髋臼骨折合并坐骨神经损伤的手术治疗

目的总结髋臼骨折合并坐骨神经损伤内固定和神经探查的手术治疗体会.方法对33例患者行重建钢板、拉力螺钉固定髋臼骨折,同时行坐骨神经探查术,神经损伤者予以神经松解减压或束膜吻合.结果髋臼骨折复位程度按Matta标准:解剖复位14例,满意复位16例,不满意复位3例.坐骨神经功能恢复按MCRR标准评定:优15例,良13例,可3例,差2例,优良率为84%.髋关节功能按修订的dAubigen-Postel髋关节评分标准:优13例,良13例,可5例,差2例,优良率为79%.结论手术复位内固定及坐骨神经探查术治疗髋臼骨折合并坐骨神经损伤可获得良好的效果.     

髋臼后壁骨折伴髋关节后脱位与坐骨神经损伤的临床分析

目的 探讨髋臼后壁骨折伴髋关节后脱位合并坐骨神经损伤的创伤机制、类型和预后关系.方法 笔者收治髋臼后壁骨折伴髋关节后脱位合并坐骨神经损伤21例,在骨折内固定时,均行坐骨神经探查术,按MCRR标准评定神经功能恢复情况.结果 21例在术后24个月内,神经均有不同程度的功能恢复,优11例,良9例,可1例,优良率为95.2%.本组无一例出现医源性损伤.结论 髋臼后壁骨折伴髋关节后脱位常合并坐骨神经损伤者,在骨折内固定时应探查神经,结合损伤性质和程度,采取相应疗措施,有利于正确判断预后和恢复神经功能.     

髋臼骨折合并坐骨神经损伤的治疗(附20例报告)

目的　探讨髋臼骨折合并坐骨神经损伤的创伤机制及治疗。方法　分析本组髋臼骨折合并坐骨神经损伤共 2 0例 ,均行肌电图检查。 4例采用患肢持续股骨髁上牵引非手术治疗 ;16例采用髋臼骨折切开复位内固定手术治疗 ,术中视坐骨神经损伤程度作神经外膜松解或束间松解。结果　坐骨神经恢复情况 :优 7例 ,良 6例 ,可 4例 ,差 3例。结论　应根据临床检查 ,X线及CT所示骨折移位情况和有无髋关节后脱位 ,作电生理检查 ,结合临床有无造成神经严重损伤的因素而决定是否探查坐骨神经 ;术中肉眼观察坐骨神经损伤程度对指导手术和判断预后有一定意义 ,神经的恢复情况与术中所见损伤程度有关     

GSS系统内固定及骶管减压治疗不稳定骶骨骨折伴神经损伤

目的探讨不稳定骶骨骨折伴神经损伤手术治疗方法。方法5例不稳定骶骨骨折伴神经损伤患者使用GSS内固定系统固定及骶管减压。结果骨折均一期愈合,4例坐骨神经损伤中,3例下肢顽固性疼痛和感觉过敏者,2例疼痛消失,1例疼痛减轻,感觉均恢复;1例足下垂未恢复;1例鞍区麻木、大小便失禁者,术后鞍区感觉及括约肌功能得到恢复。结论GSS内固定及骶管减压治疗不稳定骶骨骨折伴神经损伤是一种较为理想的方法。     

骨盆骨折伴骶丛神经损伤手术治疗25例分析

目的探讨骨盆骨折合并腰骶丛神经损伤的临床特点和治疗方法。方法对2000年1月至2006年4月间随访到的25例骨盆骨折伴骶丛神经损伤进行回顾性分析。结果25例骨盆骨折合并腰骶丛神经损伤,随访8个月~6年。10例骶骨骨折合并腰骶丛神经损伤,有明显骨块压迫,行骶丛神经探查,5例完全恢复正常,3例部分恢复,2例未恢复;15例骶骨骨折合并腰骶丛神经损伤,未行神经探查,12例恢复正常,2例部分恢复,1例未恢复。结论对于骨盆骨折并腰骶丛神经损伤的患者实施积极复位及内固定治疗,是非常重要的一环。有明显骨块压迫者,宜行神经探查松解术。     

