损伤控制理论在创伤骨科中的指导作用

损伤控制理论自上世纪末提出后,已逐渐为创伤外科各专科医师接受并应用于临床中,我国亦有不少学者报告了损伤控制理论在临床实践中应用的经验,现将损伤控制理论的由来及一些基础的知识做一介绍,以供临床医师在实际使用时参考.     

损伤控制骨科学在严重创伤动物模型中的应用

目的 探讨损伤控制骨科学在双侧股骨干骨折合并失血性休克动物模型中应用的必要性.方法 将36只新西兰大白兔随机分为3组,制作双侧股骨干骨折合并失血性休克和复苏模型;A组兔骨折行扩髓髓内钉固定(ETC组),B组兔骨折行外固定架固定(DCO组),C组为对照组(CON组).分析比较3组兔骨折治疗后平均动脉压(MAP)、呼吸频率(RR)、心率 (HR)、炎性因子浓度[白细胞介素(IL)-6、IL-10、肿瘤坏死因子(TNF)-α]以及主要器官(肺、肝、肾、心)组织学表现的变化.结果 3组动物骨折治疗后出现的生命体征变化和炎性因子浓度的升高在ETC组最明显(P<0.05).ETC组和DCO组肺组织学表现与对照组比较差异有统计学意义(P<0.01);在肝脏,ETC组与对照组差异有统计学意义(P<0.01),而DCO组与对照组差异无统计学意义(P>0.05);在肾脏和心脏,3组动物之间差异无统计学意义(P>0.05).结论 双侧股骨干骨折合并失血性休克骨折治疗,早期扩髓髓内钉固定会引起更强烈的生命体征变化和炎性反应,以及对肺脏和肝脏产生更多的组织学损害.

Abstract：

Objective To explore the necessity of damage control orthopedics (DCO) in managing a model of bilateral femoral fractures associated or complicated with shock. Methods Thirty-six male New Zealand White rabbits were divided into three groups. A model of bilateral femoral shaft fractures associated with shock was made. A reamed intramedullary nailing fixation was performed in group A (ETC group), an external fixation device was applied in group B (DCO group), and group C served as the control group (CON group). Changes of the mean arterial pressures (MAP), respiratory rate (RR), heart rate (HR), inflammatory mediators [interleukin (IL)-6, IL-10, tumor necrosis factor (TNF)-α] concentrations, and histological changes of main organs after the procedures were compared and analyzed between the groups. Results Compared to group B and CON group, the extent of vital signs changes and the exaggerated levels of the inflammatory mediators in ETC group were most significant (P<0.05). As to histological appearances, there was very significant difference between ETC group or DCO group and CON group as far as lungs were concerned (P<0.01). As to the liver, there was significant difference between ETC group and CON group (P<0.01), but no significant difference was found between DCO group and CON group (P>0.05). In terms of the kidney and heart, there was no significant difference among the groups (P>0.05). Conclusion An early reamed intramedullary nailing fixation procedure resulted in more adverse effects on vital signs, inflammatory response, and the injuries also cause histological damages to the lungs and liver.     

损伤控制理论在创伤骨科救治领域的应用

对严重创伤患者的救治观念正在从早期全面救治向损伤控制治疗转变,其原因为严重创伤可引发机体全身炎症反应,以白细胞介素-6、血清降钙素原为代表与炎症反应有关的标记物在血液中浓度升高,可导致患者体温降低、酸中毒和凝血机制异常,进而引起急性呼吸窘迫综合征和多器官功能衰竭。长时间的手术治疗可视为二次打击,加重患者的病情。对于严重创伤患者的股骨干骨折急性期以外固定治疗为宜;骨盆骨折以外固定架固定为主,对难控制骨盆部出血的患者可行直接手术止血、骨盆动脉造影和栓塞、骨盆填塞止血;脊柱骨折早期治疗的目的是保持脊柱的稳定性,避免脊髓的二次损伤,开放性脊柱损伤要注意相邻重要脏器损伤的治疗,同时要预防感染的发生。早期手术治疗对不完全脊髓损伤患者的治疗效果好。     

