Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen

Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence‐based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on‐call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on‐call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence‐based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non‐therapeutic laparotomy rates.     

选择性动脉造影与栓塞在血流动力学不稳定骨盆骨折诊治中的应用

目的 探讨选择性动脉造影与栓塞在诊治骨盆骨折伴血流动力学不稳定患者中的应用.方法 回顾性分析2002年1月至2008年12月收治的62例骨盆骨折伴动脉损伤患者资料,骨折采用AO分型:A2型2例;B1型6例,B2型9例,B3型8例;C1型16例,C2型13例,C3型8例.其中开放性损伤6例(Gustilo分型:Ⅱ型1例,Ⅲ型5例).多发伤患者46例,12例发生休克.62例患者在积极补液及应用血管活性药物的同时进行动脉造影检查,其中59例患者行栓塞治疗. 结果 62例患者行动脉造影79次,其中行2次以上动脉造影患者12例.损伤动脉由多至少依次为臀上动脉、髂腰动脉、骶外侧动脉、闭孔动脉、臀下动脉、阴部内动脉以及髂内动脉和髂外动脉的主干.32例患者伴有两条以上动脉(分支)损伤.59例行骨盆内动脉损伤栓塞治疗的患者中,56例有效.7例患者因腹腔脏器严重损伤抢救无效而死亡,10例失访,45例患者术后获6～52个月(平均14个月)随访.11例患者患侧臀部肌肉力量较健侧弱,未见其他明显并发症.12例多次行选择性动脉造影与(或)栓塞治疗的患者均获随访,其中2例发生患侧臀部肌肉力量减弱. 结论 选择性动脉造影与栓塞是诊治骨盆骨折患者动脉损伤的有效措施.对于多发动脉损伤或延迟动脉损伤的患者,重复性动脉造影和栓塞治疗是必要且安全有效的.     

Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures

Objective

To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation.

Methods

A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n = 20) or early pelvic angiography (ANGIO group, n = 20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded.

Results

The PACK group underwent operative packing at a median of 45 min from admission; the median time to angiography in the ANGIO group was 130 min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24 h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage.

Conclusions

Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.     

不稳定骨盆骨折的手术治疗

2003年9月~2005年1月,我科对6例不稳定型骨盆骨折患者实施手术切开复位内固定,取得了较好的疗效。1材料与方法1.1病例资料本组6例均为男性,年龄25~50岁。按Tile分型:B1型1例,B3型3例;C1型2例,均急诊入院。合并伤:休克2例,转子间骨折2例,下肢骨折3例,颅脑损伤2例,腰椎骨折3例。1     

改良骨盆骨外固定器治疗不稳定骨盆骨折43例

目的:观察改良骨盆骨外固定器治疗不稳定骨盆骨折临床疗效。方法:43例不稳定骨盆骨折,男27例,女16例;年龄12～72岁。开放性骨折3例,闭合性骨折40例。骨折按Tile分型,B型损伤10例,C型损伤33例,均应用改良骨盆骨外固定器治疗。结果:2例患者因合并严重的颅脑、胸、腹脏器损伤死亡。41例患者痊愈,随访6个月～3年6个月,优29例,良10例,尚可2例,优良率88.37%。轻微跛行步态9例,较严重者3例;活动后腰骶部疼痛者1例。X线复查,骨盆倾斜5例,骨盆旋转1例。结论:改良骨盆骨外固定器治疗不稳定型骨盆骨折不仅能控制骨盆出血、缓解疼痛、方便护理、安装简便,而且还满足临床腹部手术需要,在辅助牵引下还能作为大部分骨折的终极治疗。     

