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  • 1. Ð. Øàãäàðñ¿ðýí Æ. Îëçâîé Ñ. Îòãîíãýðýë Ñ. Áààòàðæàâ Óëààíáààòàð õîò, 2006 1
  • 2. Ð. Øàãäàðñ¿ðýí Æ. Îëçâîé Ñ. Îòãîíãýðýë Ñ. Áààòàðæàâ Ãýìòýë, ñîãîã ñóäëàëàëûí îð÷èí ¿åèéí ¿çýë áàðèìòëàë Õÿíàí òîõèîëäóóëäñàí Í.Áààñàíæàâ / Àêåäåìèê ïðîôåññîð / Óëààíáààòàð õîò 2006. 2
  • 3. ªìíºòãºë ¿ã Äýëõèéí õýìæýýíä õîòæèëò, òåõíèêæèëò, èðãýíøèëò èõñýõèéí õèðýýð îñîë ãýìòýëä ºðòºãñäèéí òîî, õ¿íä ãýìòëýýñ íàñ áàðàãñäûí òîî ÷ íýìýãäýæ áàéíà. Äýëõèé íèéòýä íýã æèëä 5 ñàÿ õ¿í îñîë ãýìòýë õ¿÷èðõèéëëèéí óëìààñ íàñ áàðæ áàéíà. Ìîíãîë îðíû õóâüä ÷ ñ¿¿ë÷èéí 15 æèëä ãýìòýãñäèéí òîî ýðñ íýìýãäýæ, îñîë ãýìòýë õ¿÷èðõèéëýëòýé õîëáîîòîé íàñ áàðàëò 3 – ð áàéðàíä îðîõ áîëîâ. ßëàíãóÿà çàì òýýâðèéí îñîë, õ¿í õîîðîíäûí õ¿÷èðõèéëýë çîíõèëîõ õóâèéã ýçëýæ áàéãàà þì. Èéìýýñ ÷ Ìîíãîë óëñûí çàñãèéí ãàçàð Îñîë ãýìòëýýñ ñýðãèéëýõ ¿íäýñíèé õºòºëáºð ãàðãàí 2003 îíîîñ õýðýãæ¿¿ëæ áàéãàà áèëýý. Õºòºëáºðèéí ¿íäñýí çîðèëòóóäûí íýã íü îñîë ãýìòýëä ºðòºãñäºä ¿ç¿¿ëýõ ýìíýëãèéí òóñëàìæèéí ÷àíàð õ¿ðòýýìæèéã ñàéæðóóëàõ ÿâäàë þì. Îñîë ãýìòýëä ºðòºãñäèéí äîòîð õàâñàðñàí õ¿íä ãýìòëèéí ýçëýõ õóâü íýìýãäñýíýýð íàñ áàðàëò, ¿¿ðäèéí òàõèð äóòóó áîëîõ õóâü ÷ èõýñ÷ áàéíà. Èéìä îñîë ãýìòëèéí ýðò ¿åä íü îëîí óëñûí àíãèëëûí äàãóó îíîøëîõ íü öààøäàà ýì÷èëãýýã îíîâ÷òîé õèéõ, ãàð÷ áîëîõ õ¿íäðýëýýñ ñýðãèéëýõýä ÷óõàë à÷ õîëáîãäîëòîé þì. Åð íü àíàãààõ óõààíä çºâ îíîøëîõ íü ýì÷èëãýýíèé 50%-òàé òýíöýíý ãýñýí îéëãîëò áàéäàã. 2000 îíîîñ ìàíàé ýìíýëãèéí îëîí óëñûí õàðèëöàà ºðãºæèæ ÀÍÓ, Øâåéä, Øâåéöàðè, ÁÍÕÀÓ áîëîí Ôðàíöûí ýì÷ íàðòàé õàìòðàí àæèëëàõ áîëñíîîð òóëãóóð áîëîí ìº÷äèéí ÿñíû ÀÎ àíãèëëûã ººðèéí îðíû íºõöºëä õýðýãæ¿¿ëæ áàéíà. ̺í ISS... AIS áîëîí PTS áóþó ýðõòýí ìº÷èéã ãýìòëèéí çýðãýýð íü àíãèëñàí îëîí óëñûí øàòàëáàðûã àâ÷ õýðýãæ¿¿ëæ ýõëýýä áàéíà. Ýäãýýð îëîí óëñûí àíãèëàë áîëîí øàòàëáàðûã áóñàä ýì÷ ýìíýëã¿¿äèéí õ¿ðýýíä óëàì ºðãºí àøèãëàõ øààðäëàãàòàéã õàðãàëçàí áèä Ìîíãîë, Îðîñ, Àíãëè õýëýýð ýìõýòãýí íýãýí ãàðûí àâëàãà áîëãîõ çîðèëò òàâüñàí þì. Îëîí óëñûí íýãäñýí àíãèëëûã õýðýãëýñíýýð áèäíèé öààøäûí ñóäàëãàà øèíæèëãýýíä àðãà ç¿éí ÷óõàë à÷ õîëáîãäîëòîé áîëîõ þì. Ñ¿¿ëèéí æèë¿¿äýä õºãæèíã¿é îðíóóäàä áè÷èë ìýñ çàñëûí àðãûã ºðãºí õýðýãëýñíýýð óðüä íü ýì÷èëãýýã¿éä òîîöîãääîã áàéñàí õ¿íä ãýìòýë, ñîãîãóóä, ò¿¿íèé ¿ëäýö¿¿äèéã àìæèëòòàé ýì÷èëäýã áîëëîî. Ìàíàé óëñûí ýì÷ ìýðãýæèëòýíã¿¿ä ãýìòýë ñîãîãèéí ºâ÷íèé îíîøëîãîî, ýì ÷èëãýýíä íýãýíò òîãòñîí îëîí óëñûí àíãèëëûí ñòàíäàðòûã ìºðäºõ, ãýìòýëèéí áè÷èë ìýñ çàñëûí ìýäëýãýý óëàì á¿ð òýëýõ øààðäëàãàä íèéö¿¿ëýí ãàðûí àâëàãûã òóóðâèñàí áèëýý. 3
  • 4. Ìàíàé ýìíýëãèéí ýì÷ íàð ÿëàíãóÿà äýýä ìº÷äèéí õ¿íä ãýìòëèéí ¿åä õèéãäýõ áè÷èë ìýñ çàñëûí àðãóóäûã ïðàêòèê ýì÷èëãýýíäýý íýâòð¿¿ëñýí ìýñ çàñëûí òóðøëàãàäàà ¿íäýñëýí ãàð ñàðâóóíû áè÷èë ìýñ çàñëûí àðãûã ýë íîìîíäîî îðóóëñíûã äóðäúÿ. ̺í õ¿¿õäýä òîõèîëäîõ, ÿñíû òºðºëõèéí ñîãîãóóäûí îëîí óëñûí îð÷èí ¿åèéí àíãèëëûã òîâ÷ òàéëáàðòàéãààð àíãëè õýëýýð îðóóëñàí áîëíî. Ýíý íü õîé÷ èðýýä¿éä ìàíàé àìüäðàëä õýðýãæèõ ¿íäýñòýé þì. Ýíýõ¿¿ ãàðûí àâëàãàòàé òàíèëöàí ÷èí ñýòãýëýýñýý çºâëºãºº ºã÷ òóñàëñàí À.Ó.Y.Õ¿ðýýëýíãèéí çàõèðàë Àêàäåìèê Í.Áààñàíæàâ, ÝÌØÓÈÑ-ûí óäàìç¿éí òýíõèìèéí ýðõëýã÷ ïðîôåññîð Ä.Ï¿ðýâäîðæ íàðò ã¿í òàëàðõàë èëýðõèéëüå. Ýë íîì íü ìàíàé îðíû õóâüä ÷ áèäíèé õóâüä ÷ îëîí óëñûí íýãäñýí àíãèëàë, äýýä ìº÷äèéí áè÷èë ìýñ çàñëààð àíõíû á¿òýýë ó÷ðààñ, àëäàà ìàäàã, çàñ÷ çàëðóóëàõ òàë äýýð ñàíàëàà õàðàìã¿é õàéðëàíà ãýäýãò ìýðãýæèë íýãò íºõºä人 èòãýíýì. Çîõèîã÷èä 4
  • 5. ת̪ÃÒ ßÑÍÓÓÄÛÍ ÕÓÃÀÐÀËÛÍ ÄÝËÃÝÐÝÍÃ¯É ÀÍÃÈËÀË (ÀÎ ÒÎÃÒÎËÖÎÎ) ׺ìºãò ÿñíóóäûí äýëãýðýíã¿é àíãèëàë Õóãàðëûí õ¿íä õºíãºíèéã òóñãàñàí áºãººä ò¿¿íèé ýì÷èëãýý, öààøäûí ¿ð ä¿íã ¿íýëýõ¿éö çºâõºí òèéì àíãèëàë ë àøèãòàé… Ìþëëåð Àíãèëëûí çàð÷èì Ýíý àíãèëëûí ãîë çîðèëãî íü ìº÷íèé ñåãìåíò á¿ðèéí õóãàðëûã ¿íäñýí 3 òºðºë, òºðºë á¿ðèéã 3 á¿ëýã, á¿ëýã á¿ðèéã 3 äýä á¿ëýã áîëãîí, õóãàðëûí á¿òöèéí õ¿íä õºíãºí, òýäãýýðèéí ýì÷èëãýý, öààøäûí òàâèëàí çýðãèéã õàðãàëçàí õóâààæ, ýìõëýæ öýãöýëñýíä îðøèíî. -ßìàð õýëáýð?, -ßìàð á¿ëýã?, -ßìàð äýä á¿ëýã? ãýñýí 3 àñóóëòààð õóãàðàë á¿ðò òîõèðñîí õàðèóëò àâàõ íü ýíý àíãèëëûí ãîë ò¿ëõ¿¿ð íü þì. Àíãèëëûí ñõåì Ãóðâàí õýëáýðèéã À, Â, Ñ ãýíý. Õýëáýð á¿ð 3 á¿ëýãò õóâààãäàíà. À1, À2, À3, Â1, Â2, Â3, Ñ1, Ñ2, Ñ3 èíãýæ 9 á¿ëýã áîëíî. Öààø á¿ëýã á¿ð 3 äýä á¿ëýãò õóâààãäàõûã 1, 2, 3 ãýâýë á¿ãä 27 äýä á¿ëýã áîëíî. Äýä á¿ëýã á¿ð, á¿ëýã äîòîðõ 3 ÿíçûí õóãàðëûã çààíà. Íîãîîí, ÿãààí, óëààí ºíãºí¿¿ä õóãàðàë õ¿íäýð÷ áóéã õàðóóëíà. À1-òàâèëàí ñàéòàé ýíãèéí õóãàðëûã çààæ áàéõàä, Ñ3-òàâèëàí ìóóòàé èë¿¿ õ¿íä õóãàðëûã çààæ áàéõ æèøýýòýé. Èíãýñíýýð íýã òîî íü õóãàðëûí àíãèëëûã, íºãºº íü õ¿íä õºíãºíèéã çààæ, õàìãèéí ñàéí ýì÷èëãýýíèé àðãûã ñîíãîõîä äºõºì ¿ç¿¿ëýõ áîëíî. Çóðàã 1, 2 5
  • 6. Çóðàã 1. 6
  • 7. Çóðàã 2 7
  • 8. Òàéëáàð Á¿õ õóãàðàë íü æèðèéí áîëîí îëîí ñýëòðýëòýé áàéæ áîëíî. Æèðèéí: Äèàôèç, ìåòàôèçèéí æèðèéí õóãàðàë, ¿åíèé ãàäàðãûí æèðèéí õóãàðàë áîëíî. Æèðèéí õóãàðàë íü (äèàôèç, ìåòàôèçèéí) ìóøãèðñàí, òàøóó áîëîí õºíäëºí ÷èãëýëòýé áàéäàã. Îëîí ñýëòðýëòýé: íýã áîëîí îëîí ñýëòýðõèé íü ¿íäñýí õóãàðëààñ á¿ðýí ñàëñàí áàéõ áºãººä äèàôèç ìåòàôèç õýñýãò âåäæå (V) áîëîí íèéëìýë õóãàðëóóä áàéäàã. V áîëîí íèéëìýë õóãàðàë íü çºâõºí äèàôèç, ìåòàôèçèéí õýñýãò áàéäàã. Âåäæå (V): Õóãàðëûí çàâñàðûí ñýëòýðõèéòýé áîëîâ÷ ýâë¿¿ëñíèé äàðàà õóãàðëûí ¿íäñýí ¿ç¿¿ð¿¿ä íü ÿìàð íýã õýìæýýãýýð õ¿ðýëöýæ áàéäàã (êîíòàêò); Ìóøãèðñàí áîëîí òàõèéñàí âåäæå ñýëòýðõèé íü á¿òýí ýñâýë õóâààãäñàí áàéæ áîëíî. Íèéëìýë (Êîìïëåêñ): Ýíý õóãàðëûí ¿åä õóãàðëûí çàâñàðûí íýã áà îëîí ñýëòýðýëòýé áºãººä ýâë¿¿ëñíèé äàðàà õóãàðëûí ¿íäñýí ¿ç¿¿ð¿¿ä íü õ¿ðýëöýõã¿é áàéäàã. Íèéëìýë õóãàðàë íü ìóøãèðñàí, õî¸ðëîñîí, ýñâýë õýâèéí áóñ (àíãèëàõ áîëîìæã¿é) ãýæ õóâààãäàíà. Øèãäñýí õóãàðàë: Ýïè-ìåòàôèçèéí áèå áèåíäýý øèãäñýí, æèðèéí òîãòâîðòîé õóãàðëóóä þì. Ñåãìåíòèéí äýýä äîîä òºãñãºëèéí ºâºðìºö íýð òîìú¸î Ýë õýñýãò õóãàðëóóä íýã áîë ¿åíèé ãàäóóð, ýñâýë áàéäàëòàé áàéäàã. ¯åèéí ãàäóóðõ õóãàðëóóä: Ýë õóãàðëóóä ¿åíèé õîëáîîã¿é áàéäàã àâ÷ çàðèìäàà ¿åíèé êàïñóë äîòîð áàéäàã. ýïèôèç õýñãèéí õóãàðëóóä áàãòàíà. ¯åí äîòîðõ õóãàðëûí ¿åä ¿åíèé ãàäàðãóó ãýìòýõ áºãººä á¿òýí ãýæ õóâààãäàíà. ¿åí äîòóóðõ ãàäàðãóóòàé Ýíä àïîôèç, äîòðîî õàãàñ 8
  • 9. ¯åí äîòîðõ õàãàñ õóãàðëóóä: Ýë õóãàðëóóä íü ¿åíèé ãàäàðãûí çºâõºí íýã õýñãèéã õàìðàõ áºãººä ¿åíèé ¿íäñýí õýñýã íü äèàôèç ÿñòàé õîëáîîòîé áàéíà. ¯åíèé õàãàñ õóãàðëûí õýëáýð¿¿ä -Ǻâõºí öóóðàõ: ¯åíèé ãàäàðãóó äàãóó äàðàõ õ¿÷íèé ¿éë÷ëýëä óðòààø öóóðàõ. Äàðàëò íü ¿åíèé ãîëä áîëîí çàõààð ¿éë÷ëýíý. -Ǻâõºí øàõàãäàõ: ¯åíèé ãàäàðãóóä äàðàãäàæ õóãàðàõ áîëîâ÷ öóóðàëòã¿é áàéíà. Øàõàãäàõ íü òºâ人 ýñâýë çàõààð áàéðëàæ áîëíî. -Øàõàãäàæ, öóóðñàí õóãàðàë: ¯åíèé ãàäàðãóó øàõàãäàæ öààø öóóð÷ õóãàðñíààñ ñýëòðýë íü ñàëñàí áàéäàã. -Îëîí ñýëòðýëòýé øàõàãäàëò: ¯åíèé ãàäàðãûí íýã õýñýã øàõàãäàí, íýãýýñ äýýø ñýëòðýë ¿¿ñ÷ öóóðñíààñ çºð¿¿ ¿¿ñãýäýã. -¯åíèé äîòóóðõ á¿òýí õóãàðàëò ¯åíèé ãàäàðãóó òàñàð÷, äèàôèç õýñãýýñ á¿ðýí ñàëàõ. Ýë õóãàðëûí õ¿íä õºíãºí íü ¿åíèé áîëîí ìåòàôèçèéí õóãàðëóóä (æèðèéí áîëîí îëîí ñýëòýðõèéòýé)-ààñ øàëòãààëíà. Îíîø Þó ? Õààíà? ßñ 1234 Ñåãìåíò 1234 Õýëáýð ÀÂÑ Á¿ëýã 123 Äýä á¿ëýã .1 .2 .3 11 –Àòãààë ÷ºìºãíèé äýýä òºãñãºëèéí õóãàðàë À1. ¯åíèé ãàäóóðõ òºâãºðèéí íýã ñýëòðýëòýé 1. Èõ òºâãºðèéí çºð¿¿ã¿é 2. Èõ òºâãºðèéí çºðñºí 3. ¯åíèé ìóëòðàëòàé À2. ¯åíèé ãàäóóðõ, ìåòàôèçèéí íýã õýñãèéí øèãäñýí õóãàðàë 1. Ôðîíòàë çºð¿¿ã¿é 2. Valus çºð¿¿òýé 3. Valgus çºð¿¿òýé À3. ¯åíèé ãàäóóðõ, ìåòàôèçèéí íýã õýñãèéí øèãäýýã¿é õóãàðàë 1. ªíöºãëºñºí æèðèéí 2. Õºíäëºí 3. Îëîí ñýëòðýëòýé 9
  • 10. Â1. ¯åíèé õàãàñ ãàäíà áîñîî øèãäñýí õóãàðàë 1. Õàæóóãèéí+èõ òºâãºð 2. Äîòîð+áàãà òºâãºð 3. Àðûí+èõ òºâãºð Â2. ¯åíèé ãàäóóðõ, ìåòàôèçèéí õî¸ð õýñãèéí øèãäýýã¿é õóãàðàë 1. Ýïèôèçèéí õýñýã íü ýðãýëòèéí çºð¿¿ã¿é 2. Ýïèôèçèéí õýñýã íü ýðãýæ çºðñºí 3. Ìåòàôèçèéí îëîí ñýëòðýëò àëü íýã òºâãºðèéí Â3. ¯åíèé ãàäóóðõ õî¸ð õýñýãò õóãàðàë, ¿åíèé ìóëòðàë 1. Õ¿ç¿¿íèé áîñîî õóãàðàë+èõ òºâãºð á¿òýí+ óðàãø ýñâýë äîòîãø ìóëòàðñàí 2. Õ¿ç¿¿íèé áîñîî õóãàðàë+èõ òºâãºð õóãàðñàí+óðàãø, äîòîãø ìóëòàðñàí 3. Áàãà òºâãºð õóãàðñàí+àðàãø ìóëòàðñàí Ñ1. Áàãà øèã çºð¿¿òýé ¿åíèé õóãàðàë 1. Valgus çºð¿¿òýé òîëãîé òºâãºðèéí 2. Varis çºð¿¿òýé, òîëãîé òºâãºðèéí 3. Àíàòîìèéí õ¿ç¿¿ Ñ2. Ìýäýãäýõ¿éö çºð¿¿òýé ¿å äàéðñàí øèãäñýí õóãàðàë 1. Valgus çºð¿¿òýé òîëãîé òºâãºðèéí 2. Varis çºð¿¿òýé, òîëãîé òºâãºðèéí 3. Varis çºð¿¿òýé õ¿ç¿¿, òºâãºð äàéðñàí õóãàðàë Ñ3. ¯å äàéðñàí çºð¿¿òýé õóãàðàë, ìóëòðàëòàé 1. Àíàòîìèéí õ¿ç¿¿íèé 2. Àíàòîìèéí õ¿ç¿¿, òºâãºðèéí 3. Òîëãîé òºâãºðèéí ñýëòðýëòýé õóãàðàë 12 -Àòãààë ÷ºìºãíèé ãàíäàí õýñãèéí õóãàðàë À1. Æèðèéí ìóøãèðñàí õóãàðàë 1. Äýýä ãóðàâíû íýã 2. Äóíä ãóðàâíû íýã 3. Äîîä ãóðàâíû íýã À2. Æèðèéí òàøóó õóãàðàë (≥300) 1. Äýýä ãóðàâíû íýã 2. Äóíä ãóðàâíû íýã 3. Äîîä ãóðàâíû íýã À3. Æèðèéí õºíäëºí õóãàðàë (<300) 1. Äýýä ãóðàâíû íýã 2. Äóíä ãóðàâíû íýã 3. Äîîä ãóðàâíû íýã Â1. Ìóøãèðñàí âåäæå õóãàðàë 1. Äýýä ãóðàâíû íýã 2. Äóíä ãóðàâíû íýã 3. Äîîä ãóðàâíû íýã Â2. Òàõèéñàí âåäæå õóãàðàë 10
  • 11. 1. Äýýä ãóðàâíû íýã 2. Äóíä ãóðàâíû íýã 3. Äîîä ãóðàâíû íýã Â3. Õóâààãäñàí âåäæå õóãàðàë 1. Äýýä ãóðàâíû íýã 2. Äóíä ãóðàâíû íýã 3. Äîîä ãóðàâíû íýã Ñ1. Ìóøãèðñàí íèéëìýë õóãàðàë 1. Õóãàðàë çàâñàðûí 2 ñýëòðýëòýé 2. Õóãàðàë çàâñàðûí 3 ñýëòðýëòýé 3. Õóãàðàë çàâñàðûí 3-ààñ îëîí ñýëòðýëòýé Ñ2. Õýð÷èì á¿õèé íèéëìýë õóãàðàë 1. Õóãàðàë çàâñàðûí íýã õýð÷èìòýé 2. Õóãàðàë çàâñàðûí íýã õýð÷èì áîëîí íýìýëò âåäæå ñýëòðýëòýé 3. Õóãàðàë çàâñàðûí 2 ñýëòðýëòýé Ñ3. Õýâèéí áóñ íèéëìýë õóãàðàë 1. Õóãàðàë çàâñàðûí 2, 3 ñýëòðýëòýé 2. Äóíä çýðýã áÿöàðñàí (<4 ñì) 3. Èõ áÿöàðñàí (≥4 ñì) 13 –Àòãààë ÷ºìºãíèé äîîä òºãñãºëèéí õóãàðàë À1. Àïîôèç òàñàðñàí, ¿åíèé ãàäóóðõ õóãàðàë 1. Ãàäíà òºâãºð 2. Äîòîð òºâãºðèéí ¿åíä õàâ÷óóëàãäààã¿é 3. Äîòîð òºâãºðèéí ¿åíä õàâ÷óóëàãäñàí À2. ¯åíèé ãàäóóðõ ìåòàôèçèéí æèðèéí õóãàðàë 1. Äîòîãø, äîîøîî òàøóó 2. Ãàäàãø, äîîòîî òàøóó 3. Õºíäëºí À3. ¯åíèé ãàäóóðõ ìåòàôèçèéí îëîí ñýëòðýëòýé 1. Ǻð¿¿ã¿é âåäæå 2. Õóâààãäñàí âåäæå 3. Íèéëìýë Â1. ¯åí äîòîðõ õàãàñ, õàæóó áîñîî õóãàðàë 1. Òîëãîéò ¸ðâîí 2. Áëîê äàéðñàí æèðèéí 3. Áëîê äàéðñàí îëîí ñýëòýðõèéò Â2. ¯åíä õàãàñ îðñîí, äîòîð áîñîî õóãàðàë 1. Áëîêèéí äîòîð òàëûã äàéðñàí æèðèéí õóãàðàë 2. Áëîêèéí õîâèë äàéðñàí 3. Áëîê äàéðñàí îëîí ñýëòðýëòýé Â3. Íýã ÿñ ¿å ð¿¿ îðæ õóãàðñàí, íºãºº íü ¿åíèé ãàäíà 1. Áîãò ÷ºìºãíèé ¿åíä îðñîí ýíãèéí 2. Øóó ÿñ ¿å ð¿¿ îðñîí ýíãèéí 3. ¯å ð¿¿ îðñîí îëîí ñýëòðýëòýé 11
  • 12. Ñ1. ¯å á¿òýí õóãàð÷ ÿñíû ýíãèéí 1. Çàëàà ñýðòýí áîëîí øóóíû òîëãîé õóãàðàë 2. Øóóíû òîëãîé, òèòýì ñýðòýíãèéí õóãàðàë Ñ2. Õî¸ð ÿñíû ¿åíèé á¿òýí õóãàðàë, íýã íü ýíãèéí, íºãºº íü îëîí ñýëòðýëòýé 1. Çàëàà ñýðòýí îëîí ñýëòýð÷, øóóíû òîëãîé ýíãèéí 2. Çàëàà ñýðòýí ýíãèéí, øóóíû òîëãîé îëîí ñýëòðýëòýé 3. Òèòýì ñýðòýí ýíãèéí, øóóíû òîëãîé îëîí ñýëòðýëòýé Ñ3. Îëîí ñýëòðýëòýé ¿å äàéðñàí õóãàðàë 1. 2 ÿñíû òóñ á¿ð 3 ñýëòðýëòýé õóãàðàë 2. Áîãòü ÷ºìºã 3-ààñ äýýø ñýëòðýëòýé 3. Øóó ÿñíû 3-ààñ äýýø ñýëòðýëòýé 21 – Øóó, áîãòü ÷ºìºãíèé äýýä òºãñãºëèéí õóãàðàë À1. Øóó ÿñ õºíäºã人ã¿é, áîãòîñíû ¿åíèé ãàäóóðõ õóãàðàë 1. Çàëàà ÿñíààñ, ãóðâàí òîëãîéò áóë÷èíãèéí øºðìºñ òàñðàõ 2. Ìåòàôèçèéí ýíãèéí õóãàðàë 3. Ìåòàôèçèéí îëîí ñýëòðýëòýé À2. Áîãòîñ õºíäºã人ã¿é øóóíû ¿åíèé ãàäóóðõ õóãàðàë 1. Õî¸ð òîëãîéò áóë÷èíãèéí øºðìºñ ÿñòàéãàà òàñðàõ 2. Õ¿ç¿¿íèé æèðèéí 3. Õ¿ç¿¿íèé îëîí ñýëòðýëòýé À3. Õî¸ð ÿñ, ¿åíèé ãàäóóð õóãàðàë 1. Õî¸ð ÿñíû æèðèéí 2. Íýã ÿñíû æèðèéí õóãàðàë, íºãººãèéí ñýòðýëòýò õóãàðàëòàé õîñîëñîí 3. Õî¸ð ÿñíû îëîí ñýëòýðõèéò õóãàðàë Â1. Øóó õºíäºã人ã¿é, áîãòîãíû ¿åí äîòîðõ õóãàðàë 1. Íýã õýñãèéí 2. Õî¸ð õýñãèéí æèðèéí 3. Õî¸ðëîñîí ñýëòðýëòýé Â2. Áîãòîñ õºíäºã人ã¿é, øóóíû ¿åí äîòîðõ õóãàðàë 1. Æèðèéí 2. Îëîí ñýëòðýëòýé àòëàà øàõàãäààã¿é 3. Îëîí ñýëòðýëòýé, øàõàãäñàí õóãàðàë Â3. Íýã ÿñíû ¿åí äîòîðõ õóãàðàë, íºãºº ÿñíû ¿åíèé ãàäóóðõ õóãàðàëòàé õîñîëñîí 1. Áîãòîãíû ¿åí äîòîðõ æèðèéí 2. Øóóíû ¿åí äîòîðõ æèðèéí 3. ¯åí äîòîðõ îëîí ñýëòðýëòýé Ñ1. ßñíû ¿åí äîòîðõ 2 ÿñíû æèðèéí õóãàðàë 1. Çàëàà ÿñ, øóóíû òîëãîéòîé õàìò 2. Òèòýì ñýðòýí, øóóíû òîëãîéòîé Ñ2.Íýã íü æèðèéí íºãºº íü ñýëòðýëòýé, 2 ÿñíû ¿åí äîòîðõ õóãàðàë 1. Çàëàà ÿñ îëîí ñýëòðýëòýé, øóóíû òîëãîéí æèðèéí 2. Øóóíû òîëãîéí îëîí ñýëòðýëòýé õóãàðàë, çàëàà ÿñíû æèðèéí 3. Øóóíû òîëãîé áÿöàð÷, òèòýì ñýðòýíãèéí æèðèéí 12
  • 13. Ñ3. Õî¸ð ÿñíû ¿åí äîòîðõ îëîí ñýëòðýëòýò õóãàðàë 1. ßñ òóñ á¿ð ãóðâàí ñýëòðýëòýé 2. Áîãòîñ íü ãóðâààñ îëîí ñýëòðýõ 3. Øóó íü ãóðâààñ îëîí ñýëòðýõ 22 -Øóó, áîãòü ÷ºìºãíèé ãàíäàí õýñãèéí õóãàðàë À1. Øóó á¿òýí, áîãòîñíû æèðèéí õóãàðàë 1. Òàøóó 2. Õºíäëºí 3. Øóóíû òîëãîéí ìóëòðàëòàé (ìîíòåäæ) À2. Áîãòîñ á¿òýí, øóóíû æèðèéí õóãàðàë 1. Òàøóó 2. Õºíäëºí 3. Øóó áîãòîñíû äîîä òºãñãºëèéí ìóëòðàëòàé (ãàëåàöè) À3. Õî¸ð ÿñíû æèðèéí õóãàðàë 1. Øóóíû äýýä 1/3 2. Øóóíû äóíä 1/3 3. Øóóíû äîîä 1/3 Â1. Øóó á¿ðýí, áîãòîñíû âåäæå õóãàðàë 1. Ǻð¿¿ã¿é âåäæå 2. Õóâààãäñàí âåäæå 3. Øóóíû òîëãîé ìóëòàðñàí (ìîíòåäæà) Â2. Áîãòîñ á¿òýí, øóóíû ÿñíû âåäæå õóãàðàë 2. Âåäæå çºð¿¿ã¿é 3. Âåäæå íü õóâààãäñàí 4. Õî¸ð ÿñíû äîîä ¿å ìóëòàðñàí (ãàëåàöè) Â3. Íýã ÿñíû âåäæå õóãàðàë, íºãººãèéí æèðèéí áà âåäæå õóãàðàëòàé õîñîëñîí 2. Áîãòîñíû âåäæå, øóóíû æèðèéí õóãàðàëòàé 3. Øóóíû âåäæå, áîãòîñíû æèðèéí õóãàðàëòàé 4. Øóó, áîãòîñ õî¸óë âåäæå õóãàðñàí Ñ1. Áîãòîñíû íèéëìýë õóãàðàë 2. Øóóíû á¿òýí õî¸ðëîñîí 3. Øóó õóãàð÷, õî¸ðëîñîí 4. Õýâèéí áóñ Ñ2. Øóóíû íèéëìýë õóãàðàë 2. Áîãòîñ á¿òýí, õî¸ðëîñîí 3. Áîãòîñ õóãàð÷, õî¸ðëîñîí 4. Õýâèéí áóñ Ñ3. Õî¸ð ÿñíû íèéëìýë õóãàðàë 1. Õî¸ðëîñîí 2. Íýã ÿñíû õî¸ð õóãàðàë, íºãººãèéí õýâèéí áóñ õóãàðàë 3. Õýâèéí áóñ 13
