全军骨科学会创伤骨科分会成立大会暨云南省骨科学术会议通知

为了促进我军创伤骨科领域的学术交流与发展,更好地在全军范围内开展创伤骨科及相关疾病的诊;台研究,提高综合治疗水平。经全军骨科学会和云南省骨科学会商议决定,于2009年10月23日～10月25日在昆明召开全军骨科学会创伤骨科分会成立大会暨云南省骨科学术会议。     

中国创伤骨科发展历程

中国创伤骨科学是由传统中医骨伤科学和西医骨科创伤学共同发展形成的。中医骨伤科学历史悠久,具有独特的理论和治疗体系,为中国创伤骨科的形成与发展做出了重要贡献。西方医学的传入与发展极大地促进了中国创伤骨科学的建立与发展。进入20世纪中叶以来,中国在创伤骨科领域取得了诸多享誉国际的创新性成就,扩大了在国际上的学术影响。目前,中国创伤骨科已拥有自己的学术组织与学术期刊,已拥有一支强大的创伤骨科专业技术队伍,越来越多的、独立的创伤骨科专业学科相继在各大、中医院成立。目前中国创伤骨科整体上与国际基本处于同一水平,但仍有诸多方面不足。专科医生综合知识培养与正规化培训体系与制度的建立、专科诊疗技术的规范化与标准化、积极加入国际相关学术组织、不断扩大与国际的学术交流、注重专科手术与固定器材的研发等将是我国创伤骨科发展的主要对策与趋势。     

首届亚洲创伤骨科高峰论坛通知

为推动我国创伤骨科的发展，增进相互了解，扩大与亚洲地区各国的学术交流与技术合作，《中华创伤骨科杂志》社、亚洲创伤骨科学会（AAI~）与中华骨科交流学会（台湾）于2005年11月11—14日在广州联合举办“首届亚洲创伤骨科高峰论坛”。会议将就创伤骨科领域国际最新技术与进展、主要以Video Symposium（多媒体动画）形式进行广泛的学术交流。《中华创伤骨科杂志》即将进入中华医学会系列杂志，届时将同时举行《中华创伤骨科杂志》第二届编委改选及编委会会议。论坛主题为创伤骨科新技术：①创伤骨科基础研究；②计算机辅助骨科技术（CAOS）；③微创骨科技术（MIOS）；④骨盆髋臼损伤现代治疗；⑤关节外科新技术；⑥运动创伤新技术；⑦手外科新技术。     

《闭合复位技术在四肢骨折治疗中的应用》出版发行

张铁良主编的《闭合复位技术在四肢骨折治疗中的应用》一书已于2017年11月由人民卫生出版社出版。张铁良教授是我国著名创伤骨科专家、第一届中华医学会骨科分会创伤骨科学组组长。     

骨折治疗的思考-AO、BO的演变及CO时代的到来

正创伤骨科是骨科领域最古老的亚专业学科,同时也是骨科的基础,骨折治疗是创伤骨科的核心内容之一。骨折治疗的理念、理论一直影响脊柱、关节、运动医学等其他骨科亚专业学科的发展,引领骨科前进的潮流,不断在思考中发展前进,先后产生了AO、BO理论体系及治疗体系。骨折治疗发展的每一个阶段都存在着对立统一的矛盾,这与马克思哲学中事物的发展源     

骨科创伤的早期救治

创伤已成为当今社会的一大公害,而骨科创伤占现代创伤总数的1/2～2/3。为降低其死亡率和伤残率,对骨科创伤的急救应以抢救生命为核心,保持患者的呼吸道通畅和维持有效循环血容量,积极抗休克治疗和进行各项生命体征的监护,恰如其分的伤情评估和分科救治。而对骨科创伤的早期治疗应把握好全身治疗与局部治疗的关系,在生命体征稳定的情况下,早期彻底清创,稳妥固定骨折,尽早修复软组织缺损,积极防治并发症,以利提高救治成功率。     

外固定架在创伤骨科中的应用

在内固定的理念和操作技术已经被我国广大创伤骨科医生所熟悉的今天，《中华创伤骨科杂志》推出“外固定支架的应用”专刊，是对读者非常有意义的启迪。近10年来，很多创伤骨科医生把很大精力投入在内固定的学习与实践上，殊不知外固定是骨折治疗的极为重要的手段之一。仅依靠一种治疗方式治疗所有创伤骨科疾患已根本不能满足创伤骨科患者的需要。     

创伤骨科病人进入ICU状况分析(附31例报告)

