................................................................................................................................................ 39
Diagnose ............................................................................................................................................................... 40
Behandeling.......................................................................................................................................................... 40
Nabehandeling ..................................................................................................................................................... 40
Patellapeesruptuur .................................................................................................................................................. 40
Inleiding ................................................................................................................................................................ 40
Diagnose ............................................................................................................................................................... 40
Behandeling.......................................................................................................................................................... 41
Nabehandeling ..................................................................................................................................................... 41
Proximale tibiafracturen.......................................................................................................................................... 41
Inleiding ................................................................................................................................................................ 41
Diagnose ............................................................................................................................................................... 41
Behandeling.......................................................................................................................................................... 41
Nabehandeling ..................................................................................................................................................... 42
Tibiaschaftfracturen................................................................................................................................................. 42
Inleiding ................................................................................................................................................................ 42
4
, Diagnose ............................................................................................................................................................... 42
Behandeling.......................................................................................................................................................... 42
Nabehandeling ..................................................................................................................................................... 43
Distale tibiafracturen ............................................................................................................................................... 43
Inleiding ................................................................................................................................................................ 43
Diagnose ............................................................................................................................................................... 43
Behandeling.......................................................................................................................................................... 43
Nabehandeling ..................................................................................................................................................... 43
Enkelfracturen.......................................................................................................................................................... 44
Inleiding ................................................................................................................................................................ 44
Anatomie en classificatie..................................................................................................................................... 44
Diagnose ............................................................................................................................................................... 44
Behandeling.......................................................................................................................................................... 44
Nabehandeling ..................................................................................................................................................... 45
Ruptuur van de syndesmosis tibiofibularis ............................................................................................................ 45
Inleiding ................................................................................................................................................................ 45
Diagnose ............................................................................................................................................................... 45
Behandeling.......................................................................................................................................................... 45
Nabehandeling ..................................................................................................................................................... 46
Achillespeesruptuur................................................................................................................................................. 46
Inleiding ................................................................................................................................................................ 46
Diagnose ............................................................................................................................................................... 46
Behandeling.......................................................................................................................................................... 46
Nabehandeling ..................................................................................................................................................... 46
Fracturen van de talus ............................................................................................................................................. 47
Inleiding ................................................................................................................................................................ 47
Diagnose ............................................................................................................................................................... 47
Behandeling.......................................................................................................................................................... 47
Nabehandeling ..................................................................................................................................................... 47
Fracturen van de calcaneus ..................................................................................................................................... 47
Inleiding ................................................................................................................................................................ 47
Diagnose ............................................................................................................................................................... 47
Behandeling.......................................................................................................................................................... 48
Nabehandeling ..................................................................................................................................................... 48
