应用骨盆骨折Tile分类预测患者早期输血量的初步研究

目的：研究骨盆骨折Tile分类与患者早期输血量之间的相关性，便于预测骨折患者的输血量，指导急救早期对血流动力学不稳患者的治疗，减少死亡率。方法：回顾性研究5年间收治的97例骨盆骨折患者（包括复合伤患者），用KruskalWallis非参数统计检验患者在受伤后早期的输血量与Tile骨盆骨折不同分类之间的相关性。结果：三型骨折患者骨折的严重程度与输血量统计学上有显著的相关性。97例患者平均输血量为912ml，其中A组平均输血252ml，B组为892ml，C组为2200ml;ISS评分平均为18．4，其中C组为28．7。死亡率平均为5．2％，C组平均为19．0％。结论：Tile骨折分类方法和骨盆骨折患者输血量具有显著的相关性，因而有临床预测价值。骨折类型越严重，患者早期复苏时的输血量就越多，其中严重类型（C型）骨折患者平均输血达2200ml以上。     

应用骨盆骨折Tile分类预测患者早期输血量的初步研究

目的　研究骨盆骨折Tile分类与患者早期输血量之间的相关性 ,便于预测骨折患者的输血量 ,指导急救早期对血流动力学不稳患者的治疗 ,减少死亡率。方法　回顾性研究 5年间收治的 97例骨盆骨折患者 (包括复合伤患者 ) ,用Kruskal -Wallis非参数统计检验患者在受伤后早期的输血量与Tile骨盆骨折不同分类之间的相关性。结果　三型骨折患者骨折的严重程度与输血量统计学上有显著的相关性。 97例患者平均输血量为 912ml,其中A组平均输血 2 5 2ml,B组为 892ml,C组为2 2 0 0ml;ISS评分平均为 18 4 ,其中C组为 2 8 7。死亡率平均为 5 2 % ,C组平均为 19 0 %。结论　Tile骨折分类方法和骨盆骨折患者输血量具有显著的相关性 ,因而有临床预测价值。骨折类型越严重 ,患者早期复苏时的输血量就越多 ,其中严重类型(C型 )骨折患者平均输血达 2 2 0 0ml以上。     

不稳定型骨盆骨折的疗效探讨

目的 探讨不稳定型骨盆骨折(Tile B和Tilec型)的治疗和疗效。方法 比较78例骨盆骨折患者使用和非使用骨盆外固定支架手术疗效。结果 在38例骨盆骨折患者未使用骨盆外固定支架治疗中，失血性休克的纠正率为76％，死亡率10．6％，平均ISS评分11．6。而在使用骨盆外固定支架治疗的40例患者中，失血性休克的纠正率为90％，死亡率为2．5％，平均ISS评分9．87结论 骨盆外固定支架治疗不稳定型骨盆骨折合并失血性休克，手术简单，疗效可靠，大大降低了患者的死亡率。     