  • 14. 23 –Øóó, áîãòü ÷ºìºãíèé äîîä òºãñãºëèéí õóãàðàë À1. Øóó á¿òýí, áîãòîñíû ¿åíèé ãàäóóðõ õóãàðàë 2. Ñòèëîèä ñýðòýí 3. Ìåòàôèçèéí æèðèéí 4. Ìåòàôèçèéí îëîí ñýëòðýëòýé À2. Øóóíû, ¿åíèé ãàäóóðõ æèðèéí áîëîí øèãäñýí õóãàðàë 2. Ǻð¿¿ã¿é 3. Àðàãø çºðñºí (êîëëåñ) 4. Àëãà ðóó çºðñºí (ñìèò) À3. Øóóíû ¿åíèé ãàäóóðõ îëîí ñýëòðýëòýé õóãàðàë 2. Áîãèíîñîæ, øèãäñýí õóãàðàë 3. Âåäæå õóãàðàë 4. Íèéëìýë õóãàðàë Â1. Øóóíû ¿åíèé õàãàñ, áîñîî õóãàðàë 2. Ãàäíàõ æèðèéí 3. Ãàäíàõ îëîí ñýëòðýëòýé 4. Äîòîð òàëûí Â2. Øóóíû àðüñíû èðìýã ñýëòðýëòýé, ¿åíèé õàãàñ õóãàðàë (Âàðòîí) 2. Æèðèéí 3. Ãàäíà áîñîî õóãàðàëòàé 4. Ñàðâóóíû àðûí ìóëòðàëòàé Â3. Øóóíû àëãàí òàëûí èðìýã ñýëòýð÷, ¿åíèé õàãàñ õóãàðàë (Áàðòîíû) 2. Æèæèã ñýëòðýëòýé, æèðèéí 3. Òîì ñýëòðýëòýé, æèðèéí 4. Îëîí ñýëòðýëòýé Ñ1. Øóóíû ¿åí äîòîðõ á¿òýí õóãàðàë, ¿åíèé æèðèéí õóãàðàë, ìåòàôèçèéí æèðèéí õóãàðàë 2. ¯åíäýõ àð, ºâðèéí ñýëòðýëòýé 3. ¯åíäýõ áîñîî õóãàðàëòàé 4. ¯åíèé ôðîíòàë õóãàðàëòàé Ñ2. Øóóíû ¿åí äîòîðõ á¿òýí õóãàðàë, ¿åíèé æèðèéí, ìåòàôèçèéí îëîí ñýëòðýëòýé 2. ¯å äàìæñàí áîñîî õóãàðàë 3. ¯å äàìæñàí áîñîî õóãàðàë 4. Ãàíäàí ÿñ ðóó òýëæ îðñîí Ñ3. Øóóíû ¿åí äîòîðõ îëîí ñýëòðýëòýé á¿òýí õóãàðàë 1. Ìåòàôèçèéí æèðèéí 2. Ìåòàôèçèéí îëîí ñýëòðýëòýé 3. Ãàíäàí õýñýã ð¿¿ òýëæ îðñîí 14
  • 15. 31 -Äóíä ÷ºìºãíèé äýýä òºãñãºëèéí õóãàðàë À1. Ýðã¿¿ëýã, äàéðñàí ¿å îð÷èìä õóãàðàë, ýðã¿¿ëýã äàéðñàí ýíãèéí õóãàðàë 1. Ýðã¿¿ëýã õîîðîíäûí øóãàìûí äàãóó 2. Èõ ýðã¿¿ëýã äîòîðõ õóãàðàë 3. Áàãà ýðã¿¿ëýã äîîãóóðõ õóãàðàë À2. Ýðã¿¿ëýã äàéðñàí õóãàðàë, îëîí ñýëòýðõèéòýé 1. Íýã ñýëòýðýëòýé õóãàðàë 2. Õýä õýäýí ñýëòýðýëòýé õóãàðàë 3. Áàãà ýðã¿¿ëýãýýñ äîîãóóð 1 ñì ¿ðãýëæèëñýí õóãàðàë À3. Ýðã¿¿ëýã õîîðîíäûí õóãàðàë 1. Ýíãèéí òàøóó 2. Ýíãèéí õºíäëºí 3. Îëîí ñýëòýðõèéòýé Â1. Õ¿ç¿¿ òîëãîé äîîãóóð ÿëèìã¿é çºðººòýé 1. Øèãäñýí õóãàðàë (≥150) èõ (Valgus) 2. Øèãäñýí õóãàðàë (>150) èõ (Valgus) 3. Øèãäýýã¿é Â2. Õ¿ç¿¿íèé õóãàðàë 1. Õ¿ç¿¿íèé ñóóðèàð 2. Õ¿ç¿¿íèé äóíäóóð (Adduction) 3. Õ¿ç¿¿í äóíäóóð òàñàðñàí õóãàðàë Â3. Õ¿ç¿¿íèé õóãàðàë, òîëãîé äîîãóóð, øèãäýýã¿é çºðººòýé 1. Ãàäíà ýðãýö barus ¿¿ññýí áàãà çýðýã çºðººòýé 2. Õºíäëºí õóãàð÷ ãàäàãø ýðãýñýí áàãà çýðýã çºðººòýé 3. Ìýäýãäýì çºðººòýé Ñ1. Òîëãîé õóãàðàë äàãóóäàà öóóðàõ 1. Teres õîëáîîñ òàñàðñàí 2. Òeres õîëáîîñ óðàãäñàí 3. Òîìîîõîí ñýëòýð÷ õóãàðàõ Ñ2. Òîëãîéí õóãàðàë (øàõàãäàõ) äàðàãäàõ 1. Àðûí áîëîí äýýä õýñýãò 2. Óðä áîëîí äýýä õýñýãò 3. Øàõàãäñàí õýñã¿¿ä õóâààãäàõ Ñ3. Òîëãîé, õ¿ç¿¿, õàìò õóãàðàõ 1. Õ¿ç¿¿ õºíäëºí õóãàð÷ õýäýí õýñýãò õóâààãäàõ 2. Õ¿ç¿¿, òîëãîé äîîãóóð õóãàð÷ õóâààãäàõ 3. Õ¿ç¿¿ øàõàãäàæ õóãàðàõ 15
  • 16. 32 –Äóíä ÷ºìºãíèé ãàíäàí õýñãèéí õóãàðàë À1. Ýíãèéí ìóøãèðñàí õóãàðàë 1. Ýðã¿¿ëýã¿¿ä äîîãóóð 2. Äóíä ò¿âøèí 3. Çàõûí ò¿âøèí À2. Ýíãèéí òàøóó (≥300) 1. Ýðã¿¿ëýã äîîãóóð 2. Äóíä ò¿âøèí 3. Äîîä ò¿âøèí À3. Ýíãèéí õºíäëºí (<300) 1. Ýðã¿¿ëýã äîîãóóð 2. Äóíä ò¿âøèí 3. Äîîä ò¿âøèí Â1. Øààíò õýëáýðòýé ñýëòðýëòýé òàõèéñàí õóãàðàë 1. Ýðã¿¿ëýã¿¿ä äîîãóóð 2. Äóíä ò¿âøèí 3. Çàõûí ò¿âøèí Â2. Øààíò õýëáýðèéí õóãàðàë òàõèéñàí (wedge) 1. Ýðã¿¿ëýã äîîãóóð 2. Äóíä ò¿âøèí 3. Äîîä ò¿âøèí Â3. Øààíò õýëáýðèéí ñýëòðýëò õóâààãäñàí õóãàðàë 1. Ýðã¿¿ëýã äîîãóóð 2. Äóíä ò¿âøèí 3. Äîîä ò¿âøèí Ñ1. Ìóøãèðñàí, òºâºãòýé íèéëìýë õóãàðàë 1. Õóãàðàëûí çàâñàð õî¸ð ñýëòýðõèéòýé 2. Õóãàðàëûí çàâñàð ãóðâàí ñýëòýðõèéòýé 3. Õóãàðàëûí çàâñàð ãóðâààñ èë¿¿ ñýëòýðõèéòýé Ñ2. Õýñýã÷ëýí õóâààãäñàí íèéëìýë, òºâºãòýé õóãàðàë 1. Íýã ñýëòýðõèéòýé 2. Íýã ñýëòýðõèé, øààíò õýëáýðèéí ñýëòýðõèéòýé õàì 3. 2 ñýëòýðõèéòýé õóãàðàë Ñ3. Áÿöàðñàí íèéëìýë, õýâèéí áèø õóãàðàë 1. Õî¸ð áóþó ãóðâààñ äýýø ñýëòýðõèéòýé 2. Áÿöðàë, ñýëòýðõèé (≤5 ñì) áàãà 3. Áÿöðàë, ñýëòýðõèé (≥5 ñì) èõ 33 –Äóíä ÷ºìºãíèé äîîä òºãñãºë õýñãèéí õóãàðàë À1. ¯ñíèé ãàäóóðõè ýíãèéí õóãàðàë 1. Àïîôèç òàñàðñàí 2. Ìåòàôèçèéí òàøóó, ìóøãèðñàí õóãàðàë 16
  • 17. 3. Ìåòàôèçèéí õºíäëºí õóãàðàë À2. ¯åíèé ãàäóóðõ ìåòàôèçèéí øààíò õýëáýðèéí õóãàðàë 1. Ǻðººã¿é 2. Ãàäíà òàëûí ñýëòýðýëòýé 3. Äîòîð òàëûí ñýëòýðýëòýé À3. ¯åíèé ãàäíà ìåòàôèçèéí íèéëìýë õóãàðàë 1. Ìåòàôèçèéí õóãàðàëûí çàâñàð òàñàðñàí õýð÷èìòýé 2. Ìåòàôèçèéí õÿçãààðëàãäìàë õýâèéí áèø õóãàðàë 3. Õýâèéí áèø äèàôèç ð¿¿ãýý îðñîí õóãàðàë Â1. ¯åíèé õàãàñ, ãàäíà áóëóóíû áîñîî õóãàðàë 1. Åðäèéí õóãàðàë 2. Åðäèéí õóãàðàëûí ãàäàðãóó äàéðñàí 3. Îëîí ñýëòýðõèéòýé Â2. ¯åíèé õýñýã÷èëñýí äîòîð áóëóóíû áîñîî õóãàðàë 1. Ýíãèéí õóãàðàë 2. Åðäèéí õóãàðàë ãàäàðãóó íü äàðàãäñàí 3. Îëîí ñýëòýðõèéòýé Â3. Õýñýã÷èëñýí ôðîíòàëü ¿åíèé äîòîðõè õóãàðàë 1. Óðä áà õàæóóãèéí çàõàëñàí 2. Íýã áóëóóíû àð õýñãèéí (hogfa) 3. 2 áóëóóíû àð òàë Ñ1. ¯å á¿õëýýðýý õóãàðñàí ¿åíèé ýíãèéí, ìåòàôèçûí ýíãèéí õóãàðàë 1. Ò áóþó ¯ õýëáýðèéí ÿëèõã¿é çºðººòýé 2. Ò áóþó ¯ õýëáýðèéí èõ çºðººòýé 3. Ò õýëáýðèéí ýïèôèç ð¿¿ãýý îðñîí Ñ2. ¯åíèé á¿òýí õóãàðàë, ¿åíèé ýíãèéí, ìåòàôèçûí ýíãèéí 1. Øèãäñýí øààíò õýëáýðèéí 2. Øèãäýýã¿é øààíò õýëáýðèéí 3. Íèéëìýë Ñ3. ¯åíèé á¿òýí õóãàðàë, îëîí ñýëòýðõèéòýé 1. Ìåòàôèçûí ýíãèéí 2. Ìåòàôèçûí 2-îîñ äýýø ñýëòýðõèé 3. Ìåòàôèç, äèàôèçûí îëîí ñýëòýðõèéòýé 41 –Øààíò, òàõèëçóóð ÿñíû äýýä òºãñãºëèéí õóãàðàë À1. ¯åíèé ãàäíà òàñàðñàí õóãàðàë 1. Òàõèëçóóð ÿñíû òîëãîé õóãàðàë 2. Øààíò ÷ºìºã òºâãºð 3. Õýðýýñò õýëáýð õîëáîîñíû ãýìòýëòýé À2. ¯åíèé ãàäíà ìåòàôèçèéí ýíãèéí 1. Ôðîíòàë õàâòãàéä òàøóó õóãàðàë 2. Ñàãèòàëü õàâòãàéä òàøóó õóãàðàë 3. Õºíäëºí õóãàðàë À3. ¯åíèé ãàäíà ìåòàôèç îëîí ñýëòýðõèéòýé õóãàðàë 1. Øèãäñýí øààíò õýëáýð 2. Øèãäýýã¿é øààíò õýëáýð 17
  • 18. 3. Íèéëìýë Â1. ¯å ð¿¿ãýý áàãà çýðýã îðñîí òàñàðñàí õóãàðàë 1. ¯åíèé ãàäíà ãàäàðãóó 2. ¯åíèé äîòîð ãàäàðãóó 3. Øààíò ÷ºìºãíèé íýã áóëóóíààñ áóëóó õîîðîíäûí åðâàí äàéðñàí õóãàðàë Â2. ¯å ð¿¿ãýý áàãà çýðýã îðñîí öýâýð äàðàãäñàí 1. Ãàäíà áóëóó õýñýã÷ëýë 2. Ãàäíà áóëóó á¿õýëäýý 3. Äîòîð áóëóó Â3. ¯åíèé ãàäàðãóó áàãà çýðýã îðîëöîæ òàñàð÷ øàõàãäàõ, áóëóó 1. Õàæóó (ãàäíà) 2. Äîòîð 3. Øààíò ÷ºìºãíèé íýã áóëóóíààñ, áóëóó õîîðîíäûí ¸ðâîíã äàéðñàí òàøóó õóãàðàë Ñ1. ¯å ð¿¿ãýý á¿ðýí îðñîí ¿åíèé ýíãèéí ìåòàôèçèéí ýíãèéí õóãàðàë 1. Áàãà çýðýã çºðººòýé 2. Íýã áóëóó çºðñºí 3. 2 áóëóó çºðñºí Ñ2. ¯åíèé á¿ðýí, ¿åíèé ýíãèéí ìåòàôèçèéí îëîí õóãàðàë 1. Øèãäñýí øààíò õýëáýð 2. Øèãäýýã¿é øààíò õýëáýð 3. Íèéëìýë Ñ3. ¯åíèé íèéëìýë õ¿íäýðñýí õóãàðàë, îëîí ñýëòýðõèéòýé 1. Ãàäíà õàæóó 2. Äîòîð õàæóó 3. Ãàäíà áà äîòîð 42 –Øààíò, òàõèëçóóð ÿñíû ãàíäàí õýñãèéí õóãàðàë À1. Ýíãèéí ìóøãèðñàí õóãàðàë 1. Òàõèëçóóð ÿñ øèãäñýí 2. Òàõèëçóóð ÿñ õóãàðàë ººð ò¿âøèíä õóãàðñàí 3. Òàõèëçóóð ÿñ èæèë ò¿âøèíä õóãàðñàí À2. Òàøóó ýíãèéí òàøóó (≥300) 1. Òàõèëçóóð ÿñ çºðººã¿é 2. Òàõèëçóóð ÿñ ººð ò¿âøèíä 3. Òàõèëçóóð ÿñ èæèë ò¿âøèíä À3. Ýíãèéí õºíäëºí õóãàðàë (<300) 1. Òàõèëçóóð ÿñ çºðººã¿é 2. Òàõèëçóóð ÿñ ººð ò¿âøèíä 3. Òàõèëçóóð ÿñ èæèë ò¿âøèíä Â1. Øààíò õýëáýðèéí ñýëòðýë, ìóøãèðñàí õóãàðàë 1. Òàõèëçóóð ÿñ çºðººã¿é õóãàðñàí 2. Òàõèëçóóð ÿñ ººð ò¿âøèíä õóãàðñàí 3. Òàõèëçóóð ÿñ èæèë ò¿âøèíä õóãàðñàí Â2. Øààíò õýëáýðèéí õóãàðàë, ºíöºãëºñºí 18
  • 19. 1. Òàõèëçóóð ÿñ çºðººã¿é õóãàðñàí 2. Òàõèëçóóð ÿñ ººð ò¿âøèíä õóãàðñàí 3. Òàõèëçóóð ÿñ èæèë ò¿âøèíä õóãàðñàí Â3. Øààíò õýëáýðèéí õóãàðàë, îëîí ñýëòðýëòýé 1. Òàõèëçóóð ÿñ çºðººã¿é õóãàðñàí 2. Òàõèëçóóð ÿñ ººð ò¿âøèíä õóãàðñàí 3. Òàõèëçóóð ÿñ èæèë ò¿âøèíä Ñ1. Ìóøãèðñàí îëîí ñýëòðýëò õóãàðàë 1. 2 ñýëòðýëòýé 2. 3 ñýëòðýëòýé 3. 3-ààñ äýýø ñýëòðýëòýé Ñ2. Õî¸ð÷èëñîí õóãàðàë 1. Íýã ñýëòðýëòýé 2. Íýã ñýëòðýëòýé øààíò õýëáýðèéí ñýëòðýëòýé õóãàðàë 3. 2 ñýëòðýëòýé õóãàðàë 2 ñýëòýðõèéòýé õóãàðàë Ñ3. Áÿöàðñàí íèéëìýë õóãàðàë 1. 2-3 ñýëòýðõèéòýé 2. Áÿöàðñàí õóãàðàë (<4 ñì) 3. Áÿöðàë èõòýé (≥4 ñì) 43 –Øààíò, òàõèëçóóð ÿñíû ãàíäàí õýñãèéí õóãàðàë À1. ¯åíèé ãàäíàõ áîëîí ìåòàôèçèéí ýíãèéí õóãàðàë 1. Ìóøãèðñàí 2. Òàøóó 3. Õºíäëºí À2. ¯åíèé ãàäíà ìåòàôèçèéí øààíò õýëáýð 1. Àð õàæóó îðîëöñîí 2. Óðä äîòîð òàëûí øààíò ìàÿãûí 3. Äèàôèç ð¿¿ãýý îðñîí À3. ¯åíèé ãàäíà ìåòàôèçèéí íèéëìýë õóãàðàë 1. 3 ñýëòýðõèéòýé 2. 3-ààñ äýýø ñýëòýðõèéòýé 3. Äèàôèç ð¿¿ãýý îðñîí Â1. ¯å ð¿¿ãýý áàãà çýðýã îðñîí òàñàðñàí õóãàðàë 1. Ôðîíòàëü õàâòãàéä 2. Ñàãèòàëü õàâòãàéä 3. Ìåòàôèçèéí îëîí ñýëòýðõèéòýé Â2. ¯å ð¿¿ãýý áàãà çýðýã îðñîí òàñàðñàí, äàðàãäñàí õóãàðàë 1. Ôðîíòàëü õàâòãàé 2. Ñàãèòàëü õàâòãàé 3. Òºâëºæ ñýëòýðñýí Â3. Áàãà çýðýã ¿å ð¿¿ãýý îðñîí, îëîí ñýëòðýëòýé äàðàãäñàí õóãàðàë 1. Ôðîíòàëü õàâòãàé 2. Ñàãèòàëü õàâòãàé 3. Òºâëºæ ñýëòýðñýí 19
  • 20. Ñ1. ¯åíèé á¿ðýí õóãàðàë 1. Òîãòâîðòîé 2. Òîãòâîðã¿é 3. Äèàôèç ð¿¿ãýý îðñîí Ñ2. ¯åíèé á¿ðýí, ýíãèéí ìåòàôèçèéí îëîí ñýëòðýëòýé 1. Àñèììåòðèí áàéäàëòàé äàðàãäñàí 2. Ñèììåòðèí áàéäàëòàé äàðàãäñàí 3. Äèàôèç ð¿¿ îðñîí Ñ3. ¯åíèé á¿ðýí õóãàðàë îëîí ñýëòýðõèéòýé 1. Ýïè-ôèçåîëèç 2. Ýïè-ìåòàôèç 3. Ýïè-ìåòà äèàôèç 44 –Øààíò, òàõèëçóóð ÿñíû øàãàéí õàâ÷ààðóóäûí õóãàðàë À1. Äàí ñèíòäåñìîçûí äîîãóóðõ ãýìòýë 1. Ãàäíà õàæóó õîëáîî òàñðàõ 2. Ãàäíà õàâ÷ààðûí îðîé òàñðàõ 3. Ãàäíû õàâ÷ààðûí õºíäëºí õóãàðàë À2. Äîòîð õàâ÷ààðûí õóãàðàëòàé õîñîëñîí, ñèíäåñìîçûí äîîãóóðõ ãýìòýë 1. Ãàäíà õàæóóãèéí õîëáîîñ òàñðàõ 2. Ãàäíà õàâ÷ààðûí îðîé òàñðàõ 3. Ãàäíàõ õàâ÷ààðûí õºíäëºí õóãàðàë À3. Àð, äîòîð òàëûí õóãàðàëòàé õîñîëñîí, ñèíäåñìîçûí äîîãóóðõ ãýìòýë 1. Ãàäíà õàæóóãèéí õîëáîîñ òàñðàõ 2. Ãàäíà õàâ÷ààðûí îðîé òàñðàõ 3. Ãàäíà õàâ÷ààðûí õºíäëºí õóãàðàë Â1. Ñèíäåñìîç äàéðñàí, òàõèëçóóð ÿñíû äàí õóãàðàë 1. Æèðèéí 2. ªâðèéí ñèíäåñìîçûí ãýìòýëòýé õîñîëñîí æèðèéí õóãàðàë 3. Îëîí ñýëòðýëòýé Â2. Äîòîð õàâ÷ààðûí ãýìòýëòýé õîñîëñîí, ñèíäåñìîç äàéðñàí òàõèëçóóðûí õóãàðàë 1. ªâðèéí ñèíäåñìîç, äîòîð õàæóó õîëáîîñíû òàñðàëòàé õîñîëñîí æèðèéí õóãàðàë 2. ªâðèéí ñèíäåñìîç, äîòîð õàâ÷ààðûí õóãàðàëòàé õîñîëñîí æèðèéí õóãàðàë 3. Îëîí ñýëòðýëòýé Â3. Äîòîð øàãàéí ãýìòýë áîëîí ôîëüêìàí (øààíòíû àð ãàäíà èðìýãèéí õóãàðàëòàé) õîñîëñîí, ñèíäåñìîç äàéðñàí òàõèëçóóðûí õóãàðàë 1. Äîòîð õàæóó õîëáîîñ òàñàð÷, òàõèëçóóðûí æèðèéí õóãàðàë 2. Äîòîð õàâ÷ààðûí õóãàðàë, òàõèëçóóðûí æèðèéí õóãàðàëòàé õîñîëñîí 3. Äîòîð õàâ÷ààðûí õóãàðàëòàé õîñîëñîí òàõèëçóóðûí îëîí ñýëòðýëòýé õóãàðàë Ñ1. Òàõèëçóóðûí äèàôèçèéí æèðèéí õóãàðàë, ñèíäåñìîçîîñ äýýã¿¿ðõ ãýìòýëòýé õîñîëñîí 1. Äîòîð õàæóó õîëáîîñ òàñðàõ 20
  • 21. 2. Äîòîð õàâ÷ààðûí õóãàðàëòàé 3. Äîòîð õàâ÷ààðûí õóãàðàëòàé õîñîëñîí Äþïþéòðåíû ãýìòýëòýé Ñ2. Òàõèëçóóðûí ñýëòðýëòýé õóãàðàë, ñèíäåñìîçûí äýýã¿¿ðõ ãýìòýëòýé õîñîëñîí 1. Äîòîð õàæóóãèéí õîëáîîñíû òàñðàë 2. Äîòîð õàâ÷ààðûí õóãàðàëòàé 3. Äîòîð õàâ÷ààðûí õóãàðàë, Äþïþéòðåíû ãýìòýëòýé õîñîëñîí Ñ3. Ñèíäåñìîçûí äýýã¿¿ðõ ãýìòýëòýé, òàõèëçóóðûí äýýã¿¿ðõ õóãàðàëòàé õîñîëñîí 1. Áîãèíîñîëòã¿é, Äþïþòðåíû ãýìòýëòýé õîñëîîã¿é 2. Áîãèíîññîí ìºðò뺺 Äþïþéòðåíòýé õîñëîîã¿é 3. Äîòîð õàâ÷ààðûí ãýìòýë áà Äþïþéòðåíòýé õîñëîîã¿é ÕÀÌ Õ¯ÍÄ ÃÝÌÒËÈÉÍ ÁÀÉÄËÛà ÁÎÄÈÒÎÉÃÎÎÐ ÒÎÄÎÐÕÎÉËÎÕ ØÀËÃÓÓÐ ¯ÍÝËÃÝÝ COMMON TRAUMA SCOZINIG SYSTEMS Õàì ãýìòëèéí õ¿íä áàéäëûã òîäîðõîéëîí ¿íýëýõ àñóóäàë íü áèäíèé àíõààðëûí òºâä áàéñààð ãýìòýãñäèéí áàéäëûã ýì÷èëãýýíèé ¿ð ä¿íòýé õàðüöóóëàõ íü çºâõºí ÿìàð íýã á¿õ íèéòýýð õ¿ëýýí çºâøººðºãäñºí ¿íýëãýýíèé òîãòîëöîîí äýýð õèéãäýæ áàéõ íü íîòëîãäñîí áàéíà. Áèä äýëõèéä ºðãºí ò¿ãýýìýë õýðýãëýãääýã ãýìòëèéí Abbreviated Injury Scale (AIS) àíãèëëûã çîõèñòîé ãýæ äàõèí àâ÷ ¿çñýí áàéíà. AIS íü ãýìòñýí ýðõòíèé àíàòîìèéí ººð÷ëºëòºíä ñóóðèëàãäñàí htt/wwwfrauma org/scores/ais (ntml). Ýíý òîãòîëöîîíû äàãóó á¿õ ãýìòëèéã 6 àíãèëàëä õóâààíà. Õàìãèéí õºíãºí (AIS1)-ýýñ õ¿íèé àìüòàé çîõèöîõã¿é (AIS6) õ¿ðòýë AIS ãýìòýë øèíæ áàéäàë õýìæ¿¿ðèéí òîâ÷îî AIS îíîî 1 2 3 4 5 6 Ãýìòëèéí øèíæ áàéäàë Áàãà Äóíä çýðýã Õ¿íäýâòýð Õ¿íä Òóéëûí õ¿íä Àìüäðàëä ¿ë íèéöýõ Îäîî 1990 îíîîñ (AIS-90) äàõèí øèíý÷ëýàãäýí ººð÷ëºãäñºí AIS-90 ñèñòåìèéã àøèãëàæ áàéíà. 21