Fracturen van de metatarsalen............................................................................................................................... 48
Inleiding ................................................................................................................................................................ 48
Diagnose ............................................................................................................................................................... 48
5
, Behandeling.......................................................................................................................................................... 49
Nabehandeling ..................................................................................................................................................... 49
Hoofdstuk 9: letsels van het bewegingsstelsel: fracturen van het groeiende skelet (kinderen)............................ 50
Inleiding .................................................................................................................................................................... 50
Classificatie ............................................................................................................................................................... 50
Diagnose ................................................................................................................................................................... 50
Behandeling.............................................................................................................................................................. 51
Nabehandeling ......................................................................................................................................................... 51
Hoofdstuk 10: letsels van het bewegingsstelsel: fracturen van het osteoporotische skelet.................................. 52
Inleiding .................................................................................................................................................................... 52
Diagose...................................................................................................................................................................... 52
Behandeling.............................................................................................................................................................. 52
Nabehandeling ......................................................................................................................................................... 53
Hoofdstuk 11: Letsels van het bewegingsstelsel: posttraumatische complicaties.................................................. 54
Non-union (gestoorde fractuurheling) ................................................................................................................... 54
Inleiding ................................................................................................................................................................ 54
Etiologie ................................................................................................................................................................ 54
Classificatie ........................................................................................................................................................... 54
Diagnose ............................................................................................................................................................... 55
Behandeling.......................................................................................................................................................... 55
Malunion................................................................................................................................................................... 55
Inleiding ................................................................................................................................................................ 55
Classificatie ........................................................................................................................................................... 56
Diagnose ............................................................................................................................................................... 56
Behandeling.......................................................................................................................................................... 56
Fractuurgerelateerde infectie ................................................................................................................................. 56
Inleiding ................................................................................................................................................................ 56
Pathogenese ......................................................................................................................................................... 57
Diagnose ............................................................................................................................................................... 57
Behandeling.......................................................................................................................................................... 57
Compartimentsyndroom ......................................................................................................................................... 58
Inleiding ................................................................................................................................................................ 58
Etiologie ................................................................................................................................................................ 59
Classificatie ........................................................................................................................................................... 59
Diagnose ............................................................................................................................................................... 59
Behandeling.......................................................................................................................................................... 60
Hoofdstuk 12: thoraxtrauma....................................................................................................................................... 61
6
,Inleiding .................................................................................................................................................................... 61
Behandeling.......................................................................................................................................................... 61
ABCDE ................................................................................................................................................................... 61
Acuut levensbedreigend letsel ................................................................................................................................ 62
Tracheobronchiale letsels.................................................................................................................................... 62
(spannings)pneumothorax .................................................................................................................................. 62
Open pneumothorax............................................................................................................................................ 62
Traumatische hemothorax .................................................................................................................................. 62
Harttamponnade.................................................................................................................................................. 63
Potentieel levensbedreigend letsel ........................................................................................................................ 63