损伤控制骨科理论在严重肢体骨折合并腹部创伤中的应用

背景：严重肢体骨折常合并有腹部创伤,正确的诊断和处理是提高患者生存率的重要保障。损伤控制骨科理论（DCO）符合严重肢体骨折合并腹部创伤患者的病理生理特点,正确地应用DCO理论是提高患者救治成功率的关键。目的：探讨DCO理论在严重肢体骨折合并腹部创伤中的应用。方法：回顾性分析2009年1月至2013年6月收治的38例严重肢体骨折合并腹部创伤患者的临床资料。骨折情况：单纯四肢骨折20例,骨盆骨折6例,骨盆合并四肢骨折4例,脊柱骨折4例,脊柱合并四肢骨折4例;闭合性骨折21例,开放性骨折17例。腹部损伤情况：脾破裂20例,肝破裂8例,肝脾破裂5例,肠破裂3例,肝破裂＋肠破裂1例,肝破裂＋肾破裂1例。损伤严重度（ISS）评分平均39.3分。结果：本组38例患者经DCO理论救治后死亡2例,36例患者病情稳定后行骨折确定性手术,实施确定性手术的时间为6~62 d,平均12.5 d。其中12例发生各种并发症。除2例死亡、4例失随访外,其余32例均获得随访,随访时间为10~25个月,平均15.4个月。其中28例骨折正常愈合,愈合时间为12~25周,平均21.2周;3例骨折出现延迟愈合,经石膏外固定后愈合,总愈合时间为10~12个月;1例骨折术后10个月发现骨不连,经二期手术并植骨后愈合。所有随访者均部分或完全恢复正常工作生活。结论：DCO理论符合严重肢体骨折合并腹部创伤患者的病理生理特点,尽早进行针对性的损伤控制手术和ICU复苏是实施DCO的关键,可提高严重此类患者的救治成功率。     

创伤控制骨科理论在严重多发伤中的应用

严重多发伤患者的死亡率高,早期死因主要是难以控制的出血,晚期则是感染引发的多器官功能障碍综合征。近年来,创伤控制骨科理念的形成,试图使伤者受到"第一次打击"后的"持续打击"最小化,控制炎症级联反应,从而提高严重多发伤的生存率。创伤控制骨科理念主要包括3个阶段:首先准确合理地选择适应证,采用快速有效的措施控制出血、污染并进行临时固定;其次在重症监护室进一步纠正死亡三联征;最后进行有计划的二次确定性手术。目前的难点在于适应证的选择和早期处理(特别是对伴发骨盆骨折者),二次手术的时机和方式也存在一定的争议。减少伤者"二次打击"的各种微创手术日益受到重视。     

计算机辅助骨科手术在创伤骨科中的应用

计算机辅助骨科手术（computer—assisted orthopaedic surgery，CAOS）是利用计算机对数字化医学影像的高速处理及控制能力，通过虚拟手术环境为骨科医生从技术上提供支援，使手术更微创、更安全、更准确的一门新技术。正因为这是一项基于术中图像，应用相应定位手段，对手术部位及术中的手术器械进行实时跟踪、显示、引导而进行手术的技术，其工作原理犹如在航空、航海中为飞机和舰船进行导航一样，所以也有很多学者把CAOS称为影像辅助导航手术（image guidance fluoroscopic navigation surgery，IGFNS）。CAOS应用的是以计算机图像处理工作站及影像跟踪设备为核心的手术系统，此系统的基本功能是将医学影像设备提供的图像进行信息化处理，并结合立体定位系统（stereotactic localization system）对真正的人体肌肉、骨骼解剖结构进行显示和定位，     

骨科损伤控制在严重骨盆骨折治疗中的应用

目的探讨骨科损伤控制（DCO）在严重骨盆骨折治疗中的应用及效果。方法对2004年1月～2006年1月应用DCO方法指导治疗的15例严重骨盆骨折患者进行回顾性分析，并以2003年1月～2006年1月未采用DCO方法指导治疗的15例严重骨盆骨折患者作为对照。治疗组中5例骨盆骨折以外固定支架作为终极手术治疗，10例一期行外固定支架治疗，待患者一般情况稳定后二期采用切开复位方法治疗。“开书状”骨盆前环骨折采用外固定支架临时固定，不稳定后环骨盆骨折采用骶髂螺钉、锁定加压钢板微创内固定，骨盆前后环均有严重损伤的患者采用前后路联合微创固定治疗。对照组患者均一期采用切开复位内固定术治疗。结果治疗组13例患者存活，2例死亡，其中1例死于失血性休克，1例死于多器官功能衰竭。术后并发症包括：急性呼吸窘迫综合征3例，腹腔感染1例，股骨骨折骨不连1例，骨盆外固定支架钉道感染2例。对照组10例患者存活，5例死亡，其中2例死于失血性休克，其中2例死于弥散性血管内凝血，1例死于重度感染。结论将DCO应用于严重骨盆骨折的临床治疗有利于对患者进行迅速有效的、旨在抢救生命的整体治疗，提高患者生存率，减少并发症的发生。     

