四爪接骨板内固定治疗多发性肋骨骨折和连枷胸的有限元建模和临床分析

摘要：目的评价四爪接骨板行多发性肋骨骨折和连枷胸内固定术的临床疗效。方法回顾性分析上海市浦东医院2011年12月至2012年11月93例多发性肋骨骨折和连枷胸患者的临床资料,其中男78例、女15例;年龄20～80岁。均采用四爪接骨板内固定治疗,对固定后的四爪接骨板进行有限元建模分析。结果93例患者平均肋骨骨折数（5．9±2．1）根,内固定数（3．8±1-3）根,入院后手术时间（6．3±3．2）d。患者经四爪接骨板内固定治疗后,骨折错位的肋骨及连枷胸胸壁塌陷得到矫正,患者疼痛缓解。术后胸部CT三维重建显示四爪肋骨接骨板内固定区无松脱移位,肋骨骨折复位好,胸廓恢复正常;通过有限元分析发现四爪接骨板内同定后能承受的最大应力是正常肋骨的两倍。结论四爪肋骨接骨板内固定治疗肋骨骨折效果好,并且切口小,胸壁肌肉损伤小,有较高的实用价值。     

Cartilage Plating in Flail Chest Fixation

Introduction: Operative stabilization of flail chest has been shown to have several benefits over nonoperative management. Often, flail chest injuries will involve the anterior ribs and their associated costal cartilage. In certain cases, operative fixation with open reduction and internal fixation (ORIF) of anterior rib fractures involving the costal cartilage may be warranted. Currently, there is scant literature regarding the surgical approach and clinical outcomes of ORIF involving the costal cartilage. The purpose of this study is to describe the surgical approach and first reported clinical series for patients undergoing anterior rib ORIF involving the costal cartilage.Patients and Methods: After Institutional Review Board approval was obtained, a retrospective case series was performed at a single urban level 1 trauma center including patients 18 years of age or older who underwent ORIF of anterior rib fractures involving the costal cartilage. All surgical approaches were performed with muscle-sparing techniques. Patients were followed during their hospitalization period and postoperatively as routinely scheduled. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed.Results: Thirty patients, with a mean age of 54.4 years, were included in this study. All patients had a flail chest injury and were treated with ORIF on average 4.1 days following injury. There were no intraoperative complications reported. Total hospital length of stay averaged 22.8 days with an intensive care unit stay averaging 6.1 days; total ventilator time averaged 5.2 days. Six patients were diagnosed with postoperative pneumonia and no postoperative superficial infections, deep infections, or seromas were noted. Eight patients required tracheostomy postoperatively. Only 1 patient had evidence of radiographic malunion, and a separate patient had evidence of screw loosening; no patients required or requested implant removal. Union rate was 100% and one-year mortality was 0%.Conclusion: Open reduction and internal fixation of anterior rib fractures involving the costal cartilage is a safe procedure with low complication rates and favorable postoperative outcomes including hospital length of stay, intensive care unit length of stay, postoperative pneumonia, need for tracheostomy, and mechanical ventilation time.     

微创肋骨内固定术治疗多发肋骨骨折

目的探讨肋骨内固定术治疗肋骨骨折的临床效果。方法对多发肋骨骨折,2006年8月～2008年8月采用非内固定手术(包括加压包扎、呼吸机辅助呼吸、胸腔穿刺等)治疗63例,2008年8月～2010年8月采用微创肋骨内固定术治疗60例,即采用日本Gunze Limited,Medical Material Center生产的各型号NiTi记忆合金-抓握式接骨板及江苏亚华生物科技工程有限公司生产的各型号聚左旋乳酸可吸收骨固定系统(刚子)微创内固定复位。比较2组疗效及并发症情况。结果与非内固定手术组相比,微创肋骨内固定组住院时间短[(15.5±3.4)d vs.(21.3±5.6)d,t=-6.996,P=0.000],疼痛轻[视觉模拟评分(2.1±1.1)分vs.(5.7±1.5)分,t=-14.854,P=0.000],镇痛药用量少[哌替啶总用量(67.5±27.0)mgvs.(128.6±33.6)mg,t=-11.094,P=0.000],但住院费用高[(3.8±1.8)万元vs.(1.5±1.4)万元,t=8.011,P=0.000]。结论 微创肋骨内固定术治疗肋骨骨折优于非内固定手术治疗,具有较高的临床应用价值。     

