老年肱骨近端3或4部分骨折:手术治疗是最优选择吗?

<正>肱骨近端骨折是急诊常见骨折类型,占全身骨折的4%~5%[1]。老年人群肱骨近端骨折较为常见,在年龄超过65岁的老年骨折患者中发生率位于第3位[2]。随着人口老龄化日益加剧,预计在未来几十年内此类骨折的发生率将增加2倍[3]。根据Neer分型,肱骨近端3或4部分骨折指肱骨近端主要解剖结构(大、小结节,肱骨头,肱骨干)发生的粉碎性移位骨折,占所有肱骨近端骨折的13%~16%[1]。虽然老年     

肱骨近端骨折治疗方法选择与现状

<正>肱骨近端骨折是肩部最常见的骨折之一,占全身骨折总数的5%~9%,多好发于老年人及骨质疏松患者,男女比例约为3∶7[1]。85%的肱骨近端骨折为无移位或仅有轻微移位,可选择非手术治疗且肩关节功能恢复较好。但对于粉碎程度严重、移位明显的3部分及4部分骨折,闭合复位保守治疗往往难以取得满意疗效,应尽可能手术治疗。Court Brown等[2]发现70%的3、4部分肱骨近端骨折发生在60岁以上的患者,50%发生于70岁以上的     

肱骨近端骨折和肘关节创伤的现代概念

肱骨近端骨折是临床最常见的骨折之一,占全部骨折的4%～5%,在人群中总年发病率为6.6/1000。65岁以上老年人大多存在骨质疏松,肱骨近端骨折发病率排在髋部骨折和桡骨远端骨折之后,位列第3位,占全部骨折的10%[1]。肱骨近端骨折的治疗理念近年来有所发展,其一是锁定钢板的应用,其二是重视骨折周围软组织损伤的修     

锁定接骨板治疗肱骨近端移位骨折

肱骨近端骨折常见于老年人.国内报道发生率占全身骨折的2.5%[1],国外文献报道为4%～5%[2].其中85%为无移位或轻度移位骨折,经适当制动和早期功能锻炼等保守治疗可取得良好效果;而约15%的移位骨折,需手术治疗.本院2001年1月至2003年3月,采用Synthes肱骨近端锁定接骨板(Locking proximal humerus plate,LPHP)治疗的肱骨近端移位骨折26例,报告如下.     

MIPPO技术结合PHILOS治疗老年骨质疏松性肱骨近端骨折

[目的]探讨采用MIPPO技术结合肱骨近端内固定锁定系统(PHILOS)治疗老年骨质疏松性肱骨近端骨折的疗效。[方法]回顾分析本院2009年4月²012年5月具有完整随访资料的68例老年骨质疏松性肱骨近端骨折患者,其中采用MIPPO技术结合PHILOS治疗老年骨质疏松性肱骨近端骨折患者37例(MIPPO组),传统切开复位内固定(ORIF)PHILOS治疗老年骨质疏松性肱骨近端骨折患者31例(ORIF组)。记录切口长度、手术时间、出血量、住院天数,观察骨折愈合时间、功能恢复情况及并发症,并进行统计学分析。[结果]68例患者术后随访122012年5月具有完整随访资料的68例老年骨质疏松性肱骨近端骨折患者,其中采用MIPPO技术结合PHILOS治疗老年骨质疏松性肱骨近端骨折患者37例(MIPPO组),传统切开复位内固定(ORIF)PHILOS治疗老年骨质疏松性肱骨近端骨折患者31例(ORIF组)。记录切口长度、手术时间、出血量、住院天数,观察骨折愈合时间、功能恢复情况及并发症,并进行统计学分析。[结果]68例患者术后随访12³6个月(平均19.7个月),MIPPO组切口长度、手术时间、出血量、住院天数、骨折愈合时间等比较明显优于ORIF组,差异具有统计学意义(P<0.05);而功能恢复优良率及并发症发生率等比较MIPPO组优于ORIF组,但差异未见统计学意义(P>0.05)。[结论]MIPPO技术结合PHILOS治疗老年骨质疏松性肱骨近端骨折符合生物学固定原则,较传统切开复位内固定方法具有轻微优势,如:创伤小、切口小、住院时间短、出血量少、手术时间短、骨折愈合早等优点,是治疗老年骨质疏松性肱骨近端骨折的有效方法。     