目的:介绍我院创伤骨科进入ICU监护治疗情况。探讨创伤骨科进入ICU的主要疾病及进入途径。方法:收治31例创伤骨科病人进行分析,总结进入ICU的主要疾病是:骨科重大手术后5例,多发骨折血压不稳定9例,多发伤合并创伤性失血性休克9例,多发伤合并ARDS6例,高位脊柱骨折并高位脊髓损伤截瘫2例。进入ICU途径是:从急诊室直接到ICU6例,从骨科到ICU9例,从手术室进入ICU15例,外院转入1例。结果:31例中2例在ICU死亡,29例经过ICU康复稳定后转入骨科治疗。结论:我院创伤骨科需要进入ICU治疗的主要疾病是:①骨科常规重大手术后生命体征不稳定;②多发骨折血压不稳定;③多发伤合并创伤失血性休克;④多发伤合并ARDS;⑤脊髓高位损伤需要呼吸机支持。进入ICU的主要途径是急诊手术后进入、骨科病房进入及急诊室三种途径。     

距骨全脱位治疗的研究进展

距骨全脱位是创伤骨科较为罕见的损伤。距骨解剖结构特殊,无单独血管供应,全脱位后易发生缺血性坏死,其处理方法一直以来未能达成一致,治疗后并发症较多,效果欠佳。本文对距骨全脱位的损伤机制、治疗策略及并发症预防和处理等方面的研究进展进行综述,旨在为创伤骨科医师的治疗选择提供参考。     

创伤骨科自主创新

过去20年, 随着我国工业、交通运输业的高速发展和老龄化水平不断加剧, 骨折发病率持续上升, 给个体、家庭、医疗系统以及社会带来沉重负担[1-2]。自主创新是医疗体系升级的关键, 也是引领整个医疗领域不断发展的强大动力源, 在创伤骨科领域更是如此。在中华医学会骨科学分会"创新、持续创新、继续创新"和中国医师协会骨科医师分会"创新与转化"主题的持续引领下, 我国创伤骨科不断提升自主创新水平, 在治疗理念、微创技术、内固定物及辅助装置研发等方面取得显著突破, 为患者提供了更微创、更精准、更安全、更高效的治疗方案。本期"创伤骨科自主创新"专刊汇集了7篇创新研究文章, 从内置物和辅助装置的研发与应用、技术创新与应用以及基于临床应用的基础研究等多方面展示了创伤骨科领域的最新成果, 笔者欣然为之述评, 抛砖引玉, 旨在激发广大骨科同仁的自主创新热情, 提升科技创新能力。     

Management of open fractures in the multiple trauma patient

The management of open fractures in the multiple trauma patient is discussed. It is concluded that operative stabilization of the open fracture both enhances the survival of these patients and reduces the complications of the fracture while enhancing extremity function. This procedure must be conducted so as to avoid devascularization of more tissue and especially bone fragments and so that adequate stability is provided. In general, all open fractures are left open with the degree of openness depending upon the magnitude of the soft tissue trauma. In grade I and II open fractures, stabilization can usually be achieved by internal fixation or by a combination of minimal internal fixation (usually lag screws) and external fixation. In grade III open fractures, stabilization is usually best achieved by external fixation. However, the external fixation must be carefully designed to allow the subsequent soft tissue coverage operations which are usually required in third degree open fractures. In general, the external fixator should be viewed as a device to gain sufficient stability for patient mobilization and soft tissue management and not as definitive fracture care. For this reason, in the tibia unilateral frames are usually best and bilateral or trilateral frames should be reserved for segmental defects and severe zonal comminution. Definitive fracture care is then administered after soft tissue healing by cast or internal fixation.     

Update on the roles of angiography and embolisation in pelvic fracture

Trauma accounts for approximately 1 in 10 deaths worldwide. The presence of a pelvic fracture increases this mortality risk. Successful management depends on accurate diagnostic staging and control of fracture-related haemorrhage. From the standpoint of the trauma surgeon, this necessitates thorough compression and stabilisation of the fracture using external compression, combined with retroperitoneal or preperitoneal packing. However, vascular injury in many parts of the body can preferentially and effectively be treated on an emergency basis with angiographic procedures, using superselective embolisation in combination with other interventional techniques. The option of combining open surgery and angiographic methods should be kept in mind, but there are no uniform guidelines. In the literature, numerous studies and reports have documented the feasibility of interventional radiological procedures in trauma cases with pelvic fracture. Thus all level I trauma centres should be able to provide this service on a 24h basis.     

Open Pelvic Fractures

Abstract An open pelvic fracture represents one of the most significant insults to the human frame. Anatomically, the skeleton apart, many soft-tissue structures will be damaged requiring a multidisciplinary approach. The management of an open fracture challenges any health care system. This article in no way attempts to provide an ultimate management protocol for such injuries—how patients are managed will depend on the trauma system both locally and nationally. However, certain principles must be observed and a management protocol can be developed for each institution. The essence of ideal treatment of such injuries is urgent transportation to an appropriate institution, rapid resuscitation and assessment with the involvement of senior specialists from a wide spectrum of specialities.     

