儿童孟氏骨折的手术治疗及功能康复

目的 对儿童孟氏骨折的手术治疗及功能康复进行评价。方法 1994年～2001年对78例非手术治疗失败的新鲜及陈旧性孟氏骨折全部采用手术治疗，并随机分为两组，第1组(单针固定组)45例，其中新鲜骨折16例，陈旧性骨折29例，复位肱桡关节后，单枚克氏针固定，石膏外固定，尺骨骨折不作内固定；第2组(双针固定组)33例，其中新鲜骨折14例，陈旧性骨折19例，复位肱桡关节及尺骨骨折后，分别用克氏针固定，石膏外固定。结果 术后78例伤口愈合佳，无感染。均获随访，时间6个月～7年，平均4．6年．尺骨骨折愈合好，无骨不连及骨延迟愈合。手术疗效按肘关节屈伸及前臂旋转功能标准评价，第1组优37例，良5例，差3例，优良率93．3％；第2组优22例，良7例，差4例，优良率87．9％，两组比较无统计学意义(P＞0．05)。结论 手术治疗孟氏骨折整合复位肱桡关节，并予单枚克氏针内固定加石膏外固定，其操作简便、安全、组织损伤小及尺骨骨折愈合快，术后肢体功能恢复好。     

儿童孟氏骨折的手术治疗

目的对儿童孟氏骨折的两种手术治疗效果进行分析。方法1992年9月～2005年9月,对58例孟氏骨折患儿采用手术治疗,包括闭合复位失败的新鲜骨折22例及陈旧性骨折36例。34例采用单针固定（新鲜骨折12例,陈旧性骨折22例）;24例采用双针固定。新鲜骨折环状韧带可行简单修补,但不需重建;陈旧性骨折不行环状韧带修复或重建,术后均行石膏固定4～6周。结果58例患儿均获得随访,时间1～9年,平均4.2年。根据李汉民等制定的标准对患儿肢体功能进行评定。单针固定组：优28例,良4例,一般1例,差1例,优良率94.1%;双针固定组：优16例,良5例,一般2例,差1例,优良率87.5%。结论儿童新鲜孟氏骨折治疗应首选闭合复位,对于手法复位失败的新鲜孟氏骨折及陈旧性骨折需手术治疗,其中手术切开复位、整复肱桡关节后给予克氏针加石膏外固定,可获得满意疗效。     

儿童Monteggia＇s骨折的治疗选择

摘要：[目的]探讨儿童Monteggia＇s骨折的治疗方法及效果。[方法]本组患儿66例，男47例，女19例，其中新鲜骨折61例，陈旧性骨折5例。按Bado分型：Ⅰ型46例，Ⅱ型4例，Ⅲ型15例，Ⅳ型1例。采用非手术和手术治疗方法，对患儿进行针对性的个体化治疗。非手术治疗行手法复位、石膏固定，手术治疗则是在手法复位成功后，分别采用单针固定尺骨或肱桡关节、双针固定尺骨和肱桡关节，再行石膏固定，手术中均未修复或重建环状韧带。[结果]66例患儿在门诊获得6个月～5年的随访，参照李汉民等制定的评定标准，非手术组的优良率为95．7％，手术组的优良率为84．2％。未发生骨化性肌炎、骨间背侧神经损伤、尺桡骨骨性连接、尺骨骨不连、迟发性桡骨小头脱位等并发症，合并神经损伤的患儿术后2～4个月均完全恢复。[结论]儿童Monteggia＇s骨折的治疗效果优良，治疗的关键在于应争取在急诊下复位，并根据骨折类型及肱桡关节的复位情况，采用针对性的内固定措施以防止骨折移位及再脱位的发生，防止漏诊。     

儿童Monteggia''s骨折的治疗选择

[目的]探讨儿童Monteggia's 骨折的治疗方法及效果.[方法]本组患儿66例,男47例,女19例,其中新鲜骨折61例,陈旧性骨折5例.按Bado分型:I型46例,Ⅱ型4例,Ⅲ型15例,Ⅳ型1例.采用非手术和手术治疗方法,对患儿进行针对性的个体化治疗.非手术治疗行手法复位、石膏固定,手术治疗则是在手法复位成功后,分别采用单针固定尺骨或肱桡关节、双针固定尺骨和肱桡关节,再行石膏固定,手术中均未修复或重建环状韧带.[结果]66例患儿在门诊获得6个月～5年的随访,参照李汉民等制定的评定标准,非手术组的优良率为95.7%.手术组的优良率为84.2%.未发生骨化性肌炎、骨问背侧神经损伤、尺桡骨骨性连接、尺骨骨不连、迟发性桡骨小头脱位等并发症,合并神经损伤的患儿术后2～4个月均完全恢复.[结论]儿童Monteggia's骨折的治疗效果优良,治疗的关键在于应争取在急诊下复位,并根据骨折类型及肱桡关节的复位情况,采用针对性的内固定措施以防止骨折移位及再脱位的发生,防止漏诊.     