骨盆骨折致坐骨神经损伤机制及预后的相关因素

目的：探讨骨盆骨折所致坐骨神经损伤的创伤机制及影响预后的相关因素。方法：分析本组骨盆骨折所致的坐骨神经损伤共53例：39例行骨盆骨折复位内固定、坐骨神经探查松解手术治疗，14例保守治疗。结果：获得随访47例，随访12个月～6年，平均2年。根据MCRR标准，手术治疗组优19例、良10例、一般4例、差1例，保守治疗组优6例、良2例、一般3例、差2例。结论：骨盆骨折致坐骨神经损伤者宜早期行骨折复位内固定，坐骨神经探查松解减压或束膜吻合，可获得较好疗效。     

髋臼骨折、髋关节脱位合并坐骨神经损伤的临床分析

目的探讨髋臼骨折、髋关节脱位合并坐骨神经损伤的临床特点及发病机制。方法回顾髋臼骨折、髋关节脱位及髋臼骨折合并髋关节脱位的患者155例(159侧),其中合并坐骨神经损伤35侧。分析髋臼骨折、髋关节脱位的流行病学特点及坐骨神经损伤与髋臼骨折、髋关节脱位分型的关系。结果81.3%的患者为男性,86.5%的患者年龄为20～50岁,83.9%为车祸伤所致。坐骨神经损伤总发病率为22.01%,而在髋臼骨折为17.19%,在单纯髋关节后脱位为12.90%,在髋臼骨折合并髋关节后脱位为36.36%。31侧坐骨神经损伤中48.39%为腓总神经成分损伤,51.61%为腓总神经 胫神经损伤。结论车祸伤是髋臼骨折、髋关节脱位的主要原因,多见于成年男性。坐骨神经损伤主要发生于髋臼后壁、后柱骨折合并髋关节后脱位患者,且腓总神经成分损伤多见。     

Intraoperative somatosensory evoked potential monitoring of pelvic and acetabular fractures.

The efficacy of intraoperative somatosensory evoked potential (SSEP) monitoring was evaluated in the surgical management of 82 patients with pelvic and acetabular fractures. The injuries consisted of 45 acetabular fractures, 30 pelvic ring disruptions, and seven combined injuries. Preoperative neurological deficits were recorded in 34% of the study group (29% of those with an acetabular fracture and 47% of those with a pelvic ring injury). Three patients sustained an iatrogenic sciatic nerve injury during the study period (all of which were documented in the first 40 cases). Two patients sustained an exacerbation of an existing sciatic nerve injury. In the group of pelvic fractures, hazardous parts of the exposure, reduction, and fixation were identified by the SSEP monitoring. Removal of the provocative stimulus by the surgeon led to reversal of the SSEP abnormalities, and none of this group of patients sustained an iatrogenic injury. When the intraoperative SSEP changes were noted during an acetabular fracture fixation, immediate attempts were made to relieve the excessive tension on the sciatic nerve by replacing or removing a retractor, flexing the knee, extending the hip, or dividing the femoral insertion of the gluteus maximus. None of the SSEP changes were associated with the lacerative injury to the sciatic nerve. For the method to be clinically effective in reducing the incidence of neurological deficit, even subtle changes in the SSEP tracing must be recognized immediately by the neurophysiologist so that a corresponding corrective measure can be rapidly undertaken by the surgeon to remove the offending stimulus.     