Ribfracturen, sternumfractuur en fladderthorax .............................................................................................. 63
Longcontusie ........................................................................................................................................................ 63
Traumatische aortaruptuur................................................................................................................................. 64
7
, MENSELIJK BEWEGINGSSTELSEL:
TRAUMATOLOGIE
HOOFDSTUK 1: INLEIDING
DEFINITIES EN BASISBEGRIPPEN TRAUMATOLOGIE
Wonde = verstoring van continuïteit van weefsel, door externe factoren veroorzaakt, waarbij al of niet weefsel
is verloren gegaan
Contusie = letsel van het (onderhuidse) weefsel door inwerking van stomp geweld. Er ontstaat een
bloeduitstorting en een ontstekingsreactie die de heling op gang brengt
- ‘kneuzing’
- Weke delen
Distorsie = uitrekken van ligamenten en kapsel van een gewricht door een beweging die groter is dan de
normale beweeglijkheid van dat gewricht. Door het uitrekken ontstaan er scheuren die gaan van
microscheuren (= uitwendige structuur van de ligamenten blijft bewaard, maar er scheuren inwendig een
aantal vezels) tot volledig scheuren van de gewrichtsband
- ‘verstuiking’
- Gewricht
Luxatie = ernstige distorsie, waarbij het gewricht niet meer in een normale anatomische verhouding staat
- ‘ontwrichting’
- Gewricht
Spierscheur = onderbreking in continuïteit van spier
Peesscheur = onderbreking in continuïteit van pees
- In de pees of thv enthese (plaats waar pees aan bot vastzit)
Fractuur = onderbreking in de continuïteit van bot
Fractuurluxatie = combinatie van luxatie en fractuur die uitloopt in het gewricht
INDELING FRACTUREN VAN LANGE PIJPBEENDEREN
- Ad axim: hoekstand
o Antecurvatie: hoek naar voren
o Recurvatie: hoek naar achteren
o Valgus: hoek naar binnen (X-stand)
o Varus: hoek naar buiten (O-stand)
- Ad latum: zijdelingse verplaatsing
- Ad longitudinem: verkorting
- Ad periferiam: exo- of endorotatie
- Cum distractione: diastase
- Cum implantatione: instuiking (inclavatie)
8
,HOOFDSTUK 2: WONDHELING
INLEIDING
Wonde = verstoring van continuïteit van weefsel, door externe factoren veroorzaakt, waarbij al of niet weefsel
is verloren gegaan
Externe factoren
- Stomp of scherp geweld
- Inwerking van chemisch, thermisch, elektrisch, toxisch of radiatieagens
Genezing
- Primair: chirurgisch gesloten wonde
- Secundair: wond openlaten en door contractie en reëpithelialisatie uit zichzelf genezen
- ‘Tertiair’: uitgestelde primaire wondgenezing → wonde wordt gesloten na verzorging
FASEN VAN DE WONDHELING
Van 3 naar 4 fasen:
/ Hemostasefase
Inflammatoire fase Inflammatoire fase
Proliferatiefase Proliferatiefase
Remodelleringsfase Remodelleringsfase
HEMOSTASEFASE
- Seconden tot minuten na trauma
1. Lichaam reageert op bloedvatschade door vasoconstrictie en coagulatie → verder bloedverlies
vermijden + hypoxie → lichaamsweefsel onvoldoende zuurstof
2. Thrombocyten gaan samen klonteren → stollingsmechanisme → °hematoom → barrière tegen
bacteriën en verder bloedverlies
INFLAMMATIEFASE
- 0 tot 2 dagen na trauma
1. Bloeding stoppen → hypoxie → °vasodilatatie → °ontstekingsreactie → zwelling in wondgebied
2. Thrombocyten < modulatoren (cytokines, groeifactoren) → angiogenese en collageensynthese
3. Chemotaxis: thrombocyten trekken andere cellen aan door productie van cytokines
o Neutrofielen (leukocyten)
▪ Acute ontstekingsreactie
▪ Fagocyterende en bacteriedodende werking → voorkomen bacteriële contaminatie
en infectie
o Monocyten (leukocyten)
▪ Omzetten in macrofagen → fagocytose van debris en vernietigen van bacteriën
o Leukopenie: afwezigheid neutrofiele infiltratie en macrofagen → wonde zal genezen, maar
grotere kans op infectie
9
, 4. Fibrine → °onrijpe matrix → wond overbruggen + spanning → wondranden bij elkaar komen
o Fibronectine en hyaluronzuur → overbrugging verstevigen
5. Groeifactoren
PROLIFERATIEFASE
Wondcontractie = proces waarbij de wond concentrisch kleiner wordt
- 3 tot 28 dagen na trauma
- Aanleiding:
o Complementsysteem
o Bacteriële eiwitten
o Aantrekken neutrofielen, monocyten, lymfocyten, plasmacellen en mastcellen
1. Migratie en proliferatie van cellen → weefselherstel
2. Chemotaxis: cytokines en groeifactoren trekken andere cellen aan naar wondgebied
o Vasculaire endotheelcellen
o Keratinocyten
o Fibroblasten
3. Angiogenese (neovascularisatie) → zuurstof en voedingsstoffen transporteren naar wondgebied
o Uitgroei capillaire vaten en deling van endotheelcellen in de voorlopige wondmatrix
o Primaire wondheling: geen granulatieweefsel
o Secundaire wondheling: granulatieweefsel → onrijpe vaten → granulair rood weefsel en
gemakkelijk bloeden
4. Basale keratinocyten uit wondranden migreren naar wondbed → re-epithelialisatie → herstel
integriteit van huid → vochtbalans in evenwicht
o Voorkomen eiwitverlies
o Herstellen thermoregulatie en weerstand tegen bacteriën
o Groeifactoren + mediatoren
5. Fibroblasten produceren collageen (collageensynthese) → bepaalt sterkte van weefsel (huid, bot,
pees) en genezende wonde + verdere contractie wondranden
o Deels intracellulair, deels extracellulair
o Collageenfibrillen vervangen fibrine + fibronectine + proteoglycanen van voorlopige matrix
o 2-3 weken na verwonding
6. Fibroblasten produceren matrixmetalloproteïnasen → matrixcomponenten afbreken
7. Fibroblasten omzetten in myofibroblasten → vermogen om te contraheren
o Brandwonden: onvoldoende huid aanwezig om door contractie de huid te sluiten →
°littekendeformiteit → °contractuur
REMODELLERINGSFASE
- 28 dagen tot 1 jaar na trauma
- Remodellering van collageen: balans tussen opbouw en afbraak
- Duur is afhankelijk van type weefsel (pees langzaam genezen, huid snel genezen) → inzage dynamiek
treksterkte wonde kan voorspellen hoelang hechtingen moeten blijven zitten
o Elleboog: meer beweging → meer spanning → langer hechtingen zitten
10
Hoofdstuk 1: inleiding .....................................................................................................................................................8
Definities en basisbegrippen traumatologie .............................................................................................................8
Indeling fracturen van lange pijpbeenderen.........................................................................................................8
Hoofdstuk 2: wondheling................................................................................................................................................9
Inleiding .......................................................................................................................................................................9
Fasen van de wondheling ...........................................................................................................................................9
Hemostasefase ........................................................................................................................................................9
Inflammatiefase ......................................................................................................................................................9
Proliferatiefase ..................................................................................................................................................... 10
Remodelleringsfase.............................................................................................................................................. 10
Vertraagde wondheling ........................................................................................................................................... 11
Hoofdstuk 3: fractuurheling ........................................................................................................................................ 12
Inleiding .................................................................................................................................................................... 12
Biologie ..................................................................................................................................................................... 12
Inflammatie .......................................................................................................................................................... 13
