应用伤害控制骨科学原则治疗骨科严重多发创伤

目的 探讨伤害控制骨科学(damage control orthopaedics,DCO)原则治疗骨科严重多发创伤的可行性和有效性.方法 按照DCO原则收治严重多发创伤患者47例,男35例,女12例;年龄17～55岁,平均32.8岁;开放骨折28例,闭合骨折19例;颅脑损伤15例,胸部损伤20例,腹部损伤17例.患者术前损伤严重度评分平均33.4分,系统炎性反应评分平均2.9分,格拉斯哥昏迷评分平均11.4分.结果 一期手术中骨科处理时间平均65 min,术中出血量平均185 ml;一期术后平均7 d行骨折确定性手术,平均手术时间(142±29)min,术中出血量(420±70)ml.一期术后3例患者死亡,其中1例伴严重创伤性颅脑损伤,2例伴严重胸腹部损伤.术后3例出现腹腔内脓肿,经引流冲洗后治愈;2例发生外固定架针道浅表感染和1例深部感染,经治疗后愈合.无一例出现脂肪栓塞、深静脉血栓等其他并发症和与骨科治疗有关的其他系统病情的恶化.39例患者获得随访,随访时间3～14个月,平均9个月.骨折愈合时间5～14个月,未发现畸形愈合及远期并发症.结论 运用DCO原则治疗骨科多发创伤,可减少患者二次打击程度,控制炎性反应水平的增加,降低手术治疗风险,临床结果较好.     

微创稳定系统治疗多发伤合并胫骨骨折

目的探讨应用微创稳定系统治疗多发伤合并胫骨骨折的临床疗效。方法在处理多发伤以及遵循损伤控制骨科的基础上,应用微创稳定系统（LISS）治疗多发伤合并胫骨骨折31例。结果31例均获得随访,时间5～48个月。骨折全部愈合,无延迟愈合和不愈合。共发生并发症6例：呼吸窘迫综合征3例、膈下脓肿1例、小腿骨筋膜室综合征1例、小腿皮肤坏死1例,经相关治疗后均获痊愈。结论应用LISS钢板治疗多发伤合并胫骨骨折符合损伤控制骨科理论,手术时间短,创伤小,固定可靠。可减少多发伤引起的并发症,降低病死率。     

外固定支架在严重多发骨折损伤控制骨科中的应用

目的 评价外固定支架在严重多发骨折早期损伤控制骨科(DCO)中的应用价值. 方法 自2006年1月至2010年6月应用外固定支架救治42例严重多发骨折患者,男29例,女13例;年龄21～ 62岁,平均39.2岁.其中28例合并其他脏器损伤,31例合并不同程度的失血或创伤性休克,创伤严重度评分平均为34分.在积极抗休克的同时,早期采用外固定支架固定骨折,然后进行复苏治疗,维持血流动力学稳定.病情稳定后再根据患者具体情况选择最终确定性手术方案. 结果 本组患者死亡2例,1例死于失血性休克,1例死于颅脑外伤,死亡率为4.8％.发生并发症4例:合并急性呼吸窘迫综合征l例,肺栓塞1例,下肢深部感染2例.除死亡2例外,4例失访,36例患者获得随访,时间8～36个月,平均16个月.最终骨折均获得愈合,平均愈合时间为22周. 结论 外固定支架在严重多发骨折早期DCO中具有操作简便迅速、创伤小、并发症少等特点,有效地降低了死亡率,有利于多发骨折的进一步治疗.     

单臂外固定架在多发伤救治中的应用

目的探讨单臂外固定架在严重多发创伤患者骨折早期固定中的安全性和有效性。方法2005年1月～2007年1月，按伤害控制骨科学（DCO）原则治疗伴有主要骨折的多发创伤患者34例，ISS评分平均29．4分，GCS评分平均12．5分；单发骨折24例，多发骨折10例，其中股骨骨折17处，胫腓骨14处，肱骨7处，前臂6处，复杂骨盆骨折3处。人院后均予以快速复苏，按照伤害控制性手术方案实施单臂外固定架临时固定骨折，完成复苏后行确定性的骨折内固定。结果开放性骨折平均每处骨折清创、外固定手术时间65min（30～140min），出血量185mL（70～250mL）；闭合性骨折平均每处手术时间45．8min（31～65min），出血量30mL（10～50mL）。平均间隔14．2d（5～45d）更换内固定，确定性骨折固定每处平均手术时间142min（60。171min），出血量420mL（200～490mL）。2例复苏期间死亡，1例针道感染，1例深部感染。余32例出院后均得到随访，平均随访18个月（8～32个月），骨折均获得愈合。未出现急性呼吸功能障碍、脂肪栓塞、多器官功能衰竭等严重并发症。结论单臂外固定架是一种安全、简便、有效的早期骨折固定的方法，正确运用可以控制手术规模和减少手术时间，为确定性手术创造了必备的条件。     

