严重骨盆骨折合并毗邻脏器损伤的救治

目的探讨严重骨盆骨折合并毗邻脏器损伤的急诊处理方法。方法对14年中收治的79例严重骨盆骨折合并毗邻脏器损伤患者的资料做回顾性分析。结果骨盆大出血行髂内动脉结扎术33例、栓塞术8例;膀胱造口和后期尿道重建35例、尿道会师术7例;腹膜外直肠伤做结肠造口并骶前引流13例、一期修补4例;腹膜内结直肠伤一期手术19例、结肠造口3例。死亡率9％(7／79),主要死于休克和合并伤。共发生并发症7例：直肠膀胱瘘4例、右髂总动脉血栓形成1例、胸伤后急性呼吸窘迫综合征(ARDS)1例、截瘫1例,除截瘫均治愈。结论迅速准确的诊断治疗是成功的关键。髂内动脉断血术配合骨盆外固定支架的使用、膀胱造口和乙状结肠近端造口,是危重患者急诊治疗时常采用的有效方法。     

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.     

Multifocal arterial haemorrhage in a partially stable pelvic fracture after a crush injury: a case report

Introduction: Most pelvic haemorrhages are thought to be caused by injury to small arteries or veins in the fractured cancellous pelvic bone or in the surrounding soft-tissues, and only 6–18% of patients with unstable pelvic fractures have haemorrhage from larger arteries. When arterial injuries are present, the majority involve branches of the internal iliac artery with only few published reports of injuries to the external iliac artery or its branches. Materials and methods: We report of a patient who sustained a combined pelvic and acetabular fracture with multifocal bleeding involving branches of both the internal iliac as well as the external iliac arteries after a crush injury. The primary attention was focused on the most probable arterial injury, the internal iliac artery and only at repeat angiography was the injury to the internal epigastric artery, caused by degloving injury to the trunk, recognized. Results: Arterial control was achieved only following aggressive fluid resuscitation, pelvic packing, repeated embolization and ligation of the peripelvic inferior epigastric artery. After initial haemodynamic control was achieved, the patient sustained multiple complications, partly as a consequence of the injury, but also as a consequence of the life-saving treatments. Conclusion: The case describes a rare combination of arterial injuries in a complex pelvic fracture constituting a partially stable pelvic fracture and a dislocated acetabular fracture in a patient with pelvic crush injury and a degloving injury to the trunk. The case also describes the complex nature of these injuries and rarely reported problems related to the treatment of them. None of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. No identifiable conflicts of interest are present.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Common and external iliac artery injuries associated with pelvic fractures.

BACKGROUND: Common and external iliac artery injuries associated with pelvic fractures are uncommon. The diagnosis of such injuries is based on clinical findings and confirmed by arteriography. DESIGN: Retrospective chart review. SETTING: University Level I trauma center. PATIENTS: Five men and three women, aged seventeen to seventy-six years, with injuries to the common and external iliac arteries associated with pelvic fractures. RESULTS: All patients sustained complex pelvic fractures associated with multiple blunt injuries. Five injuries occurred on the right side. Two patients had an associated right vertical shear pelvic fracture. In five patients, vascular injury was diagnosed in the first six hours after admission. One patient presented with an aneurysm of the right common iliac artery two months after his initial injury. All patients underwent surgical repair with an interposition graft, which failed in two patients, who underwent vascular reconstruction ten hours after the injury. One patient died of associated injuries. CONCLUSIONS: Arterial hyperextension with intimal damage seems to be the most likely cause of this injury. Ideally, an extraperitoneal approach should be attempted to minimize blood losses and, due to the size of the iliac vessels, an interposition graft should be used for reconstruction.     