骨盆骨折合并阴道损伤的早期诊断和治疗

 目的 探讨骨盆骨折合并阴道损伤的早期诊断和治疗策略。方法 回顾性分析2000年1月至2010年7月收治的13例骨盆骨折合并阴道损伤患者的病历资料,年龄17～52岁,平均31.7岁。按Tile骨盆骨折分类系统分类：B1型4例、B2型1例(Tilt骨折)、B3型4例、C1型3例、C2型1例。3例急诊行阴道损伤修复、骨盆骨折切开复位内固定术;5例血流动力学不稳定者,积极抗休克治疗,病情稳定后急诊行阴道修复、骨盆骨折外固定支架固定术;2例延迟诊断阴道损伤,确诊后及时行阴道修复术,1例行骨盆骨折切开复位内固定术,另1例行外固定支架固定术;2例因外院漏诊阴道损伤,形成盆腔脓肿,行彻底清创、骨盆骨折外固定支架固定术,待感染控制后二期行阴道重建术。结果 12例存活,1例入院后6 h死亡。11例获得随访,平均随访17个月(8~36个月)。阴道损伤一期修复的9例患者中已婚者6例,5例性生活正常,1例存在性交时疼痛;未婚者3例,月经正常。阴道损伤二期重建的2例患者,均存在性交时疼痛。末次随访时Majeed骨盆骨折术后功能评分平均82.2分(56～96分),优6例、良3例、可2例。结论 女性骨盆骨折存在骨盆前环损伤,应高度怀疑阴道损伤的可能。早期诊断并修复阴道损伤是处理的关键,可获得较好的临床效果;延误诊断和治疗可导致严重的并发症,临床效果差。     

Outcome of operatively treated type-C injuries of the pelvic ring

BACKGROUND: Internal fixation has become the preferred treatment for type-C pelvic ring injuries, but controversies persist regarding surgical approach and surgical technique. PATIENTS: We evaluated 101 consecutive patients with type C1-C3 pelvic ring injuries who had been treated with standardized reduction and internal fixation techniques. RESULTS: Our findings suggest a correlation between excellent reduction followed by sufficient fixation of the pelvic ring and functional outcome. Unsatisfactory reduction (displacement > 5 mm), failure of fixation, loss of reduction and a permanent lumbosacral plexus injury were the commonest reasons for an unsatisfactory functional result. All 40 patients with an associated lumbosacral plexus injury showed at least some evidence of neurological recovery. 14 underwent complete neurologic recovery. 8 had only sensory deficits and the remaining 18 also had motor deficits at the final followup. Complications were rare, but some of them were severe: loss of reduction in 8%, malunion in 10%, deep wound infection in 2%, and a lesion of the L5 nerve root in 1%. INTERPRETATION: Our results suggest that special attention should be paid to preoperative planning, reduction of the fracture, decompression of the nerve roots, and fixation of the most severe sacral fractures. Our results seem to favor internal fixation of displaced (> 10 mm) and unstable rami fractures and symphyseal disruptions in conjunction with posterior fixation, to achieve better stability of the whole pelvic ring.     

切开复位内固定治疗耻骨联合浮动伤

 目的 探讨耻骨联合浮动损伤的临床特点及采用切开复位内固定治疗的效果。方法 回顾性分析2008年1月至2013年1月采用切开复位内固定治疗48例耻骨联合浮动损伤患者资料,男31例,女17例;年龄20~61岁,平均36.5岁;车祸伤35例,坠落伤8例,挤压伤5例。骨盆骨折AO分型: B型13例,C型35例。其中45例合并骨盆后环骨折,14例合并髋臼骨折,17例合并四肢骨折,11例合并胸腹部损伤,6例合并泌尿生殖系统损伤。受伤至手术时间3~25 d,平均7 d。骨盆前环固定方法：重建钛板固定双侧耻骨支骨折41例,微创空心钉固定7例。同时固定后环损伤41例,其中12例采用骶髂前钢板固定,5例采用骶髂螺钉固定,18例采用髂骨后“M”型板固定,6例采用髂腰固定。结果 44例获得随访,随访时间12~36个月,平均16个月,骨折全部临床愈合,愈合时间10~16周,平均12.6周。采用Matta标准评价骨折复位情况,其中优21例,良16例,可7例,优良率为84.1%（37/44）。末次随访时Majeed评分为65~100分,平均81.5分,其中优30例,良10例,可4例,优良率为90.9%（40/44）。术后3天,2例患者发生脂肪液化,经换药2~3周后治愈;术后5~15 d,平均10 d,8例发生下肢深静脉血栓,经给予低分子肝素等保守治疗1~6个月,平均3.5个月后血栓治愈;术后5~7 d,平均6 d,3例出现耻骨疼痛,给予抗炎止痛药物、理疗等治疗1年后疼痛解除。无一例发生钢板断裂脱出、感染及医原性神经、血管损伤等并发症。结论 耻骨联合浮动伤是一类严重的骨盆骨折,多数合并后环损伤,影响骨盆稳定性,切开复位内固定可以稳定骨盆,有助于早期活动及功能锻炼,从而获得良好临床效果。     

