127例颅底骨折的治疗与分型

颅底骨折在头部外伤中很常见，临床上习惯将颅底骨折按所在部位分前颅窝骨折、中颅窝骨折和后颅窝骨折三种类型。但这些以解剖概念简明的观点，难以确切反映颅底骨折后的临床状况，我们结合多年临床，依据诊疗特征。加以更新和补充成以下6个类型，并总结各自的临床诊疗特点。     

开放性颅脑损伤合并前颅窝底骨折急诊术中行“三明治法”颅底重建的效果评价

目的探究开放性颅脑损伤合并前颅窝底骨折急诊术中行"三明治法"颅底重建的疗效及安全性。方法选取2014年5月～2017年11月期间于我院确诊并接受治疗的46例开放性颅脑损伤合并前颅窝底骨折的患者作为本次研究对象,全部患者按照随机数表法随机分为试验组和对照组各23例,试验组行"三明治法"颅底重建进行治疗,对照组患者进行硬脑膜颅底重建手术治疗。比较两组患者的手术成功率、术后治愈、死亡率及颅内感染、脑膜脑膨出等不良反应发生情况。结果两组患者硬脑膜损伤差异无统计学意义(P0.05);试验组手术成功率和术后治愈率显著高于对照组,差异有统计学意义(P0.05);试验组术后死亡率显著低于对照组,差异有统计学意义(P0.05);试验组术后并发症发生率显著低于对照组,差异有统计学意义(P0.05)。结论 "三明治法"颅底重建治疗开放性颅脑损伤合并前颅窝底骨折临床效果更好,且安全性更高,值得临床推广应用。     

螺旋CT薄层扫描高分辨重建技术在颅底骨折的应用研究

目的探讨螺旋CT薄层扫描高分辨重建技术对诊断颅底骨折的诊断价值,为临床选择治疗方案提供指导。方法对120例临床怀疑颅底骨折脑外伤患者,除进行常规颅脑CT扫描外,又针对其颅底进行高分辨率CT扫描。结果120脑外伤患者颅底高分辨CT扫描发现颅底骨折91例276处,其中线样骨折99处,粉碎性骨折177处;而常规CT扫描仅发现颅底骨折65例163处,其中线样骨折62处,粉碎性骨折101处;薄层扫描对中颅窝、前颅窝极不易直径显示骨折的部位也可清晰显示,同时可清晰显示出筛窦、蝶窦、及乳突气房内积液情况,常规CT扫描和薄层扫描两组比较,差异有统计学意义（P〈0．05）。结论对颅脑外伤患者进行CT检查时,增加颅底薄层高分辨扫描,能提高颅底骨折的检出率,减少漏诊。为临床的诊断和治疗提供了可靠依据。     

合并脑脊液漏的前颅底骨折的颅底重建

目的：探讨合并脑脊液漏的前颅底骨折颅底重建的指征及时机。方法回顾性分析2006年～2012年117例前颅底骨折合并脑脊液漏患者的临床资料。分析术前螺旋CT扫描并根据影像数据将患者被分为3组。Ⅰ型组：单纯骨折无明显移位（垂直脑膜方向≤5 mm）；Ⅱ型组：骨折移位明显但不伴有气颅；Ⅲ型组：无论骨折是否移位伴气颅。所有患者均纳入定期随访机制。结果70例患者保守治疗后脑脊液漏停止，24例患者因颅内血肿或脑疝一期手术同时行颅底修复，20例患者因脑脊液漏或继发脑膜炎二期颅底重建。Ⅱ型和Ⅲ型患者进行二期颅底重建术与Ⅰ型相比较差异有统计学意义。结论合并脑脊液漏的前颅底骨折患者术前应仔细评估三维CT并作出最佳治疗选择，气颅及骨折移位均是颅底重建的重要指征，应结合病人临床情况及时修复。     

