临床病例讨论——股骨颈骨折术后股骨头缺血坏死

病历摘要 患者,男性,13岁,因"机动车撞伤致右髋部疼痛1 h"于2007年4月30日至本院骨科就诊.急诊查体:患者痛苦面容,右侧髋关节和膝关节轻度屈曲,右下肢轻度外旋,局部无明显肿胀,右侧腹股沟韧带中点压痛明显,右髋关节主动运动丧失,被动活动疼痛加重,触诊检查大转子,大转子位于髂-坐骨结节连线之上,大转子与髂前上棘之间的距离右侧较左侧短缩约1.5 cm.急诊摄双侧股骨上段正位X线片示右侧股骨颈基底骨折(Garden Ⅳ型),移位明显(图1).急诊诊断:右侧股骨颈基底骨折.收治入院后,经完善术前常规检查,在与患者家属讨论治疗方案后,即日在硬膜外麻醉下急诊行"右侧股骨颈骨折闭合复位3枚空心钉固定术".     

Tetracycline labeling of the femoral head following acute intracapsular fracture of the femoral neck

The purpose of this study was to assess the utility of tetracycline hydrochloride (HCl) labeling of the femoral head following acute intracapsular fracture of the femoral neck to indirectly assess femoral head viability and vascularity. A standard labeling (1.5-3.0 g) and fixative protocol (70% ethanol) was used. The initial tetracycline dose was given in the emergency room. The time from last dose to bone sampling in the operating room ranged from six to 36 hours (average, 21.2 hours). There was no evidence of tetracycline deposition at the bone-osteoid interface in any of the femoral head specimens or the ipsilateral extracapsular greater trochanter control specimens. Sources of labeling failure are multifactorial: problems with label delivery to the patient, in vivo deposition of the label, and the fixation protocol.     

股骨颈骨折后股骨头坏死的病理学特点观察

股骨头坏死是股骨颈骨折的主要并发症 ,虽然股骨颈骨折后引起头坏死的因素很多 ,但其根本原因是供应头的营养血管损伤 ,血供中断而造成头的部分缺血或整个头的无血状态。为了详细观察和了解股骨颈骨折后头坏死、修复的过程和影响因素 ,为以后股骨头坏死早期诊断和股骨颈骨折的治疗提供依据 ,笔者设计了此实验。1　材料与方法1 1　动物与分组　同一批 6个月龄健康新西兰大白兔共 66只 ,雌雄不限 ,体重 3～ 3 5ｋｇ ,实验组 60只 ,随机分成 10个小组 ,每组 6只 ,另 6只作对照组。1 2　实验过程　实验组 :用 2 5 %硫喷妥钠通过耳缘静脉作连续…     

股骨颈骨折后股骨头坏死

简要叙述股骨颈骨折后股骨头坏死的早期诊断和坏死预测等的最新进展。为使骨折后骨坏死尽量减少，早期手术和关节穿刺减压，避免髋关节放置在伸直及内旋位是必要的，建议屈曲位牵引。应用Gd-DTPA增强MRI T1脂肪浸润扫描，可预测股骨头坏死的可能性。建议将股骨头坏死分为静息型骨坏死和临床型骨坏死．     

Avascular necrosis of the femoral head after femoral neck fracture

Trauma-induced avascular necrosis of the femoral head represents the most common femoral head aseptic necrosis. An alteration in blood supply to the femoral head is the cause of the vascular necrosis. Another mechanism in the genesis of femoral head necrosis is the tamponade effect. Femoral head necrosis may be asymptomatic for a long time, even in patients in whom late segmental collapse already is present. Radiography does not allow diagnostic reliability until 6 months after fracture. The presence of a low signal intensity band away from the fracture line on magnetic resonance images clearly delimits the necrotic area. Once segmental collapse has developed, the diagnosis becomes simple using plain radiographs. The treatment of established femoral necrosis complicating fractures of the upper end of the femur is approached as a therapeutic problem lacking an optimal solution. The main therapeutic options are femoral head-preserving procedures and joint reconstruction. Among the procedures that preserve the femoral head are joint unloading, femoral head core decompression, electric stimulation, osteotomy, and bone grafting. Joint reconstruction procedures including cup arthroplasty, hemiresurfacing, total hip resurfacing, femoral head replacement, femoral head endoprosthesis, and total arthroplasty will be reviewed.     