Sciatic nerve release following fracture or reconstructive surgery of the acetabulum

BACKGROUND: Sciatic neuropathy associated with acetabular fractures can result in disabling long-term symptoms. The purpose of this retrospective study was to evaluate the effect of sciatic nerve release on sciatic neuropathy associated with acetabular fractures and reconstructive acetabular surgery. METHODS: Between 2000 and 2004, ten patients with sciatic neuropathy associated with an acetabular fracture were treated with release of the sciatic nerve from scar tissue and heterotopic bone. Additional surgical procedures included open reduction and internal fixation of the acetabulum (five patients), removal of hardware and total hip arthroplasty (three patients), and removal of hardware alone (one patient). The average age of the patients was forty-three years. All patients were followed with serial examinations and assessments for a minimum of one year (average, twenty-six months). RESULTS: All patients had partial to complete relief of radicular pain, of diminished sensation, and of paresthesias after the nerve release. Four of seven patients with motor loss and two of five patients with a footdrop demonstrated improvement in function after the nerve release. No patient had evidence of worsening on neurologic examination after the release. CONCLUSIONS: Sciatic nerve release during reconstructive acetabular surgery can decrease the sensory symptoms of preoperative sciatic neuropathy associated with a previous acetabular fracture. Motor symptoms, however, are less likely to resolve following nerve release.     

Monitoring of somatosensory and motor evoked potentials during open reduction and internal fixation of pelvis and acetabular fractures

Monitoring of motor and somatosensory evoked potentials provides instantaneous intraoperative assessment of a patient's neurologic status. Monitoring of the sciatic nerve through motor and somatosensory evoked potentials can be used during open reduction and internal fixation of pelvic and acetabular fractures. A review of 12 pelvic and acetabular fractures treated with open reduction and internal fixation was conducted and assessed with a combination of intraoperative motor and somatosensory evoked potential monitoring. Results revealed intraoperative motor evoked potential monitoring was 100% sensitive and 100% specific in predicting postoperative sciatic nerve deficits, whereas somatosensory evoked potentials were not accurate in predicting postoperative sciatic nerve deficits. Combined monitoring of the sciatic nerve with motor and somatosensory evoked potentials is beneficial at predicting postoperative sciatic nerve deficits during open reduction and internal fixation of pelvic and acetabular fractures.     

骨盆骨折合并腰骶丛压迫性损伤的早期诊断与手术治疗

目的 探讨骨盆骨折合并腰骶丛压迫性损伤的临床特点和手术疗效.方法 2000年1月至2009年1月,手术治疗19例骨盆骨折合并腰骶从压迫性损伤患者.男13例,女6例;年龄21～56岁,平均34.7岁.骨盆类型按Tile分型,A型2例,B型6例,C型11例;按Young-Burgess分型,前后挤压型1例,侧方挤压型10例,垂直剪切型3例.复合型5例.采用神经减压进行治疗,其中后路减压8例,前路减压6例,前后联合入路减压5例.16例行骨折复位内同定,其中骶髂前路重建钢板内固定6例,经皮骶髂螺钉内崮定3例,后路"M"形钢板内固定4例,髂腰固定3例;同时将前环固定6例.结果 19例患者术中均证实神经有压迫性损伤,手术切口均一期愈合,无皮肤坏死及感染.17例获得随访,随访时间12～72个月,平均27个月.骨折全部临床愈合,愈合时间8～14周,平均10.6周.神经功能完全恢复12例,部分恢复4例,未恢复1例.6例术前合并鞍区感觉减退及排便困难者,4例恢复正常,2例部分恢复.结论 骨盆骨折合并腰骶丛损伤时,应根据临床表现、影像学资料确定神经损伤的性质及部位,如证实神经损伤为骨性压迫,宜尽早手术减压;对骨折移位明显、骨盆不稳者可同期行骨折复位内固定,以获得较好的临床效果.     