掌骨基底关节外骨折预后的预测因素分析

目的 探讨掌骨基底关节外骨折患者预后的预测因素.方法 回顾性分析102例掌骨关节外骨折患者的临床资料,根据术后骨愈合情况的不同将患者分为愈合良好组(n=55)和愈合不良组(n=47).比较2组患者的临床资料[年龄、性别、手术固定类型、骨折原因、骨折分型、术后感染、骨折类型以及骨形态发生蛋白(BMP)、骨骼生长因子(SGF)、血小板衍生生长因子(PDGF)水平],采用受试者工作特征(ROC)曲线分析BMP、SGF和PDGF水平预测掌骨关节外骨折术后骨愈合不良的曲线下面积、灵敏度、特异度,并通过Logistic回归分析模型明确掌骨关节外骨折术后骨愈合不良的危险因素.结果 愈合不良组术后感染、开放性骨折、粉碎性骨折等比率高于愈合良好组,差异有统计学意义(P＜0.05);愈合不良组BMP、SGF和PDGF水平低于愈合良好组,差异有统计学意义(P＜0.05).ROC曲线分析结果显示,BMP、SGF和PDGF的曲线下面积分别为0.618、0.644和0.737.多因素Logistic回归分析显示,术后感染、开放性骨折、粉碎性骨折、BMP＜ 7.415 pg/mL、SGF＜ 85.705 ng/mL和PDGF ＜5.235 ng/mL是骨关节外骨折术后骨愈合不良的危险因素(P＜0.05).结论 术后感染、开放性骨折、粉碎性骨折等临床特征和BMP ＜7.415 pg/mL、SGF＜ 85.705 ng/mL、PDGF＜5.235 ng/mL均可能引起骨关节外骨折患者术后骨愈合不良.     

重型颅脑损伤后高血糖与预后的关系

目的 明确在重型颅脑损伤中高血糖对患者预后的影响.方法 回顾分析符合以下条件的重型颅脑损伤患者84例,无糖尿病史及重要颅外合并伤,均行开颅手术治疗,伤后6个月格拉斯哥预后评分(GOS).根据GOS将84例患者分为预后良好组及预后较差组,分析两组间伤后血糖与预后的关系.结果 预后良好组伤后血糖较预后较差组低.两组差异有统计学意义(P<0.05).结论 重型颅脑损伤后高血糖能够作为早期预测预后的简便指标.     

早期建立人工气道干预脑卒中后吞咽障碍患者预后的效果评价

目的 观察急性脑血管病吞咽障碍患者早期建立人工气道对改善预后的应用效果.方法 用吞咽筛选试验将入院的急性脑血管病中有吞咽功能障碍的151例患者,随机分成观察组(气管导管组)和对照组(常规治疗组),观察两组患者吞咽功能障碍改善情况,窒息、吸入性肺炎的发生率、病程、治愈率和死亡率.结果 观察组窒息和吸入性肺炎的发生率比对照组明显降低(P＜0.01).2周后,两组患者吞咽功能障碍改善情况无统计学差异,1个月后,观察组死亡2例,对照组死亡12例,具有显著性差异(P＜0.01);观察组吞咽能力恢复也明显高于对照组(P＜0.05).两组住院时间比较有统计学差异(P＜0.01).结论 早期经鼻气管插管建立人工气道,加强气道管理以及营养支持的护理干预急性脑血管病后吞咽障碍的患者的预后,能有效降低吸人性肺炎和窒息的发生率,恢复吞咽能力.缩短患者的病程,提高治愈率,降低死亡率.     

老年股骨转子间骨折患者术后发生深静脉血栓的影响因素分析

目的 分析老年股骨转子间骨折患者术后发生深静脉血栓的影响因素.方法 回顾性分析2019年3月至2020年8月该院收治的102例股骨转子间骨折患者的临床资料,根据术后是否发生深静脉血栓分为发生组(35例)和未发生组(67例).比较两组基础资料及实验室检查结果,包括性别、年龄、骨折部位、固定类型、骨折原因、骨折类型、骨折至入院时间、术后感染情况和血小板衍生生长因子(PDGF)水平;采用受试者工作特征(ROC)曲线分析PDGF预测老年股骨转子间骨折患者术后发生深静脉血栓的价值;将两组差异有统计学意义的指标纳入多因素Logistic回归分析模型,分析老年股骨转子间骨折患者术后发生深静脉血栓的危险因素.结果 两组性别、年龄、骨折部位、固定类型和骨折原因比较,差异无统计学意义(P>0.05);发生组横行骨折、术后感染患者比例及骨折至入院时间显著高于或长于未发生组,PDGF水平显著低于未发生组,差异均有统计学意义(P<0.05).ROC曲线分析显示,PDGF预测老年股骨转子间骨折患者术后发生深静脉血栓的曲线下面积为0.737,最佳截断值为5.235 ng/mL,灵敏度为54.5％,特异度为76.6％.多因素Logistic回归分析显示,横行骨折、骨折至入院时间较长、术后感染和PDGF<5.235 ng/mL是老年股骨转子间骨折患者术后发生深静脉血栓的危险因素(P<0.05).结论 影响老年股骨转子间骨折患者术后发生深静脉血栓的危险因素较多,包括横行骨折、术后感染、骨折至入院时间较长、PDGF<5.235 ng/mL.     