Vorming zachte callus .......................................................................................................................................... 13
Vorming harde callus ........................................................................................................................................... 13
Remodellering ...................................................................................................................................................... 13
Belang van bloedvoorziening .................................................................................................................................. 14
Biomechanica en fractuurheling ............................................................................................................................. 14
Niet-operatieve behandeling van fracturen....................................................................................................... 14
Operatieve behandeling van fracturen .............................................................................................................. 14
Methoden van fractuurfixatie................................................................................................................................. 15
Interne fixatie ....................................................................................................................................................... 15
Externe fixatie ...................................................................................................................................................... 16
Basisprincipes van operatieve fractuurbehandeling ............................................................................................. 16
Gewrichtsfracturen .............................................................................................................................................. 16
Schaftfracturen..................................................................................................................................................... 16
Metafysaire fracturen.......................................................................................................................................... 16
Intracapsulaire kop-halsfracturen....................................................................................................................... 16
Avulsiefracturen (tubercula, epicondylen)......................................................................................................... 17
Hoofdstuk 4: polytrauma en de basisprincipes van opvang van de traumapatiënt................................................ 18
Inleiding .................................................................................................................................................................... 18
Opvang...................................................................................................................................................................... 18
Behandeling.............................................................................................................................................................. 18
1
,Hoofdstuk 5: letsels van het bewegingsstelsel: open fracturen ............................................................................... 20
Inleiding .................................................................................................................................................................... 20
Classificatie ............................................................................................................................................................... 20
Behandeling.............................................................................................................................................................. 20
Systemische antibioticaprofylaxe ....................................................................................................................... 20
Fractuurstabilisatie .............................................................................................................................................. 20
Lokale antibiotica ................................................................................................................................................. 20
Wekedelenbedekking .......................................................................................................................................... 20
Hoofdstuk 6: letsels van het bewegingsstelsel: bovenste lidmaat ........................................................................... 21
Claviculafracturen .................................................................................................................................................... 21
Inleiding ................................................................................................................................................................ 21
Diagnose ............................................................................................................................................................... 21
Classificatie ........................................................................................................................................................... 21
Behandeling.......................................................................................................................................................... 21
Nabehandeling ..................................................................................................................................................... 22
Scapulafracturen ...................................................................................................................................................... 22
Inleiding ................................................................................................................................................................ 22
Diagnose ............................................................................................................................................................... 22
Classificatie ........................................................................................................................................................... 23
Behandeling.......................................................................................................................................................... 23
Nabehandeling ..................................................................................................................................................... 23
Proximale humerusfracturen .................................................................................................................................. 24
Inleiding ................................................................................................................................................................ 24
Diagnose ............................................................................................................................................................... 24
Classificatie ........................................................................................................................................................... 24
Behandeling.......................................................................................................................................................... 24
Nabehandeling ..................................................................................................................................................... 25
Humerusschaftfracturen ......................................................................................................................................... 26
Inleiding ................................................................................................................................................................ 26
Diagnose ............................................................................................................................................................... 26
Behandeling.......................................................................................................................................................... 26