儿童不稳定骨盆骨折治疗的回顾分析

 目的 总结儿童不稳定骨盆骨折的治疗方法与教训。方法 1998年 10月至 2011年 3 月, 治疗不稳定骨盆骨折患儿 30例, 男 19例, 女 11例;年龄 2~16岁, 平均 7.9岁;均为 Torode-Zieg郁 型, 其中骶髂关节前脱位 4例。合并其他部位骨折 11例, 合并泌尿生殖系统损伤 14例, 合并骶丛损伤3例, 合并髂血管损伤 2例, 合并膈肌破裂、膈疝 1例;发生失血性休克 14例。 15例行保守治疗, 9例行外 固定治疗, 4例行内固定治疗, 1例行内、外联合固定治疗, 1例行半骨盆离断术。结果 1例患儿因大量失血而在急诊手术中死亡;13例失访, 16例获得随访, 随访时间 3个月~11年。根据 Cole等评分标准, 优 12例, 良 1例, 可2例, 差 1例;优良率为 81.25%。 1例患儿骨牵引后残留骶髂关节垂直移位, 遗留骨 盆倾斜, 双下肢不等长。 1例患儿因坐骨神经损伤而发生髋关节半脱位, 致严重跛行。 1例合并骶丛损伤 的患儿术后发生轻度跛行。结论 儿童不稳定骨盆骨折的治疗不同于成人, 损伤控制对其更为重要, 下肢骨牵引仍是主要治疗手段之一, 常可获得良好预后。若牵引治疗对垂直移位复位不理想, 则可考虑手术治疗。此外, 合并神经损伤是影响患儿预后的重要因素, 应注意检查和随访。     

闭合复位带锁髓内钉适宜治疗合并桡神经损伤的肱骨干骨折吗?

目的探讨肱骨干骨折合并的桡神经损伤是否会因为带锁髓内钉置入时的闭合复位操作而导致神经损伤的加重。方法2002年1月～2005年1月手术治疗的353例肱骨干骨折患者中,63例术前合并桡神经损伤。对此63例患者的体检、手术记录、X线片及治疗结果进行回顾性分析。11例行闭合复位带锁髓内钉固定；52例行切开复位内固定术及桡神经探查术,应用PEMS 3．1版本的卡方检验对11例行闭合复位带锁髓内钉固定术的患者与19例可以采用带锁髓内钉固定但行切开复位内固定术及桡神经探查术的患者桡神经恢复情况进行统计学分析。结果52例行切开复位内固定术及桡神经探查术的患者中,9例(17．3%)桡神经被骨折端嵌压,其余43例均为桡神经挫伤。63例患者中,除2例外,桡神经损伤均于术后2～12周(平均8周)自行恢复。所有患者术后3～4个月获骨性愈合。闭合复位带锁髓内钉术与切开复位内固定及神经探查术对肱骨干骨折合并桡神经损伤患者的影响差异无显著性意义(P=0．3931)。结论闭合复位带锁髓内钉固定治疗合并桡神经损伤的肱骨干骨折患者是适宜的。     

Avulsion fracture of the tibial tuberosity in late adolescence

Between January 1982 and May 1985, eight patients with avulsion fractures of tibial tuberosity were seen at the University of South Alabama Medical Center. All were boys, average age, 15 years 8 months. Six of eight had a positive history of Osgood-Schlatter disease. Seven patients underwent open reduction and internal fixation, one had closed reduction and cast. Followup ranged from 5 months to 3.5 years, averaging 19.5 months. All, except one who had lateral meniscectomy, regained practically full ROM and reported no pain or limitation of activities. No patient developed genu recurvatum deformity or leg length discrepancy due to the injury. Open reduction and internal fixation is the treatment of choice in displaced intra-articular fractures. Lateral parapatellar incision is a more direct approach to this fracture and is less likely to injure the infrapatellar branch of the saphenous nerve.     