不同内固定时机治疗创伤性连枷胸患者的临床效果研究

目的:探讨不同内固定时机治疗创伤性连枷胸患者的临床效果。方法:回顾性收集我院2016年1月2017年12月行内固定术治疗创伤性连枷胸患者74例的基本资料,按照患者受伤至接受内固定术的时机进行分组,其中受伤后72 h以内行内固定手术的44例患者,为早期组;受伤后在72 h以外行内固定手术的30例患者,为晚期组,比较两组患者术后恢复状况、胸部AIS评分、创伤严重程度评分(ISS)、血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、呼吸频率(RR)、心率(HR),记录并发症状况。结果:早期组的通气时间、胸腔引流管拔管时间、胸外ICU时间、住院时间分别为[(25.12±4.35)h、(3.21±0.67)d、(3.75±0.79)d、(11.63±4.35)d],均低于晚期组[(36.82±5.39)h、(4.36±0.84)d、(4.89±0.93)d、(16.72±5.19)d],差异有统计学意义(P<0.05)。早期组和晚期组手术后3天胸部AIS评分分别为(3.15±0.32)、(3.67±0.34),ISS评分分别为(14.91±3.58)、(17.29±4.27),均低于术前,差异具有统计学意义(P<0.05)。与手术前比,两组患者手术后3天的PaO2升高,PaCO2、RR、HR降低;但手术后3天早期组和晚期组的PaO2、PaCO2、RR、HR比较差异无统计学意义(P>0.05)。早期组救治成功率95.45%(42/44)高于晚期组救治成功率80.00%(24/30),差异有统计学意义(P<0.05),两组间并发症发生率比较差异无统计学意义(P>0.05)。结论:与晚期比较,早期行内固定手术治疗创伤性连枷胸患者,有助于患者术后恢复,且在吸循环功能与术后不良反应上无明显差异。     

The Usefulness of Early Surgical Rib Stabilization in Flail Chest

Background : Flail chest is a clinical condition observed in patients with blunt thorax trauma. Surgical stabilization methods performed on selected patients shorten the durations of mechanical ventilation and intensive care monitoring and significantly reduce the rates of ventilator-associated morbidity and mortality.

Material and Method : Patients treated and diagnosed with flail chest between 2009 and 2014 were studied retrospectively.

Results : There were two groups: 10 patients in the group treated surgically and 10 patients in the group treated non-surgically. The groups were similar in terms of age, ISS score, degree of pulmonary contusion, number of rib fractures and location of flail chest. There were no significant differences between the stabilization and non-surgical therapy groups in hospitalization and mechanical ventilation period, tracheostomies, hospital costs and mortality. However, there were significant differences in the intensive care period. The number of the patients who developed pneumonia was significantly lower in the stabilization group, and the difference was statistically significant.

Conclusion : Early surgical rib stabilization in flail chest is a safe treatment method which has a low complication rate and can reduce the morbidity and mortality which develop from mechanical ventilation.     

连枷胸内固定手术方法的临床应用比较

目的比较4种对多根、多段肋骨骨折内骨的内固定方法,总结其治疗经验。方法 2006年7月至2009年7月三峡大学仁和医院收治75例多根、多段肋骨骨折患者,男51例,女24例;年龄17-74岁,平均年龄43.50岁。致伤原因为：交通伤44例,高处坠落伤21例,撞击伤10例;采用钢丝固定5例,钢板固定12例,Judet固定架固定51例,人工合成树脂骨内固定7例。结果 75例患者均采用内固定手术治疗,术后胸廓恢复正常形态,纵隔摆动消失,疼痛和呼吸困难明显改善;随访6个月-2年,复查胸部X线片示：钢丝固定的患者中有2例发生2处固定移位,其余患者无再次移位,恢复良好。结论内固定手术治疗是治疗多根、多段肋骨骨折患者的有效方法,但各有利弊,应严格掌握手术适应证。     