Comminuted fractures of the iliac wing

PURPOSE: Comminuted iliac fractures are uncommon and difficult to treat. The purpose of this study is to further delineate the fractures, to present a management protocol, and to evaluate the results of treatment. DESIGN: Retrospective clinical study. SETTING: Level one trauma center at Harborview Medical Center. PATIENTS: During a sixty-eight-month period, 695 patients with pelvic ring disruptions were treated at a level one trauma center. Thirteen (1.9%) of these patients had a severely comminuted iliac fracture. All patients were men, ranging in age from twenty to eighty years (mean, 38 years). These patients were polytraumatized and had a mean Injury Severity Score of 23. Eleven of the thirteen patients had severe iliac and flank degloving injuries. Five patients had open fractures, one with fecal contamination requiring diverting colostomy. Six patients with clinical signs of hemodynamic instability had local arterial injuries associated with their fractures. All five patients with extension of the fracture into the greater sciatic notch were found to have a local arterial injury on angiography. One patient had a lumbosacral plexopathy on the fractured side. Four patients had traumatic brain injuries. INTERVENTION: All thirteen patients were treated operatively. Routine pelvic external fixation was not possible because of the iliac comminution. Stable internal fixation was accomplished by an anterior iliac surgical exposure using lag screw and plate combinations. The open wounds and degloving injuries were treated with irrigation, debridement, and closed suction drainage. MAIN OUTCOME MEASUREMENTS: Healing and stability of fixation were assessed clinically and on pelvic radiographs. RESULTS: Comminuted iliac fractures were divided into two patient groups, according to associated pelvic ring disruption. Follow-up evaluations were available for all patients at a mean of eighteen months after injury. There were no deaths. All of the fractures healed clinically and radiographically. In one patient, fecal contamination caused a polymicrobial wound infection, and this patient had an associated delay in union of the fracture. Another patient with an open fracture developed a deep wound infection. Both infections responded to local management and antibiotics. There were no complications associated with the degloving injuries. CONCLUSIONS: Comminuted iliac fractures occur in two distinct patterns and are associated with numerous local injuries that complicate management. Management protocols should include early open reduction and stable internal fixation. Traumatic open wounds should not be closed primarily. Primary closure with closed suction drainage is effective in the management of associated degloving injuries. Extension of the fracture into the greater sciatic notch warrants further evaluation with pelvic angiography.     

Primary Endoscopic Realignment in Female Urethral Injuries with Pelvic Fracture Can Reduce Avoidable Morbidity

Female urethral injuries associated with Pelvic fracture are not as uncommon as it was previously thought. Primary endoscopic realignment of proximal urethra and catheterisation on guide-wire is very good procedure in early presentation. Every female patient with urethral injury due to pelvic fracture should be referred for primary repair to decrease the avoidable morbidity of these patients.     

Acute bilateral iliac artery occlusion secondary to blunt trauma: successful endovascular treatment

INTRODUCTION: Endovascular treatment of blunt vascular trauma has been infrequently reported. PRESENTATION: A 27-year-old man was crushed between a fork-lift truck and a concrete platform. The physical examination was remarkable for hemodynamic stability, significant lower abdominal ecchymosis and tenderness, obvious pelvic fracture, and gross hematuria. Vascular examination revealed no femoral pulses, no pedal signals bilaterally, and minimal left leg and no right leg motor function. Arteriograms revealed right common iliac artery and external iliac artery occlusion and a 2-cm near occlusion of the left external iliac artery. TREATMENT: In the operating room, bilateral common femoral artery access was obtained, and retrograde arteriogram on the right side demonstrated free extravasation of contrast material at the level of the proximal external iliac artery. An angled glide wire was successfully traversed over the vascular injury, and two covered stents (Wallgraft, 10 x 50 mm and 8 x 30 mm) were deployed. The left iliac injury was similarly treated with an 8 x 30-mm covered stent. After calf fasciotomy, exploratory laparotomy revealed a severe sigmoid colon degloving injury, requiring resection and colostomy. A suprapubic catheter was placed because of bladder rupture, and an open-book pelvic fracture was treated with external fixation. Postoperatively the patient regained palpable bilateral pedal pulses and normal left leg function, but right leg paralysis persisted secondary to severe lumbar plexus nerve injury. CONCLUSION: Endovascular repair of blunt intra-abdominal arterial injuries is possible and should be particularly considered when fecal contamination, pelvic hematoma, or multiple associated injuries make conventional repair problematic.     

Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management

PURPOSE: Urethral injury in girls accompanying fracture of the pelvis is rare. We present our experience with 5 such complex cases and review the literature to define the types of problem and determine appropriate management. MATERIALS AND METHODS: We report on 5 girls with posttraumatic urethral injuries and pelvic fracture resulting in stricture as well as management based on the site and length of urethral stricture. Associated injuries and results are discussed. RESULTS: Of the 5 girls who presented with stricture 4 had undergone suprapubic cystostomy as initial treatment, whereas in 1 primary repair had failed. Urethral reconstruction using a bladder flap tube and distal urethrotomy into the vagina were performed in 3 and 1 cases, respectively. These 4 girls were continent although 1 required clean intermittent catheterization for a short period. The 3 patients with complete urethral loss had a more severe degree of pelvic fracture, including 1 treated with core through internal urethrotomy. CONCLUSIONS: Posttraumatic urethral injury accompanying pelvic fracture in young girls results in challenging management situations. More severely displaced pelvic fracture is associated with greater urethral loss and requires more complex repair. Cases of partial urethral injury or urethral transection without much displacement are better managed by primary repair of the transected urethra, which decreases morbidity. Primary repair may not be feasible in patients with extensive injury, who should be treated with secondary appropriate reconstruction after preliminary suprapubic cystostomy. Complete urethral loss may be managed by bladder flap tube neourethra creations with effective continence and excellent outcomes. Short segment distal urethral strictures may be treated with meatotomy or core through internal urethrotomy.     

Urethral injury in the multiple-injured patient

A total of 74 patients with urethral injury due to external trauma consisted of 48 posterior urethral injuries (25 complete rupture, 23 partial rupture) and 26 anterior urethral injuries (two complete rupture, 16 partial rupture, and eight contusion). The diagnosis was made by retrograde urethrography. All 48 patients with posterior urethral injury had associated injuries, including a fractured pelvis in 46, and a mortality rate of 33%. Only seven of the 26 patients with anterior urethral injury had associated injuries and a mortality rate of 14%. The management of posterior urethral injury is changing from primary realignment of the ruptured urethra to suprapubic cystostomy alone and followed later by urethral surgery for the resulting stricture. The impotence rate is significantly lower with management with suprapubic cystostomy alone. However, the type of pelvic fracture, the urethral injury itself disrupting neurovascular structures, and the surgical dissection (initial primary realignment or delayed urethroplasty) must be investigated before it can be determined whether the impotence associated with pelvic trauma is caused by the injury itself or by the surgical dissection undertaken to reconstruct the urethra.     

Treatment Outcomes of Open Pelvic Fractures Associated with Extensive Perineal Injuries

Background

The main causes of death in patients with open pelviperineal injuries are uncontrollable bleeding and pelvic sepsis. The aim of this study was to evaluate the management outcomes of open pelvic fractures associated with extensive perineal injuries.

Methods

We retrospectively studied 15 cases with open pelvic fractures associated with extensive perineal injuries (urethral and anal canal laceration) admitted between August 2006 and September 2010. Mechanism of injury, Injury Severity Score, associated injuries, hemodynamic status on arrival, resuscitation and transfusion requirements, operative techniques, intra- and postoperative complications, length of intensive care unit and hospital stay, and mortality were recorded in a computerised database for further evaluation and analysis.

Results

The male to female ratio was 12:3 with an average age of 38.6 years (ranged, 11 to 65 years). The average packed red blood cell units used were 8 units (ranged, 4 to 21 units). All patients were initially transferred to the operating room for colostomy, radical debridement and fixation of the pelvic fracture by an external fixator. One patient had acute renal failure, which improved with medical treatment and 2 patients (13.3%) died, one with type III anteroposterior compression fracture due to hemorrhagic shock and the other due to septicemia.

Conclusions

Open pelvic fractures with extensive perineal injuries are associated with high mortality rates. Early diagnosis and appropriate treatment, including reanimation, colostomy, cystostomy, vigorous and repeated irrigation and debridement, and fixation by an external fixator can improve the outcomes and reduce the mortality rate.     

Pelvic fracture urethral injuries: the unresolved controversy

PURPOSE: The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. MATERIALS AND METHODS: All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive. RESULTS: The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). CONCLUSIONS: In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.     

Blunt urethral injury: results of initial management

Fourteen men with blunt urethral disruption were treated between 1979-1985. Injuries most commonly resulted from motor-vehicle accidents, as pedestrians or passengers. All patients had additional injuries, including pelvic fracture (13), extremity fractures (10), central nervous system (5), bladder (5) and rectal injury (3); the average injury severity score was 30. Pelvic fracture patterns included ten patients with a crushed pelvis, two with single anterior pelvic ring fractures and one with a double vertical fracture. Blood at the urethral meatus was noted in only five patients, gross hematuria without metal blood in another three, and a displaced prostate on rectal exam was found in 10 cases. All patients had a suprapubic cystostomy for management of the urethral injury. Thirteen of 14 patients survived (93%). The major complication was perineal sepsis. Based on this experience, it is concluded that: 1) the classical findings of urethral injury are not found consistently, 2) certain pelvic fracture patterns, particularly disruption of the anterior pelvic ring, are frequently associated with urethral injury and 3) aggressive and appropriate management of hemorrhage, pelvic fracture and concomitant injuries is important to minimize mortality.     