颈脊髓损伤为主严重多发伤的伤害控制(附32例报告)

[目的]探讨伤害控制原则在颈脊髓损伤为主严重多发伤救治中的临床应用。[方法]回顾性分析32例颈脊髓损伤为主严重多发伤患者临床治疗资料，颈椎骨折并截瘫18例，外伤性颈椎间盘突出并高位截瘫2例，颈椎骨折脱位并截瘫12例。神经功能评定按ASIA分级。[结果]31例获得平均14个月随访。29例颈椎骨折愈合，神经症状10例完全恢复，13例有Ⅰ级以上恢复，8例无变化。死亡1例。[结论]颈脊髓损伤为主严重多发伤急诊遵循伤害控制原则，待病情稳定后7—10d内安全地进行最终手术，可提高救治成功率。     

损害控制技术在芦山地震严重多发伤救治中的应用

目的 探讨损害控制技术在芦山地震严重多发伤伤员院内救治中的应用. 方法 对2013年4月20日至5月2日应用损害控制技术救治的22例骨关节型地震严重多发伤伤员的临床资料进行回顾性分析,男13例,女9例;年龄20～60岁,平均43.1岁;创伤严重度评分为17 ～41分,平均25.8分;四肢开放性骨折11例,闭合性骨折10例. 结果 共完成骨折手术38台,其中确定性手术24台,临时性手术13台,截肢术l台.9例伤员已完成全部确定性手术并在顺利康复之中,13例尚需进一步手术治疗.除l例患者外所有开放性伤口均已闭合.术后1例患者出现切口深部感染,予清创、负压封闭引流技术控制感染,13例行外固定治疗患者无一例发生外固定支架钉道松动、感染,复查术后X线片示骨折无成角畸形. 结论 损害控制技术有利于提高地震所致严重多发伤伤员的救治成功率和减少死亡率,并为后期确定性治疗提供有利条件.     

损伤控制骨科理论在救治严重骨折伴多发伤中的应用

目的探讨严重骨折伴多发伤的防治对策以及损伤控制骨科(DCO)理论在救治严重多发伤中的应用价值、可行性和疗效。方法对2002年1月～2011年10月应用DCO理论指导救治的87例严重骨折伴多发伤患者的临床资料进行回顾性分析。结果创伤早期骨折行简单清创外固定,待ICU复苏治疗后,再择期行确定性骨科内固定手术。本组死亡率6.9%(6/87),死亡病例损伤严重度评分(ISS)平均值41分,主要死于休克和合并伤。52例获随访6~20个月,骨折均顺利愈合,肢体功能恢复理想。结论完善救治体系,合理采用DCO模式治疗严重骨折伴多发伤,能降低死亡率,减少并发症,提高救治成功率。     

伤害控制策略在严重多发伤并多发骨折治疗中的应用

目的总结严重多发伤合并多发性骨折病人的救治和应用伤害控制策略的治疗效果。方法回顾性分析2003年1月至2007年1月创伤严重度评分（injury severity score,ISS）大于25分的23例严重多发伤合并多发性骨折的病人应用伤害控制策略进行救治,并观察围手术期并发症、死亡率及骨折愈合情况,尤其是肢体和关节功能恢复情况。结果除1例右下肢严重毁损伤急诊清创骨牵引保肢术后3个月因骨缺损感染骨髓炎而作大腿截肢外,全部病例骨折愈合,未出现严重并发症,无围手术期死亡病例,肢体功能恢复满意。结论对严重多发伤合并多发性骨折的病人应用伤害控制策略治疗,效果满意。     

应用损伤控制骨科治疗复合伤中的胫骨上段粉碎骨折

目的：探讨从损伤控制骨科学观点出发治疗复合伤中复杂的胫骨上段粉碎骨折手术方法。方法：2007年1月至2009年6月,胫骨上段粉碎骨折合并其他复合伤的患者11例,男8例,女3例;年龄25～57岁,平均35.2岁。先使用外固定支架临时固定骨折端,6周后患者病情稳定、生理状况改善后再行外侧小切口LISS钢板插入闭合内固定,内侧重建钢板或支持钢板支撑。术后疗效按Lysholm评分标准进行评价。结果：所有患者术后CR示：胫骨上段骨折均获功能复位,伤口愈合良好,无感染。11例均获得随访,时间12～18个月,平均14.7个月。11例患者Lysholm平均评分为（82.8±11.6）分;疗效结果：优5例,良4例,可1例,差1例。结论：依据损伤控制骨科学,先后使用外固定支架、LISS钢板微创固定胫骨上段粉碎骨折,对于合并复合伤的患者是一种比较合适的治疗方法。     