  • 22. Äýýðõ òîãòîëöîîíä õýðýãëýñýí çàð÷ìûã ìºí (ÎIS) áóþó ýðõòíèé ãýìòëèéí àíãèëëûí òîãòîëöîîíä àøèãëàñàí ýíý òîãòîëöîîã ÀÍÓ-ûí ãýìòëèéí ìýñ çàñàë÷äûí õîëáîîíîîñ òîäîðõîé ýðõòýí áîëîí ãýìòëèéí áàéäëûã Îð÷èí ¿åä ýíýõ¿¿ òîãòîëöîîã Àìåðèêèéí ãýìòëèéí ìýñ çàñàë÷äûí õîëáîîíîîñ áîëîâñðóóëñàí ýðõòíèé ãýìòëèéí õýìæ¿¿ðò òóñãàñàí áàéíà. Iois organ injuriscate http / w.w.w traumorg / scores/ ois html Ýíý õýìæ¿¿ð íü ýðõòýí ñèñòåìèéí ãýìòëèéí áàéäëûã òîäîðõîéëæ ¿íýëýõ çîðèëãîòîé þì. OIS íü äàâóó òàë íü ãýìòñýí ýðõòíèé ãýìòëèéí áàéäëûã òîäîðõîéëæ ¿íýëýõ çîðèëãîòîé OIS äàâóó òàë íü ãýìòñýí ýðõòíèé ãýìòëèéã ìýñ çàñëûí ¿åä áîëîí ä¿ðñ áè÷ëýãèéí òóñëàìæòàéãààð îíîøëîõ, ¿íýëýõ áîëîìæòîé þì. Ýíý íü ñ¿¿ëèéí ¿åä ò¿ãýýìýë õýðýãëýõ áîëñîí õýâëèéí ãýìòýëä ìýñ çàñëûí áóñ ýì÷èëãýýã õèéõýä èõ à÷ õîëáîãäîëòîé áîëñîí AIS ñèñòåìèéí ¿íäñýí äýýð õ¿íä õàì ãýìòëèéí õýìæ¿¿ðèéí òîãòîëöîî (iss injury severty score) çîõèîñîí þì. Ýíý õýìæ¿¿ð íü õàì áîëîí îëîí ãýìòýëòýé ãýìòýãäñèéí àíàòîìèéí ººð÷ëºëòèéã á¿ðýí òîäîðõîéëæ áàéãàà þì. Ýíýõ¿¿ òîãòîëöîîíä íèéö¿¿ëýí ýõëýýä AIS õýìæ¿¿ðèéí ¿íýëýãäñýí ãýìòýë á¿ð áèåèéí 6-í õýñãèéí àëü íýãýíä õàìðàãäàíà. (òîëãîé, õ¿ç¿¿, í¿¿ð, öýýæ, õýâëèé, ìº÷, ààðöàãûã îðóóëààä, àðüñ 纺ëºí ýä) áèåèéí õàìãèéí èõ ãýìòëèéã AIS-ààð ¿íýëæ îíîîãîî òàâèíà. Ýíýõ¿¿ õýìæ¿¿ðýýð ¿íýëñýí ãýìòëèéí îíîî íü áèåèéí õàìãèéí èõ ãýìòñýí õýñãèéí AIS-ààð ¿íýëñýí îíîîíû êâàäðàòûí íèéëáýð áàéõ áîëíî. Õ¿ñíýãò 2 Õàì õ¿íä ãýìòëèéí (iss) ¿íýëãýýíèé òîîöîîíû æèøýý (http/www trauma org scores.iss.htm) Áèåèéí õýñýã Òîëãîé õ¿ç¿¿ Í¿¿ð Öýýæ Õýâëèé ¯å ìº÷ Àðüñ 纺ëºí ýä Ãýìòëèéí áàéäàë Òàðõè äîðãèõ Ãýìòýëã¿é Õàâèðãà õóãàðàí ñóë õºäºë㺺íòýé Ýëýã æèæèã õýìæýýíèé íÿöðàëòàé äýë¿¿ õàãàðñàí Äóíä ÷ºìºã õóãàðñàí Ãýìòýëã¿é Õàì õ¿íä ãýìòýë AIS 3 0 4 Òýðã¿¿ëýõ ãýìòýë çýðýã äýâø¿¿ëýõ 9 16 2 5 25 3 0 50 Ãýìòëèéí õýìæ¿¿ðèéí óòãà íü õ¿ñíýãò 2-îîñ õàðàõàä AIS òîãòîëöîîíû äàãóó áèåèéí õàìãèéí õ¿íä ãýìòñýí 3 õýñýãò ºãºãäñºí îíîîíóóäûí êâàäðàòóóäûí íèéëáýðòýé òýíö¿¿ áîëîõûã õàðóóëæ áàéíà.ý ªãºãäñºí òîäîðõîéëîëòûí äàãóó ãýìòëèéí îíîîíû óòãà íü Î ãýìòýëã¿éãýýñ 75 îíîîíû õîîðîíä áàéõ áîëíî. Õýðýâ àëü íýã õýñãèéí 22
  • 23. ãýìòëèéã AIS òîãòîëöîîãîîð 6 îíîî ãýæ ¿íýëáýë àìüäðàëä ¿ë íèéöýõã¿é ãýìòýë iss –ààð áîë 75 îíîî áîëíî. Iss-èéí òóñëàìæòàéãààð ¿íýëñýí ãýìòëèéí õýìæýý íü íàñ áàðàëò, õ¿íäðýëèéí äàâòàìæ, ýìíýëýãò õýâòýõ õóãàöààòàé áîëîí ºâ÷òºíèé áèåèéí áàéäëûí áóñàä øàëãóóðóóäòàé øóóä õàìààðàëòàé þì. GCS (Glasgox Coma ScATE) Äýëõèé íèéòýýðýý àëü ýðò õýðýãëýõ áîëñîí òàðõèíû ãýìòëèéí ìýäëýèéí ººð÷ëºëò, óõààí àëäàëòûí áàéäëûã çýðýãëýõýä Õ¿ñíýãò 3 Ãëàçãî-èéí êîìûí îíîî (GCS) Øàëãóóð Í¿äýý íýýõ (õàðàõ) Àñóóëòàíä õàðèóëàõ Õºäºë㺺í õèéõ áàéäàë Õèéõ ¿éë àæèëëàãàà ªºðºº õàðíà Äóóäàõàä õàðíà ªâòãºõºä õàðíà Õàðàõã¿é Ǻâ õàðèóëíà Áóäèëæ õàðèóëíà Áóðóó õàðèóëíà Àñóóëòûã îéëãîõã¿é Õàðèóëàõã¿é Êîìàíä áèåë¿¿ëíý Õýñýã ãàçðûí ºâäºëò ìýäýðíý ªâäºëòººñ ¿åýð çºâ íóãàëàõ õºäºë㺺í õèéíý Ǻâ áèø íóãàëàõ õºäºë㺺í õèéíý Ǻâ òýíèéëãýõ õºäºë㺺í õèéíý Õºäºë㺺íã¿é Îíîî 4 3 2 1 5 4 3 2 1 Õ¿ñíýãò 4 Áàëëûí òàéëáàð Óõààí àëäàëòûí áàéäàë Îíîî Óõààíòàé 15 áàëë Óõààí á¿äýã 13-14 áàëë Óõààíã¿é 9-12 áàëë Êîì 4-8 áàëë Òàðõè ¿õæñýí 3 áàëë Òàðõèíû íÿöðàë GCS À.Òàðõèíû õºíãºí íÿöðàë 13-15 Á.Òàðõèíû äóíä çýðãèéí íÿöðàë 9-12 Â.Òàðõèíû õ¿íä íÿöðàë ≤8 23
  • 24. Õàì õ¿íä ãýìòýëòýé ºâ÷òºíã ¿íýëýõ øàëãóóð (ISS-INGURI SEVEZITY SCORE) äàíãààð àâ÷ ¿çëýý. Äàâóó òàë: À. ISS íü ýðõòýí àíàòîìèéí áàéðøëààð àâ÷ ¿çñýí, ãýìòëèéí õ¿íäðýëèéí ò¿âøèíã íàðèéí òîãòîîõ ÷àäâàðòàé. Á. ISS çºâõºí õ¿íä ãýìòëèéã òîäîðõîéëîõîä à÷ õîëáîãäîëòîé ãýæ ø¿¿ìæèëäýã áîëîâ÷ àíàòîìèéí áàéðøëààð àâ÷ ¿çäýã ó÷èð èë¿¿ ºðãºí õýðýãëýäýã. ISS-èéí õýìæ¿¿ðèéã äýëãýðýíã¿é àâ÷ ¿çüå. Ýíý õýìæýýñ íü ãýìòëèéí ýðõòýí àíàòîìèéí áàéðøëààð íü àâ÷ ¿çñýí. Ýíý ¿íýëãýýãýýð õ¿íèéã àíàòîìèéí áàéðøëààð 5 õýñýãò õóâààíà. 1.Àðüñ, 纺ëºí ýä 2.Òîëãîé, í¿¿ð õ¿ç¿¿ 3.Öýýæ 4.Õýâëèé 5.¯å ìº÷ ¿íýëãýý 0-5 áàëëààð 1.Àëü ÷ õýñýãò ãýìòýëã¿é. 5 õýñãèéí ¿íýëãýýíèé äàðàà òýðã¿¿ëýõ 3 ãýìòëèéã êâàäðàòàä äýâø¿¿ëíý. ¯¿ãýýð ãóðâàí íèéëáýðèéã ISS ¿íýëíý. 1.1 áàëë • • àðüñ áà 纺ëºí ýä ò¿ëýíõèé 1 áóþó 2 çýðýã 10% áàéíà. Òîëãîé (õ¿ç¿¿ãýýðýý ãýìòýí óõààí àëäààã¿é òîëãîé ºâäºíº) Õ¿ç¿¿íèé ÿñàíä ãýìòýë èëðýýã¿é. Í¿ä ýâýðëýã, çîâõè, êîíüþêòèâ-í¿äíèé øèëëýã õýñýã öýãýí öóñ õàðâàëòòàé, ø¿ä óíàñàí (îëîí áèø) • Öýýæ, 纺ëºí ýä íÿöàðñàí. • Õýâëèé ºâäºíº, õýâëèéí õàíàíä çóðàãäñàí • ¯åíèé õîëáîîñ ñóíàæ òàñàðñàí, õºëíèé õóðóó õóãàðíà. 2.2 áàëë -¿íýëãýýíèé • àðüñ áà 纺ëºí ýä 2 þì óó 1 ìº÷èä àðüñ 纺ëºí ãýìòýëòýé ò¿ëýíõèé 23 çýðýã ò¿ëýãäñýí 10-20% • õ¿ç¿¿-òîëãîé-15 ìèí óõààí àëäñàí, àìíåçè èëýðíý. Í¿¿ð ãàâàë ÿñ çºðººã¿é õóãàðàëòòàé í¿äíèé àëèì óðóó íýâòýðñýí øàðõòàé, í¿äíèé òîëîã õóóðàõ ìàãàäëàëòàé. Õ¿ç¿¿ ÿñàíä õóãàðàë èëýðíý. Öýýæ: • Õàâèðãà, ºâ÷¿¿ õóãàðñàí, öýýæ 纺ëºí ýäèéí íÿöðàëò èõ ãýâ÷ ãåìà, ïíåâðîìîòîðàêñ ¿ã¿é. • Õýâëèé: õàíà ºðãºí õýìæýýíèé íÿöðàëòàé • ¯å ìº÷ -õºë, ãàðûí õóðóó îëîí õóãàðàëòàé ÷ºìºãò ÿñ õóãàðàëòàé, òîì ¿åíèé ãýìòýëòýé, ààðöàã ÿñ ãýìòýëã¿é 3.3 áàëë: • àðüñ 纺ëºí ýäèéí ãýìòýë èõ 3-4 ìº÷ëºã õàìàðñàí • òîëãîé õ¿ç¿¿ ãàâëûí ÿñ õóãàðàëòàé óõààí àëäàëò 15 ìèí. èë¿¿. Ìýäðýëèéí ãîëîìòîä ººð÷ëºëòã¿é. Ãýìòëèéí äàðààõü àìíåçè 3 öàã 24
  • 25. õ¿ðòýë ãàâëûí îðîéí ÿñíû õóãàðàë çºðººã¿é, í¿äýíä í¿äíèé ìýäðýë òàñàðíà, í¿¿ðíèé ÿñ ãýìòýëòýé, õàìðûí äàéâðóóä ãýìòñýí, õ¿ç¿¿íèé ÿñ ãýìòñýí íóãàñ äàðàãäààã¿é • Öýýæ îëîí õàâèðãà õóãàðñàí ãåìîïíåâìîòîðàêñ, óóøèã íÿöðàëòòàé, ãàäààä àìüñãàëûí õ¿íä äóòàãäàë èëðýýã¿é, ºðö õàãàðàõ øèíæ òýìäýãã¿é. • Õýâëèé, õýâèéí ýðõòýí íÿöàðñàí, àðûí çàéí öóñ õóðàëòòàé, äàâñàã ãÿëòàíãèéí ãàäíà õàãàðñàí, Ẻðíèé ñóâàã, øýýñíèé ñ¿â òàñàðñàí, á¿ñýëõèé áîëîí ñýýð íóðóó õóãàðñàí, íóãàñ äàðàãäààã¿é. • ¯å ìº÷-õºë ãàðûí õóðóó, òàñàðñàí ýíãèéí ÷ºìºãò ÿñíû áèò¿¿ õóãàðàë òîì ¿åíèé ãýìòýë, ìýäðýë-ñóäàñíû ãýìòýë 4.4 áàëë ãýìòëèéí çýðýã • Àðüñ 纺ëºí ýä-ãýìòýë èõ öóñ àëäàëòòàé • Òîëãîé õ¿ç¿¿, ãàâàë ÿñíû õóãàðàë 15 ìèíóò èë¿¿ óõààí àëäàëò, ìýäðýë ãîëîìòûí øèíæ òýìäýã èëýðñýí, àìíåçè 3-12 öàã, ãàâëûí îðîéí ÿñ õóãàðàëòòàé • Öýýæ: îëîí õàâèðãà õóãàðñàí õàâèðãà (ôëîòàöèåé) öýýæíèé íýâòýðñýí øàðõ, ïíåâìîìåäèëñòèíäè, ç¿ðõíèé áóë÷èí áýðòñýí, ç¿ðõíèé ¿éë àæèëëàãààíû ººð÷ëºëò èëðýýã¿é, ïîðè êàðäà-øàðõäñàí. • Õýâëèé: äýë¿¿ íÿöàðñàí • Áººð õàãàðñàí • Õîäîîäíû äîîðõ áóë÷èðõàé ñ¿¿ë õýñýã • Äàâõàð-ãÿëòàí äîòîð õàãàðñàí • Áýëýã ýðõòýí õ¿íä ãýìòñýí, á¿ñýëõèé, ñýýð íóðóó õóãàðàëòàé, ìýäðýëèéí ãýìòýë øèíæ òýìäýã èëýðñýí • ¯å ìº÷ òàéðàãäñàí, ÷ºìºãò ÿñíû îëîí õóãàðàëòàé 6.5 áàëë ãýìòëèéí çýðýã • àðüñ 纺ëºí ýä 50% • Òîëãîé õ¿ç¿¿. Ãàâàë ÿñ õóãàðñàí 1 õîíîã ò¿¿íýýñ èë¿¿ óõààí àëäñàí, àìíåçèÿ 12 öàãààñ äýýø, ãàâàëûí äîòîð öóñ õóðàëòòàé • Ãàâëûí äîòîîä äàðãàëò • Õ¿ç¿¿ íóðóó õóãàð÷ íóãàñ äàðàãäñàí • Àìüñãàëûí äýýä äýì áºãëºðñºí (ãýìòýë) • Öýýæ: õ¿íä ãýìòýë, öàãààí ìºãººðñºí õîîëîé õàãàð÷ • Àîðò õàãàðàõ • Ç¿ðõíèé áóë÷èí òîìðîõ • Õýâëèé- ýëýã õàãàðàõ, ïàíêåðñ, õºíäèé ýðõòýí öîîðîõ • ¯å ìº÷: òàéðàãäàõ, ÷ºìºãò îëîí ÿñ èë õóãàðàõ, õýìæ¿¿ð ºñºõ òóñàì íàñ áàðàëò ºíäºðòýé, ISS íü ºâ÷òºíèé ýì÷èëãýý, õèéìýë àìüñãàë, öóñ øèíãýí þ¿ëýõ ýì÷èëãýý ¿¿íä íàìñûã àâ÷ ¿çýýã¿é ãàâàë òàðõèíû ãýìòëèéã àâ÷ ¿çýýã¿é äóòàãäàëòàé þì. Ýíýõ¿¿ 16-ãààñ 25 áàëëààð ¿íýëýãäýíý. Øèíãåíèé îðíóóä èõýâ÷ëýí õýðýãëýæ áàéãàà ãýìòëèéí øàëãóóð PTS (polytraumaschlussel) òàâèëàí, àíãèëàë, ñòàíäàðò õýìæèãäýõ¿¿í (GCS) íýã õýñãèéí, íàñ, áèîõèìèéí ¿ç¿¿ëýëò PTS ISS áèîõèìèéí ýíãèéí ¿ç¿¿ëýëò¿¿ä 25
  • 26. Ãàâàë áàëë GCS 9-12 3 GCS 6-8 4 GCS 3-5 16 Í¿¿ð ãàâàë äóíä õóãàðàë 1 Í¿¿ð ãàâàë õ¿íä õóãàðàë 2 Àîðò õàãàðàõ 16 Õýâëèé: áàëë Äýë¿¿ õàãàðàõ 5 Ýëýã õàãàðàõ 8 Ýëýã ºðãºí õýìæýýòýé óðàãäàë 13 Ïàíêåðñ 8 Õîäîîä, ãýäýñ, ÷àöàðõàé Ẻð 5 ¿å ìº÷: äóíä ÷ºìºãíèé áÿöàðñàí õóãàðàë 8 äóíä ÷ºìºã õóãàðàõ 6 øóó, áóãàëãà 4 øèëáý 2 òîéãíû õóãàðàë, øóó òîõîéí ¿å, ºâäºãíèé õîëáîîñ, øàãàé, øèëáý, òàâõàéí ¿åèéí ãýìòýë ãóÿíû ñóäàñ 5 áóãëàãàíû ñóäàñ 4 øèëáý øóó 2 2, 3-ð çýðãèéí èë õóãàðàë¿ 3 纺ëºí ýäèéí ãýìòýë 1 coefficient Paq 02/fL 02<50 22 50-99 100-149 12 150-199 8 200-249 5 150-299 3 300-349 2 >350 0 1 öýýæ ºâ÷¿¿, 1-3 õàâèðãà õóãàðàõ 2 õýä õýäýí õàâèðãà õóãàðàõ 4 2 òàëûí õàâèðãà õóãàðàõ 10 öýýæèíä öóñ õóãàðàõ 1 Õèé õóðàõ 2 2 òàëûí óóøèã íÿöðàõ 5 ààðöàã: ýíãèéí õóãàðàë 2 íèéëìýë õóãàðàë 5 ààðöàã õóãàðààä øýýñ áýëýã ýðõòýí ãýìòýõ 8 íóðóóíû õóãàðàë 2 íóãàñ ãýìòñýí 8 Ààðöàã äàðàãäàõ 12 Íàñ 39 0 40-54 1 26
  • 27. 55-59 2 60-64 3 65-69 5 70-74 8 75-ààñ äýýø 17 ñóóðèéí äóòìàãøèë 16 26 14-15,9 26 12-13,9 20 10-11,9 14 9,9 9 6-7,9 5 1-ð çýðýã (20 îíîî –õºíãºí, õ¿íäýâòýð íàñ áàðàëò îéðîëöîîãîîð 10%) 2-ð çýðýã (20-35 îíîî) íàñ áàðàëò 25% 3-ð çýðýã (35-50 îíîî) íàñ áàðàëò 50% 4-ð çýðýã (50 áàëë äýýø) íàñ áàðàëò 75% Ëàáîðàòîðèéí øèíæèëãýýã îðóóëàõã¿éãýýð îðîí íóòàãò ä¿ãíýæ áîëíî. Ýäãýýð äýâøèãäýí õýðýãëýæ áàéãàà ìåõàíèê ãýìòëèéí ¿íýëãýý íü äýëõèéí ïðàêòèêò ºðãºí õýðýãëýãäýõ áîëñîí íü ìàíàé óëñûí õýìæýýíä 2003 îíîîñ ýõëýí õýðýãëýñýí òóðøëàãûã îëîí óëñûí õýðýãëýýòýé õàðüöóóëæ Ais áîëîí iss òóñ á¿ðèéã õàðãàëçñàí ¿íýëãýýã èë¿¿ä ¿çýæ àíàòîìèéí á¿òýö á¿ðýýð äîîðõ õ¿ñíýãòýýð ¿ç¿¿ëëýý. 27
  • 28. ªÂªÐÌªÖ ÝÐÕÒͯ¯ÄÈÉÍ ÃÝÌÒËÈÉÍ ÁÀËËÛÍ ¯ÍÝËÃÝÝÍÈÉ ÒÎÃÒÎËÖÎÎ (Moore E.E, Cogbill T.H, Malangoni M, Jurkovich G.J, Champion H.R.) Àíãèëàë I II III IV V Õ¿ç¿¿íèé ñóäàñíóóäûí ãýìòëèéí çýðýãëýë Ãýìòñýí ñóäàñ Áàìáàéí âåí Í¿¿ðíèé åðºíõèé âåí ÿðýýíèé ãàäíà âåí Àðòåðè, âåíèéí ñàëààíóóä ÿðýýíèé ãàäíà àðòåðèéí ñàëàà (çàëèãóóðûí óðóóäàõ, áàìáàéí äýýä, õýëíèé, í¿¿ðíèé, äýýä ýð¿¿íèé, äàãçíû, ÷èõíèé àð) áàìáàé, õ¿ç¿¿íèé ñàëàà áóþó àíõäàã÷ ñàëàà ÿðýýíèé äîòîð âåí ÿðýýíèé ãàäíà àðòåðè Ýãýìèéí äîîðõ âåí Íóðóóíû àðòåðè ÿðýýíèé åðºíõèé àðòåðè Ýãýìèéí äîîä àðòåðè ÿðýýíèé äîòîð àðòåðè (Ãàâàëûí ãàäíà) Ais-90 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 2-4 3-4 2-4 3-5 3-5 Ãýìòýë îëîí áîë III-IV çýðýãò I çýðýã íýìýãäýíý. Ñóäàñíû ýðãýí òîéðîí 50%-èàñ èë¿¿, IV-V àíãèëàëä ñóäàñ ýðãýí òîéðîí 25%-èàñ áàãàã¿é õàãàðñàí áîë I àíãè áóóðíà. 28
  • 29. Óóøèãíû ãýìòëèéí çýðýãëýë, õýìæýý, çýðýãëýë Àíãèëàë Õýëáýð Ãýìòñýí áàéäàë I Íÿöðàë Íýã òàëûí <1 äîëè II Íÿöðàë Íýã òàëûí 1 äîëè õàãàðàë Ïíåâìîòàðàêñ III Íÿöðàë Íýã òàëûí 1 äîëè Õàãàðàë Óðò (>72 öàã) àãààð õàÿãäàæ óóøèã (???) äîòîð íýìýãäýõã¿é áàéãàà IV Õàãàðàõ Àãààð èõ õýìæýýãýýð õàÿãäàæ óóøèã ??? äîòîð íýìýãäýõã¿é áàéãàà V Ñóäàñóóä Óóøèãíû ñóäàñóóä àíõäàã÷ààð õàãàðàõ Ñóäàñíû ¿¿äýíöýðò õàãàðàõ VI Ñóäàñóóä Óãàíäàà òàñðàõ Ais-90 3 3 3 3-4 3-4 3-5 4 4 4 Öýýæíèé ñóäàñíû ãýìòýæ ãåìàòåðîñ ¿¿ññýí, ìºí 2 òàëäàà ãýìòýëòýé áîë I çýðýã íýìýãäýíý. Àíãèëàë Õýëáýð I Íÿöðàë Òàñðàë (ðàçðûë) Õóãàðàë II Òàñðàë Õàâèðãàíû õóãàðàë III Òàñàð÷ õàãàðàõ õóãàðàë IV Õàãàðàë Òàñðàë Õóãàðàë Õóãàðàë V Öýýæíèé õºíãºí ãýìòýë Ãýìòñýí áàéäàë ßíç á¿ðèéí õýìæýýòýé àðüñ, àðûí äîîðõè ººõºí ýñëýã <3 õàâèðãà, ýãýì áèò¿¿ çºðººã¿é Àðüñ, àðüñàí äîîðõ ººõºí ýñëýã, áóë÷èí ≥3 çýðãýëäýýõ õàâèðãàíû áèò¿¿ õóãàðàë Ýãýì: èë çºðººòýé ªâ÷¿¿ áèò¿¿, çºðººã¿é Äàëíû èõ áèå áèò¿¿, èë Ïëåâð îðîëöîîä á¿õ äàâõàð ºâ÷¿¿: èë, áèò¿¿ ªâ÷¿¿ -ñóë õºäºë㺺íòýé (ôëîòèðóþùàÿ) <3 õàâèðãà ñóë õºäºë¿ãººíòýé Õàâèðãà <3, õóãàðàë ò¿âøèíäýý 纺ëºí ýä õàãàðàõ ‫ 3≤ﱠ‬õàâèðãà ñóë õºäºë㺺íòýé ≥3 õàâèðãà 2 òàëäàà, õî¸ðëîñîí Ais-90 1 1 1-2 2 1 2-3 2 2 2 2 2 2 3-4 4 5 Ýíý áîë çºâõºí õàíàíû ãýìòýë, õýâëèé öýýæíèé ýðõòí¿¿ä äàãàëäàæ ãýìòýõèéã òîîöñîíã¿é. 29
  • 30. ÖÝÝÆÍÈÉ ÑÓÄÀÑÍÛ ÃÝÌÒËÈÉÍ ÕÝÌƯ¯Ð Çýðýã I II III IV V VI Ãýìòñýí áàéäàë Õàâèðãà õîîðîíäûí àðòåðè / âåí Öýýæ, õºõíèé àðòåðè / âåí Áðîíõíû àðòåðè / âåí Óëààíõîîëîéí àðòåðè / âåí Õàãàñ, õîñ áèø âåí (nemiarygous vein) Íýðã¿é öóòãàëàí ÿðýýíèé äîòîð âåí Õîñ áèø âåí Ýãýìèéí äîîðõ âåí Íýðã¿é âåí (in nominate vena) ÿðýýíèé àðòåðè Íýðãèé àðòåðè Ýãýìèéí äîîðõ àðòåðè Óðóóäàõ àîðò Äîîä õºíäèéí âåí (öýýæíèé) Óóøèãíû ãîë àðòåðè Óóøãèí äîòîðõè ñàëààíóóä (àðòåðèéí) Óóøèãíû àíõäàã÷ âåí Óóøèã äîòîðõè ñàëààíóóä âåíèé Àîðòûí íóì, ºãñºõ õýñýã Äýýä õºíäèéí âåí Óóøèãíû àðòåðè (ãîë) Óóøèãíû ãîë âåíý Öýýæíèé àîðò áóþó óóøèãíû ¿¿äýíöýð á¿ðýí îãòëîëöñîí Ais-90 2-3 2-3 2-3 2-3 2-3 2-3 2-3 2-3 3-4 3-4 3-5 3-4 3-4 4-5 3-4 3 3 5 3-4 4 4 5 4 4 IV àíãèëàëä ñóäàñíû ýðãýí 25% áàãà õýòýðñýí áîë I çýðýã áàãàñàæ, îëîí ãýìòýëòýé, ñóäàñíû ýðãýí òîéðîíä 50% èë¿¿ ãýìòýëòýé III àíãèëàëä I çýðýã íýìýãäýíý. 30
  • 31. Àíãèëàë I II III IV V ªðöíèé ãýìòëèéí çýðýãëýë Ãýìòñýí áàéäàë Íÿöðàë Õàãàðàõ <2 ñì Õàãàðàõ 2-10 ñì Õàãàðàõ >10 ñì ≤25 ñì2 òàëáàéí àëäàãäàëòàé Õàãàðàõ >25 ñì2 èõ Ais-90 2 3 3 3 3 Õî¸ð òàëûí ãýìòýë áîë III àíãèëàë õ¿ðòýë èõñýíý. I çýðýã íýìýãäýíý. Àíãèëàë I II III IV V Àíãèëàë I II III IV Óëààí õîîëîéí ãýìòýë Ãýìòñýí áàéäàë Íÿöðàë, öóñ õóðàëò Õýñýã÷ëýí õàãàðàõ <50% ýðãýí òîéðîí ñì >50% ýðãýí òîéðîí Õýñýã÷ëýí òàñðàõ áóþó <2 ñì öóñã¿éæèõ Õýñýã÷ëýí òàñðàõ áîëîí > 2 ñì öóñã¿éæèõ Ãýìòýë îëøðîõ òóñàì 1-ýýñ 3 õ¿ðòýë I çýðýã èõñýíý. Ç¿ðõíèé ãýìòýë Ãýìòñýí áàéäàë Áàãà çýðýã áèò¿¿ ãýìòýë ÝÊà (ÇÖÁ)-ã ººð÷ëºëò ãàðíà. (ªâºðìºö áèø ST áóþó Ò ººð÷ëºã人ä ýðò òîñãóóð, õîâäîë àãøèõ áóþó òîãòâîðòîé ñèíóñ òàõèêàðäèÿ) Áèò¿¿ áóþó äåðèêàðä íýâòýðñýí ìèîêàðäèÿãýìòýýã¿é Áèò¿¿ äàìæóóëàõ òîãòîëöîîíä õîðèãòîé öóñã¿éæèëòèéí ººð÷ëºëòòýé (äåïðåññèÿ ST áóþó èíâåðñàÿ Ò) ç¿ðõíèé äóòàãäàëã¿é, Ìèàêàðäè ðóó íýâòýðñýí (ø¿ðãýñýí) øàðõòàé àíäîêàðäè ðóó îðîîã¿é òàìïîíîä áîëîîã¿é Áèò¿¿ (ç¿ðõíèé ìèíóòûí ò¿ëõýëò ≥6) áóþó õîâäîëûí àãøèëò îëøèðíî. Áèò¿¿ áîëîí õîâäîë õîîðîíäûí òàñëàâ÷ ðóó íýâòýðñýí øàðõòàé. Êëàïàíû äóòàãäàëòàé (3í õàâòàñò) õºõëºã áóë÷èíãóóäûí ¿éë àæèëëàãààíû àëäàãäàë, ç¿ðõíèé çàõûí òèòýì ñóäàñ áºãëºðñºí –ç¿ðõíèé äóòìàãøèëã¿é ¯íõýëöýã õàãàð÷, ç¿ðõíèé áàéðøèë õàçàéõ Áèò¿¿ ç¿ðõíèé äóòàãäàëòàé. Ç¿ðõíèé õºíäèéä íýâòýðñýí øàðõ, òîìïîíàä áîëñîí. Ç-í õàâòàñò õàâõëàãûí äóòàãäàë, õºõëºã áóë÷èíãèéí ¿éë àæèëëàãààíû àëäàãäàë, Ais-90 2 3 4 4 5 5 Ais-90 3 3 3 3-4 3-4 3-4 3 3-4 5 31