快速康复外科在肋骨骨折手术中的应用

目的探讨快速康复外科（FTS）措施在肋骨骨折手术中应用的可行性和有效性。方法选取南京医科大学附属明基医院2010年10月至2013年6月肋骨骨折手术患者52例.将患者分为2组：FTS组,26例,男22例、女4例,年龄（45．62±8．20）岁;对照组,26例,男2l例、女5例,年龄（46．42±7．60）岁。FTS组按照FTS方案治疗、对照组按照传统方法治疗。比较两组术后疼痛评分、胃肠功能恢复时间、术后住院时间和住院费用。结果FTS组术后早期6h、24h、48h疼痛视觉模拟评分法（VAS）评分（4．5±0.3,4.2±0．2,3．2±0．1）均明显低于对照组（6．5±0．1,6．1±0．3,4．8±0．2）,差异均有统计学意义（P〈0．05）;胃肠功能恢复时间：FTS组（O．8±0．2）d,明显短于对照组（1．5±0．5）d,差异有统计学意义（P〈0．05）;FTS组住院时间[（21．0±2．6）dVS．（26．2±3．4）d],住院总费用（[5．18±0．75）万元VS．（5．78±0．64）万元]与对照组比较差异有统计学意义（P〈0．05）。结论FTS措施的应用可有效减轻肋骨骨折患者术后的疼痛,缩短住院时间,降低住院费用,促进肋骨骨折患者术后康复。     

可吸收肋骨钉治疗多发性肋骨骨折116例

目的总结可吸收肋骨钉内固定治疗多发性肋骨骨折的手术适应证、方法及其经验。方法116例多发性肋骨骨折患者,采用可吸收肋骨钉在全麻下行手术内固定。结果16例均获随访,平均时间7(1~15)个月。骨折于3~6月内均获骨性愈合。5例胸廓稍有不对称,其余均未发现有胸廓塌陷或畸形,胸部无明显疼痛,恢复良好。110例恢复术前体力劳动,6例生活可自理。结论对于严重胸壁塌陷的多发性肋骨骨折应行内固定治疗;采用可吸收肋骨钉进行复位固定,方法简单易行,疗效满意。     

Successful Treatment of a Recalcitrant Pleural Effusion with Rib Fracture Fixation

Pulmonary complications of rib fractures typically occur in the immediate postinjury period, as a result of the forces causing the injury or subsequent rib fracture displacement. Pneumothorax, hemothorax, pulmonary contusions, or parenchymal lacerations are frequently seen with significant chest wall trauma. Hemopneumothorax is typically treated with tube thoracostomy, and full resolution of the pleural injury is expected; continued pleural fluid accumulation despite these measures is unanticipated, rare, and quite problematic. We report a case of hemorrhagic pleural effusion after rib fractures that were recurrent despite several tube thoracostomies and computed tomography-guided aspirations. The patient subsequently underwent operative fixation of her rib fractures, with successful resolution of her symptomatic pleural effusion.     

Control of Respiratory Therapy in Flail Chest

Pulmonary mechanics and oxygenation were measured in 24 consecutive patients with posttraumatic flail chest requiring continuous mechanical ventilation. The mean duration of mechanical ventilation was fourteen days. Mortality was 38% for all patients, 29% if deaths from head injury are excluded. Pneumonia occurred in 4 patients (17%) and pneumothorax in 1 (4%). Vital capacity and maximal inspiratory force measurements were useful in assessing chest wall stabilization. Total lung compliance correlated negatively with fatal outcome from respiratory failure. The alveolar-arterial oxygen gradient was not useful in assessing chest wall stabilization.     

记忆合金环抱器用于肋骨骨折内固定的手术配合

目的 总结镍钛形状记忆合金环抱器用于肋骨骨折内固定手术的配合要点.方法 对31例肋骨骨折实施镍钛形状记忆合金环抱器内固定手术,术前了解患者生命体征、血氧饱和度(SpO2)、肋骨骨折的根数及有无其他并存疾病,准备镍钛形状记忆合金环抱器及0～4℃无菌生理盐水;术中密切观察患者的生命体征变化,及时提供0～4℃生理盐水和型号合适的镍钛形状记忆合金环抱器;术后妥善固定胸腔引流管,密切观察SpO2.结果 31例手术均顺利完成,无1例出现手术并发症.结论 手术室护士对相关手术知识的掌握以及完善的术前准备和及时的术中配合是手术成功的保证.     