孟氏骨折伴桡神经骨间背侧支损伤的治疗

目的 对孟氏骨折合并桡神经骨间背侧支损伤的原因，临床表现，治疗结果进行分析。方法 自1990-2000年5月共诊治了6例患者，均为儿童。新鲜骨折手法复位石膏外固定3例，切开复位尺骨钢板内固定2例，均未做神经探查；陈旧性骨折尺骨畸形矫正 神经探查1例。结果 新鲜骨折合并神经损伤5例均自行恢复，陈旧性骨折畸形矫正神经探查术后半年恢复肌力3级。结论 孟氏骨折合并桡神经骨间背侧支损伤大多数为神经牵拉伤经观察保守治疗能够恢复，但应当注意少见的桡神经嵌顿在肱桡关节时必须早诊断和手术探查。     

儿童陈旧性孟氏骨折漏诊、误诊的原因分析及临床治疗后的疗效观察

目的分析童陈旧性孟氏骨折的漏诊、误诊原因,比较肱桡关节开放复位联合尺骨截骨克氏针内固定与尺骨截骨联合外固定架延长、肱桡关节开放或闭合复位手术的治疗儿童陈旧性孟氏骨折临床疗效。方法回顾性分析自2005-12—2020-05诊治的70例儿童陈旧性孟氏骨折,40例采用肱桡关节开放复位联合尺骨截骨克氏针内固定治疗(克氏针组),16例采用尺骨截骨联合外固定架延长、肱桡关节开放或闭合复位手术治疗(外固定架组),14例采用非手术治疗。分析出现漏诊、误诊的原因,比较克氏针组与外固定架组末次随访时临床疗效。结果 70例均完成数据的收集。造成误诊、漏诊原因:治疗方式不当32例,影像学拍摄不规范或影像学资料判读错误18例,未进行影像学资料检查6例,家庭原因6例,原因不明8例。克氏针组与外固定架组均顺利完成手术并获得至少6个月的随访,末次随访时2组临床疗效比较差异无统计学意义(P0.05)。结论对于儿童尺骨中上段骨折应拍摄准确、规范的影像学资料并根据患者情况选择合适的治疗方法以避免漏诊、误诊,儿童陈旧性孟氏骨折采用克氏针与外固定架技术进行治疗均可以取得满意的疗效。     

桡骨小头未复位的儿童陈旧孟氏骨折的手术治疗

目的：评价桡骨小头未复位的儿童陈旧孟氏骨折的手术疗效。方法：对尺骨畸形进行截骨矫形，1／3弧形钢板固定；桡骨小头切开复位，肱桡关节短期克氏针固定。结果：本组21例，术后随访时间8月至2年，平均1.2年，手术疗效优，17例（82％）；良，2例（9％），差，2例（9％）。结论：对桡骨小头未复位的儿童随旧孟氏骨折应积极手术，术后4w开始功能锻炼，可获得较好的疗效。     

低龄儿童2年以内陈旧性孟氏骨折的手术治疗

目的探讨低龄儿童2年以内陈旧性孟氏骨折手术治疗的疗效。方法对38例2年以内陈旧性孟氏骨折低龄患儿采取尺骨近端截骨克氏针内固定,桡骨小头切开复位、肱桡关节克氏针内固定。结果 38例全部得到随访,时间2~12个月。术后2例发生桡骨小头半脱位。4例桡神经损伤患儿功能完全恢复,其余患儿肘关节无畸形,无疼痛。肘关节伸直活动范围0°~20°(6°±4°),屈曲活动120°~135°(130°±5°),旋前平均80°±5°,旋后平均85°±5°。根据Mackay标准评定:优30例(78.9%),良6例(15.8%),差2例(5.3%)。结论尺骨近端截骨克氏针内固定手术治疗低龄儿童2年以内陈旧性孟氏骨折,疗效良好。     

有移位的儿童肱骨髁上骨折

我们自1974年5月至1992年12月共治疗有移位的儿童肱骨髁上骨折300例，现将治疗体会总结如下。临床资料本组300中，男221例、女79例；年龄1．5～14岁，平均8．2岁；左侧188例，右侧112例；伸直到278例，屈曲型22例；新鲜骨折292例，陈旧性骨折畸形愈合8例；闭合性骨折295例，开放性骨折5例。合并血运障碍7例，合并神经损伤13例（其中桡神经9例、正中神经4例）。治疗方法开放性骨折先行清创术，同时复位，克氏针交叉固定。新鲜闭合性骨折中，235例采用手法复位长臂石膏固定，52例切开复位内固定。陈旧性骨折畸形愈合者中，4例行切开复位内固定…     

驱血带辅助下经皮外侧克氏针固定治疗青少年GartlandⅢ型肱骨髁上骨折

目的探讨驱血带辅助下桡侧克氏针固定治疗青少年GartlandⅢ型肱骨髁上骨折的疗效。方法回顾性分析2016年9月~2018年3月收治的23例青少年GartlandⅢ型肱骨髁上骨折患者的临床资料,均为闭合性骨折,其中男14例,女9例,平均年龄12.4(10~15)岁。均行骨折端复位,驱血带维持肱骨远端复位,闭合复位经皮桡侧克氏针固定,术后长臂管型石膏固定4周,拆除石膏后进行肘关节屈伸功能锻炼。术后采用Flynn肘关节评分评估临床疗效。结果本组23例患儿均顺利完成闭合复位经皮桡侧克氏针固定,手术时间平均44(31~55)min。平均随访15.3(13~22)个月,所有患儿均获得骨性愈合,无一例出现血管神经损伤或克氏针断裂等并发症。末次随访未见肘内翻畸形,按Flynn功能评定标准:优22例,良1例,优良率100%。结论驱血带辅助下桡侧克氏针固定创伤小、复位稳定、肘内翻发生率低、医源性尺神经损伤少,是治疗青少年GartlandⅢ型肱骨髁上骨折的有效方法。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.