外固定支架在严重多发伤合并肢体骨折损伤控制中的应用

目的介绍应用外支架治疗严重多发伤合并肢体骨折的方法并评价疗效。方法2009年1月至2012年12月,作者应用外支架对28例严重多发伤合并肢体骨折进行早期临时固定,心肺复苏、ICU监护和Ⅱ期确定性手术治疗,患者中男19例,女9例;年龄25～61岁,平均40．5岁。骨折部位：骨盆骨折5例,骨盆合并四肢骨折3例,四肢骨折15例,脊柱骨折3例,脊柱合并四肢骨折2例。闭合性骨折16例,开放性骨折12例。28例患者均合并其他多部位损伤,创伤严重程度评分平均35分。结果本组患者治愈26例（92％）,死亡2例（8％）,其中1例死于多器官功能衰竭,1例死于颅脑外伤,ICU治疗平均5．6d。发生各种并发症共7例。25例患者获得随访,时间8—36个月,平均16个月。22例骨折正常愈合,平均愈合时间18．4周。2例发生骨折延迟愈合,1例发生骨不连,经二期手术并植骨后愈合。结论外支架可用于严重多发伤合并肢体骨折的早期损伤控制,具有操作简单、效果可靠、并发症少等优点,可有效提高严重多发伤合并肢体骨折的救治效果,值得临床推荐使用。     

Application of damage control orthopedics in 41 patients with severe multiple injuries

Objective： To probe the feasibility and efficacy of damage control orthopedics （DCO） in treating severe multiple injuries. Methods： A retrospective analysis was made on the clinical data of 41 patients （31 males and 10 females, aged 18-71 years, mean： 36.4） with multiple injuries admitted to our department and treated by DCO from January 1995 to December 2005.
Results： As a first-stage therapy, devascularization of internal iliac arteries was performed in 29 patients with pelvic fractures combined with massive bleeding, including ligation of bilateral internal iliac arteries in 21 patients and embolization of bilateral internal iliac arteries in 8. And early external fixation of pelvis was performed in 10 patients. Ten patients with severe multiple injuries combined with femoral fractures were managed with primary debridement and temporal external fixation and 2 patients with spinal fractures combined with spinal cord compression received simple laminectomy. Thirty-one patients received definite internal fixation after resuscitation in intensive care unit. The overall mortality rate was 12.1% （5/41） with an average injury severity score of 41.4. The main causes of death were hemorrhagic shock and associated injuries. Complications occurred in 7 patients including acute respiratory distress syndrome in 3 cases, thrombosis of right common iliac artery in 1, subphernic abscess in 2 and infection of deep wound in lower extremity in 1. After treatment, all the patients got cured.
Conclusions： Prompt diagnosis and integrated treatment are keys to higher survival rate in patients with severe multiple injuries. In this condition, DCO is an effective and safe option.     

损伤控制骨科理论在严重肢体骨折合并腹部创伤中的应用

背景：严重肢体骨折常合并有腹部创伤,正确的诊断和处理是提高患者生存率的重要保障。损伤控制骨科理论（DCO）符合严重肢体骨折合并腹部创伤患者的病理生理特点,正确地应用DCO理论是提高患者救治成功率的关键。目的：探讨DCO理论在严重肢体骨折合并腹部创伤中的应用。方法：回顾性分析2009年1月至2013年6月收治的38例严重肢体骨折合并腹部创伤患者的临床资料。骨折情况：单纯四肢骨折20例,骨盆骨折6例,骨盆合并四肢骨折4例,脊柱骨折4例,脊柱合并四肢骨折4例;闭合性骨折21例,开放性骨折17例。腹部损伤情况：脾破裂20例,肝破裂8例,肝脾破裂5例,肠破裂3例,肝破裂＋肠破裂1例,肝破裂＋肾破裂1例。损伤严重度（ISS）评分平均39.3分。结果：本组38例患者经DCO理论救治后死亡2例,36例患者病情稳定后行骨折确定性手术,实施确定性手术的时间为6~62 d,平均12.5 d。其中12例发生各种并发症。除2例死亡、4例失随访外,其余32例均获得随访,随访时间为10~25个月,平均15.4个月。其中28例骨折正常愈合,愈合时间为12~25周,平均21.2周;3例骨折出现延迟愈合,经石膏外固定后愈合,总愈合时间为10~12个月;1例骨折术后10个月发现骨不连,经二期手术并植骨后愈合。所有随访者均部分或完全恢复正常工作生活。结论：DCO理论符合严重肢体骨折合并腹部创伤患者的病理生理特点,尽早进行针对性的损伤控制手术和ICU复苏是实施DCO的关键,可提高严重此类患者的救治成功率。     