  • 32. V VI ç¿ðõíèé òèòýì ñóäàñíû çàõûí áºãëºðºë ç¿ðõíèé äóòàãäàë Ìèòðàëíûé êëàïàí áóþó àîðò áèò¿¿, íýâòýðñýí øàðõòàé Ç¿¿í õîâäîë, ç¿¿í áàðóóí òîñãóóðò íýâòýðñýí øàðõ, ìºí áèò¿¿ Ç¿ðõíèé òèòýì ñóäàñíû ýõëýõ õýñýãò áºãëºðñºí, íýâòýðñýí øàðõ Ç¿¿í òîñãóóð ðóó íýâòýðñýí øàðõ Áàðóóí õîâäîë áîëîí òîñãóóð ðóó íýâòýðñýí ýäèéí <50% àëäàãäàëòàé Ç¿ðõ áèò¿¿ õàãàðàõ, íýâòýðñýí øàðõ >50% (ýäèéí àëäàãäàë) Íýã êàìåðûí îëîí øàðõ, õýä õýäýí êàìåðûí øàðõ áàéâàë I çýðýãëýëýýð íýìýãäýíý. Õýâëèéí ñóäàñóóäûí ãýìòýë Àíãèëàë Ãýìòëèéí áàéäàë I Äýýä ÷àöàðõàéí äýýä íýðã¿é àðòåðè (ÍÄà), âåí (×ÄÂ) ×àöàðõàéí äîîä àðòåðè (×Äî à), âåí (×ÄîÂ) ªðöíèé àðòåðè, âåí Á¿ñýëõèéí àðòåðè, âåí ªíäãºâ÷èéí àðòåðè, âåí Áóñàä íýðã¿é æèæèã ñóäàñóóä Áîîõ øààðäëàãàòàé ñóäàñóóä Äýë¿¿íèé àðòåðè, âåí II Õîäîîäíû áàðóóí, ç¿¿í àðòåðè Õîäîîä, 12 ãýäýñíèé àðòåðè ×äîÀ áîëîí ×Äî (ãîë ñóäàñóóä) ×ÄÀ áîëîí ×Ä ãîë ñàëààíóóä ×Ä (ãîë ñóäàñ) áîîæ áîëíî, èæèë íýðòýé õýâëèéí ñóäàñóóä, õýâëèéí áóñàä ñóäàñ Áººðíèé àðòåðè, âåí Òàøààíû åðºíõèé àðòåðè, âåí III Òàøààíû äîòîð àðòåðè, âåí Äîîä õºíäèéí âåí (ÄÕÂ) Ẻðíèé äîîä õýñýã Õýâëèéí ãîë àðòåðè ÄÕÂ, Ẻðíèé äýýä áîëîí ýëýãíèé äîîä õýñýã IV Àîðòà, Ẻðíèé äîîä õýñýã Õààëãàí âåí Ýëýãíèé ïàðåíõèéí ãàäíàõ âåí¿¿ä ÎÄÕÂ, ýëýã, ýëýãíèé äýýä õýñýã V Àîðòà, Ẻðíèé äýýä, ºðöíèé äîîä õýñýã 5 5 5 5 6 Ais-90 ¯íýëýõã¿é (NS-ëîõ S cored) NS NS NS NS NS NS NS 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 32
  • 33. Ýíý õýìæ¿¿ðèéã ýðõòíèé ãàäóóðõ ñóäàñíû ãýìòýëä õýðýãëýíý. Õýðýâ óã ýä ýðõòýí ãýìòñýí ñóäàñààñ (>2 ñì) õîë áîë ýíý õýìæ¿¿ðèéã õýðýãëýíý, ýðõòíèé ãýìòýëòýé òîõèð÷ áàéâàë õýðýãëýíý. Ñóäàñóóäûí îð÷èí >50% áîë îëîí ãýìòýë áàéâàë III-IV íü < èõñýíý, ñóäàñ òàéðàí <25% - IV-V íü I áóóðíà. NS ¿íýëãýýã¿é. Àíãèëàë I II III IV V Çàõûí ñóäàñóóäûí ãýìòëèéí õýìæ¿¿ð Ãýìòëèéí áàéäàë A/V digitalis A/V palmaris A/V palmaris profunda A dorsalis peds A/V plantaris Íýðã¿é àðòåðè, âåíèéí ñàëààíóóä A.axillaries V. zemoralis sup.profundor V. poplitea A.brachineis A.tibaeis posterior A.peroneus Truncus tibioteroneneis A.axillaries V. zemoralis sup.profundor V. poplitea A.brachineis A.tibalis anperior A.tibaeis posterior A.peroneus Truncus tibioteroneneis A. Femoralis sup?profunda A. Poplitea A. Axillaris A. Femoraeis Communis Ais-90 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 2-3 2-3 2-3 2-3 1-3 1-3 1-3 2-3 3-4 2-3 2-3 3-4 Ýðãýí òîéðîíäîî >50% ãýìòýëòýé ìºí îëîí ãýìòýëòýé III-IV çýðýã I íýìýãäýæ, <25% áîë IV-V íü I áóóðíà. 33
  • 34. Àíãèëàë Õýëáýð I Öóñ õóðàëò Õàãàðàõ II Öóñ õóðñàí Õàãàðàõ III Öóñ õóðñàí IV Õàãàðàõ Öóñ õóðàëò Õàãàðàõ V Õàãàðàõ Ñóäàñ VI Ñóäàñ Ýëýãíèé ãýìòýë Ãýìòëèéí áàéäàë Ýðõòíèé òàëáàé <10%, êàïñóë äîð öóñ õóðñàí, íýìýãäýõã¿é áàéãàà Êàïñóë õàãàðñàí öóñ àëäàëòã¿é <1 ñì ã¿í Ýðõòíèé òàëáàé 10-50% õ¿ðòýë, ýëýã äîòîð öóñ õóðàëò d<2 ñì. Öóñ õóðàëò íýìýãäýýã¿é Êàïñóë õàãàð÷ óðò íü <10 ñì 1-3 ñì ã¿í ã¿íçãèé öóñ àëäàëò èäýâõòýé Êàïñóëûí äîð öóñ õóðàëòòàé òàëáàé >50% öóñ õóðàëò íýìýãäýõ øèíæòýé, öóñ õóðàëò, çàäàð÷ èäýâõòýé öóñ àëäàëòòàé ýëýã äîòîð öóñ õóðàëò >2 ñì áóþó öóñ àëäàëò íýìýãäýíý > ñì ã¿í Ýëýã äîòîðõè öóñ õóðàëò çàäàðñàí èäýâõòýé öóñ àëäàëòòàé Ýëýãíèé äîëèéí 25-50% õ¿ðòýë õàìàðñàí ãýìòýëòýé Ýëýãíèé äîëè >50% õàìàðñàí Ýëýãíèé ãàäíà õºíäèéí âåí, ýëýãíèé òîì âåí Ýëýã òàñàðñàí Ais-90 2 2 2 2 3 3 4 4 5 5 6 Ýëãýíä îëîí ãýìòýëòýé áîë III õ¿ðòýë àíãèëàë I íýìýãäýíý. Àíãèëàë I II III IV V Ýëýãíèé ãàäíàõ öºñíèé çàì Ãýìòëèéí áàéäàë Öºñíèé õ¿¿äèé íÿöàð÷, öóñ õóðñàí ¯¿äýíöýðèéí ýëåìåíò¿¿ä íÿöðàõ Ýëýãíèé áàéðøëààñ öºñíèé õ¿¿äèé òàñðàõ, öºñíèé öîðãî ãýìòýýã¿é Öºñíèé õ¿¿äèé öîîðîõ õàãàðàõ, öîîðîõ Öºñíèé õ¿¿äèé ýëýãíèé áàéðøëààñàà á¿ðýí òàñðàõ Öºñíèé öîðãî òàñðàõ Ýëýãíèé áàðóóí öîðãî (ÝÁÖ) á¿ðýí áóþó õýñýã÷ëýí òàñðàõ Ç¿¿í öîðãî (ÝÇÖ) á¿ðýí áóþó õýñýã÷ëýí òàñðàõ Ýëýãíèé åðºíõèé öîðãî (<50%) Ýëýãíèé öîðãîíû õýñýãò (>50%) òàñëàãäñàí ÝÁÖ áîëîí ÝÇÖ õàì ãýìòýõ Ýëýãíèé åðºíõèé öîðãî õàíàíû çàâñðààð áîëîí ïàíêðåïñûí ãýìòýë Ais-90 2 2 2 2 3 3 3 3 3-4 3-4 3-4 3-4 34
  • 35. Îëîí ãýìòýë áîë III õ¿ðòýë çýðýã I íýìýãäýíý. 12 õóðóó ãýäýñíèé ãýìòýë (12ÕÃ) Àíãèëàë Õýëáýð Ãýìòëèéí áàéäàë I Öóñ õóðàõ 12ÕÃ-èéí íýã õýñýã Õàãàðàõ Íýâòðýýã¿é II Öóñ õóðàõ 12ÕÃ-íýýñ õýñãýýñ èë¿¿ Õàãàðàõ <50% ãýäýñíèé òîéðîí III Õàãàðàõ 50-75% -12-2 (12ÕÃ) 50-100% ýðãýí òîéðîí 12-1,12-3, 12-4 IV Õàãàðàõ 12-2 äàãóóäàà öºñíèé öîðãî ãýìòýõ >75% 12-2 ýðãýí òîéðîí V Õàãàðàõ Ïàíêðåàòîäóîäåíàë á¿ñ áÿöðàõ Ñóäàñ 12Õà öóñã¿éæèõ Ais-90 2 3 2 4 4 4 5 5 5 5 III õ¿ðòýë îëîí ãýìòýëòýéä I íýìýãäýíý. 12-1, 12-4, 1-4 ãýäýñíèé õýñýã Õîäîîäîí äîîðõ áóë÷èðõàéí ãýìòýë Àíãèëàë Õýëáýð Ãýìòëèéí áàéäàë I Öóñ õóðàõ Áàãà çýðýã íÿöàðñàí öîðãî ãýìòýýã¿é II Õàãàðàõ Öîðãî ãýìòýýã¿é ãàäàðãóó õàãàðñàí Öóñ õóðàõ Èëýðõèé íÿöàðñàí ýäèéí ÷àíàð àëäàãäààã¿é, öîðãî ãýìòýýã¿é III Õàãàðàõ Ýä ã¿íçãèé õàãàðàõ öîðãî ãýìòñýí IV Õàãàðàõ Çàõûí õýñýã õºíäëºí òàñàð÷ öîðãî ãýìòñýí V Õàãàðàõ Äýýä õýñýãò õàãàðñàí áóþó àìïóë õýñýã õàìðàãäñàí Õàãàðàõ Áóë÷èðõàéí òîëãîé á¿õýëäýý òàñàðñàí Ais-90 2 2 2 3 3 4 5 Îëîí ãýìòýë III õ¿ðòýë I íýìýãäýíý. Äýýä ãýìòýë -÷àöàðõàéí äýýä áàðóóí âåí îðíî. Àíãèëàë Õýëáýð I Öóñ õóðàõ II Õàãàðàõ Öóñ õóðàõ Äýë¿¿íèé ãýìòýë Ãýìòëèéí áàéäàë Êàìïñóë äîð, öóñ àëäàëò íýìýãäýýã¿é á¿õ òàëáàéí <10% Êàìïóñ õàãàðàõ ã¿í <1 ñì öóñ àëäàëòã¿é Êàïñóë äîð 10-50% òàëáàé ýçýëíý. Öóñ àëäàëò íýìýãäýýã¿é ãåìåòîí ã¿íäýý <2 ñì Ais-90 2 2 2 35
  • 36. Õàãàðàõ III Öóñ õóðàõ IV Öóñ õóðàõ Õàãàðàõ V Õàãàðàõ Ñóäàñ 1-3 ñì ã¿í êàïñóë õàãàðñàí öóñ àëäàëòòàé ñóäàñ òðàáåêóëóóä õàìðàãäñàí Êàïñóëûí äîð öóñ õóðàõ >50% òàëáàé õàìàðñàí, öóñ àëäàëò íýìýãäýíý, öóñ õóðñàí õýñãýýñ èäýâõòýé öóñ àëäàæ áàéíà. Ýäèéí äîòîð >2ñì ã¿í öóñ õóðñàí, öóñ õóðàëò íýìýãäýæ áàéíà Ýäèéí äîòîð õàãàð÷ öóñ àëäàæ áàéãàà Ñåãìåíò¿¿äèéí ñóäàñóóä áîëîí ¿¿äýíöýð õàìàð÷ >25% öóñã¿éæèëòòýé Á¿ðýí áÿöàðñàí ¯¿äýíöýðèéí ñóäàñóóä á¿ðýí òàñàðñàí 2 3 3 4 4 5 5 III õ¿ðòýë àíãèëàëä ãýìòýë îëøèðâîë I íýìýãäýíý. IV Õîäîîäíû ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë öóñ õóðàëò Íýâòðýýã¿é õàãàðàë Õîäîîä-óëààí õîîëîéí (Õ.Ó.Õ.Ø) áóþó ïðèâðàòíèêû øèëæèõ õýñýãò õàãàðàõ <2 ñì Õîäîîäíû ýõëýõ 1/3 <5ñì õàãàðàõ Òºãñãºë õýñýãò 2/3 >10ñì Õ.Ó.Õ.Ø. áóþó ïðèâðàòíèê >2ñì Õîäîîäíû ýõëýõ õýñýã 1/3 >5ñì Õîäîîäíû òºãñãºë õýñýã 2/3 >10ñì Õîäîîäíû <2/3 òàñàð÷, ñóäàñã¿éæèõ V >2/3 Ñóäàñã¿éæèæ òàñðàõ Àíãèëàë I II III Ais-90 2 2 3 3 3 3 3 3 4 4 III àíãèëàë õ¿ðòýë îëîí ãýìòýëòýé áîë I àíãèëàë íýìýãäýíý Íàðèéí ãýäýñíèé ãýìòýë Àíãèëàë Õýëáýð I Öóñ õóðàëò II III IV V Õàãàðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ Ñóäàñóóä Íÿöðàë áóþó öóñ õóðàõ, òýæýýëýýñ ñàëààã¿é Ãýäýñíèé õàíà ðóó íýâòðýýã¿é ÿçðàë <50% - ãýäýñ òîéðîí õàãàðñàí >50% - ãýäýñ òîéðîí õàãàðàõ 100% - ãýäýñ õàãàðàõ 100% - òàñàð÷ ñåãìåíòýý àëäàõ Ñåãìåíò öóñã¿éæèõ Ais-90 2 2 3 3 4 4 4 36
  • 37. Îëîí ãýìòýëòýé áîë III õ¿ðòýë ÿâö I íýìýãäýíý. Àíãè I Õýëáýð Öóñ õóðàx Õàãàðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ II III IV V Á¿ä¿¿í ãýäýñíèé ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë öóñ õóðàëò öóñàí õàíãàìæ ººð÷ëºã人ã¿é Ãýäýñíèé õºíäèéä íýâòðýýã¿é < 50% - ãýäýñ ýðãýí òîéðîí >50% - ãýäýñ ýðãýí òîéðîí õºíäëºí áèø 100% - ãýäýñ ýðãýí òîéðîí – õºíäëºí Õºíäëºí ñåãìåíò ýäèéí ÷àíàðàà àëäàõ Ais-90 2 2 3 3 4 4 III àíãèëàë õ¿ðòýë îëîí ãýìòýëòýé áîë I àíãèëëààð èõýñíý. Àíãè I II III IV V Õýëáýð Öóñ õóðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ Ñóäàñóóä Øóëóóí ãýäýñ ãýìòýõ Ãýìòëèéí áàéäàë Íÿöðàõ, öóñ õóðàõ ãýäýñíèé òýæýýë àëäàãäààã¿é Ãýäýñíèé õºíäèéä íýâòýðýýã¿é <50% ãýäýñíèé ýðãýí òîéðîí >50% - ãýäýñíèé ýðãýí òîéðîí Ãýäýñíèé òîéðîí 100% õàãàð÷ õÿðçàí ðóó òàðõñàí Ñåãìåíò öóñã¿éæñýí Ais-90 2 2 3 4 5 5 III àíãèëàë õ¿ðòýë îëîí ãýìòýëòýé áîë I íýìýãäýíý. Àíãèëàë Õýëáýð I Õÿöðàë Öóñ õóðàëò II III Öóñ õóðàëò Õàãàðàõ IV Õàãàðàõ Ñóäàñ V Õàãàðàõ Ñóäàñ Áººðíèé ãýìòëèéí áàéäàë Ãýìòëèéí áàéäàë Ìàêðî – ìèêðîãåìàòóðèÿ áàãàæèéí øèíæèëãýýíä õýâèéí Êàïñóë äîð, ïàðåíõèì ãýìòýýã¿é öóñ õóðàëò íýìýãäýýã¿é Áººðíèé îð÷èíä öóñ õóðàëò íýìýãäýýã¿é Áººðíèé ïàðåíõèìä >1ñì, òýâøèíöýð, àñãàíöàð Ẻðíèé Êîðòèêàë (Ò.À.Ê) äàâõàð õàìààðàëã¿é áóþó øýýñ ãàäàãø õóðààã¿é Òàðõèëàã, Êîðòèêàë äàâõàðãóóä áóþó Ò.À.Ê õàìàðñàí Áººðíèé ¿íäñýí-àðòåðè, âåí ãýìòñýí öóñ àëäàëò ¿ðãýëæèëýíý. Á¿ðýí áÿöàðñàí Áººðíèé ñóäàñ á¿ðýí òàñàðñàí Ais-90 2 2 2 3 4 4 5 5 37
  • 38. III àíãèëàë õ¿ðòýë îëîí ãýìòýëòýé áîë I íýìýãäýíý. Àíãè I II III IV V Áººðíèé äýýä áóë÷èðõàéí ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë Ǻâõºí õîëòîñëîã á¿òöýíä õàãàðñàí (<2ñì) Òàðõèëàã á¿òöýíä òàðõñàí (≥2ñì) >50% - ïàðåíõèì ãýìòñýí Á¿ðýí öóñã¿éæñýí Ais-90 1 1 2 2 3 Àíãèëàë 2 òàëûí ãýìòýëä I-ýýð íýìýãäýíý. Àíãè I II III IV V Õýëáýð Öóñ õóðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ Õàãàðàõ Áººðíèé ñóâãàíöàðûí ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë, òýæýýë àëäààã¿é <50% - ýðãýí òîéðîí õàãàðñàí >50% - ýðãýí òîéðîí õàãàðñàí Õºíäëºí á¿ðýí òàñàð÷ <2ñì ýäèéí øèíæ àëäàãäñàí Õºíäëºí á¿ðýí òàñàð÷ >2ñì ýäèéí ÷àíàð Ais-90 2 2 3 3 3 Îëîí ãýìòýëòýé áîë III àíãèëàë õ¿ðòýë I íýìýãäýíý. Äàâñàãíû ãýìòýë Àíãè I II III Õýëáýð Íÿöðàë Õàãàðàõ Õàãàðàõ Õàãàðàõ IV V õàãàðàõ Õàãàðàõ Íÿöðàë, öóñ õóðàõ Äàâñàã ðóó íýâòýðýýã¿é Ãÿëòàíãèéí ãàäíà <2ñì Ãÿëòàíãèéí ãàäíà >2ñì Ãÿëòàíãèéí äîòîð <2ñì Ãÿëòàíãèéí äîòîð >2ñì Áººðíèé ñóâãàíöàð, äàâñàãíû õ¿ç¿¿ ð¿¿ òàðõñàí Ais-90 2 3 4 4 4 4 III aíãèëàë õ¿ðòýë îëîí øàðõ, ãýìòýë I àíãèàð íýìýãäýíý. Àíãèëàë Õýëáýð I Íÿöðàë II Ñóíàõ III Õýñýã÷ëýí òàñàðñàí Øýýñíèé ñ¿âíèé ãýìòýë Ãýìòëèéí áàéäàë Øýýñíèé ñ¿âýýð öóñ áóëòàéõ, óðåòðîãðàôèÿä õýâèéí Ñ¿â ñóíàæ-óðòñàí óðåòðîãðàôèÿä òîäîòãîã÷ áîäèñ îð÷èíäîî ãàðààã¿é Ñ¿âíèé ãýìòñýí ò¿âøèíãýýð òîäîòãîã÷ áîäèñ îð÷èíäîî äàâñãàíä ãàðñàí õàðàãäàíà. Ais-90 2 2 3 38
  • 39. IV Á¿ðýí õàãàðàõ V Á¿ðýí õàãàðàõ Ãýìòñýí ò¿âøèí òîäîòãîã÷ áîäèñ ãàðñàí, äàâñàãàíä òîäîòãîã÷ áîäèñ ãàðíà. Ñ¿âíèé òàñðàëûí çàé <2ñì Ñ¿âíèé òàñðàëûí çàé ≥2ñì Õàãàðàë, äàéâàð áóë÷èðõàé, õÿðçàí, ¿òðýý ð¿¿ òàðõàíà. 3 4 Àíãèëàë III õ¿ðòýë 2 òàëäàà ãýìòýëòýé áîë I àíãèàð íýìýãäýíý. Àíãèëàë I II III IV V Àíãèëàë I II III IV V Õóøãàíû ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë Õàãàðàë <25% (äèàìåòð) Õàãàðàë ≥25% (äèàìåòð) Òàñàðñàí <50% (äèàìåòð) Òàñàðñàí ≥50% (äèàìåòð) Òºìñíèé ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë, ãåìàòîì Öàãààí á¿ðõýâ÷ òàñðàíà (øèíæ òýìäýã èëðýýã¿é) Öàãààí á¿ðõýâ÷ òàñàð÷, ïàðåíõèéí >50% ãýìòýíý Öàãààí á¿ðõýâ÷ èõýýð òàñàð÷ ≤50% - ïàðåíõèì ãýìòýíý Òºìñ á¿ðýí òàñàðíà Ais-90 1 1 2 2 2 Ais-90 1 1 2 2 2 2 òàëäàà ãýìòñýí áîë V àíãèëàë õ¿ðòýë I íýìýãäýíý. Àíãèëàë I II III IV V Àíãèëàë I II III Ýð ãàäíà áýëýã ýðõòíèé ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë áóþó àðüñ òàñðàõ Êàâåðíîç-õýñýã òàñàð÷ ãýìòýýã¿é Àðüñ òàñàð÷, øýýñíèé (êîâåðíàÿ) õýñýã <2 ñì ñ¿â äóòìàãøèæ áýëýãèéí òîëãîéã òàñðàë äàéðíà Õàãàñ òàñàð÷ øýýñíèé ñ¿â êîâåðíàç õýñýãò ≥2 ñì äóòìàãøèëòàé Á¿ðýí òàñðàõ Óìàéí (æèðýìñýí áèø) ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàõ, öóñ õóðàõ ªíãºö õàãàðàõ (<1 ñì) ÿí òàñðàõ (≥1 ñì) Ais-90 1 1 3 3 3 3 3 3 Ais-90 2 2 3 39
  • 40. IV V Óìàéí àðòåðè õàãàðàõ Öóñàí õàíãàìæã¿é (òàñðàõ) 3 3 III àíãèëàë õ¿ðòýë îëîí ãýìòýëä I àíãèàð íýìýãäýíý. Àíãèëàë I II III IV V Óìàéí (æèðýìñýí) ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë, öóñ õóðàõ / èõýñ õîâõîðîîã¿é ªíãºö ÿçàðñàí (<1 ñì) èõýñèéí <25% õàãàñ õîâõîðñîí ÿí ÿçàðñàí (≥1 ñì) 2 äàõü 3 ñàðòàé áîë <25<50% ýõýñ õîâõîðñîí ÿí ÿçàðñàí (≥1 ñì) 3 äàõü 3 ñàðòàé Óìàé àðòåðè õàìàðñàí ÿçàðñàí (≥1 ñì)-ýýñ <50% ýõýñ õîâõîð÷ ã¿í õàãàðñàí Óìàé õàãàðàõ 2 äàõü 3 ñàð 3 äàõü 3 ñàðòàé Èõýñ á¿ðýí õîâõîðñîí Ais-90 2 3 3 4 4 4 4 5 4-5 III àíãèëàë õ¿ðòýë îëîí ãýìòýëòýé áîë I àíãè íýìýãäýíý. Àíãèëàë I II III IV V Óìàéí õîîëîéí ãýìòýë Ãýìòëèéí áàéäàë Íÿöàðñàí áóþó öóñ õóðàõ Ýðãýí òîéðîí <50% ÿçðàõ Ýðãýí òîéðîí ≥50% ÿçðàõ Õºíäëºí Ñóäàñ ãýìòýæ, öóñã¿éæèõ Ais-90 2 2 2 2 2 III àíãèëàë õ¿ðòýë 2 òàëäàà áîë I àíãè íýìýãäýíý. Àíãèëàë I II III IV V ªíäãºâ÷èéí ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàë áóþó öóñ õóðàõ ªíãºö ÿçðàõ (ã¿í íü<05 ñì) ÿí óðàãäàõ (ã¿í íü ≥05 ñì) Õýñýã÷ëýí õàãàðàõ öóñ õàíãàìæ îðñîí Á¿ðýí òàñàðñàí Ais-90 1 2 3 3 3 40
  • 41. III àíãèëàë õ¿ðòýë 2 òàëäàà ãýìòñýí áîë I àíãè íýìýãäýíý. Àíãèëàë I II III IV V ¯òðýýíèé ãýìòýë Ãýìòëèéí áàéäàë Íÿöðàõ áóþó öóñ õóðíà ªíãºö ÿçðàõ (çºâõºí ñàëñò á¿ðõýâ÷) ÿí ÿçðàõ áóë÷èíëàã äàâõàðò îðíî Íèéëìýë õýëáýðýýñ óðàãäàõ óìàéí õ¿ç¿¿, õÿðçàí ðóó îðñîí Çýðãýëäýýõ ýðõòýí (àíóñ, ãåñíèò, óìàé, äàâñàã ðóó îðñîí) Ais-90 1 1 2 3 3 III àíãèëàë õ¿ðòýë îëîí ãýìòýë àâñàí áîë I çýðýã íýìýãäýíý. 41