开放性骨盆骨折：治疗对策与疗效分析

目的探讨开放性骨盆骨折的治疗对策,评价其疗效。方法回顾性分析1998年1月至2008年10月我院收治的42例开放性骨盆骨折病例资料。男23例,女19例;年龄7～73岁,平均45.5岁。致伤原因：车祸伤24例,压砸伤10例,高处坠落伤8例;并发休克27例。按Tile分型：A型3例,B型9例,C型30例。软组织损伤按Gustilo-Anderson分类：Ⅰ类3例,Ⅱ类7例,Ⅲ类32例。骨盆周围皮肤软组织损伤部位：髂前上棘3例,腹股沟区5例,臀骶部5例,腰背、臀骶及大腿根部严重大面积皮肤撕脱1例。伴发其他系统损伤：颅脑损伤5例,胸部和肺部损伤7例,胃破裂2例,脾破裂3例,卵巢破裂1例,腹膜后血肿5例,空回肠破裂5例,直肠乙状结肠损伤7例,泌尿系统挫裂伤23例,会阴挫裂伤19例。运动系统其他合并损伤：坐骨神经损伤3例,股神经损伤2例,骶丛损伤6例,腰椎骨折伴脊髓损伤4例,股骨头骨折2例,股骨颈骨折2例,转子下骨折3例,股骨干骨折6例,胫骨平台骨折4例,胫腓骨骨折8例,胫骨远端骨折1例,内外踝骨折2例,桡骨远端骨折3例。ISS评分9～58分,平均31.5分。结果治愈37例,死亡5例。42例患者中,骨盆骨折以外组织的损伤数量为123处,是骨盆骨折的2.9倍,其中泌尿系统挫裂伤占54.8%,会阴损伤占45.2%,肠道损伤率占28.6%。剖腹探查率42.9%,初期乙状结肠造瘘率26%,延期乙状结肠造瘘率23%。本组死亡率为11.9%,死亡组平均ISS评分为41.5分,且骨折类型均为Tile C型。存活组平均ISS评分为28.2分。骨盆骨折采用外固定支架固定29例,单纯内固定9例,未同定4例。42例开放性骨盆骨折的创面平均手术3.1次,5例出现深部感染,其中1例为会阴、肛周撕裂伤,受粪便污染而导致创面感染形成深部脓肿,经多次清创和乙状结肠造瘘而治愈。3例为内固定术后感染,其中2例形成窦道,经久不愈,最终去除内固定而愈合;另1例术后出现严重感染,因败血症而死亡。1例为剖?     

损伤控制骨科在Tile B、C型骨盆骨折合并四肢骨折治疗中的可行性研究

[目的]探讨损伤控制骨科(damage control orthopedics,DCO)对Tile B、C型骨盆骨折合并四肢骨折治疗的可行性及疗效。[方法]对本院2014年3月~2016年3月收治的34例Tile B、C型骨盆骨折合并四肢骨折患者进行研究,分为DCO组及早期全面处理(early total care,ETC)组,每组17例,DCO组先稳定生命体征,二期固定骨折,其中3例患者的骨盆骨折以外架作为终极手术固定,其余患者及骨折或临时外架固定或骨牵引、石膏固定,待生命体征稳定后采用切开复位方法治疗;ETC组患者在生命体征稳定后于24~48 h内实施一期骨折固定。比较两组患者术中出血量、手术时间及各项生理指标的恢复情况,统计所有患者的损伤严重程度评分(ISS),根据欧洲五维健康量表(EQ-5D)评估术后生活质量。[结果]与ETC组比较,DCO组体温、PT、APTT的恢复时间、出血量及手术时间均得到明显改善;两组患者均随访1年,DCO组及ETC组的EQ-5D分别为:(0.56±0.17)、(0.57±0.26),两组间评分差异无统计学意义(P0.05)。[结论]两组患者均能获得较好的生活质量,DCO用于Tile B、C型骨盆骨折的治疗更能满足患者需要,不仅提高治疗效果,也能降低并发症及死亡率。     

不稳定型骨盆骨折的救治及手术治疗

[目的]探讨不稳定型骨盆骨折的早期救治和二期手术治疗经验.[方法]回顾性分析总结2006年7月～ 2009年12月救治的21例不稳定型骨盆骨折的临床资料.平均年龄37岁(19～58岁);男13例,女8例;平均创伤严重性评分(ISS)为34分(16 ～59分);按照Tile分型:B型16例(B1型7例,B2型6例,B3型3例),C型5例;17例患者合并其他部位损伤.一期行稳定骨盆、抗休克、处理合并伤等,待生命体征稳定后行切开复位内固定治疗.术后通过Majeed量表评估患者功能愈后.[结果]本组病例平均随访27个月(16～ 42个月).平均手术时间为195 min (60～510 min);平均输血量为700 ml (400 ～1 800 ml);平均骨折愈合时间为13周(11 ～ 17周);平均Majeed评分为84.3分(62 ～ 100分),其中优10例,良9例,中2例,优良率为90.4％.有1例存在明显步态异常,1例存在马蹄足畸形,均为神经损伤患者.[结论]不稳定型骨盆骨折的合理术前急救处理非常重要,对于此类损伤,应及时稳定骨盆骨折并处理合并伤,在合适的手术时机二期行切开复位内固定治疗,多可获得满意的疗效.     