股骨近端螺旋刀片抗旋髓内钉内固定和人工股骨头置换治疗高龄患者转子间骨折的疗效分析

目的 回顾性分析运用股骨近端螺旋刀片抗旋髓内钉(PFNA)内固定和人工股骨头置换治疗转子间骨折的高龄患者,确定两手术的各自适应证.方法 收集我院2005~2010年转子间骨折的高龄(≥75岁)患者,股骨头置换84例,PFNA内固定162例,从手术时间、术中出血量、下地承重所需时间、髋关节功能及术后6个月内并发症(褥疮、肺炎、泌尿系感染、再发骨折)的发生情况进行综合分析,确定这两种手术各自的适应证.结果 临床资料比较结果:两组患者手术时间、术中出血量有统计学差异(P＜0.05),住院天数统计结果显示,两组差异无统计学意义(P＞0.05).随访比较结果:患者开始下地承重的时间有统计学意义(P＜0.05),在术后并发症、切口感染及再发骨折方面差异无统计学意义(P＞0.05),而在褥疮、肺炎及泌尿系感染方面具有统计学差异(P＜0.05).两组患者髋HARRIS功能评分统计分析结果显示,髋关节在早、中、晚各期的功能差异均无统计学意义(P＞0.05).结论 PFNA内固定治疗在减少手术时间及术中出血量方面有优势,而在早期功能锻炼及减少术后并发症方面稍逊于人工股骨头置换.而远期髋关节功能无显著差异.     

重症中暑患者的临床特点及集束化治疗

目的 探讨36例重症中暑患者的临床特点,并提出集束化治疗策略.方法 回顾性统计36例重症中暑住院患者的临床资料.将其中32例生产性中暑患者进行分组,根据高温环境中暴露时间长短分为两组,长时间暴露组(>6 h)及短时间暴露组(<6 h),对两组患者临床资料进行分析.结果 36例重症中暑患者中生产性中暑占88.9%,生活性中暑占11.1%.长时间暴露组高热、昏迷、休克、低钠血症、酶谱显著升高、血肌酐升高、血小板下降发生率与短时间暴露组比较,均差异有统计学意义(P<0.05).结论 长时间暴露于高温环境中,多器官功能障碍发生率高.对重症中暑患者采取"早期快速降温、早期快速扩容、早期抗凝、积极支持脏器功能等"集束化治疗策略,可有效防治多器官功能障碍,缩短住ICU时间,改善预后.     

CT图像重叠技术对后颅凹脑功能变化价值的探讨

INTRODUCTIONDuetoeffectofcranii,especiallyoccipitalboneknotandmastoidsonbothsides,therewereradiateandcloudyartifactonthefossacraniposteriorduringCTscaningwhichaffectthecorrectdiagnosis犤1-4犦.ToavoidthesesituationaandtoimprovecorrectrateofCTdiagnosisonfossacraniiposterior,overexposurewereused.Nevertheless,al-thoughartifactswerereduced,theradiologicaldoseimposedonpa-tientswereincreasedandisnotgoodforpatients.Whilesignal/noiseratioisreducedusingthinlayerscanning.Recently,weemployedoverlap…     

Early computerized tomography accurately determines the presence or absence of scaphoid and other fractures

Objective: To validate the use of early CT in predicting scaphoid fracture and other fractures in patients with suspected scaphoid fracture. Method: A prospective observational study of adult patients with a diagnosis of clinical scaphoid fracture presenting to a regional ED. Patients were immobilized in a scaphoid plaster and had a CT (wrist and carpals) same or next day. The gold standard used was the diagnosis on Day 10 with clinical examination and X‐rays, with MRI performed in patients with persistent tenderness but normal X‐rays. Results: Forty‐seven patients completed the study protocol from September 2004 until February 2006. For all fractures, early CT had a 96.8% negative predictive value and 100% positive predictive value (94.4% sensitive, 100% specific). No scaphoid fracture was missed by early CT. One patient had a trapezium fracture on CT, with a coexistent subtle capitate fracture only detected on MRI. Conclusion: Early CT scans show promise in the diagnosis of scaphoid and other fractures of the wrist and carpals. Further study is warranted to validate early CT in clinical scaphoid fracture as an alternative to other early advanced imaging, or plaster immobilization and 2 week review.     