  • 42. The Comprehensive Classification of Fractures of Long Bones A classification is useful only if it considers the severity of the bone lesion and serves as basis for treatment and for evaluation of the results. Maurice E. Muller. The Principle of the Classification The fundamental principle of this classification is the division of all fractures of a bone segment into three types and their further subdivision into three groups and their subgroups, and the arrangement of these in ascending order of severity according to the morphologic complexities of the fracture, difficulties inherent in their treatment, and their prognosis. Which type?... Which group? … Which subgroup?... These three questions, and the three possible answers to each, are the key to the classification. The three types labeled A, B and C. Each type divided into three groups. A1, A2, A3; B1, B2, B3; C1, C2, C3.Thus there are 9 groups. As each group is further subdivided into 3 subgroups, denoted by a number .1, .2, .3, there are 27 subgroups for each segment. The subgroups represent the 3 characteristic variations within the group. The colours green, orange, and red, as well as the darkening arrows, indicate the increasing severity. A1 indicates the simplest fracture with the best prognosis and the C3 most difficult fracture with the worst prognosis. Thus when one has classified a fracture one has established its severity and obtained a guide to its best possible treatment. 42
  • 43. 43
  • 44. The Anatomic Location This is designated by two numbers, one for the bone and one for its segment. The Long Bones Ulna and Radius, and tibia and fibula are each considered as one bone. Therefore we have four long bones. 1=humerus, 2=radius/ ulna, 3=femur, 4=tibia/ fibula The Bone Segments Each long bone has three segments: the proximal, the diaphyseal and the distal segment (Fig. 2.). The malleolar segment is an exception and is classified as the fourth segment of the tibia/ fibula (44-). The segments are designated by numbers: 1=the proximal, 2=the middle, 3=the distal segment. The proximal and distal segments of long bones are each defined by a square whose sides are the same length as the widest part of the epiphysis (exceptions: 31- and 44- ). Before a fracture can be assigned to a segment, one must first determine its center. In a simple fracture the center is at the level of the broadest part of the wedge. In a complex fracture the center can only be determined after reduction. Any fracture associated with a displaced articular component is classified as an articular fracture. If the fracture is associated only with an undisplaced fissure reaches the joint, it is classified as metaphyseal or diaphyseal depending on the location of its center. 44
  • 45. 45
  • 46. The Fracture Types Diaphyseal Segment All fracture of the diaphyseal segment ( see Glossary ) are either “simple” ( type A ) or “multifragmentary”. Multifragmentary fractures are either “wedge” fractures (type B) or “complex” fractures ( type C). Proximal and Distal Segments In the proximal and distal segments the fractures are either “extra-articular” (type A) or “articular”. The articular fractures are either “partial articular” (type B) or “complete articular” (type C). The 3exceptions are: the proximal humerus ( A=extra-articular unifocal, B=extraarticilar biafocal, and C=articular ), the proximal femur ( A=trochanteric area, B=neck, C=head ), and the malleolar segment ( A=infrasyndesmotic, B=transsyndesmotic, and C=suprasyndesmotic ). The Coding of the Diagnosis The diagnosis of a fracture is obtained by combining its anatomic location with its morphological characteristic. The answers to the “Where?” … and “What?”… are the key to the diagnosis. An alpha-numeric coding system was chosen to express the diagnosis in order to facilitate computer storage and retrieval. Two numbers are used to express the location of the fracture. These are followed by a letter and two numbers which express the morphological characteristics of the fracture ( Fig. 5). Example of the coding of a fracture of a diaphyseal segment: 32-B2.1 3 Femur 2diaphysis B Wedge fracture 2 Bending wedge .1 Subtrochanteric Example of the coding of a fracture of a distal segment: 33-C3.2 3 3C 3 .2 Femur distal Complete multiMetaphyseal articular fragmentary multifracture fragmentary Fig.4 THe fracture types of the diaphyseal ( A=simple, B=wedge, C=complex ) and of most of the proximal and distal segments ( A=extra-articular, B=partial articular, C=complete articular ) of long bones. Fig.5 Alpha-numeric coding of the diagnosis ( =location+morphological characteristic ). 46
  • 47. 47
  • 48. Glossary All fractures are either simple or multifragmentary. simple: A term used to characterize a single circumferential disruption of a diaphysis or metaphysis or a single disruption of an articular surface. Simple fractures of the diaphusis or metaphysic are spiral, oblique or transverse. Multifragmentary: A term used to characterize any fracture with one or more completely separated intermediate fragment(s). In the diaphuseal and metaphyseal segments, it includes wedge and the complex fractures. The term wedge and complex are used only for diaphyseal or metaphyseal fractures. -wedge: A fracture with one or more intermediate fragment(s) in which, after reduction, there is some contact between the main fragment(s). The spiral or bending wedge maybe intact or fragmented. -complex: A fracture with one or more intermediate fragment(s) in which, after reduction, there is no contact between the main proximal nad distal fragments. The complex fractures are spiral, segmental or irregular. The term comminuted is imprecise and should not be used. Impacted: Stable and usually simple fracture of the metaphysis or epiphysis in which the fragments are driven one into the other. Specific Terms for the Proximal and Distal Segments Fractures of the proximal and distal segments are either extra-articular or articular. Extra-articular fractures: These do not involve the articular surface, although they may be intra-capsular. They include apophyseal and metaphyseal fractures. Articular fractures involve the articular surface. They are subdivided into partial and complete. Partial articular fractures: The fractures involve only part of the articular surface, while the rest of that surface remains attached to the diaphysis. Varieties of the partial articular fractures: -pure split: A fracture, resulting from a sharing force, in which the deriction of the split is usually longitudinal. -pure depression: An articular fracture in which there is pure depression of the articular surface without a split. The depression may be central or peripheral. -split depression: A combination of a split and depression in which the joint fragments are usually separated. -multifagmentary depression: A fracture in which part of the joint is depressed and the fragments are completely separated. Complete articular fragments: The articular surface is disrupted and completely separated from the diaphysis. The severity of these fractures depents on whether its articular and metaphyseal components are simple of multifragmentary. 48
  • 49. 11-Humerus proximal A1 = Extra-articular unifocal fracture, tuberosily 1. greater tuberosity, not displaced 2. greater tuberosity, displaced 3. with a glenohumeral dislocation A2 = Extra-articular unifocal fracture, impacted metaphyseal 1. without frontal malalignment 2. with varus malalignment 3. with valgus malalignment A3= Extra-articular unifocal fracture, non-impacted metaphyseal 1. simple, with angulation 2. simple, with translation 3. multifragmentary B1 = Extra-articular bifocal fracture, with metaphyseal impaction 1. lateral + greater tuberosity 2. medial + lesser tuberosity 3. posterior + greater tuberosity B2 = Extra-articular bifocal fracture, without metaphyseal impaction 1. without rotatory displacement of the epiphyseal 2. with rotatory displacement of the epiphyseal fragment 3. multifragmentary metaphyseal + one of the tuberosities B3 = Extra-articular bifocal fracture, with glenohumeral dislocation 1. <<vertical>> cervical line + greater tuberosity intact + anterior and medial dislocation 2. <<vertical>> cervical line + greater tuberosity fractured + anterior and medial dislocation 3. lesser tuberosity fractured + posterior dislocation C1 = articuler fracture, with slight displacement 1. cephalotubercular, with valgus malalignment 2. cephalotubercular, with varus malalignment 3. anatomical neck C2 = articuler fracture, impacted with marked displacement 1. cephalotubercular, with valgus malalignment 2. cephalotubercular, with varus malalignment 3. transcephalic and tubercular, with varus malalignment C3 = articuler fracture, dislocated 1. anatomical neck 2. anatomical neck and tuberosities 3. cephalotubercular fragmentation 49
  • 50. 50
  • 51. 12- Humerus Diaphysis A=Simple fracture A1 Simple fracture, spiral 1. proximal zone 2. middle zone 3. distal zone A2 Simple fracture, oblique (≥300) 1. proximal zone 2. middle zone 3. distal zone A3 Simple fracture, transverse (<300) 1. proximal zone 2. middle zone 3. distal zone B=Wedge fracture B1 Wedge fracture, spiral wedge 1. proximal zone 2. middle zone 3. distal zone B2 Wedge fracture, bending wedge 1. proximal zone 2. middle zone 3. distal zone B3 Wedge fracture, fragmented wedge 1. proximal zone 2. middle zone 3. distal zone C= Complex fracture C1 Complex fracture, spiral 1. with two intermediate fragments 2. with three intermediate fragments 3. with more intermediate fragments C2 Complex fracture, segmental 1. with one intermediate segmental fragments 2. with one intermediate segmental and additional wedge fragment(s) 3. with two intermediate segmental fragments C3 Complex fracture, irregular 1. with two or three intermediate fragments 2. with limited shattering (<4cm ) 3. with extensive shattering (≥4cm) 51
  • 52. 52
  • 53. 13-Humerus Distal A=Extra-articular fracture A1. Extra-articular fracture, apophyseal avulsion 1. lateral epicondyle 2. medial epicondyle, non incarcerated 3. medial epicondyle, incarcerated A2. Extra-articular fracture, metaphyseal simple 1. oblique downwards and inwards 2. oblique downwards and outwards 3. transverse A3. Extra-articular fracture, metaphyseal multifragmentary 1. with an intact wedge 2. with a fragmented wedge 3. complex B=Partial articular fracture B1. Partial articular fracture, lateral sagittal 1. capitellum 2. transtrochlear simple 3. transtrochlear multifragmentary B2. Partial articular fracture, medial sagittal 1. transtrochlear simple, through the medial side ( Milch I ) 2. transtrochlear simple, through the groove 3. transtrochlear multifragmentary B3. Partial articular fracture, frontal 1. capitellum 2. trochlea 3. capitellum and trochlea C=Complete articular fracture C1. Complete articular fracture, articular simple, metaphyseal simple 1. with slight displacement 2. with marked displacement 3. T-shaped epiphyseal C2. Complete articular fracture, articular simple, metaphyseal multifragmentary 1. with an intact wedge 2. with an fragmented wedge 3. complex C3. Complete articular fracture, multifragmentary 1. metaphyseal simple 2. metaphyseal wedge 3. metaphyseal complex 53
  • 54. 54
  • 55. 21-Radius/Ulna Proximal A=Extra-articuler fracture A1. Extra-articuler fracture, of the ulna, radius intact. 1. avulsion of the triceps insertion from the olecranon 2. metaphyseal simple 3. metaphyseal multifragmentary A2. Extra-articuler fracture, of the radius, ulna intact 1. avulsion of the bicipital tuberosity of the radius 2. neck simple 3. neck multifragmentary A3. Extra-articuler fracture, of both bones 1. simple of both bones 2. multifragmentary of one bone and simple of the other 3. multifragmentary of both bones B=Articular fracture of one bone B1. Articular fracture, of the ulna, radius intact 1. unifocal 2. bifocal simple 3. bifocal multifragmentary B2. Articular fracture, of the radius, ulna intact 1. simple 2. multifragmentary without depression 3. multifragmentary with depression B3. Articular fracture, of the one bone with extra-articular fracture of the other 1. ulna, articular simple 2. radius, articular simple 3. articular multifragmentary C= Articular fracture of both bones C1. Articular fracture, of both bones, simple 1. olecranon and head of radius 2. coronoid process and head of radius C2. Articular fracture, of both bones, simple and the other multifragmentary 1. olecranon multifragmentary, radial head simple 2. olecranon simple, radial head multifragmentary 3. coronoid process simple, radial head multifragmentary C3. Articular fracture, of both bones, multifragmentary 1. three fragments of each bone 2. ulna, more than three fragments 3. radius, more than three fragments 55
  • 56. 56