加速康复外科理念下跟骨关节内骨折诊疗规范专家共识

跟骨骨折是最常见的后足骨折,通过国内外医师学者的长期研究,其在诊治方面有了长足的进步。近年来,加速康复外科(ERAS)理念的引入,更加规范了跟骨骨折围手术期的处理流程,有助于提高治疗效果,改善患者治疗体验。本共识以ERAS理念为指导,以循证医学证据为基础,经全国创伤骨科专家讨论形成。本共识从多模式镇痛、术前宣教、围手术期饮食管理、手术微创操作等ERAS涉及的多个方面进行推荐,为治疗此类骨折提供参考。     

Current management of tibial shaft fractures: A survey of 450 Canadian orthopedic trauma surgeons

Background and purpose?Strategies to manage tibial fractures include nonoperative and operative approaches. Strategies to enhance healing include a variety of bone stimulators. It is not known what forms of management for tibial fractures predominate among Canadian orthopedic surgeons. We therefore asked a representative sample of orthopedic trauma surgeons about their management of tibial fracture patients.

Methods?This was a cross-sectional survey of 450 Canadian orthopedic trauma surgeons. We inquired about demographic variables and current tibial shaft fracture management strategies.

Results?268 surgeons completed the survey, a response rate of 60%. Most respondents (80%) managed closed tibial shaft fracture operatively; 47% preferred reamed intramedullary nailing and 40% preferred unreamed. For open tibial shaft fractures, 59% of surgeons preferred reamed intramedullary nailing. Some surgeons (16%) reported use of bone stimulators for management of uncomplicated open and closed tibial shaft fractures, and almost half (45%) made use of this adjunctive modality for complicated tibial shaft fractures. Low-intensity pulsed ultrasound and electrical stimulation proved equally popular (21% each) and 80% of respondents felt that a reduction in healing time of 6 weeks or more, attributed to a bone stimulator, would be clinically important.

Interpretation?Current practice regarding orthopedic management of tibial shaft fractures in Canada strongly favors operative treatment with intramedullary nailing, although respondents were divided in their preference for reamed and unreamed nailing. Use of bone stimulators is common as an adjunctive modality in this injury population. Large randomized trials are needed to provide better evidence to guide clinical decision making regarding the choice of reamed or unreamed nailing for tibial shaft fractures, and to inform surgeons about the actual effect of bone stimulators.     

Strategies for surgical treatment of multiple trauma including pelvic fracture. Review of the literature

OBJECTIVE: In the management of multiply injured patients the question of the optimal time point for surgical treatment of individual injuries still remains open. Especially in severely injured patients with pelvic fractures, this decision differs between rapid surgical interventions in life-threatening situations or time-consuming reconstructive surgery. Besides the "early" operative treatment, i.e., within the first 24 h after trauma, the "late," i.e., definitive or secondary surgical fracture stabilization, exists. The following study represents a review of the current recommendations in the literature concerning the optimal time and fracture management of multiply injured patients with pelvic fracture. METHODS: Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches), reviewed, and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: According to the literature there is consensus on "early" operative stabilization of multiply injured patients with hemodynamically and mechanically unstable pelvic fractures, open pelvic fractures, or complex pelvic trauma. External fixation and the pelvic C-clamp are the methods of choice in emergency situations, whereas currently internal fracture fixation is only proposed in exceptional circumstances. In contrast, the point in time for the secondary definitive fracture stabilization remains controversially discussed. This discussion ranges from the postulation that extensive definitive fracture treatment be avoided during days 2-4 after trauma to the recommendation that definitive internal fixation of pelvic fractures be undertaken early, i.e., within the 1st week after trauma. CONCLUSION: Basically, the principles of trauma management of multiply injured patients with life-threatening hemorrhage from mechanically unstable pelvic fractures are divided into two main time periods. On the one hand, there is the emergency stabilization of the pelvic ring as the most important goal within the acute period to control the bleeding, at least with extraperitoneal tamponade if necessary. On the other hand, once the hemorrhaging has been stopped, the "late" and definitive internal fracture stabilization of the pelvis should be performed depending on the fracture pattern.     