股骨头毁损三联征:股骨头骨折-脱位合并股骨颈骨折

股骨头合并同侧股骨颈骨折是一种严重而复杂的创伤,保髋手术大多会失败。其治疗的难点及预后的关键在股骨颈骨折上。鉴于股骨颈骨折的发生与股骨头骨折-脱位之间存在明显的、前后关联的贯序特点,笔者认为以股骨头毁损三联征（disastrous triad of femoral head,DTFH）来概括这种类型的损伤,更能反映其损伤机制和预后特点。结合临床观察和文献资料,DTFH可分为3个类型：Ⅰ型,普通型DTFH,股骨颈骨折的发生紧随于股骨头骨折-脱位之后,是同一暴力造成的损伤;Ⅱ型,医源型DTFH,是在股骨头骨折-脱位的诊疗过程中发生了医源性股骨颈骨折;Ⅲ型,应力型DTFH,发生于股骨头骨折-脱位的治疗之后,在股骨头骨折面的远侧缘发生应力性股骨颈骨折。本文对各型DTFH的临床特点进行了初步的讨论。     

Avascular necrosis of the femoral head after osteosynthesis of femoral neck fracture

The reported incidence of avascular necrosis after femoral neck fracture fixation varies widely, and there is no consensus regarding its risk factors. We evaluated the incidence of avascular necrosis of the femoral head with the use of contemporary techniques for femoral neck fracture fixation. We then sought to determine what potential risk factors influenced the development of avascular necrosis.Between 1990 and 2005, one hundred sixty-three intracapsular femoral neck fractures in 163 patients were treated with internal fixation at our level-I trauma center. All patients were monitored until conversion to total hip arthroplasty or for a minimum of 2 years postoperatively. Ten patients (10 hips) died and 7 patients (7 hips) were lost to follow-up. The remaining 146 patients (146 hips) had a mean 5.2 years of follow-up (range, 3 months to 17 years). The incidence of avascular necrosis was 25.3% (37 hips). The average time to diagnosis of avascular necrosis was 18.8 months (range, 3-47 months). Patient sex, age, interval from injury to surgery, and mechanism of injury were statistically not associated with the development of avascular necrosis. The quality of fracture reduction, adequacy of fixation, degree of displacement, and comminution of the posterior cortex were significantly associated. After we controlled for patient and radiographic characteristics, multivariate analyses indicated that the important predictors for avascular necrosis are poor reduction (odds ratio=13.889) and initial displacement of the fracture (odds ratio=4.693).     

Deep infection following femoral neck fracture osteosynthesis

Summary During the last decade a decrease in postoperative infections in femoral neck fracture osteosynthesis was noted which led us to review all femoral neck fractures for infection. In a retrospective series of 1894 femoral neck fractures, the majority of which were included in other limited prospective studies, a total of 15 deep infections were diagnosed (0.8%). Staph. aureus was the most common bacterium cultured, and the diagnosis was established more than 4 months postoperatively in 9 of the patients. A total of 658 of the 1894 patients, who had pre- or peroperative tetracycline administration for measuring bone turnover, had two deep infections (0.3%). Among the remaining 1236 patients without antibiotic prophylaxis, 13 deep infections were diagnosed (1.0%). This difference suggests considering antibiotic prophylaxis in femoral neck fracture osteosynthesis. Eight of the infections led to THR, usually two-stage ; no signs of recurrent infection ensued, and the hip function of these patients was restored. The remaining 7 patients had Girdlestone procedures, also without recurrent infection, but with inferior functional outcome.     