髂腹股沟微创小切口在骨盆前环损伤中的应用

目的：探讨有限切开,微创内固定治疗骨盆前环损伤的可行性、技术要点及临床效果。方法：2009年3月至2012年3月,选择经髂腹股沟微创小切口内固定治疗骨盆前环损伤患者20例,男13例,女7例;年龄25-61岁,平均41．6岁。前环损伤按Tile分型：A2型5例,B1型2例,B2型9例,B3型1例,C1型3例。单纯前环骨折15例,前环骨折合并耻骨联合分离2例,前后环均骨折3例。观察内容包括手术时间、术中出血量、股神经及髂血管损伤情况、术后骨折复位情况等。结果：所有患者伤口I期愈合,无感染、深静脉血栓、股神经及髂血管损伤等并发症发生。根据Matta复位标准,优12例,良7例,可1例。18例患者获得随访,时间6～32个月,平均16.3个月。根据Majeed疗效评价标准,优15例,良3例,Majeed评分94．3±6．0。结论：经髂腹股沟微创小切口内固定治疗骨盆前环损伤具有手术时间短、创伤小、术中出血少等优点,临床操作安全可行,疗效满意。     

损伤控制手术在以腹部损伤为主的严重胸腹联合伤中的应用

目的：探讨损伤控制手术（DCO）在治疗以腹部损伤为主的严重胸腹联合伤中的应用。方法：回顾性分析2008年3月—2011年6月收治的71例严重胸腹联合伤患者的临床资料,其中,行损伤控制手术41例,另外30例患者行一期确定性手术。结果：损伤控制手术组患者复苏后乳酸水平,pH值,体温,凝血酶原时间（PT）与一期确定性手术组的患者无统计学差异（均P>0.05）。71例患者均治愈后安全出院,但损伤控制手术组患者粘连性肠梗阻、感染的发生率明显低于一期确定性手术组（均P<0.05）。结论：在正确掌握适应证的前提下,损伤控制性手术对于严重胸腹部损伤患者是理想的治疗策略。     

骨盆环微创内固定治疗骨盆C型骨折

目的 :探讨骨盆前、后环微创内固定在骨盆C型骨折治疗中的可行性、技术要点以及临床效果。方法:自2010年12月至2015年12月,选择经髂腹股沟微创小切口重建接骨板内固定治疗骨盆前环损伤;经皮骶髂关节螺钉内固定治疗骨盆后环损伤患者18例,男11例,女7例;年龄29~68岁,平均43.6岁。骨折按Tile分型:C1型14例,C2型3例,C3型1例。耻骨骨折合并同侧骶骨骨折12例,耻骨骨折合并同侧骶髂关节脱位2例,双侧耻骨骨折合并单侧骶骨骨折伴耻骨联合分离3例,双侧耻骨骨折合并双侧骶髂关节骨折脱位1例。观察结果包括手术时间、手术出血量、腰骶神经及髂血管损伤情况、骨折复位情况等。结果:所有患者伤口Ⅰ期愈合,无感染、深静脉血栓、腰骶神经及髂血管损伤、异位骨化等并发症发生。根据Matta复位标准,优14例,良3例,可1例。16例患者获得随访,时间6~33个月,平均16.7个月。根据Majeed疗效评价标准,优15例,良1例,Majeed评分92.13±5.44。结论:骨盆前环损伤选择经髂腹股沟微创小切口重建接骨板内固定,骨盆后环损伤选择经皮骶髂关节螺钉内固定治疗骨盆C型骨折具有手术时间短、创伤小、出血少等优点,临床操作安全可行,疗效满意。     

Minimally invasive plate osteosynthesis using posterolateral approach for distal tibial and tibial shaft fractures

ObjectiveThe objective of the study was to evaluate the effectiveness of the posterolateral minimally invasive plate osteosynthesis (MIPO) method for managing distal tibial or tibial shaft fractures with severe anterior and medial soft tissue injuries.Materials and methodsFive consecutive patients with three distal tibial and two tibial shaft fractures (three open fractures) at a level-1 trauma and tertiary referral center were retrospectively reviewed. All patients were definitively treated and followed to bone union. Main outcome was measured by American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score, complications, and bone union on radiographs.ResultsThe average follow-up period was 15.8 months (range, 12–24 months). The average AOFAS score was 88.2 (range, 81–90). There were no complications, such as incision breakdown, deep infection, or impingement of the flexor hallucis longus tendon. Bone union was achieved in all cases.ConclusionsPosterolateral MIPO is a feasible option when treating these fractures, especially in cases with severe anterior and medial soft tissue injuries.     