Management of male pelvic fracture urethral injuries: Review and current topics

Pelvic fractures from high‐energy blunt force trauma can cause injury to the posterior urethra, known as pelvic fracture urethral injury, which is most commonly associated with unstable pelvic fractures. Pelvic fracture urethral injury should be suspected if a patient with pelvic trauma has blood at the meatus and/or difficulty voiding, and retrograde urethrography should be carried out if the patient is stable. Once urethral injury is confirmed, urinary drainage should be established promptly by placement of a suprapubic tube or primary realignment of the urethra over a urethral catheter. Although pelvic fracture urethral injury is accompanied by subsequent urethral stenosis in a high rate and it has been believed that primary realignment can reduce the risk of developing urethra stenosis, it also has a risk of complicating stenosis and its clinical significance remains controversial. Once inflammation and fibrosis have stabilized (generally at least 3 months after the trauma), the optimal management for the resulting urethral stenosis is delayed urethroplasty. Delayed urethroplasty can be carried out via a perineal approach using four ancillary techniques in steps (bulbar urethral mobilization, corporal separation, inferior pubectomy and urethral rerouting). Although pelvic trauma can impair continence mechanisms, the continence after repair of pelvic fracture urethral injury is reportedly adequate. Because erectile dysfunction is frequently encountered after pelvic fracture urethral injury and most patients are young with a significant life expectancy, its appropriate management can greatly improve quality of life. In the present article, the key factors in the management of pelvic fracture urethral injury are reviewed and current topics are summarized.     

Operative Versorgungsstrategien beim Polytrauma mit Beckenfraktur

Objective

In the management of multiply injured patients the question of the optimal time point for surgical treatment of individual injuries still remains open. Especially in severely injured patients with pelvic fractures, this decision differs between rapid surgical interventions in life-threatening situations or time-consuming reconstructive surgery. Besides the “early” operative treatment, i.e., within the first 24 h after trauma, the “late,” i.e., definitive or secondary surgical fracture stabilization, exists. The following study represents a review of the current recommendations in the literature concerning the optimal time and fracture management of multiply injured patients with pelvic fracture.

Methods

Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches), reviewed, and classified into evidence levels (1 to 5 according to the Oxford system).

Results

According to the literature there is consensus on “early” operative stabilization of multiply injured patients with hemodynamically and mechanically unstable pelvic fractures, open pelvic fractures, or complex pelvic trauma. External fixation and the pelvic C-clamp are the methods of choice in emergency situations, whereas currently internal fracture fixation is only proposed in exceptional circumstances. In contrast, the point in time for the secondary definitive fracture stabilization remains controversially discussed. This discussion ranges from the postulation that extensive definitive fracture treatment be avoided during days 2–4 after trauma to the recommendation that definitive internal fixation of pelvic fractures be undertaken early, i.e., within the 1st week after trauma.

Conclusion

Basically, the principles of trauma management of multiply injured patients with life-threatening hemorrhage from mechanically unstable pelvic fractures are divided into two main time periods. On the one hand, there is the emergency stabilization of the pelvic ring as the most important goal within the acute period to control the bleeding, at least with extraperitoneal tamponade if necessary. On the other hand, once the hemorrhaging has been stopped, the “late” and definitive internal fracture stabilization of the pelvis should be performed depending on the fracture pattern.     

Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and management.

Orthopaedic traumatologists have recognized the unique fracture patterns and injury constellations of pediatric pelvic fractures. However, an understanding of the effect of advancing skeletal maturation is needed to avoid applying adult classifications and management. The authors determined how pelvic fracture patterns and management change with advancing skeletal maturity. At their pediatric trauma center, they identified 166 consecutive pelvic fractures. Eighty percent of patients had plain radiographs adequate to evaluate the triradiate cartilage. Physes were scored as open, narrowed, or closed. The Risser sign, fracture pattern, survival after injury, and need for open reduction and internal fixation were recorded. Ninety-seven patients (mean age 5.7 years) had an open triradiate or an "immature pelvis." Thirty-two patients (mean age 14 years) had a closed triradiate cartilage or a "mature pelvis." The immature group had a higher propensity for isolated pubic rami and iliac wing fractures. The mature group had a higher predilection for acetabular fractures and pubic or sacroiliac diastasis. All patients requiring open reduction and internal fixation had a mature pelvis. The incidences of specific pelvic fracture patterns between the two groups were statistically different. Management of fractures to the immature pelvis should focus on associated injuries. Once the triradiate cartilage has closed, adult pelvic fracture classifications and management principles should be used.     

The role of laser Doppler flowmetry in assessing the viability of bone fragments in an open fracture

The management of open fractures requires excision of all devitalised tissues, both bony and soft tissue, and failure to do so is likely to increase the risk of infection. This study evaluated the applicability of laser Doppler flowmetry for the objective evaluation of fracture fragment viability in an experimental open ballistic fracture over a period of 12 h. The results indicate that this technique could not be used to distinguish between vascularised and non-vascularised fragments at any time, and did not aid the surgeon in their decision making at the time of wound excision. Subjective evaluation, based upon the degree of soft tissue attachment of fragments, was a far better indicator of fragment vascularity, although it had a relatively low specificity. There remains the need for education and training for trauma surgeons in the evaluation of fragment viability to ensure adequate wound excision as part of fracture management.