神经内镜治疗中颅窝蛛网膜囊肿的作用及疗效探讨

目的探讨神经内镜手术治疗中颅窝蛛网膜囊肿的手术指征、手术方法及疗效。方法回顾性分析采用神经内镜手术治疗的39例中颅窝蛛网膜囊肿患者临床资料，术后3个月至18个月行临床和影像学随访。结果术前有I临床症状的27例患者共有症状43项，其中症状消失或明显改善34项（78．05％），未改善者（21．95％）以癫痫症状为主；术前无临床症状者12例，术后亦无临床症状。25例有影像学随访结果的患者，囊肿消失7例（28％），缩小13例（52％），无变化5例（20％）。结论采用神经内镜手术治疗中颅窝蛛网膜囊肿创伤小，疗效满意，可作为本病治疗首选的手术方法。     

X线检查在踝关节骨折诊断中的应用及影像学特点研究

目的:探讨X线检查在踝关节骨折诊断中的应用及影像学特点。方法:回顾性分析我院2018年10月至2019年6月收治的50例踝关节扭伤导致踝关节骨折的患者,所有患者进行X线检查,并将检查结果与多层螺旋CT作对比。结果:50例踝关节骨折的患者均经多层螺旋CT检查证实为骨折。其中中X线检查诊断出45例,诊断符合率为90.00%。其中包括9例内踝骨折,11例外踝骨折,19例踝骨粉碎性骨折,5例距骨骨折,1例合并根骨骨折。5例为踝关节周围软组织肿胀合并关节囊肿胀。结论:X线检查在踝关节骨折诊断中的应用价值高,诊断符合率高,X线表现中踝关节周围软组织肿胀合并关节囊肿胀的患者需要着重考虑是否存在踝关节骨折。该检查方法值得临床推广应用。     

Morbidity and mortality among patients with hip fractures surgically repaired within and after 48 hours

OBJECTIVE: The objectives were (1) to compare the morbidity and mortality of patients with hip fractures surgically repaired within and after 48 hours of the occurrence of fracture and (2) to establish whether timing of repair alone had a major role in determining how the patients fared after the surgical repair or whether comorbidities also affected outcomes. SAMPLE: The study involved the medical records of 49 patients (aged 51 to 99 years) admitted to Coney Island Hospital between January 2003 and January 2004 with a primary diagnosis of hip fracture who underwent surgical repair. DESIGN: Analysis of data was done by retrospective chart review of patients admitted with the diagnosis of hip fracture to an acute care hospital setting. Follow-up continued until the patients were transferred to a rehabilitation facility for physical or occupational therapy after surgery. OUTCOME MEASURES: The preoperative health status of each patient was assessed by cardiopulmonary risk index score, based on comorbid conditions, and postoperative outcome was determined by complications (such as bed sores, pneumonia, urinary tract infection, deep vein thrombosis, or pulmonary embolism) or death. RESULTS: Patients who underwent early surgical repair (within 48 hours) had fewer postoperative complications (14.7%, as compared with 33.3% in the group undergoing surgery >48 hours after fracture). CPRI scores in the early and delayed surgery groups were also compared with regard to postoperative mortality and morbidity. It appeared that there was a higher statistical correlation between CPRI scores and complications among patients in the early surgery group (P=0.39) and an insignificant correlation among patients in the delayed surgery group (P=0.07). CONCLUSION: Surgical repair of hip fractures within the first 48 hours was associated with better health outcomes in a nationally representative sample, as observed in an acute care facility, irrespective of comorbid conditions.     

Temporal bone fractures: a clinical diagnosis.

Temporal bone fractures may be complicated by intracranial haemorrhage, C.S.F. leakage and infection, damage to the middle and inner ear and damage to the seventh and eighth cranial nerves. Accurate early diagnosis is important to enable adequate investigation and prompt treatment of any complications. We present eight cases seen in a 12 month period in which a temporal bone fracture was not diagnosed at presentation in spite of a full clinical examination and standard skull radiographs. Five of these cases developed complications which resulted in their referral. The absence of a visible fracture on plain skull radiographs does not exclude a fracture, and those patients with clinical signs of a fracture should be treated appropriately and further investigations performed. Therefore the clinical examination is vital in diagnosing temporal bone fractures and must include careful otoscopy together with assessment of the function of the seventh and eighth cranial nerves.     