比较纱布填塞术与造影栓塞术治疗骨盆骨折大出血的效能

 目的 比较纱布填塞术与造影栓塞术在骨盆骨折大出血治疗中的效能。方法 回顾性分析2004年4月至2012年4月治疗43例骨盆骨折大出血的患者资料。按照骨盆骨折的救治流程进行救治,其中26例应用纱布填塞术（填塞组）,17例应用造影栓塞术（栓塞组）。填塞组26例,男15例,女11例;平均年龄41.6岁;车祸伤12例,坠落伤8例,砸伤6例;骨盆骨折Tile分型：B型16例,C型10例,其中4例为开放性骨盆骨折,5例伴有腹部脏器损伤。栓塞组17例,男10例,女7例;平均年龄39.2岁;车祸伤9例,坠落伤5例,砸伤3例;骨盆骨折Tile分型：A型2例,B型11例,C型4例。比较两组患者的创伤严重程度评分（ISS）、手术时间、输血量、并发症等。结果 填塞组平均ISS评分为（52.4±15.3）分,栓塞组为（40.6±12.4）分;填塞组平均手术时间为（42.0±2.1） min,栓塞组为（86.0±3.6） min;填塞组术后24 h内输血量平均为（6.0±1.6） U,栓塞组为（10.0±2.1） U;填塞组ICU住院时间平均为（8.0±3.6） d,栓塞组为（11.0±1.8） d;以上指标两者比较差异均有统计学意义。填塞组术前输血量平均为（15.0±4.7） U,栓塞组为（13.0±5.4） U,两者比较差异无统计学意义。填塞组2例行二次纱布填塞止血,栓塞组6例行二次纱布填塞治疗。填塞组术后5例死亡,无因大出血而死亡的患者;栓塞组术后4例死亡,1例因大出血而于术后32 h死亡。填塞组3例患者术后7～9 d发生深部感染,其中1例于术后第16天死亡,另2例与栓塞组1例（术后第9天发生浅表感染）经换药处理后好转。结论 纱布填塞术较造影栓塞术手术时间短,止血效果确切,可明显减少术后输血量、ICU住院时间及术后的死亡率,更适用于我国国情及基层医院的骨盆骨折出血的抢救。     

伴直肠肛管损伤的开放性骨盆骨折的早期急救处理策略及死亡危险因素分析

目的 探讨伴有直肠、肛管损伤的开放性骨盆骨折的早期急救处理策略及死亡危险因素.方法 回顾性分析2001年4月至2010年4月两家医院救治的25例伴有直肠、肛管损伤的开放性骨盆骨折患者,男23例,女2例;年龄16～56岁,平均(30.1±10.9)岁.采用Fisher精确概率法及多因素Logistic回归分析法对可能的死亡危险因素进行统计学分析.结果 19例存活,6例死亡,死亡率为24%.经Fisher精确概率法分析显示:骨盆骨折Tile分型、创伤严重程度评分(injury severity score,ISS)、格拉斯哥昏迷评分(glasgow coma score,GCS)及改良创伤评分(revised trauma score,RTS)是此类损伤的死亡危险因素.当Tile分型为C型、ISS≥25分、GCS≤8分或RTS≤8分时,患者的死亡概率较大.对此4个危险因素进行多因素Logistic回归分析后发现,RTS≤8分是此类损伤的独立危险因素.结论 积极稳定血流动力学,创口彻底清创引流,早期结肠造瘘以及骨盆固定是此类损伤早期急救处理的关键.RTS是否≤8分可作为判断患者死亡概率的可靠指标.     

损伤严重程度评分在骨盆骨折并后尿道断裂治疗中的应用

目的：探讨损伤严重程序评分（ISS）在骨盆骨折并后尿道断裂治疗中应用的意义。方法以AIS－90版为基础,采用ISS评分对293例男性闭合性骨盆骨折并后尿道断裂病人进行评估分析。结果ISS值随损伤部位数增加而增高,ISS值高,死亡率亦高,Ⅰ期尿道吻合组ISS＜16分,尿道会师术组ISS16－39分,膀胱造瘘组ISS平均≥40分。结论骨盆骨折并后尿道断裂为多发损伤,尿道断裂急症处理方法的选择应根据病人伤情程度及局部情况等决定,ISS评分在骨盆骨折并后尿道断裂的治疗选择中有重要的指导意义。     