  • 57. 22-Radius/Ulna Diaphysis A=Simple fracture A1. Simple fracture, of the ulna, radius intact 1. oblique 2. transverse 3. with dislocation of the radial head ( Monteggia ) A2. Simple fracture, of the radius, ulna intact 1. oblique 2. transverse 3. with dislocation of the distal radio-ulnar joint ( Galeazzi ) A3. Simple fracture, of the both bones 1. radius, proximal bones 2. radius, middle zone 3. radius, distalzone B=Wedge fracture B1. Wedge fracture, of the ulna, radius intact 1. intact wedge 2. fragmented wedge 3. with dislocation of the radial head ( Monteggia ) B2. Wedge fracture, of the radius, ulna intact 1. intact wedge 2. fragmented wedge 3. with dislocation of the distal radio-ulnar joint ( Galeazzi ) B3. Wedge fracture, of the one bone, simple or wedge fracture of the other 1. ulnar wedge and simple fracture of the radius 2. radius wedge and simple fracture of the ulna 3. ulnar and radial wedges C=Complex facture C1. Complex facture, of the ulna 1. bifocal, radius intact 2. bifocal, radius fractured 3. irregular C2. Complex facture, of the radius 1. bifocal, radius intact 2. bifocal, radius fractured 3. irregular C3. Complex facture, of the bones 1. bifocal, radius intact 2. bifocal, radius fractured 3. irregular 57
  • 58. 58
  • 59. 23-Radius/Ulna Distal A= Extra-articuler fracture A1. Extra-articuler fracture, of the ulna, radius intact. 1. styloid process 2. metaphyseal simple 3. metaphyseal multifragmentary A2. Extra-articuler fracture, of the radius, simple and impacted 1. without any tilt 2. with dorsal tilt ( Pouteau-Colles ) 3. with volar tilt ( Goyrand-Smith ) A3. Extra-articuler fracture, of the radius, multifragmentary 1. impacted with axial shortening 2. with a wedge 3. complex B=Partial articular fracture B1. Partial articular fracture, of the radius, sagittal 1. lateral simple 2. lateral , multifragmentary 3. medial B2. Partial articular fracture, of the radius, dorsal rim ( Barton ) 1. simple 2. with lateral sagittal fracture 3. with dorsal dislocation of the carpus B3. Partial articular fracture, of the radius, volar rim ( reverse Barton, Goyrand-Smith II ) 1. simple, with a small fragment 2. simple, with a large fragment 3. multifragmentary C=Complete articular fracture C1. Complete articular fracture, of the radius, articular simple, metaphyseal simple 1. postero-medial articular fracture 2. sagittal articular fracture line 3. frontal articular fracture line C2. Complete articular fracture, of the radius, articular simple, metaphyseal multifragmentary 1. sagittal articular fracture line 2. frontal articular fracture line 3. extending into ht ediaphysis C3. Complete articular fracture, of the radius, metaphyseal 1. metaphyseal simple 2. metaphyseal multifragmentary 3. extending into ht ediaphysis 59
  • 60. 60
  • 61. 31-Femur Proximal A=Trochanteric area fracture A1. Trochanteric area fracture, pertrochanteric simple 1. along the intertrochanteric line 2. through the greater trochanter 3. below the lesser trochanter A2. Trochanteric area fracture, pertrochanteric multifragmentary 1. with one intermediate fragment 2. with several intermediate fragment 3. extending more than 1cm below the lesser trochanter A3. Trochanteric area fracture, intertrochanteric 1. simple, oblique 2. simple, transverse 3. multifragmentary B=Neck fracture B1. Neck fracture, subcapital, with slight displacement 1. impacted in valgus ≥150 2. impacted in valgus <150 3. non-impacted B2. Neck fracture, transcervical 1. basicervical 2. midcervical adduction 3. midcervical shear B3. Neck fracture, subcapital, non-impacted, displaced 1. moderate displacement in varus and external rotation 2. moderate displacement with vertical translation and external rotation 3. marked displacement C=Head fracture C1. Head fracture, split 1. avulsion of the ligamentum teres 2. with rupture of the ligamentum teres 3. large fragment C2. Head fracture, with depression 1. posterior and superior 2. anterior and superior 3. split-depression C3. Head fracture, with neck fracture 1. split and transcervical neck fracture 2. split and subcapital neck fracture 3. depression and neck fracture 61
  • 62. 62
  • 63. 32-Femur Diaphysis A=Simple fracture A1. Simple fracture, spiral 1. subtrochanteric zone 2. middle zone 3. distal zone A2. Simple fracture, oblique (≥300) 1. subtrochanteric zone 2. middle zone 3. distal zone A3. Simple fracture, transverse (<300) 1. subtrochanteric zone 2. middle zone 3. distal zone B=Wedge fracture B1. Wedge fracture, spiral wedge 1. proximal zone 2. middle zone 3. distal zone B2. Wedge fracture, bending wedge 1. proximal zone 2. middle zone 3. distal zone B3. Wedge fracture, fragmented wedge 1. proximal zone 2. middle zone 3. distal zone C= Complex fracture C1. Complex fracture, spiral 1. with two intermediate fragments 2. with three intermediate fragments 3. with more intermediate fragments C2. Complex fracture, segmental 1. with one intermediate segmental fragments 2. with one intermediate segmental and additional wedge fragment(s) 3. with two intermediate segmental fragments C3 . Complex fracture, irregular 1. with two or three intermediate fragments 2. with limited shattering (<5cm ) 3. with extensive shattering (≥5cm) 63
  • 64. 64
  • 65. 33-Femur Distal A= Extra-articuler fracture A1. Extra-articuler fracture, simple 1. apophyseal 2. metaphyseal oblique or spiral 3. metaphyseal transverse A2. Extra-articuler fracture, metaphyseal wedge 1. intact 2. fragmented, lateral 3. fragmented, medial A3. Extra-articuler fracture, metaphyseal complex 1. with an intermediate split segment 2. irregular, limited to the metaphysis 3. irregular, extending into the diaphysis B= Partial articular fracture B1. Partial articular fracture, lateral condyle, sagittal 1. simple, through the notch 2. simple, through the load-bearing surface 3. multifragmentary B2. Partial articular fracture, medial condyle, sagittal 1. simple, through the notch 2. simple, through the load-bearing surface 3. multifragmentary B3. Partial articular fracture, frontal 1. anterior and lateral flake fracture 2. unicondylar posterior ( Hoffa ) 3. bicondylar posterior C=Complete articular fracture C1. Complete articular fracture, articular simple, metaphyseal simple 1. T- or Y-shaped, with slight displacement 2. T- or Y-shaped, with marked displacement 3. T- shaped epiphyseal C2. Complete articular fracture, articular simple, metaphyseal multifragmentary 1. with an intact wedge 2. with a fragmented wedge 3. complex C3. Complete articular fracture, multifragmentary 1. metaphyseal simple 2. metaphyseal multifragmentary 3. metaphyseo-diaphyseal multifragmentary 65
  • 66. 66
  • 67. 41-Tibia/Fibula Proximal A= Extra-articuler fracture A1. Extra-articuler fracture, avulsion 1. of the febular head 2. of the tibial tuberosity 3. of the cruciate insertion A2. Extra-articuler fracture, metaphyseal simple 1. oblique in the frontal plane 2. oblique in thesagittal plane 3. transverse A3. Extra-articuler fracture, metaphyseal multifragmentary 1. intact wedge 2. fragmented wedge 3. complex B= Partial articular fracture B1. Partial articular fracture, pure split 1. of the lateral surface 2. of the medial surface 3. oblique, involving the tibial spines and one of the surface B2. Partial articular fracture, pure depression 1. lateral total 2. lateral limited 3. medial B3. Partial articular fracture, split-depression 1. lateral 2. medial 3. oblique, involving the tibial spines and one of the surface C= Complete articular fracture C1. Complete articular fracture, articular simple, metaphyseal simple 1. slight displacement 2. one condyle displaced 3. both condyle displaced C2. Complete articular fracture, articular simple, metaphyseal multifragmentary 1. with an intact wedge 2. with a fragmented wedge 3. complex C3. Complete articular fracture, multifragmentary 1. lateral 2. medial 3. lateral and medial 67
  • 68. 68
  • 69. 42-Tibia/Fibula Diaphysis A=Simple fracture A1. Simple fracture, spiral 1. fibula intact 2. fibula fractured at another level 3. fibula fractured at the same level A2. Simple fracture, oblique (≥300) 1. fibula intact 2. fibula fractured at another level 3. fibula fractured at the same level A3. Simple fracture, oblique (<300) 1. fibula intact 2. fibula fractured at another level 3. fibula fractured at the same level B=Wedge fracture B1. Wedge fracture, spiral wedge 1. fibula intact 2. fibula fractured at another level 3. fibula fractured at the same level B2. Wedge fracture, bending wedge 1. fibula intact 2. fibula fractured at another level 3. fibula fractured at the same level B3. Wedge fracture, fragmented wedge 1. fibula intact 2. fibula fractured at another level 3. fibula fractured at the same level C= Complex fracture C1. Complex fracture, spiral 1. with two intermediate fragments 2. with three intermediate fragments 3. with more intermediate fragments C2. Complex fracture, segmental 1. with one intermediate segmental fragments 2. with one intermediate segmental and additional wedge fragment(s) 3. with two intermediate segmental fragments C3 . Complex fracture, irregular 1. with two or three intermediate fragments 2. with limited shattering (<4cm ) 3. with extensive shattering (≥4cm) 69
  • 70. 70
  • 71. 43-Tibia/Fibula Distal A= Extra-articuler fracture A1. Extra-articuler fracture, metaphyseal simple 1. spiral 2. oblique 3. transverse A2. Extra-articuler fracture, metaphyseal wedge 1. postero-lateral impaction 2. antero-medial wedge 3. extending into the diaphysis A3. . Extra-articuler fracture, metaphyseal complex 1. three intermediate fragments 2. more than three intermediate fragments 3. extending into the diaphysis B= Partial articular fracture B1. Partial articular fracture, pure split 1. frontal 2. sagittal 3. metaphyseal multifragmentary B2. Partial articular fracture, split-depression 1. frontal 2. sagittal 3. of the central fragment B3. Partial articular fracture, multifragmentary depression 1. frontal 2. sagittal 3. metaphyseal multifragmentary C= Complete articular fracture C1. Complete articular fracture, articular simple, metaphyseal simple 1. without depression 2. with depression 3. extending into the diaphysis C2. Complete articular fracture, articular simple, metaphyseal multifragmentary 1. with asymmentric impaction 2. without asymmentric impaction 3. extending into the diaphysis C3. Complete articular fracture, multifragmentary 1.epiphyseal 2. epiphyseo-metaphyseal 3. epiphyseo-metaphyseo-diaphyseal 71
  • 72. 44-Tibia/Fibula, Malleolar Segment A=Infrasyndesmotic lesion A1. Infrasyndesmotic lesion, isolated 1. rupture of the lateral collateral ligament 2. avulsion of the tip of the lateral malleolus 3. transverse fracture of the lateral malleolus A2. Infrasyndesmotic lesion, with fracture of the medial malleolus 1. rupture of the lateral collateral ligament 2. avulsion of the tip of the lateral malleolus 3. transverse fracture of the lateral malleolus A3. Infrasyndesmotic lesion, with postero-medial fracture 1. rupture of the lateral collateral ligament 2. avulsion of the tip of the lateral malleolus 3. transverse fracture of the lateral malleolus B=Transsyndesmotic fibular fracture B1. Transsyndesmotic fibular fracture, isolated 1. simple 2. simple, with rupture of the anterior syndesmosis 3. multifragmentary B2. Transsyndesmotic fibular fracture, with medial lesion 1. simple, with rupture of the medial collateral ligament and rupture of the anterior syndesmosis 2. simple, with fracture of the malleolus and rupture of the anterior syndesmosis 3. multifragmentary B3. Transsyndesmotic fibular fracture, with medial lesion and a Volkmann 1. fibula simple, with rupture of the medial collateral ligament 2. fibula simple, with fracture of the medial malleolus 3. fibula multifragmentary, with fracture of the medial malleolus C=Suprasyndesmotic lesion C1. Suprasyndesmotic lesion, diaphyseal fracture of the fibula, simple 1. with rupture of the medial collateral ligament 2. with fracture of the medial malleolus 3. with fracture of the medial malleolus and a Volkmann (=Dupuytren) C2. Suprasyndesmotic lesion, diaphyseal fracture of the fibula, simple, multifragmentary 1. with rupture of the medial collateral ligament 2. with fracture of the medial malleolus 3. with fracture of the medial malleolus and a Volkmann (=Dupuytren) C3. Suprasyndesmotic lesion, proximal fibular lesion 1. without shortening, without Volkmann 2. with shortening, without Volkmann 3. medial lesion and a Volkmann 72