Nabehandeling ..................................................................................................................................................... 27
Distale humerusfracturen........................................................................................................................................ 27
Inleiding ................................................................................................................................................................ 27
Diagnose ............................................................................................................................................................... 27
Behandeling.......................................................................................................................................................... 27
Nabehandeling ..................................................................................................................................................... 28
2
, Olecranonfracturen.................................................................................................................................................. 28
Inleiding ................................................................................................................................................................ 28
Diagnose ............................................................................................................................................................... 28
Behandeling.......................................................................................................................................................... 28
Nabehandeling ..................................................................................................................................................... 29
Radiuskopfracturen.................................................................................................................................................. 29
Inleiding ................................................................................................................................................................ 29
Diagnose ............................................................................................................................................................... 29
Behandeling.......................................................................................................................................................... 29
Nabehandeling ..................................................................................................................................................... 30
Distale bicepspeesruptuur....................................................................................................................................... 30
Inleiding ................................................................................................................................................................ 30
Diagnose ............................................................................................................................................................... 30
Behandeling.......................................................................................................................................................... 30
Nabehandeling ..................................................................................................................................................... 30
Fracturen van de radius- en/of ulnaschaft............................................................................................................. 31
Inleiding ................................................................................................................................................................ 31
Diagnose ............................................................................................................................................................... 31
Behandeling.......................................................................................................................................................... 31
Nabehandeling ..................................................................................................................................................... 31
Distale radiusfracturen ............................................................................................................................................ 32
Inleiding ................................................................................................................................................................ 32
Diagnose ............................................................................................................................................................... 32
Behandeling.......................................................................................................................................................... 32
Nabehandeling ..................................................................................................................................................... 32
Hoofdstuk 7: letsels van het bewegingsstelsel: bekkenfracturen ............................................................................ 33
Fracturen van de bekkenring .................................................................................................................................. 33
Inleiding ................................................................................................................................................................ 33
Diagnose ............................................................................................................................................................... 33
Behandeling.......................................................................................................................................................... 33
Fracturen van het acetabulum ................................................................................................................................ 33
Inleiding ................................................................................................................................................................ 33
Diagnose ............................................................................................................................................................... 33
Behandeling.......................................................................................................................................................... 34
Nabehandeling ..................................................................................................................................................... 34
Hoofdstuk 8: letsels van het bewegingsstelsel: onderste lidmaat ........................................................................... 35
Heupfracturen .......................................................................................................................................................... 35
3
, Inleiding ................................................................................................................................................................ 35
Diagnose ............................................................................................................................................................... 35
Classificatie ........................................................................................................................................................... 35
Behandeling.......................................................................................................................................................... 36
Nabehandeling ..................................................................................................................................................... 37
Femurschaftfracturen.............................................................................................................................................. 37
Inleiding ................................................................................................................................................................ 37