陈旧性肩关节后脱位伴反Hill-Sachs损伤1例报道

<正>肩关节后脱位是一种罕见的损伤,仅占所有肩关节脱位的2%～5%^[1]。根据Neer的报道,肩关节后脱位造成的骨折占肩部骨折的0.9%^[2]。2012年Jacobson等^[3]在综述中报道了肩关节后脱位造成的骨折类型,反Hill-sachs损伤最常见,占29.3%,肱骨解剖颈骨折占18.5%,大结节骨折占7.8%,小结节骨折占14.3%,肱骨干、肩胛骨、锁骨等其他骨折占6%。     

肱骨近端骨折治疗进展

肱骨近端骨折是指包括肱骨外科颈在内及其以上部位的骨折,国内文献报道其发生率约占全身骨折的2·5%[1],国外文献报道占全身骨折的4%~5%[2]。对这类骨折的治疗有多种方法,特别是对不稳定及粉碎性肱骨近端骨折的处理一直存在分歧。根据国内外近年文献对肱骨近端骨折的治疗综述如下。1骨折的临床分型骨折的正确临床分型对肱骨近端骨折治疗方法的选择和预后的判定有一定的指导意义,目前临床上常用的是Neer分型和AO分型。Neer于1970年提出了肱骨近端骨折的四部分分类法[3],此分类法是按照移位骨块的数量(移位>1cm或成角>45°,否则不能认为是移…     

肱骨近端骨折的治疗理念与思考

肱骨近端骨近是临床上常见的骨折之一,约占全部骨折的4%～5%,在人群中的总年发病率为6.6/1000;65岁以上老年人大多存在骨质疏松,其肱骨近端骨折发病率排在髋部骨折和桡骨远端骨折之后,位列第3位,占全部骨折的10%,以每年13.7%的速度增加;如果这种趋势继续,未来30年,其发生率将是目前的3倍[1]。伴随着肱骨近端骨折发生率不断升高,如何选择最合理的治疗方式,以缓解肩关节疼痛,恢复肩关节功能,并降低医疗费     

肱骨近端骨折保守治疗后并发症的探讨

[目的]探讨肱骨近端骨折经保守治疗后并发症的发生原因,并提出相应对策。[方法]2010年1月²013年1月,回顾总结随访资料完整的49例肱骨近端骨折经保守治疗的患者,其中男15例,女34例,平均年龄78岁(672013年1月,回顾总结随访资料完整的49例肱骨近端骨折经保守治疗的患者,其中男15例,女34例,平均年龄78岁(67⁹2岁)。治疗后平均随访21.5个月(1092岁)。治疗后平均随访21.5个月(10⁴0个月),采用Constant-Murley评分以及肩关节前屈、外展、外旋、后伸内旋活动度评价肩关节功能。同时采用独立样本t检验来比较并发症组与非并发症组的肩关节功能评分及活动度,并分析并发症原因及所做的相应处理。[结果]49例患者得到随访,9例出现并发症,并发症发生率为18.4%,非并发症组的肩关节功能结果及活动度(除了后伸内旋外)比并发症组有显著的提升。[结论]对老年的肱骨近端骨折患者,通过保守治疗可以获得较好的临床功能预后,但是仍存在一定的并发症发生率。需要充分评估患者的情况,根据骨折类型,医生的经验合理选择治疗方案,尽量减少并发症的发生。     

建立肱骨近端骨折内固定模型中值得商榷的一些问题

<正>肱骨近端骨折是常见的老年骨质疏松性骨折,随着人口结构的老龄化和预期寿命的延长,其发病人数呈快速上升趋势[1],但是无移位或轻微移位骨折在整个肱骨近端骨折中下降了近50%[2]。保守治疗对移位肱骨近端骨折疗效差[3]。近年来对移位肱骨近端骨折患者进行手术治疗的比例在欧美国家逐年上升[4]。切开复位锁定钢板内固定治疗移位肱骨近端骨折的总体疗效优于人工关节置换     

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.     

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.     

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.     

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.