Voiding and sexual dysfunctions after pelvic fracture urethral injuries treated with either initial cystostomy and delayed urethroplasty or immediate primary urethral realignment.

OBJECTIVE: The aim of this study is to evaluate the effects of the different immediate treatment modalities on the sexual and voiding functions in pelvic fracture urethral injuries. METHODS: The records of 38 male patients with traumatic posterior urethral injuries were reviewed, 18 of whom were treated by initial suprapubic cystostomy and delayed repair (Group 1), and 20 by primary urethral realignment (Group 2). Types of pelvic fractures and urethral injuries were classified according to surgical and radiological findings. Long-term voiding functions were determined by the patient questionnaire, residual urine and uroflow. Sexual functions were also determined by the patient questionnaire and a penile duplex ultrasound study. RESULTS: Mean follow-ups of Groups 1 and 2 were 37 and 39 months, respectively. Membranous urethral disruption extending to the urogenital diaphragm was the most frequent urethral injury (type 3), with incidences of 66.7% and 77.7%, respectively. There were no statistically significant differences in mean age, incidence of pelvic fracture types and urethral injury types between groups (p > 0.05). After the immediate treatments, 16.7% and 55% of the patients regained normal urination, and stricture developed in 83.3% and 45% of the patients, respectively. In 44.4% of the patients in Group 1 and 10% in Group 2, urethral strictures required open urethroplasty (p < 0.05). Erectile impotence before urethroplasty in 17.6% and 20%, anejaculation after urethroplasty in 17.6% and 15% and incontinence in 5.6% and 10% of the patients were found in Groups 1 and 2, respectively (p > 0.05). However, 88.8% and 90% of patients eventually achieved normal urination with complete continence. CONCLUSION: Sexual and voiding dysfunction after pelvic fracture posterior urethral injury seem to be the result of the injury itself, not of the immediate treatment modalities. In urethral disruption injuries, primary urethral realignment seems more favourable than suprapubic cystostomy and delayed repair.     

Damage control of multiple injuries headed by cervica spinal cord injury

Objective ： To explore the strategy of damage control in clinical treatment of multiple injuries headed by cervical spinal cord injury. Methods： A retrospective analysis was performed in 32 patients. Cervical fractures associated with tetraplegia occurred in 18 patients, traumatic intervectebral disk hernia associated with tetraplegia in 2 patients, and cervical fractures and dislocation associated with tetraplegia in 12 patients. Seventeen cases were combined with craniocerebral injury, 7 combined with pulmonary contusion, multi-fractures of rib or hemopneumothorax, 2 combined with pelvic fracture and other 8 combined with fracture of limbs. The neural function was assessed by the American Spinal Injury Association （ASIA） scale. Results： Thirty-one patients were followed up for an average of 14 months. Of them, 10 got complete recovery, 13 obtained improvement of more than one ASIA grade, 8 did not improve, and 1 died. Conclusions ： For the emergency treatment of multiple injuries headed by cervical spinal cord injury, the damage control strategy is the principle to follow. The final operations are preferably performed within 5 to 10 days after injury so as to raise the successful rate of remedy.     

Iliac vein injuries in hemodynamically unstable patients with pelvic fracture caused by blunt trauma

BACKGROUND: Major pelvic venous injuries secondary to blunt trauma can be a difficult problem in diagnosis and management. This study aimed to elucidate the clinical significance of iliac vein injuries demonstrated by venography in patients with blunt pelvic injuries who remained unstable even after transcatheter arterial embolization (TAE). METHODS: We reviewed the records of 72 patients with unstable pelvic fracture who presented with shock at our center after blunt trauma from 1999 through 2003. The average Injury Severity Score was 34.3 in this study population. RESULTS: TAE was the first method of choice to control bleeding from pelvic fracture in 61 patients. Thirty-six patients recovered from shock after TAE. Eighteen of 25 who did not recover from shock died. In 11 of these 25, transfemoral venography with a balloon catheter was performed, revealing significant venous extravasation in 9: common iliac vein in 5, internal iliac vein in 3, and external iliac vein in 1. The average Injury Severity Score of patients with iliac vein injury was 45.8. Treatments for venous injuries were laparotomy for hemostasis (n = 1, survivors = 0), retroperitoneal gauze packing (n = 3, survivors = 1), and endovascular stent placement (n = 3, survivors = 3). Two patients suffered from cardiac arrest before treatment for venous injury. External fixations were performed after TAE according to fracture type. CONCLUSION: The iliac vein injury is the principal cause of hemorrhagic shock in some patients with unstable pelvic fractures after blunt trauma. Venography is useful for identifying iliac vein injuries.     