不稳定型骨盆骨折的内固定治疗

目的探讨不稳定型骨盆骨折内固定治疗的疗效。方法对48例骨盆骨折患者采用钢板、螺钉等内固定材料进行骨折复位、固定,恢复骨盆前后环的稳定。结果 43例患者获得随访,时间8～24个月。患者均获得骨性愈合,未出现腰腿痛、肢体缩短和跛行等。根据Matta评分标准:优30例,良8例,可3例,差2例,优良率为88.4%。结论手术复位、内固定治疗不稳定型骨盆骨折可以恢复骨盆的正常结构,重建骨盆的稳定性,临床疗效满意。     

损伤控制指导治疗不稳定型骨盆骨折的临床分析

[目的]探讨应用骨科损伤控制理论指导治疗不稳定型骨盆骨折的意义,规范不稳定型骨盆骨折的治疗。[方法]本组39例不稳定型骨盆骨折,在骨科损伤控制理论指导下,首先采取各种措施稳定生命体征,过渡性简单外固定,然后实施有效内固定恢复骨盆的稳定性。[结果]39例病人无一死亡,骨折一期愈合,所有病人均未因骨盆骨折而留有并发症或重度残疾。按Matta评定标准评价疗效,治疗组优21例,良11例,中4例,差3例,优良率82.1%,而对照组优良率51.8%。差异有显著性(x2=9.16,P<0.001)。[结论]骨科损伤控制理论对于不稳定型骨盆骨折的治疗具有肯定的指导意义,骨科损伤控制应该成为不稳定型骨盆骨折治疗的临床路径。     

不稳定骨盆骨折的外固定架治疗

近年来,不稳定骨盆骨折,尤其在多发伤患者中的不稳定骨盆骨折受到众多学者的重视。早期进行骨盆外固定架固定可有效地控制失血、稳定骨折,利于重症患者的转运和抢救。同时,对于特定类型的骨盆骨折,外固定技术可以作为一种有效的治疗方法。我院自2001年3月-2005年6月,应用骨盆外固定架固定治疗不稳定骨盆骨折,取得了良好效果。1临床资料本组26例,男14例,女12例;年龄18~64岁,平均35·4岁。按Tile分类[1]:B1型12例,B2型9例,C1型2例,C2型3例,其中开放骨折1例。骨折均为高能量创伤,车祸伤14例,压砸伤6例,高处坠落伤6例。并发休克13例,合并直肠…     

外固定架技术在不稳定型骨盆骨折中应用

目的 探讨骨盆外固定架治疗不稳定型骨盆骨折的临床效果。方法 2001年9月-2006年5月采用骨盆外固定架治疗不稳定型骨盆骨折28例，Tile B1型12例、B2型9例、C1型2例、C2型3例、C3型2例。结果 27例经6—26个月随访，根据骨折复位情况、疼痛、步态、肢体长度、髋关节活动度，按Matta评定标准，本组总优良率96％。结论 外固定架治疗骨盆骨折操作简单，是一种安全有效的方法。     

Robot‐assisted percutaneous screw placement combined with pelvic internal fixator for minimally invasive treatment of unstable pelvic ring fractures

Purpose

The purpose of this study was to investigate the safety and efficacy of the combination of robot‐assisted percutaneous screw placement and pelvic internal fixator (INFIX) for minimally invasive treatment of unstable anterior and posterior pelvic ring injuries.

Methods

From September 2016 to June 2017, twenty‐four patients with unstable anterior and posterior pelvic ring injuries were treated with TiRobot‐assisted percutaneous sacroiliac cannulated screw fixation on the posterior pelvic ring combined with robot‐assisted pedicle screw placement in the anterior inferior iliac spine along with INFIX on the anterior pelvic ring. The results of the treatment, including surgery duration, fluoroscopy frequency, total drilling, amount of blood loss, fracture healing time, and postoperative functional outcomes were recorded and compared with another 21 similar patients who underwent conventional manual positioning surgery.