Diagnose ............................................................................................................................................................... 37
Behandeling.......................................................................................................................................................... 37
Nabehandeling ..................................................................................................................................................... 38
Distale femurfracturen ............................................................................................................................................ 38
Inleiding ................................................................................................................................................................ 38
Diagnose ............................................................................................................................................................... 38
Behandeling.......................................................................................................................................................... 38
Nabehandeling ..................................................................................................................................................... 38
Quadricepspeesruptuur........................................................................................................................................... 39
Inleiding ................................................................................................................................................................ 39
Diagnose ............................................................................................................................................................... 39
Behandeling.......................................................................................................................................................... 39
Nabehandeling ..................................................................................................................................................... 39
Patellafracturen........................................................................................................................................................ 39
Inleiding ................................................................................................................................................................ 39
Diagnose ............................................................................................................................................................... 40
Behandeling.......................................................................................................................................................... 40
Nabehandeling ..................................................................................................................................................... 40
Patellapeesruptuur .................................................................................................................................................. 40
Inleiding ................................................................................................................................................................ 40
Diagnose ............................................................................................................................................................... 40
Behandeling.......................................................................................................................................................... 41
Nabehandeling ..................................................................................................................................................... 41
Proximale tibiafracturen.......................................................................................................................................... 41
Inleiding ................................................................................................................................................................ 41
Diagnose ............................................................................................................................................................... 41
Behandeling.......................................................................................................................................................... 41
Nabehandeling ..................................................................................................................................................... 42
Tibiaschaftfracturen................................................................................................................................................. 42
Inleiding ................................................................................................................................................................ 42
4
, Diagnose ............................................................................................................................................................... 42
Behandeling.......................................................................................................................................................... 42
Nabehandeling ..................................................................................................................................................... 43
Distale tibiafracturen ............................................................................................................................................... 43
Inleiding ................................................................................................................................................................ 43
Diagnose ............................................................................................................................................................... 43
Behandeling.......................................................................................................................................................... 43
Nabehandeling ..................................................................................................................................................... 43
Enkelfracturen.......................................................................................................................................................... 44
Inleiding ................................................................................................................................................................ 44
Anatomie en classificatie..................................................................................................................................... 44
Diagnose ............................................................................................................................................................... 44
Behandeling.......................................................................................................................................................... 44
Nabehandeling ..................................................................................................................................................... 45
Ruptuur van de syndesmosis tibiofibularis ............................................................................................................ 45
Inleiding ................................................................................................................................................................ 45
Diagnose ............................................................................................................................................................... 45
Behandeling.......................................................................................................................................................... 45
Nabehandeling ..................................................................................................................................................... 46