What are the risk factors for complications after combined injury of the pelvic ring and acetabulum?

Purpose

Combined acetabular and pelvic ring injuries represent a unique subset of pelvic trauma and little is known regarding their complications and outcomes. We sought to further evaluate these injury patterns and quantify their outcomes.

Methods

A retrospective review at a single level 1 trauma center was performed on all patients with operatively treated combined ring and acetabulum injuries during a seven-year period. Main outcome measurements include all-cause complication including residual neurologic deficit, deep infection, conversion to total hip arthroplasty, deep venous thrombosis and mortality.

Results

Seventy operatively treated combined ring and acetabulum patients with one-year follow-up were reviewed. The overall complication rate was 44%. Hip dislocation occurred in 40% of the cohort and was significantly associated with residual neurologic deficit and all-cause complication. Angiography with embolization was not associated with an increased rate of deep infection. Open acetabular approaches had a significantly higher complication rate compared to percutaneous procedures. Delay to definitive fixation greater than 36 h trended toward but did not reach association with all complications.

Conclusion

Combined injuries to the acetabulum and pelvic ring have high rates of complications. No individual fracture patterns were identified as risk factors, but hip dislocation was associated with an increased rate of complications. When possible, percutaneous reduction and fixation of acetabular fractures and early definitive fracture fixation lead to lower rates of complications. Use of angiography with embolization appears to be safe and does not increase the risk of infection or other complications.

     

Epidemiology of pelvic fractures in adult: Our experience at two tertiary care hospital in Dhaka,Bangladesh

PurposeIn Bangladesh the incidence of pelvic fracture is increasing day by day due to suboptimal roads and heavy traffic. However, there is no epidemiological study of these injuries in Bangladesh. Our aim was to study the epidemiology of patients admitted with pelvic fractures at two tertiary care hospital in Dhaka, Bangladesh.MethodsThis was a prospective study carried out on trauma patients with pelvic fracture at two level 1 trauma care center of two tertiary care hospital in Dhaka, Bangladesh. The study period was from July 2015 to June 2019 (48 months). Patient’s data including demography of patients, mechanism of injuries, fracture types, associated injuries, method of treatment, post-operative complications, length of hospital stay were recorded according to a unified protocol.ResultsThe study population was comprised of 696 patients, where 556 (79.88%) were male and 140 (20.12%) were female. Mean age was 37.75 years and road traffic accidents were the most common mode of injuries. Lateral compression fractures were the most common injuries and Urethral injuries were the most common associated injuries. Death was the outcome in 3.5% of the cases due to high energy trauma.ConclusionThis study revealed that pelvic fractures were significantly more frequent in men. Most frequent cause was road traffic accident. The majority of these cases did not required surgery. Mortality was associated with high velocity trauma with severe injuries.     

Epidemiology of pelvic fractures in adult: Our experience at two tertiary care hospital in Dhaka,Bangladesh

PurposeIn Bangladesh the incidence of pelvic fracture is increasing day by day due to suboptimal roads and heavy traffic. However, there is no epidemiological study of these injuries in Bangladesh. Our aim was to study the epidemiology of patients admitted with pelvic fractures at two tertiary care hospital in Dhaka, Bangladesh.MethodsThis was a prospective study carried out on trauma patients with pelvic fracture at two level 1 trauma care center of two tertiary care hospital in Dhaka, Bangladesh. The study period was from July 2015 to June 2019 (48 months). Patient’s data including demography of patients, mechanism of injuries, fracture types, associated injuries, method of treatment, post-operative complications, length of hospital stay were recorded according to a unified protocol.ResultsThe study population was comprised of 696 patients, where 556 (79.88%) were male and 140 (20.12%) were female. Mean age was 37.75 years and road traffic accidents were the most common mode of injuries. Lateral compression fractures were the most common injuries and Urethral injuries were the most common associated injuries. Death was the outcome in 3.5% of the cases due to high energy trauma.ConclusionThis study revealed that pelvic fractures were significantly more frequent in men. Most frequent cause was road traffic accident. The majority of these cases did not required surgery. Mortality was associated with high velocity trauma with severe injuries.