骨盆骨折分型与输血量关系的初步研究

目的探讨闭合性骨盆骨折类型与患者伤后早期输血量的关联性。方法回顾性分析自2010-01—2017-12诊治的497例闭合性骨盆骨折,AO-A型骨折395例,AO-B型骨折63例,AO-C型骨折39例,分析骨盆骨折类型与伤后6 h内输血量的关联性。结果 497例闭合性骨盆骨折患者中104例需要输血,伤后6 h内输血量为100～10 000 mL,平均1 213.9 mL。104例中53例输血量为100～600 mL,9例输血量600～900 mL,14例输血量900～1 500 mL,28例输血量1 500 mL。最终9例因失血性休克死亡,A型骨盆骨折患者1例,B型骨盆骨折患者4例,C型骨盆骨折患者4例。A型骨盆骨折患者中49例需要输血,输血量平均437.8 mL;B型骨盆骨折患者中32例需要输血,输血量平均1 603.1 mL;C型骨盆骨折患者中23例需要输血,输血量平均2 191.3 mL。C型骨盆骨折患者输血比例高于A型与B型骨盆骨折患者,同时输血量也大于A型与B型骨盆骨折患者;B型骨盆骨折患者输血比例高于A型骨盆骨折患者,同时输血量也大于A型骨盆骨折患者,差异有统计学意义(P0.05)。结论随着骨盆骨折程度的加重,需要输血的患者比例升高,同时输血量也相应增多,临床医师要有针对性地加强输血救治措施,预防休克发生。     

Management and outcome of open pelvic fractures: a retrospective study of 41 cases

Background

Open pelvic fractures occur uncommonly. Despite serious sequelae, they have been infrequently reviewed.

Methods

We conducted a retrospective review of all patients with open pelvic fractures in our department from January 2001 to April 2010.

Results

Forty-one patients (32 men, 9 women) with these injuries were identified. The average Injury Severity Score (ISS) was 31.4, with 80% of patients having a score ≥16. The average blood transfusion in the first 24 h was 17.2 units, and the average hospital stay was 60 days. Overall mortality was 24%(n = 10): 3 early deaths and 7 late deaths. Factors associated with overall mortality by univariate analysis were ISS, RTS, GCS, age, pelvic sepsis, Gustilo classification of soft-tissue injury, and Young classification of bony fracture. Factors associated with late mortality by univariate analysis were: ISS, RTS, pelvic sepsis, Gustilo classification of soft-tissue injury, and blood transfusion in the first 24 h. Moreover, multivariate analysis showed that only RTS was independently associated with both overall and late mortality.

Conclusion

Despite treatment advances, mortality rates remain high in patients with open pelvic fractures. The urogenital and/or intra-abdominal injuries are not associated with mortality. RTS ≤ 8 might be a predictor of poor outcome in open pelvic fractures patients. Open reduction and internal fixation might be used in those unstable pelvic fractures without gross contamination in the fracture region after extensive cleansing and lavage. More emphasis needs to be placed on this injury complex.     

Pelvic fracture among polytrauma decedents

Pelvic fractures (PF) sustained from accidents are commonly believed to be a major cause of mortality in polytraumatized patients. The purpose of this paper is to determine whether PF are usually the primary cause or a contributing cause of mortality in these patients. A 10-year retrospective review was performed of all polytrauma patients with PF who were admitted to, and died, at a large, level-I trauma center. The pelvic injury was graded according to Schatzker and Tile into stable (type A), partially stable (type B), and unstable (type C). The injury severity score (ISS), which incorporates associated injuries and their potential impact on mortality, was calculated for all patients. For each patient, a separate subjective designation of the probable cause of death was determined. We identified 74 decedents with PF following deceleration trauma. The pelvic fractures were classified as 12 type A (16%), 36 type B (49%), and 26 type C (35%). The mean ISS was extremely high, 40.6 +/- 1.4 (range 18-75), more than four times the score for simply a severe PF. The ISS was also not significantly different among the three pelvic fracture groups (P = 0.613). The records subjectively identified PF as the precipitating cause of death in only 13% of the patients. In this study, patients who died with PF had an ISS that implicated at least one or two additional major visceral injuries. These data do not support the hypothesis that PF, regardless of its complexity, is the usual primary cause or the major precipitating event of death in the polytraumatized patient. In these patients, mortality appears to be a function of the associated injuries based on the ISS calculation.     

Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes

BACKGROUND: Pelvic fractures are often associated with major intraabdominal injuries or severe bleeding from the fracture site. OBJECTIVE: To study the epidemiology of pelvic fractures and identify important risk factors for associated abdominal injuries, bleeding, need for angiographic embolization, and death. METHODS: Trauma registry study on pelvic fractures from blunt trauma. Stepwise logistic regression was used to identify risk factors of severe pelvic fractures, associated abdominal injuries, need for major blood transfusion, therapeutic embolization, and death from pelvic fracture. Adjusted relative risks and 95% confidence intervals were derived. RESULTS: There were 16,630 trauma registry patients with blunt trauma, of whom 1,545 (9.3%) had a pelvic fracture. The incidence of abdominal injuries was 16.5%, and the most common injured organs were the liver (6.1%) and the bladder and urethra (5.8%). In severe pelvic fractures (Abbreviated Injury Scale [AIS] > or =4), the incidence of associated intraabdominal injuries was 30.7%, and the most commonly injured organs were the bladder and urethra (14.6%). Among the risk factors studied, motor vehicle crash is the only notable risk factor negatively associated with severe pelvic fracture. Major risk factors for associated liver injury were motor vehicle crash and pelvis AIS > or = 4. Risk factors of major blood loss were age > 16 years, pelvic AIS > or =4, angiographic embolization, and Injury Severity Score (ISS) > 25. Age> 55 years was the only predictor for associated aortic injury. Factors associated with therapeutic angiographic embolization were pelvic AIS > or =4 and ISS > 25. The overall mortality was 13.5%, but only 0.8% died as a direct result of pelvic fracture. The only pronounced risk factor associated with mortality was ISS>25. CONCLUSIONS: Some epidemiological variables are important risk factors of severity of pelvic fractures, presence of associated abdominal injuries, blood loss, and need of angiography. These risk factors can help in selecting the most appropriate diagnostic and therapeutic interventions.     

Pelvic fracture in geriatric patients: a distinct clinical entity

BACKGROUND: The purpose of this study was to describe differences in demographics, injury pattern, transfusion needs, and outcome of pelvic fractures in older versus younger patients. METHODS: This was a retrospective registry review of all patients with pelvic fractures admitted directly from the scene between January 1998 and December 1999. RESULTS: We cared for 234 patients with pelvic fractures during the study period. Mean age was 37.2 years, 51% were men, and mean Injury Severity Score (ISS) was 19. Overall mortality was 9%. Eighty-three percent were under the age of 55 years and 17% were older than 55 years. Severe pelvic fractures (AP3, LC3) were more common in young patients (p < 0.05). Admitting systolic blood pressure was lower and heart rate higher, although ISS was not different between the two age groups. Older patients were 2.8 times as likely to undergo transfusion (p < 0.005), and those undergoing transfusion required more blood (median, 7.5 units vs. 5 units). Older patients underwent angiography more frequently and were significantly more likely to die in the hospital even after adjusting for ISS (p < 0.005). This was most marked with ISS 15 to 25. Lateral compression (LC) fractures occurred 4.6 times more frequently in older patients than anteroposterior (AP) compression, and 8.2 times more frequently in those older patients undergoing transfusion as compared with AP compression. Ninety-eight percent of LC fractures in older patients were minor (LC1,2). However, older patients with LC fractures were nearly four times as likely to require blood compared with younger patients. CONCLUSION: In older patients, pelvic fractures are more likely to produce hemorrhage and require angiography. Fracture patterns differ in older patients, with LC fractures occurring more frequently, and commonly causing significant blood loss. The outcome of older patients with pelvic fractures is significantly worse than younger patients, particularly with higher injury severity. Recognition of these differences should help clinicians to identify patients at high risk for bleeding and death early, and to refine diagnostic and resuscitation strategies.     

Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess

Introduction

Radiology-based classifications of pelvic ring injuries and their relevance for the prognosis of morbidity and mortality are disputed in the literature. The purpose of this study was to evaluate potential differences between the pelvic ring injury classification systems by Tile and by Young and Burgess with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.

Patients and methods

Two-hundred-and-eighty-five consecutive patients with pelvic ring fractures were analyzed for mortality within 30 days after admission, number of blood units and total volume of fluid infused during the first 24 h after trauma, the Abbreviated Injury Severity (AIS) scores for head, chest, spine, abdomen and extremities as a function of the Tile and the Young–Burgess classifications.

Results

There was no significant relationship between occurrence of death and fracture pattern but a significant relationship between fracture pattern and need for blood units/total fluid volume for Tile (p < .001/p < .001) and Young–Burgess (p < .001/p < .001). In both classifications, open book fractures were associated with more fluid requirement and more severe injuries of the abdomen, spine and extremities (p < .05). When divided into the larger subgroups “partially stable” and “unstable”, unstable fractures were associated with a higher mortality rate in the Young–Burgess system (p = .036). In both classifications, patients with unstable fractures required significantly more blood transfusions (p < .001) and total fluid infusion (p < .001) and higher AIS scores.

Conclusions

In this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.     

导航下经皮微创螺钉内固定治疗骨盆骨折

目的:探讨计算机辅助导航技术在骨盆骨折治疗中的应用及相关术前术中注意事项。方法:2010年5月至12月,采用导航下经皮微创螺钉内固定方法治疗骨盆骨折16例,男12例,女4例;年龄20～54岁,平均37岁;车祸伤5例,重物压伤5例,高坠伤6例。单纯前环骨折1例,前后环均骨折15例,其中骶髂关节脱位6例,骶骨骨折9例(均未累及骶管)。根据Tile分型:C型15例,B型1例。观察内容包括螺钉置入时间,螺钉置入准确率,术中失血量,神经、血管、脏器损伤情况,术后骨折复位情况等。导航下经皮微创螺钉固定方法包括骶髂螺钉固定、耻骨支空心钉固定、耻骨联合分离空心钉固定。16例患者中单纯骶髂螺钉固定4例;骶髂螺钉固定、耻骨支空心钉固定、耻骨联合分离空心钉固定2例;骶髂螺钉固定及耻骨支空心钉固定8例;单纯行耻骨支空心钉固定2例。结果:置入螺钉36枚,平均每枚螺钉置入时间约20min,术中出血10～20ml。术后骨盆X线片及三维CT显示,所有骨折良好复位,螺钉无错误置入。伤口均Ⅰ期愈合,无伤口感染及固定失败;术后均未出现神经、血管及其他脏器损伤。结论:导航下经皮微创螺钉内固定治疗骨盆骨折具有创伤小、术中失血少、手术并发症发生率低、固定可靠、无须输血等优点,能很好地重建骨盆环的稳定性,但是对术者的技术要求较高,应注意充分的术前准备。     

Pelvic fractures in a pediatric level I trauma center

OBJECTIVES: Assess the characteristics associated with the risk of complications and mortality in children sustaining pelvic fractures. SETTING: Urban university pediatric Level I trauma center in a large metropolitan community. PATIENTS/PARTICIPANTS: Retrospective analysis of 57 consecutive children with 66 pelvic fractures seen between 1993 and 1999. INTERVENTION: Fifty-two patients were treated nonoperatively, and five patients required operative stabilization (four acetabular fractures and one partial sacroiliac joint disruption). MAIN OUTCOME MEASURE: Type and cause of pelvic fracture, type of management used, incidence of associated injuries, hemorrhage requiring transfusion, and mortality. RESULTS: Hemorrhage directly related to the pelvic fracture occurred in only one patient (2%), whereas 11 other patients required transfusions associated with other body-area injuries. Three patients with pelvic fractures died (5%), but deaths were due to other body-area injuries. CONCLUSIONS: Children with pediatric pelvic fractures require careful evaluation for other body-area injuries, as these are most likely to be related to hemorrhage or mortality.