  • 73. Classification of articular and periarticuler fractures in children with involvement of the physeal plate: three main groups (M.E. Muller) A. The fracture passes through the junction of the zones of hypertrophy and provisional ossification. The fracture line does not involve the growth zones. Growth disturbance is unlikely (expect at the proximal femur and proximal radius), even with incomplete reduction. Deformity in the plane of motion is likely to remodel itself as long as growth continues. A1. ( Salter-Harris type I ) This is a pure shearing injury of the physeal plate and usually results from a rotational force. A2. ( Salter-Harris type II ) This is partly a shear injury of the physis and partly a metaphyseal fracture (Thurston-Holland fragment). 70% of physeal injuries are type A2. B. The fracture line transverses all layers of the physis. If reduction is not anatomically perfect, growth disturbance is highly. Likely. B1. (Salter-Harris type III ) Partial physeal separation witn an intra-articuler epiphyseal fracture. Open reduction with screw fixation is strongly indicated. The screw must not penetrate the physeal plate. B2. (Salter-Harris type IV ) The fracture plane passes from of the joint surface through all layers of thr physis and through thr metaphysis. As in tape B1, screw fixation is strongly indicated using one screw in the epiphysis and one in the metaphysis, with neither crossing the growth plate. B3. ( M.E. Muller ) An avulsion fracture of an insertion of a collateral ligament, taking with it a portion of the perichondrial ring ( zone of Ranvier ). Accurate reduction and fixation are required, but growth disturbance can still follow. B4. ( M. Rang ) Open abrasive damage to the periphery of the physis, also injuring the zone of Ranvier. Partial closure is the usual sequel. C. (Salter-Harris type V ) There is compression of the articular surface and impaction of epiphyseal bone into metaphyseal bone, with consequent disorganisation of part of the physeal cartilage. Partial growth arrest is to be expected and reconstructive procedures, such as those of Langenskiold and Osterman (1983), are necessary later. C1,C2. Different degrees of impaction. 73
  • 74. Skin lesions IC ( Closed Fractures ) For the description of the skin lesion the letter “I” was chosen for Integument, which translates well into most Latin and Anglo-Saxon languages. The letters “C” and “O” designate closed and open fractures. Thus, for closed fractures: IC1 = no skin lesion IC2 = no skin laceration, but contusion IC3 = circumscribed devolving IC4 = extensive, closed devolving IC5 = necrosis from contusion Skin Lesions IO ( Open Fractures ) IO1 = skin breakage from inside out IO2 = skin breakage from outside in <5cm, contused edges IO3 = skin breakage >5cm, increased contusion, devitalized edges IO4 = considerable, full-thickness contusion, abrasion, extensive open devolving, skin loss. This grading of skin wounds fits well with the three-grade system for open fractures but adds a fourth grade for really extensive skin destruction. Muscle / Tendon Injury (MT) 74
  • 75. As there may be considerable injury to the muscle envelope and, rarely, also to the tendons in open as well in closed fractures, and since this feature is highly prognostic, a grading of the extent of muscle tissue and tendon involvement is considered essential: MT1 = no muscle injury MT2 = circumscribed muscle injury, one compartment only MT3 = considerable muscle injury, two compartments MT4 = muscle defect, tendon laceration, extensive muscle contusion MT5 = compartment syndrome/crush syndrome with wide injury zone Neurovascular Injury ( NV ) The neurovascular injuries are described with the letter “NV” as follows: NV1 = no neurovascular injury NV2 = isolated nerve injury NV3 = localized vascular injury NV4 = extensive segmental vascular injury NV5 = combined neurovascular injury, including subtotal or even total amputation Examples - A simple, closed spiral tibia shaft fracture with no relevant lesions of skin, muscle / tendons, nerves and vessels becomes: 42-À1/ IÑ1-ÌÒ1-NV1 - A severe open complex irregular tibia shaft fracture with extensive muscular damage and an isolated nerve injury becomes: 42-C3/104-MT2 or 3-NV2 or 3 - The near-amputation or complex irregular tibia shaft fracture with extensive skin loss, muscle and tendon damage plus a combined neurovascular injury now becomes: 42-C3/104-MT4-NV5 TRAUMA SCORING AND MEASUREMENTS OF INJURY SEVERITY 75
  • 76. I.OVERVIEW: A. Triage of the trauma patient is systematically organized through a trauma scoring system that allows comparison of multiply injured victims in need of medical attention. A trauma scoring system allows the physician to prioritize medical care and aids in initial assessment of degree of injury. Most scoring systems are based on the rapid assessment of overall condition without attention to specific organ injury. Trauma scoring provides a definitive language for communication between hospital personnel and has proved to be most useful in organizing medical attention for multiply injured patients. B. Many trauma scoring systems have been devised over the past several years. Most currently available systems involve measuring physiologic variables included in the brief initial assessment (vital signs, airway, and level of consciousness). Trauma scoring makes possible the initial assessment of potential patient morbidity and mortality at the scene of the accident or in the emergency room. II. COMMON TRAUMA SCORING SYSTEMS: 1.Glasgow Coma Scale. The Glasgow Coma Scale (GCS) is a clinical index for assessing the degree of impaired consciousness. a. The GCS is calculated by determining the patient’s best motor, verbal, and eye opening responses (Table.1).These parameters reflect the function of the central nervous system (CNS), its degree of integration, and brainstem function, respectively. b. Scores range from 3 to 15, increasing as the level of consciousness and integration capabilities improve. Scores ≤8 indicate coma. c. As initially described, the GCS did not account for the patient who was intubated or pharmacologically paralyzed. The patient with a GCS score of 3 because of head injury can be very different from the patient who was pharmacologically paralyzed and intubated for airway control, but who then has a GCS score of 3. In the latter circumstance, the GCS score should be recorded as 3TP, indicating that the patient was intubated (T) and pharmacologically paralyzed (P). d. The motor component is the most important value in the GCS. The motor component score correlates highly with the total GCS score. Table 1. Glasgow Coma Scale Eye opening Verbal response Motor response Spontaneous -To voice -To pain -None Oriented Confused Inappropriate Incomprehensible None Obeys command Localizes pain 4 3 4 1 5 4 3 2 1 6 5 76
  • 77. Withdraws (pain) Flexion Extension (pain) None Total score 4 3 2 1 3-15 2. Abbreviated Injury Scale (AIS). This system is based on the summation of multiple system scores. Each system is scored for injury on an arbitrary numerical scale of 1 to 6, with injury severity increasing with number. The AIS places numerical value on an individual organ system, so a summary score is of necessity to evaluate organ-injured trauma patients. 3. Injury Severity Score: a. The Injury Severity Score (ISS) was designed to assess the severity of the multiple injured trauma patient in a precise, reproducible fashion. b. Correlation of the ISS with the AIS is as follows. Any patient with an AIS of 6 is assigned an ISS of 75. The ISS of less severely injured patients is derived by a sum of the squares of the three highest AIS scores for different areas of the body (head, shoulder, extremities). For example, Abdomen Ruptured spleen AIS 2 Chest Fractured ribs AIS 2 Extremity Femur fracture AIS 3 The ISS is 22+22+32=17. c. The ISS scores only the most severe injury in each category, which has brought much criticism to the scoring system. The ISS does correlate with mortality as effectively as any other scoring system and is at present the system most frequently used to assess severity of various anatomic injuries. 4. Injury scales Ais-90 Trauma scoring Cervical vascular organ injury scale Grade‫٭‬ I II III Description of injury Thyroid vein Common facial vein External jugular vein Unnamed arterial or venous branches External carotid arterial branches (ascending pharyngeal, superior thyroid, lingual, facial, maxillary, occipital, posterior auricular) Thyrocervical trunk or primary branches Internal jugular vein External carotid artery Subclavian vein AIS – 90 1-3 1-3 1-3 1-3 1-3 1-3 1-3 2-3 3-4 77
  • 78. IV V Vertebral artery Common carotid artery Subclavian artery Internal carotid artery (extracranial) 2-4 3-5 3-4 3-5 ‫٭‬Increase one crade for multiple grade III or IV injuries involving >50% vessel circumference. Decrease one grade for <25% vessel circumference disruption for grade IV or V. AIS, Abbreviated Injury Score Chest wall injury scale Grade‫٭‬ I Injury type Contusion Laceration Fracture II Laceration Fracture III Laceration Fracture IV Laceration V Fracture Laceration Description of injury AIS – 90 Any size Skin and subcutaneous tissue Fewer than three ribs, closed; nondisplaced clavicle closed Skin, subcutaneous tissue and muscle Three or more adjacent ribs, closed Open or displaced clavicle Nondisplaced sternum, closed Scapular body, open or closed Full thickness, including pleural penetration Open or displaced sternum flail sternum Unilateral flail segment (<3 ribs) Avulsion of chest wall tissues with underlying rib fractures Unilateral flail chest (≥ 3 ribs) Bilateral flail chest (≥ 3 ribs on both sides) 1 1 1-2 1 2-3 2 2 2 2 2 3-4 4 3-4 5 Lung injury scale Grade‫ ٭‬Injury type I Contusion II Contusion Laceration III Confusion Laceration Hematoma IV Laceration Hematoma Vascular V Vascular Description of injury Unilateral, less than one lobe Unilateral, single lobe Simple pneumothorax Unilateral more than one lobe Persistent (>72 hours) air leak from distal airway Nonexpanding intraparenchymal Major (segmental or lobal) air leak Expanding intraparenchymal Primary branch intrapulmonary vessel disruption Hilar vessel disruption AIS – 90 3 3 3 3 3-4 4-5 3-5 4 78
  • 79. VI Vascular Total uncontained transaction of pulmonary hilum 4 ‫ ٭‬Advance one grade for bilateral injuries up to grade III. Hemothorax is scored under thoracic vascular injury scale. AIS, abbreviated Injury Score. Thoracic vascular injury scale Grade‫٭‬ I II III IV V VI Description of injury Intercostal artery or vein Internal mammary artery or vein Bronchial artery or vein Esophageal artery or vein Hemiazygous vein Unnamed artery or vein Azygos vein Internal jugular vein Subclavian vein Innominate vein Carotid artery Innominate artery Subclavian artery Thoracic aorta, descending Inferior vena cava (intrathoracic) Pulmonary artery, primary intraparenchymalbranch Pulmonary vein , primary intraparenchymalbranch Thoracic aorta, ascending and arch Superior vena cava Pulmonary artery, main trunk Pulmonary vein, main trunk Uncontained total transaction of thoracic aorta or pulmonary hilum AIS – 90 2-3 2-3 2-3 2-3 2-3 2-3 2-3 2-3 3-4 3-4 3-5 3-4 3-4 4-5 3-4 3 3 5 3-4 4 4 4 ‫٭‬Increase one crade for multiple grade III or IV injuries if >50% vessel circumference; decrease one grade for grade IV or V injuries if <25% circumference. AIS, Abbreviated Injury Score Pancreas injury scale Grade‫٭‬ III Type of injury Hematoma Laceration Hematoma Laceration Laceration IV Laceration I II Description of injury Minor contusion without duct injury Superficial laceration without duct injury Major contusion without duct injury or tissue loss Major laceration without duct injury or tissue loss Distal transection or parenchymal injury with duct injury Proximal transection or parenchymal injury AIS – 90 2 2 2 3 3 4 79
  • 80. V Laceration involving ampulla Massive disruption of pancreatic head 5 Esophagus injury scale Grade‫٭‬ I II III IV V Description of injury Contusion or hematoma Partial thickness laceration Laceration circumference <50% Laceration circumference ≥50% Segmental loss or devascularization <2 cm Segmental loss or devascularization ≥2 cm AIS – 90 2 3 4 4 5 5 Stomach injury scale Grade‫٭‬ I II III IV V Description of injury Contusion or hematoma Partial thickness laceration Laceration GE junction or pyloris <2cm In proximal one third of stomach <5cm In distal two thirds of stomach <10cm Laceration >2cm in GE junction or pyloris In proximal one third of stomach ≥5cm In distal two thirds of stomach ≥10cm Tisue loss or devascularization < two thirds of stomach Tissue loss or devascularization > two thirds of stomach AIS – 90 2 2 3 3 3 3 3 3 4 4 Duodenum injury scale 80