疼痛评分和动脉血氧分压作为筛选指标在肋骨内固定手术中的应用

目的探讨疼痛评分和动脉血氧分压（PaO2）作为肋骨内固定手术指征筛选指标的可行性。方法回顾性分析2010年9月至2013年2月上海市浦东医院收治48例肋骨骨折患者的临床资料。采用视觉模拟评分法,选取其中3d后疼痛评分≥6分、PaO2〈60mmHg患者共24例作为试验组[男16例,女8例;年龄（49．294-15．73）岁];另选取3d后疼痛评分≤5分、PaO,≥60mmHg患者共24例作为对照组[男19例,女5例;年龄（48．634-13．49）岁]。两组患者均采用爪形钢板行肋骨内固定术。术后3d、1周观察疼痛评分和PaO2。结果试验组术后3d疼痛评分小于术前[（4．09±0．93）分VS．（8-21±1．18）分,尸〈0．05],术后1周疼痛评分小于术前[（3,204-0．98）分VS．（8．214±1．18）分,P〈0．05];对照组术后3d疼痛评分与术前比较差异无统计学意义（P〉0．05）,术后l周疼痛评分小于术前（P〉0．05）。试验组术后3dPa02大于术前[（61．004±3．47）mmHgVS．（53．004-3．97）mmHg,P〈0．05];对照组术后3dPaO：大于术前[（66．714-5．15）mmHgVS．（66．004-5．00）mmHg,P〉0．05]。术后3d试验组发生肺炎4例,对照组2例（X2=0．762,P〉0．05）。术后3d疼痛评分下降值试验组高于对照组[（4．134-1．45）分VS．（0．004±0．42）分,P〈0．05],术后1周疼痛评分下降值试验组高于对照组[（5．044-1．23）分VS．（0．08±0．28）分,P〈0．05],术后3dPaO2升高值试验组高于对照组[（7．424-3．59）mmHgVS．（0．214±0．98）mmHg,P〈0．05]。结论将肋骨骨折后3d疼痛评分≥6分、PaO2〈60mmHg作为肋骨内固定手术的筛选指标具有合理性和可行性。     

肋骨环抱接骨板内固定治疗多发性肋骨骨折的临床分析

目的探讨肋骨环抱接骨板内固定治疗多发性肋骨骨折的疗效。方法回顾性分析我科2010年6月～2011年3月收治的56例多发性肋骨骨折患者的临床资料,比较肋骨环抱接骨板内固定组(A组)与加压包扎外固定组(B组)的疗效。结果患者均治愈出院,骨折断端骨性愈合。A组肺部感染、肺不张、胸廓畸形、骨折移位等并发症的发生率均较B组低(P<0.01);而且A组患者在胸腔引流管留置时间、术后卧床时间和住院时间上均短于B组(P<0.05)。结论肋骨环抱接骨板内固定治疗多发性肋骨骨折具有操作简便、创伤小、痛苦小、组织相容性好、并发症少、固定可靠、术后恢复快等特点,利于促进骨折愈合和改善呼吸功能,是治疗多发性肋骨骨折较理想的方法。     

电视胸腔镜手术及常规手术治疗多发性肋骨骨折的对比分析

目的比较电视胸腔镜手术与常规手术治疗多发性肋骨骨折的临床效果。方法自2010年1月至2012年12月,都江堰市人民医院收治多发性肋骨骨折173例,其中男122例,女51例;年龄19～71（41.3±7．1）岁。173例患者根据采用的治疗方法不同分为3组,非手术组：83例,肋骨骨折（4．9±1．3）处,连枷胸20例;常规手术组41例,肋骨骨折（5．2-＋1．1）处,连枷胸11例;电视胸腔镜手术组：49例,肋骨骨折（5_3±1．5）处,连枷胸14例。观察住院时间、疼痛时间、手术切口长度、手术时间、胸腔闭式引流时间及并发症发生情况,并进行比较。结果电视胸腔镜手术组切口长度[（5．2±1．5）cmvs．（8．5±2-3）cm,P=0．031]、手术时间[（1．1±0.3）hVS．（1．8±0．2）h,P=0．003]、胸腔引流时间[（0-3±0．0）dVS．（3．2±1．1）d,P=0．007]和住院时间[（13．7±1．5）dVS．（17．3±2．3）d,P=0．017]均短于常规手术组。本组159例患者完成随访,于出院后1、3、6个月随访复查胸部x线片,3个月后患者的肋骨骨折处均有明显的骨痂生长,未行手术治疗的部分患者肋骨畸形愈合。结论对多发性肋骨骨折的治疗,随着内固定材料的发展,手术治疗逐渐成为趋势,而电视胸腔镜手术具有微创手术的优点,效果良好。