物理治疗在创伤骨科中的应用

在新加坡中央医院进修期间,对理疗在创伤骨科的应用有一些粗浅的了解。创伤科常见疾病有股骨头、转子间等髋部骨折,股骨干、胫腓骨及踝关节、跖骨等下肢骨骨折。其中,上肢骨骨折少于下肢骨骨折。这或许与新加坡是个工业国家,手工劳动者较少,而老龄人口又相对较多等社会因素有关。     

外固定架在创伤骨科中的应用

在内固定的理念和操作技术已经被我国广大创伤骨科医生所熟悉的今天，《中华创伤骨科杂志》推出“外固定支架的应用”专刊，是对读者非常有意义的启迪。近10年来，很多创伤骨科医生把很大精力投入在内固定的学习与实践上，殊不知外固定是骨折治疗的极为重要的手段之一。仅依靠一种治疗方式治疗所有创伤骨科疾患已根本不能满足创伤骨科患者的需要。     

Craniocerebral war wounds: non-specialist management.

The non-specialist management of 28 craniocerebral war wounds is described. Of these, 26 were operated upon of which three died. Two of the survivors developed wound abscesses in the early postoperative period. None developed epilepsy while in hospital. Aspects of the operative management are discussed.     

A management algorithm for chronically exposed war wounds of bone

Chronically exposed war wounds of bone are common in field hospitals in developing countries. This algorithm aids their management. It is an extension of basic war surgery principles and takes the natural history of wounds into account. The importance of excision of dead bone is stressed. Methods of fracture immobilization and reconstruction are considered. The management of chronic bone exposure by basic principles is considered in relation to a multispecialist approach to severe open tibial fractures in civilian practice.     

Surgical management of war wounds of the abdomen

An attempt has been made to relate the lessons learned in the management of over 300 war wounds of the abdomen treated on the author's service in an evacuation hospital overseas. Opportunity to follow up a varying number of these cases and similar one's was afforded at the close of severa of the campaigns and included an officially sponsored follow-up tour of general hospitals in the ET0 treating these cases in the later phases of their care. Complications which may occur have been mentioned. The late care of colostomies has been only mentioned as their care and closure when properly constructed initially follows standard surgical procedures. The importance of early supportive treatment, especially transfusion with whole blood has been stressed and the need for stabilization of the circulatory system, especially if continued hemorrhage has been excluded before undertaking surgery has been emphasized, being even more important than the time preoperatively. The value of intratracheal anesthesia has been discussed. Finally the complications to be looked for have been recounted.     

The role of reconstructive surgery in the management of war wounds.

Reconstructive surgery can be used within a framework of management of war wounds by basic principles. It falls into three groups: i. Primary (emergency) reconstruction; performed as part of initial surgery and as a life-saving procedure. ii. Delayed primary (essential) reconstruction; performed at the time of delayed closure. iii. Elective or non-essential reconstruction. All surgeons involved with the early management of war wounds should be prepared to perform primary and delayed primary reconstruction.     

Reconstructive challenges in war wounds

War wounds are devastating with extensive soft tissue and osseous destruction and heavy contamination. War casualties generally reach the reconstructive surgery centre after a delayed period due to additional injuries to the vital organs. This delay in their transfer to a tertiary care centre is responsible for progressive deterioration in wound conditions. In the prevailing circumstances, a majority of war wounds undergo delayed reconstruction, after a series of debridements. In the recent military conflicts, hydrosurgery jet debridement and negative pressure wound therapy have been successfully used in the preparation of war wounds. In war injuries, due to a heavy casualty load, a faster and reliable method of reconstruction is aimed at. Pedicle flaps in extremities provide rapid and reliable cover in extremity wounds. Large complex defects can be reconstructed using microvascular free flaps in a single stage. This article highlights the peculiarities and the challenges encountered in the reconstruction of these ghastly wounds.KEY WORDS: Delayed reconstruction, reconstructive challenges, war wound, wound debridement     

Perineal anorectal wounds in war surgery

Wounds of perineal rectum represent an emergency by reason of immediate and secondary seriousness, their ultimate sequelas (15%). From their experience, review of the literature, the authors define a surgical attitude available for civilian injuries: terminal colostomy, large drainage, cautious surgical treatment of rectal injury.