  • 81. Grade‫٭‬ III Type of injury Hematoma Laceration Hematoma Laceration Laceration IV Laceration V Laceration Vascular I II Description of injury Involving single portion of duodenum Partial thickness, no perforation Involving more than one portion Disruption <50% of circumference Disruption 50% to 75% of circumference of D2 Disruption 50% to 100% of circumference of D1, D3, D4 Disruption >75% circumference of D2 Involving ampulla or distal common bile duct Massive disruption of duodenopancreatic complex Devascularization of duodenum AIS – 90 2 3 2 4 4 4 5 5 5 5 Small bowel injury scale Grade‫٭‬ II III Type of injury Hematoma Laceration Laceration Laceration IV V Laceration Laceration I Vascular Description of injury Contusion or hematoma without devascularization Partial thickness, no perforation Laceration <50% of circumference Laceration ≥50% of circumference without transection Transection of the small bowel Transection of the small bowel with segmental tissue loss Devascularization segment AIS – 90 2 2 3 3 4 4 4 Colon injury scale Grade‫٭‬ II III Type of injury Hematoma Laceration Laceration Laceration IV V Laceration Laceration I Description of injury Contusion or hematoma without devascularization Partial thickness, no perforation Laceration <50% of circumference Laceration ≥50% of circumference without transection Transection of the colon Transection of the colon with segmental tissue loss AIS – 90 2 2 3 3 4 4 Rectum injury scale 81
  • 82. Grade‫٭‬ II III IV Type of injury Hematoma Laceration Laceration Laceration Laceration V Laceration I Description of injury Contusion or hematoma without devascularization Partial – thickness, laceration Laceration <50% of circumference Laceration ≥50% of circumference Full – thickness laceration with extension into the perineum Devascularized segment AIS – 90 2 2 3 4 5 5 Abdominal vascular injury scale Grade‫ ٭‬Description of injury I Non – named superior mesenteric artery or superior mesenteric vein branches Non – named inferior mesenteric artery or inferior mesenteric artery or inferior mesenteric vein branches Phrenic artery or vein Lumbar artery or vein Gonadal artery or vein Ovarian artery or vein Other non – named, small arterial or venous structures requiring ligation II Right, left, or common hepatic artery Splenic artery or vein Right or left gastric arteries Gastroduodenal artery Inferior mesenteric artery, or inferior mesenteric vein, trunk Primary named branches of mesenteric artery (e.g., ileocolic artery) or mesenteric vein Other named abdominal vessels requiring ligation or repair III Superior mesenteric vein, trunk Renal artery or vein Iliac artery or vein Hypogastric artery or vein Vena cava, infrarenal IV Superior mesenteric artery, trunk Celiac axis proper Vena cava, suprarenal and infrahepatic Aorta, infrarenal V Portal vein Extraparenchymal hepatic vein Vena cava, retrohepatic or suprahepatic Aorta suprarenal, subdiaphragmatic AIS – 90 NS NS NS NS NS NS NS 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3/5 5 4 82
  • 83. Adrenal organ injury scale Grade‫٭‬ I II III IV V Description of injury Contusion Laceration involving only cortex (<2cm) Laceration extending into medulla (≥2cm) Parenchymal destruction (>50%) Total parenchymal destruction (including massive intraparenchymal hemorrage) Avulsion from blood supply AIS – 90 1 1 2 2 3 3 Kidney injury scale Grade‫٭‬ I Type of injury Contusion Hematoma II Hematoma Laceration III Laceration IV Laceration Vascular V Laceration Vascular Description of injury Microscopic or gross hematuria, urologic studies normal Subcapsular, nonexpanding without parenchymal laceration Nonexpanding perirenal hematoma confined to renal retroperitoneum Parenchymal depth of renal cortex (<1.0cm) without urinary extravasation Parenchymal depth of renal cortex (>1.0cm) without collecting system rupture or urinary extravasation Parenchymal laceration extending htrough the renal cortex, medulla, and collecting system Main renal artery or vein injury with contained hemorrhage Completely shattered kidney Avulsion of renal hilum which devascularizes kidney AIS – 90 2 2 2 2 3 4 4 5 5 Ureter injury scale Grade‫ ٭‬Type of injury I Hematoma II Laceration III Laceration IV Laceration V Laceration Description of injury AIS – 90 Contusion of hematoma without devascularization 2 Transection <50% 2 Transection ≥50% 3 Complete transaction with <2 cm devascularization 3 Avulsion with > 2cm of devascularization 3 Bladder injury scale 83
  • 84. Grade‫٭‬ I II III Injury type Hematoma Laceration Laceration Laceration IV V Laceration Laceration Description of injury Contusion intramural hematoma Partial thickness Extaperitoneal bladder wall laceration <2cm Extaperitoneal (≥2cm) or intraperitoneal (<2cm) bladder wall laceration Intraperitoneal bladder wall laceration ≥2 cm Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone) AIS – 90 2 3 4 4 4 4 Urethra injury scale Grade‫٭‬ I Injury type Contusion II Stretch injury III Partial disruption Complete disruption Complete disruption IV V Description of injury AIS – 90 Blood at urethral meatus; urethrography normal 2 2 Elongation of urethra without extravasation on urethragraphy Extravasation of urethrography contrast at injury site with visualization in the bladder; Extravasation of urethrography contrast at injury site with visualization in the bladder; <2 cm of urethral separation Complete transaction with ≥ 2cm urethral separation, or extension into the prostate or vagina Uterus (nonpregnant) injury scale Grade‫٭‬ I II III IV V Description of injury Contusion or hematoma Superficial laceration (<1 cm) Deep laceration (≥1cm) Laceration involving uterine artery Avulsion / devascularization AIS – 90 2 2 3 3 3 Uterus (pregnant) injury scale 84 2 3 4
  • 85. Ovary injury scale Grade‫٭‬ Description of injury I II III Contusion or hematoma (without placental abruption) Superficial laceration (<1 cm) or partial placental abtuprion <25% Deep laceration (≥1cm) occurring in second trimester or placental abruption <25% but 50% Deep laceration (≥1 cm) in third trimester Laceration involving uterine artery Deep laceration (≥1 cm) with >50% placental abruption Uterine rupture Second trimester Third trimester Complete placental abruption Description of injury AIS – 90 Contusion or hematoma 1 Superficial laceration (depth <0.5 cm) 2 Deep laceration ( depth ≥0.5cm) 3 Partial disruption of blood supply 3 Avulsion or complete parenchymal destruction 3 IV V Grade‫٭‬ I II III IV V Fallopian tube injury scale Grade‫٭‬ I II III IV V Description of injury Contusion or hematoma Laceration <50% circumference Laceration ≥50% circumference Transection Vascular injury; devascularized segment AIS – 90 2 2 2 2 2 Vagina injury scale Grade‫٭‬ I II III IV V Description of injury Contusion or hematoma Laceration, superficial (mucossa only) Laceration, deep into fat or muscle Laceration, complex, into cervix or peritoneum Injury into adjacent organs (anus, rectum, urethra, bladder) AIS – 90 1 1 2 3 3 85 AIS – 90 2 3 3 4 4 4 4 5 4-5
  • 86. Vulva injury scale Grade‫٭‬ I II III IV V Description of injury Contusion or hematoma Laceration, superficial (skin only) Laceration, deep (into fat or muscle) Avulsion: skin, fat or muscle Injury into adjacent organs (anus, rectum, urethra, bladder) AIS – 90 1 1 2 3 3 Testis injury scale Grade‫٭‬ I II III IV V Description of injury Contusion or hematoma Subclinical laceration of tunica albuginea Laceration of tunica albuginea with <50% parenchymal loss Major laceration or tunica albuginea with ≥50% parenchymal loss Toatl testicular destruction or avulsion AIS – 90 1 1 2 2 2 Penis injury scale Grade‫٭‬ I II III IV V Description of injury Cutaneous laceration or contusion Buck’s fascia (cavernosum) laceration without tissue loss Cutaneous avulsion Laceration through glans or meatus Cavernosal or uretral defect <2cm Partial penestomy Cavernosal or urethral defect ≥2cm Total penectomy AIS – 90 1 1 3 3 3 3 3 3 Peripheral vascular organ injury scale Grade‫٭‬ I II III Description of injury Digital artery or vein Palmar artery or vein Deep palmar artery or vein Dorsalis pedis artery Plantar artery or vein Non – named arterial or vein branches Basilic or cephalic vein Saphenous vein Radial artery Ulnar artery Axillary vein AIS – 90 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 2-3 86
  • 87. Superficial or deep femoral vein Popliteal vein Brachial artery Anterior tibial artery Posterior tibial artery Peroneal artery Tibioperoneal trunk Superficial or deep femoral artery Popliteal artery Axillary artery Common femoral artery IV V 2-3 2-3 2-3 1-3 1-3 1-3 2-3 3-4 2-3 2-3 3-4 Àøèãëàñàí íîì. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Í.Áààñàíæà⠓̺÷í¿¿äèéí ñóäàñíû ãýìòëèéã íºõºí ñýðãýýõ ìýñ çàñëûí àðãóóä” 1998 îí Ð.Øàãäàðñ¿ðýí “Øóó, áóãóéí ò¿âøèí äýõ õàì ãýìòëèéí áè÷èë çàñàë” 1998 îí Äèñåðòàöèÿ Õ35-43 Ð.Øàãäàðñ¿ðýí, Æ.Îëçáàé ׺ìºãò ÿñíû õóãàðëûí äýëãýðýíã¿é àíãèëàë, “ÀΔ – òîãòîëöîî “Ìýñ çàñàë” ñýòã¿¿ë 2002 îíû ¹3 4 õ. 2128 Ð. Øàãäàðñ¿ðýí, Í.Áààñàíæàâ “Äýýä ìº÷äèéí õàì ãýìòýëèéí áè÷èë ìýñ çàñàëûí ýì÷èëãýý” Ìîíãîëûí àíàãààõ óõààí ñýòã¿¿ë 2005 îí ¹4 Õ24-29 Ð.Øàãäàðñ¿ðýí, Í.Áààñàíæàâ. Êëèíèêèéí ëåêö¿¿ä, “Òóëãóóð õºäºë㺺íèé ýðõòýíèé îíîøëîãîî ýì÷èëãýýíèé îð÷èí ¿åèéí ¿çýë áàðèìòëàë Àëèåâ Ì.À Àõìåòîâ Ê.Ê ×åíöåâ È.äð Âîñüìèëåòíèé îïûò âíåäðåíèÿ ìåòîäîâ ìèêðîõèðóðãèé “Ìåæäóíàðîäíûè Ñèìïîçèóì ïî ïëàñòè÷èñêîé è ðåêîíñòðóêòèâíîé ìèêðîõèðóðãèé” ïðîáëåìû ìèêðîõèðóðãèé Òåç äîêë.ì 1994 ñ 11-12 ËÍ Àíêèí, ÍË Àíêèí “Ïðàêòè÷åñêàÿ òðàâìàòîëîãèÿ (Åâðîïåéñêèå Ñòàíäàðòû äèàãíîñòèêû è ëå÷åíèå Ñ-31-Ñ52) Áåëîóñîâ À.Å, Ïàí÷óê Â.Ä “Ìèêðîõèðóðãè÷åñêèå âìåøàòåëüñòâî â ëå÷åíèé òÿæåëîé òðàìû Êèñòè Ãåç IV âñåñ. Ñúåçäà òðàâìàòîëîãî è Îðòîïåäîâ 1991 Ì.1Ñ 147-149 À.Å Áåëîóñîâ, ÑÑ. Òêà÷åíêà. Ìèêðîõèðóðãèÿ â òðàâìàòîëîãèé / ñâîáîäíîÿ ïåðåñàäêà êîïëåêîâ òêàêåé ñ ìèêðîíàñòîìîçàìè ñîñóäîâ è íåðâîâ ñ110-155 Âàíöÿõ Í.Ý Ïåðâè÷íàÿ õèðóðãè÷åñêàÿ îáðàáîòêà ñî÷åòàííûõ ïîâðåæäåíèé êèñòè è ïàëüöåâ Ñ.èñïîëüçîâîíåé ìèêðîõèðóðãè÷èñêîé òåõíèêè Äèññ. Êàíä.ìåä Íàóê 199. Ñ139-143 Âîëêîâà À.Ì. Ëå÷åíèå áîëüíûõ ñ ïîñëåäñòâèÿìè ñî÷åòàííûõ ïîâðåæäåíèé ñóõîæèëèé è íåðâîâ êèñòè õèðóðãèÿ 1997 ¹10 Ñ25-28 American Academy of Orthopaedic Surgeons (AAOS) Symposium on Tendon Surgery in Hand (1995) (X) 88-99 The Abbreviated Injury Scale – 1990 Revision. Des Plaines, IL: American Association for Automotive Medicine, 1990 87
  • 88. 14. Baker SP, O’Neill B, Haddon W, et.al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1979; 14: 187-196 15. Baxt WG, Berry CC, Epperson MD, et al. The failure of prehospital trauma prediction rules to classify trauma patients accurately. Ann Emerg Med 1989;18(X)1-8. 16. Baxt WG, Jones G, Fortlage D. Trauma triage rule: a new, resoursebased approach to the prehospital identification of major trauma victims. Ann Emerg Med 1990; 19: 1401-1406. 17. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. J Trauma 1987; 27:170-375. 18. Cayten CG. Stahl WM. Murphy JG, et al. Limitations of the TRISS method for interhospital comparisons: a multihospital study. J.Trauma 1991; 31;471. 19. Champion HR, Sacco WJ, Carnazzo AJ, et al. Trauma score. Crit Care Med 1981:9 20. Champion H 672-676, Sacco W, Copes W: Trauma scoring. In Moore EE, Mattox KL, Feliciano DV, editors: Trauma, East Norwalk, Conn, Appleton & Lange, pp 47-65, 21. Committee on trauma: Advanced trauma life support program, Chicago, 1988, American College of Surgeons, pp 137-138. 22. David. P, Green.D “Operative Hand Surgery volume 1, 2, 3” X44-88, 1329, 27-47 23. Flint L, Richardson J: Organization for trauma care. In Richardson J, Polk H, Flint L, editors: Trauma: clinical care and pathophysiology, Chicago, Year Book, pp 8-9. 24. Henkert.K, Salisbury R.E; Flexor Tendon recontructonin Severely damaged hands, J.Bone Joint Surg 53A-829,1994 25. Herman T,Smith. T “Tissue Transfers in Reconstructive surgery” 1994, X98-118 26. Harri ef. Al Flexor C25-28 tendon injuries within the finger a study of the results of tendon surfare and tendon graft. Trauma 8:987, 103-1974 27. Morrison W, Nguyen T. Electrical injures /south. Med .J 2002 Äåê 93(12) – 1165-8 28. ME Muller. M.Allogoewer. Schneider. H Willenegger Manual of internal Fixation, Techniques Recommended by the AO – ASIF group Appendix.A pp 118-150, pp 692-718 29. Pulverfoft R.G. Problems of flexor tendon Surgery of the Hand D.J Bone joint Surg 47A; 123-1985 30. Rollin.K, Daniel, Julia. K “Reconstructive Microsurgery” 1988 X5-21 31. Susae, Mackinnon. R “Surgery of the Peripheral Nerve” 1986 X39-83 32. Stephan.J, Mathes.M, “Clinical applications for muscle and musculocutareous flaps” 1982, X204-306 88