Pelvic fracture-associated urethral injuries in girls: experience with primary repair

OBJECTIVE: To present our experience with four urethral injuries in females accompanying a pelvic fracture, managed with primary repair or realignment of the urethra. PATIENTS AND METHODS: There were three teenage girls and one adult (22 years old). All the patients had complete urethral injuries associated with a pelvic fracture from accidents. They were managed by immediate suprapubic cystostomy followed by repair or realignment of the urethra over a catheter on the same day. The catheter was removed after 3 weeks and a voiding cysto-urethrogram taken. Thereafter they were followed with regular urethral calibration. RESULTS: All patients voided satisfactorily with a good stream; three were fully continent and the fourth had transient stress urinary incontinence. One patient needed dilatation at 2 months and another visual internal urethrotomy at 5 months. At a mean (range) follow-up of 33 (9-60) months all the patients had a normal voiding pattern and were continent; none developed vaginal stenosis. CONCLUSION: Primary repair of the urethra, and if that is impossible, simple urethral realignment over a catheter, is the procedure of choice for managing female urethral injury associated with a pelvic fracture. The procedure has the additional advantage of reducing the risk of vaginal stenosis.     

转流性结肠造瘘在骨盆骨折合并会阴部损伤中的应用

 目的 总结转流性结肠造瘘在骨盆骨折合并会阴部损伤中的应用效果。方法 2005年 4 月至 2011年 4月, 治疗 27例骨盆骨折合并会阴部损伤患者, 男 23例, 女 4例;年龄 16~62岁, 平均 32.9岁;交通伤 19例, 高处坠落伤 4例, 挤压伤 2例, 重物砸伤 2例。骨盆骨折按 Tile分型: A型 4例, B 型 10例, C型 13例。采用骨盆外固定支架固定, 稳定血流动力学, 选择性应用转流性结肠造瘘及骨折复 位固定术进行治疗。应用 Fisher精确概率法对早期(伤后48h内)和非早期(损伤超过 48h或未造瘘) 行转流性结肠造瘘术患者的感染率进行比较。结果 24例患者存活, 3例死亡, 死亡率为 11%。存活的 24例患者均获得随访, 随访时间 4~42个月, 平均 10.9个月。 13例早期行结肠造瘘患者均未发生感染。 11例非早期行结肠造瘘患者中, 4例发生感染。早期行转流性结肠造瘘术患者的感染率显著低于非早 期患者, 两者比较差异有统计学意义。结论 骨盆骨折合并会阴部损伤早期急救重点为稳定血流动力学、选择性应用转流性结肠造瘘及早期骨盆固定。对于累及直肠、肛管的会阴部损伤或虽不累及直肠、 肛管但软组织损伤广泛的会阴部损伤均应行转流性结肠造瘘术。伤后 48h内行转流性结肠造瘘, 不但可有效降低感染率, 而且对保持患者良好营养状态、节省医疗开支及降低医护人员工作量有重要意义。     

Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture: Therapeutic Alternatives

Purpose

We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children.

Materials and Methods

From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3).

Results

In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries.

Conclusions

As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapubic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.     

Experience with management of posterior urethral injury associated with pelvic fracture

Review of records from 205 patients with pelvic fracture and hematuria revealed that 121 underwent urologic and radiographic evaluation. Of these patients 20 had severe posterior urethral injuries documented by urethrography of voiding cystourethrography: 9 underwent primary repair and 11 had delayed scrotal-inlay urethroplasty after initial cystostomy alone. Patients who underwent primary repair had a 77 per cent incidence of stricture, a 22 per cent incidence of incontinence and a 33 per cent incidence of impotency. Patients who underwent delayed closure had no incidence of stricture, incontinence or impotence. Patients in both groups had urinary tract infections. Simple cystostomy followed by delayed scrotal-inlay urethroplasty appears superior to primary realignment in the management of patients with posterior urethral injuries.