Achillespeesruptuur................................................................................................................................................. 46
Inleiding ................................................................................................................................................................ 46
Diagnose ............................................................................................................................................................... 46
Behandeling.......................................................................................................................................................... 46
Nabehandeling ..................................................................................................................................................... 46
Fracturen van de talus ............................................................................................................................................. 47
Inleiding ................................................................................................................................................................ 47
Diagnose ............................................................................................................................................................... 47
Behandeling.......................................................................................................................................................... 47
Nabehandeling ..................................................................................................................................................... 47
Fracturen van de calcaneus ..................................................................................................................................... 47
Inleiding ................................................................................................................................................................ 47
Diagnose ............................................................................................................................................................... 47
Behandeling.......................................................................................................................................................... 48
Nabehandeling ..................................................................................................................................................... 48
Fracturen van de metatarsalen............................................................................................................................... 48
Inleiding ................................................................................................................................................................ 48
Diagnose ............................................................................................................................................................... 48
5
, Behandeling.......................................................................................................................................................... 49
Nabehandeling ..................................................................................................................................................... 49
Hoofdstuk 9: letsels van het bewegingsstelsel: fracturen van het groeiende skelet (kinderen)............................ 50
Inleiding .................................................................................................................................................................... 50
Classificatie ............................................................................................................................................................... 50
Diagnose ................................................................................................................................................................... 50
Behandeling.............................................................................................................................................................. 51
Nabehandeling ......................................................................................................................................................... 51
Hoofdstuk 10: letsels van het bewegingsstelsel: fracturen van het osteoporotische skelet.................................. 52
Inleiding .................................................................................................................................................................... 52
Diagose...................................................................................................................................................................... 52
Behandeling.............................................................................................................................................................. 52
Nabehandeling ......................................................................................................................................................... 53
Hoofdstuk 11: Letsels van het bewegingsstelsel: posttraumatische complicaties.................................................. 54
Non-union (gestoorde fractuurheling) ................................................................................................................... 54
Inleiding ................................................................................................................................................................ 54
Etiologie ................................................................................................................................................................ 54
Classificatie ........................................................................................................................................................... 54
Diagnose ............................................................................................................................................................... 55
Behandeling.......................................................................................................................................................... 55
Malunion................................................................................................................................................................... 55
Inleiding ................................................................................................................................................................ 55
Classificatie ........................................................................................................................................................... 56
Diagnose ............................................................................................................................................................... 56
Behandeling.......................................................................................................................................................... 56
Fractuurgerelateerde infectie ................................................................................................................................. 56
Inleiding ................................................................................................................................................................ 56
Pathogenese ......................................................................................................................................................... 57
Diagnose ............................................................................................................................................................... 57
Behandeling.......................................................................................................................................................... 57
Compartimentsyndroom ......................................................................................................................................... 58
Inleiding ................................................................................................................................................................ 58