Results

The TiRobot group incurred significantly shorter duration of surgery; less fluoroscopy frequency, intraoperative bleeding, and total drilling than in the conventional group (P < 0.05). Postoperative radiological follow‐up showed that all screws were in the safe area and no screw penetrated the cortex. All wounds healed by primary intention and no iatrogenic damage to the blood vessels, nerves, and organs occurred. Patients showed good tolerance to INFIX and reported no discomfort. The mean follow‐up duration was 5.4 months; the fractures were all healed, no loss of reduction occurred, and the mean Majeed score at the last follow‐up did not show any difference.

Conclusion

TiRobot‐assisted percutaneous screw placement combined with INFIX for the anterior and posterior pelvic ring injuries is accurate, safe, less invasive, and shows satisfactory efficacy, suggesting it is a better method for minimally invasive treatment of unstable pelvic ring fractures.     

垂直不稳定性骨盆骨折内固定的生物力学研究

目的 探讨垂直不稳定骨盆骨折３种后环内固定方法及单纯固定后环和前后环同时固定稳定性的差异。方法 将１２只尸体骨盆随机分成３组,每组４具。２组造成垂直不稳定骨盆骨折,１组分别采用骶骨棒、四孔方形钢板、松质骨螺钉单纯固定后环,另１组上述方法固定后环同时用四孔钢板固定前环;第３组作为完整骨盆,进行骨盆稳定性测试。结果 使用骶骨棒、四孔方形钢板、板质骨螺钉单纯固定后环时,骨盆的稳定性分别达完整骨盆的１７．     

一期联合手术治疗不稳定型骨盆骨折并发后尿道断裂伤5例报告

目的:探讨一期联合手术治疗不稳定型骨盆骨折并发后尿道断裂伤的可行性.方法:自2001年6月～2007年6月,共收治骨盆骨折并发尿道断裂患者24例.对其中5例不稳定型骨盆骨折并发后尿道断裂伤的患者采取急诊尿道吻合或尿道会师术,同期行骨盆骨折复位内或外固定术.术后均随访 ,时间为3～12个月.结果:1例发生耻骨后感染,无死亡和尿道二期手术;术后随访,3例患者排尿满意,2例出现不同程度的排尿困难,经定期尿道扩张后排尿满意.结论:骨盆骨折的早期复位和有效固定是实现尿道修复的解剖基础,一期联合手术治疗不稳定型骨盆骨折并发后尿道断裂伤是可行的.     

脊柱骨盆骨折合并腹部闭合伤的早期诊断

目的 探讨脊柱骨盆骨折合并腹部闭合损伤的诊断方法,提高其诊断水平。方法 回顾分析１９８０￣１９９８年本院收治的８４例脊柱骨盆骨折合并腹部闭合损伤病人的临床资料,对比各种诊断方法与手术结果。结果 腹腔穿刺阳性率８２％,ＣＴ阳性率７４％,Ｂ超阳性率７０％。１２ｈ内手术病死率９．８％,７２ｈ后手术病死率３６％。结论 脊柱骨盆骨折合并腹部闭合损伤易发生误诊,漏诊。其病死率与手术时机有明显关系,腹腕穿刺是一     

不稳定型骨盆骨折的疗效探讨

目的 探讨不稳定型骨盆骨折(Tile B和Tilec型)的治疗和疗效。方法 比较78例骨盆骨折患者使用和非使用骨盆外固定支架手术疗效。结果 在38例骨盆骨折患者未使用骨盆外固定支架治疗中，失血性休克的纠正率为76％，死亡率10．6％，平均ISS评分11．6。而在使用骨盆外固定支架治疗的40例患者中，失血性休克的纠正率为90％，死亡率为2．5％，平均ISS评分9．87结论 骨盆外固定支架治疗不稳定型骨盆骨折合并失血性休克，手术简单，疗效可靠，大大降低了患者的死亡率。     

Guidelines for management of urinary incontinence

In Japan, only the following two guidelines are available: ‘Guidelines on Urinary Incontinence in the Elderly’ based on research funded by the Longevity Sciences Research Grant (chief investigator: Kikuo Okamura) and ‘Guidelines on Urinary Incontinence in Women’ based on ‘Research on Treatment Standardization in the Urological Field’ funded by the Health Sciences Research Grant (group leader: Osamu Nishizawa). This paper is an English translation of these two guidelines originally published in Japanese.     