Outcomes and secondary prevention strategies for male hip fractures

OBJECTIVE: To assess clinical outcomes and determine whether osteoporosis assessment and secondary prevention strategies were performed for male veterans hospitalized for hip fractures. DESIGN: Retrospective chart review for male veterans hospitalized for hip fracture from January 1993 through July 1999. SETTING: The Veterans Affairs Medical Center, Madison, WI. RESULTS: Medical charts were available for 46 of 53 male patients admitted for hip fracture during the study period. Three subjects were excluded because hip fracture was associated with high-impact trauma. Mean age of the 43 study patients was 72 years (range 43-91 y), and mean length of hospitalization was 16 days (median 11 d, range 3-108 d). Thirty-two (82%) of 39 veterans whose disposition was documented were discharged to a nursing home. Eleven (26%) of 43 men died within 12 months after fracture. Twelve (28%) had fractured previously. Four (10%) subsequently had another fracture. Three of 9 patients with documented ambulation status were ambulatory at 1 year. Three patients received a bone mass measurement within a prespecified time interval of 6 months subsequent to fracture. No patient's records included a diagnosis of osteoporosis either before or within 6 months after fracture. One-third of the patients had documentation of calcium or multivitamin supplementation at discharge. One patient was receiving calcitonin at the time of fracture and continued to receive it afterward. No other patient was prescribed antiresorptive therapy by the time of hospital discharge. CONCLUSIONS: Male veterans with hip fractures received inadequate evaluation and treatment for osteoporosis, although a substantial portion had documentation of recurrent fractures. Education of clinicians and creation of algorithms for management of established osteoporosis may improve outcomes for these individuals.     

颈动脉海绵窦瘘的治疗

本文报告30例颈动脉海绵窦瘘治疗方法。其中外伤性25例,自发性5例,前者均行可脱性球囊、微弹簧圈等血管内栓塞治疗,颈内动脉通畅率为85％,血管杂音、球结膜水肿、充血、突眼完全消失。自发性颈内动脉海绵窦瘘,可用保守疗法,但较重的或保守治疗失败者,常需要血管内栓塞治疗。本文对各种疗法做了讨论及评价。     

切开复位内固定治疗儿童锁骨骨干骨折

[目的]探讨切开复位和内固定治疗儿童锁骨骨干完全移位骨折的疗效.[方法]：对24例平均年龄12岁8个月（7～16岁）病例,锁骨骨干完全移位骨折,采用切开复位和内固定方法治疗.24例中,3例为斜形骨折,其余21例为横形骨折.内固定方式：2例斜形骨折分别应用克氏针和螺钉固定,另1例斜行骨折和全部21例横形骨折应用锁骨重建钢板固定.观察患儿治愈率,影像学结果,功能恢复情况以及并发症.[结果]：全部病例得到随访,手术效果满意,骨折完全愈合时间为2～4.5个月,平均愈合时间为3个月,手术至恢复体育运动时间为5～12个月,平均时间为8月.平均随访时间为2年2个月（12个月至5年7个月）.没有发生切口感染和骨不连.87%（21/24）的患儿完全恢复了伤前的运动水平.2例患儿感觉到瘢痕处不适.1例患儿由于初始外伤遭受的尺神经损伤导致一过性的尺神经支配区域麻痹.所有的骨折都完全愈合,所有的内固定器均在骨折愈合后择期取出.[结论]：切开复位内固定治疗儿童锁骨中段完全移位骨折是一种安全,有效的方法.     

后入路内固定治疗肩胛骨骨折疗效分析

目的探讨经后入路内固定治疗肩胛骨骨折的疗效。方法回顾性分析2007年12月至2009年12月收治的经手术治疗的17例肩胛骨骨折的临床资料。根据Miller的分型方法,ⅠA型1例,ⅡA型2例,ⅡB型1例,Ⅲ型10例,Ⅳ型3例。采用后入路对肩胛骨骨折使用重建钢板、拉力螺钉等进行治疗。结果 17例患者全部获得随访,随访时间12~30个月,平均18个月。根据Hardegger的疗效评价标准,优13例,良2例,可2例,优良率为88.24%。结论采用后入路重建钢板及拉力螺钉治疗肩胛骨骨折效果确切,利于早期进行康复功能锻炼,疗效满意。