Etiologie ................................................................................................................................................................ 59
Classificatie ........................................................................................................................................................... 59
Diagnose ............................................................................................................................................................... 59
Behandeling.......................................................................................................................................................... 60
Hoofdstuk 12: thoraxtrauma....................................................................................................................................... 61
6
,Inleiding .................................................................................................................................................................... 61
Behandeling.......................................................................................................................................................... 61
ABCDE ................................................................................................................................................................... 61
Acuut levensbedreigend letsel ................................................................................................................................ 62
Tracheobronchiale letsels.................................................................................................................................... 62
(spannings)pneumothorax .................................................................................................................................. 62
Open pneumothorax............................................................................................................................................ 62
Traumatische hemothorax .................................................................................................................................. 62
Harttamponnade.................................................................................................................................................. 63
Potentieel levensbedreigend letsel ........................................................................................................................ 63
Ribfracturen, sternumfractuur en fladderthorax .............................................................................................. 63
Longcontusie ........................................................................................................................................................ 63
Traumatische aortaruptuur................................................................................................................................. 64
7
, MENSELIJK BEWEGINGSSTELSEL:
TRAUMATOLOGIE
HOOFDSTUK 1: INLEIDING
DEFINITIES EN BASISBEGRIPPEN TRAUMATOLOGIE
Wonde = verstoring van continuïteit van weefsel, door externe factoren veroorzaakt, waarbij al of niet weefsel
is verloren gegaan
Contusie = letsel van het (onderhuidse) weefsel door inwerking van stomp geweld. Er ontstaat een
bloeduitstorting en een ontstekingsreactie die de heling op gang brengt
- ‘kneuzing’
- Weke delen
Distorsie = uitrekken van ligamenten en kapsel van een gewricht door een beweging die groter is dan de
normale beweeglijkheid van dat gewricht. Door het uitrekken ontstaan er scheuren die gaan van
microscheuren (= uitwendige structuur van de ligamenten blijft bewaard, maar er scheuren inwendig een
aantal vezels) tot volledig scheuren van de gewrichtsband
- ‘verstuiking’
- Gewricht
Luxatie = ernstige distorsie, waarbij het gewricht niet meer in een normale anatomische verhouding staat
- ‘ontwrichting’
- Gewricht
Spierscheur = onderbreking in continuïteit van spier
Peesscheur = onderbreking in continuïteit van pees
- In de pees of thv enthese (plaats waar pees aan bot vastzit)
Fractuur = onderbreking in de continuïteit van bot
Fractuurluxatie = combinatie van luxatie en fractuur die uitloopt in het gewricht
INDELING FRACTUREN VAN LANGE PIJPBEENDEREN
- Ad axim: hoekstand
o Antecurvatie: hoek naar voren
o Recurvatie: hoek naar achteren
o Valgus: hoek naar binnen (X-stand)
o Varus: hoek naar buiten (O-stand)
- Ad latum: zijdelingse verplaatsing
- Ad longitudinem: verkorting
- Ad periferiam: exo- of endorotatie
- Cum distractione: diastase
- Cum implantatione: instuiking (inclavatie)
8
,HOOFDSTUK 2: WONDHELING
INLEIDING
Wonde = verstoring van continuïteit van weefsel, door externe factoren veroorzaakt, waarbij al of niet weefsel
is verloren gegaan
Externe factoren
- Stomp of scherp geweld
- Inwerking van chemisch, thermisch, elektrisch, toxisch of radiatieagens
Genezing
- Primair: chirurgisch gesloten wonde
- Secundair: wond openlaten en door contractie en reëpithelialisatie uit zichzelf genezen
- ‘Tertiair’: uitgestelde primaire wondgenezing → wonde wordt gesloten na verzorging
FASEN VAN DE WONDHELING
Van 3 naar 4 fasen:
/ Hemostasefase
Inflammatoire fase Inflammatoire fase
Proliferatiefase Proliferatiefase
Remodelleringsfase Remodelleringsfase
HEMOSTASEFASE
- Seconden tot minuten na trauma
1. Lichaam reageert op bloedvatschade door vasoconstrictie en coagulatie → verder bloedverlies
vermijden + hypoxie → lichaamsweefsel onvoldoende zuurstof
2. Thrombocyten gaan samen klonteren → stollingsmechanisme → °hematoom → barrière tegen
bacteriën en verder bloedverlies
INFLAMMATIEFASE
- 0 tot 2 dagen na trauma
1. Bloeding stoppen → hypoxie → °vasodilatatie → °ontstekingsreactie → zwelling in wondgebied
2. Thrombocyten < modulatoren (cytokines, groeifactoren) → angiogenese en collageensynthese
3. Chemotaxis: thrombocyten trekken andere cellen aan door productie van cytokines
o Neutrofielen (leukocyten)
▪ Acute ontstekingsreactie
▪ Fagocyterende en bacteriedodende werking → voorkomen bacteriële contaminatie
en infectie
o Monocyten (leukocyten)
▪ Omzetten in macrofagen → fagocytose van debris en vernietigen van bacteriën
o Leukopenie: afwezigheid neutrofiele infiltratie en macrofagen → wonde zal genezen, maar
grotere kans op infectie
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, 4. Fibrine → °onrijpe matrix → wond overbruggen + spanning → wondranden bij elkaar komen
o Fibronectine en hyaluronzuur → overbrugging verstevigen
5. Groeifactoren
PROLIFERATIEFASE
Wondcontractie = proces waarbij de wond concentrisch kleiner wordt
- 3 tot 28 dagen na trauma
- Aanleiding:
o Complementsysteem
o Bacteriële eiwitten
o Aantrekken neutrofielen, monocyten, lymfocyten, plasmacellen en mastcellen
1. Migratie en proliferatie van cellen → weefselherstel
2. Chemotaxis: cytokines en groeifactoren trekken andere cellen aan naar wondgebied
o Vasculaire endotheelcellen
o Keratinocyten
o Fibroblasten
3. Angiogenese (neovascularisatie) → zuurstof en voedingsstoffen transporteren naar wondgebied
o Uitgroei capillaire vaten en deling van endotheelcellen in de voorlopige wondmatrix
o Primaire wondheling: geen granulatieweefsel
o Secundaire wondheling: granulatieweefsel → onrijpe vaten → granulair rood weefsel en
gemakkelijk bloeden
4. Basale keratinocyten uit wondranden migreren naar wondbed → re-epithelialisatie → herstel
integriteit van huid → vochtbalans in evenwicht
o Voorkomen eiwitverlies
o Herstellen thermoregulatie en weerstand tegen bacteriën
o Groeifactoren + mediatoren
5. Fibroblasten produceren collageen (collageensynthese) → bepaalt sterkte van weefsel (huid, bot,
pees) en genezende wonde + verdere contractie wondranden
o Deels intracellulair, deels extracellulair
o Collageenfibrillen vervangen fibrine + fibronectine + proteoglycanen van voorlopige matrix
o 2-3 weken na verwonding
6. Fibroblasten produceren matrixmetalloproteïnasen → matrixcomponenten afbreken
7. Fibroblasten omzetten in myofibroblasten → vermogen om te contraheren
o Brandwonden: onvoldoende huid aanwezig om door contractie de huid te sluiten →
°littekendeformiteit → °contractuur
REMODELLERINGSFASE
- 28 dagen tot 1 jaar na trauma
- Remodellering van collageen: balans tussen opbouw en afbraak
- Duur is afhankelijk van type weefsel (pees langzaam genezen, huid snel genezen) → inzage dynamiek
treksterkte wonde kan voorspellen hoelang hechtingen moeten blijven zitten
o Elleboog: meer beweging → meer spanning → langer hechtingen zitten
10