A pelvic fracture model for the assessment of treatment options in a laboratory environment

BACKGROUND: Optimal prehospital and clinical management of patients with severe pelvic trauma is controversial. Prospective evaluations of different treatment strategies have not been performed and treatment is currently not evidence-based. The purpose of the present study was to develop a porcine model of reproducible severe pelvic trauma for subsequent laboratory trials. METHODS: The study was performed on 13 juvenile porcine cadavers. Pelvic fractures were created by applying a pure anterior-posterior compression load to the pelvic ring using a servohydraulic material testing machine. Fracture patterns were classified according to the Young-Burgess classification and the Tile classification using postfracture CT scans including 3D-reconstructions. RESULTS: Disruptions of the posterior pelvic ring segment were unilateral in 12 cases and bilateral in one case transforaminal vertical sacrum fractures. Injuries of the anterior ring segment were obturator ring fractures bilateral, ipsilateral or contralateral to the injury of the posterior ring segment. According to the Tile classification this resulted in 12 type C1 and 1 type C3 fractures. In the Young classification all injuries were classified as type APC III. In six cases transverse process fractures were found ipsilateral to the posterior ring disruption. Initial force drops indicating bony or ligamentous injuries occurred at mean forces of 4030 +/- 269N (range, 3617-4374N). CONCLUSION: The present model was able to create reproducible unstable pelvic fractures and can be used for controlled laboratory trials to study the management of patients with pelvic fractures.     

复杂骨盆骨折的早期急救处理

目的探讨复杂骨盆骨折的早期急救处理方法及疗效。方法回顾性分析我院2006年1月至2010年4月收治的复杂骨盆骨折23例资料,采取重症监护为主、多科协作、早期积极处理并发症和合并症进行治疗,研究死亡例数、住院时间、X线结果、骨折愈合等临床指标。结果除2例患者死亡外,余病例术后双下肢等长,行走步态正常,未遗留严重后遗症。Majeed评分,优良率为87％。结论及时、快速、有效的早期处理,才能降低复杂骨盆骨折的死亡率和并发症,重症监护为辛、多科协作、早期积极处理并发症和合并症是治疗复杂骨盆骨折的重要保证。     

The external fixateur in the management of unstable colles' fracture

Summary Colles' fracture is frequently unstable with a high incidence of redisplacement, varying from 40–60% in various published series. Redisplacement following reduction can be avoided with a small external fixateur using two pins placed at right angles to each other both in the distal fragment and the radial shaft. This technique has been employed in twenty-two patients with secondary displacement of Colles' fracture and the end results evaluated by the McBridge points system was excellent or good in twenty-one of the twenty-two patients.

---

Résumé Les fractures de l'extrémité inférieure du radius sont souvent instables, d'où un pourcentage important de déplacement itératif, variant, selon les séries publiées, de 40 à 60%. Ce redéplacement après réduction peut être évité grâce à l'utilisation d'un petit fixateur externe, dont deux fiches sont placées perpendiculairement l'une à l'autre dans le fragment distal et deux autres dans la diaphyse. Cette technique a été utilisée chez 22 blessés présentant un déplacement secondaire après réduction d'une fracture de Pouteau-Colles. Les résultats, évalués selon la cotation de Mc Bride, ont été bons ou excellents dans 21 cas sur 22.

     

TSRH系统治疗Tile C型骨盆骨折

2003年8月～2008年8月,我科采用TSRH系统治疗Tile C型骨盆骨折患者13例,均取得较好效果。1材料与方法1.1病例资料本组13例,男9例,女4例,年龄19～52岁。其中6例伴有肢体骨折,3例合并腹腔脏器伤,2例合并