Outcome of operatively treated type-C injuries of the pelvic ring

Background?Internal fixation has become the preferred treatment for type-C pelvic ring injuries, but controversies persist regarding surgical approach and surgical technique.

Patients?We evaluated 101 consecutive patients with type C1-C3 pelvic ring injuries who had been treated with standardized reduction and internal fixation techniques.

Results?Our findings suggest a correlation between excellent reduction followed by sufficient fixation of the pelvic ring and functional outcome. Unsatisfactory reduction (displacement > 5 mm), failure of fixation, loss of reduction and a permanent lumbosacral plexus injury were the commonest reasons for an unsatisfactory functional result. All 40 patients with an associated lumbosacral plexus injury showed at least some evidence of neurological recovery. 14 underwent complete neurologic recovery. 8 had only sensory deficits and the remaining 18 also had motor deficits at the final followup. Complications were rare, but some of them were severe: loss of reduction in 8%, malunion in 10%, deep wound infection in 2%, and a lesion of the L5 nerve root in 1%.

Interpretation?Our results suggest that special attention should be paid to preoperative planning, reduction of the fracture, decompression of the nerve roots, and fixation of the most severe sacral fractures. Our results seem to favor internal fixation of displaced (> 10 mm) and unstable rami fractures and symphyseal disruptions in conjunction with posterior fixation, to achieve better stability of the whole pelvic ring.     

老年移位髋臼骨折手术治疗策略及疗效

目的探讨切开复位内固定术和一期全髋关节置换术治疗老年髋臼骨折的临床疗效并进行比较研究。方法1998～2005年间共收治45位年龄超过60岁的髋臼骨折患者，其中21例行切开复位内固定，10例行一期全髋关节置换术。手术距受伤时间不到2周，平均7d。术后常规给予抗凝药预防深静脉血栓形成，按康复计划进行恢复性功能锻炼，定期随访行髋关节功能Harris评分。结果本组随访1．5～7年，平均4年；最后随访时，切开复位内固定组Harris评分为69～84分，平均79分，优良率为57％，伴有较高的创伤性关节炎、异位骨化、股骨头骨坏死发生率；全髋关节置换术组患者的Harris评分为75～90分，平均84分，优良率为80％，仅有髋臼杯轻度移动（〈4mm），无假体松动、深部感染等并发症。结论全髋关节置换术治疗老年移位髋臼骨折可以取得比切开复位内固定更好的稳定性，术后恢复快、功能质量高，并发症少，是一种较好的选择。     

长重建钢板结合MIPPO技术固定骨盆前环骨折

目的: 探讨长重建钢板结合微创经皮钢板内固定术(minimally invasive percutaneous plate osteosynthesis,MIPO)技术治疗不稳定骨盆骨折前环骨折疗效。方法: 自2013年1月至2019年2月收治16例不稳定骨盆骨折患者,其中男12例,女4例;年龄20~60岁,平均46.5岁。骨盆骨折依据Tile分型,B1型4例,B2型6例,C1型4例,C2型2例。所有骨折为闭合性,受伤至手术时间7~10 d,平均6.2 d。术后对16例患者手术时间、术中出血量、骨折复位质量、骨折愈合时间、并发症情况及肢体功能进行评价。结果: 16例患者均获得随访,时间12~23个月,平均19.1个月。手术时间60~180 min,平均107.8 min;术中出血量120~600 ml,平均368.1 ml;骨折愈合时间12~20周,平均16.3周。依据Matta标准对骨折复位情况进行评价,优6例,良8例,可2例。1例患者术中股外侧皮神经损伤,术后出现大腿外侧感觉减退,6个月后恢复;1例患者由于自觉髂窝处内固定物刺激疼痛,内固定取出后症状改善,16例患者骨折均取得满意愈合,无内固定物松动。末次随访Majeed评分67~95分,优10例,良4例,可2例。结论: 运用长重建钢板结合MIPPO技术通过前方入路闭合复位固定骨盆前环骨折,损伤小,术中出血时间少,节省手术时间,术中安全性及骨折愈合率高,术后可早期功能锻炼,能有效治疗骨盆前环骨折。