A pathological fracture of the femoral neck associated with osteonecrosis of the femoral head and a stress fracture of the contralateral femoral neck

A pathological fracture of the right femoral neck associated with osteonecrosis of the right femoral head and a stress fracture of the contralateral femoral neck occurred in a 47-year-old man. Osteonecrosis was noted in almost the entire femoral head, and the pathological fracture occurred at the subcapital area. Six months later, a stress fracture was detected in the contralateral femoral neck. The stress fracture of the left femoral neck might have been caused by the incremental repetitive mechanical loading in the left hip as a result of the pathological fracture in the right hip. Therefore, it might be necessary to conduct a careful examination, using either a magnetic resonance imaging scan or a bone scan, of patients with extensive osteonecrosis of the femoral head because of the risk of osteonecrosis in the contralateral femoral head as well stress fractures in the contralateral femoral neck.     

Avascular femoral head necrosis following fracture fixation

A prospective, randomized trial of 104 consecutive patients with displaced fractures of the femoral neck treated with either a sliding screw plate or four AO cancellous bone screws was performed to study the influence of the fixation device and the fixation procedure on the vascularity of the femoral head. The vitality of the femoral head was determined by 99mTc-MDP scintigraphy performed 2-3 months after the operation. Eighty-seven patients (84 per cent) were available for assessment. The two treatment groups were comparable with regard to age, degree of primary displacement and quality of reduction. There were significantly more (P less than 0.01) avascular femoral heads or femoral heads with reduced vascularity in the sliding screw plate group (14/40, 35 per cent) than in the four AO cancellous bone screw group (5/47, 11 per cent).     

骨水泥型人工股骨头治疗高龄股骨颈骨折

目的 探讨应用骨水泥型双极人工股骨头置换治疗高龄股骨颈骨折患者的临床疗效.方法 对38例高龄股骨颈骨折患者行骨水泥型双极人工股骨头置换治疗,根据Harris评分法评定术后疗效.结果 38例均获得随访,时间1～3年.髋关节功能根据Harris评分:优14例,良19例(其中1例随访至第14个月死亡),中5例,优良率为84.2%.结论 应用骨水泥型双极人工股骨头置换治疗高龄患者股骨颈骨折手术风险小、费用低、疗效满意,患者可早期下床活动,提高患者生存质量.     

Vitality of the femoral head after femoral neck fracture evaluated by tetracycline labeling

Summary Three cases featuring the coincidence of 2 different primary bone tumors at the same site are presented. In 2 cases, the combination was one of giant cell tumor and enchondroma, in the 3rd one, of giant cell tumor and non-ossifying fibroma. The pathogenetical and prognostical problems of these cases are discussed.With support by Federal Health Office and Protek-Fonds     

股骨颈骨折病人的股骨头样本结构的Micro-CT评估

[目的]利用Micro-CT（Micro-computed Tomography）对正常人和老年股骨颈骨折病人的股骨头松质骨样本进行三维评价和比较。[方法]对6位正常人（正常组，27～36岁）和9位老年股骨颈骨折病人（骨折组，70～78岁）的股骨头松质骨样本进行DEXA检查，获取骨矿物密度数据。行Micro-CT扫描，得到松质骨小梁空间结构的计算机三维图形，并进行三维计量。[结果]与正常组相比，股骨颈骨折病人股骨头负重区样本的骨小梁结构在骨体积分数BV／TV、骨表面积体积比BS／TV、骨小梁厚度Tb.Th、骨小梁间隙Tb．Sp存在显著差异（P〈0．01），而骨小梁数目Tb．N、结构模型指数SMI和骨小梁模型因子Tb．Pf之间无统计学差别。骨密度检测两组没有显著性差异（P〉0．05）。[结论]股骨头松质骨的空间结构会因年龄增大而发生改变。