损伤控制骨科技术在严重多发伤合并骨折治疗中的应用

目的 探讨严重多发伤时损伤控制骨科(damage control orthopedics,DCO)技术应用的可行性、适应证和疗效.方法 对1998-2008年应用DCO方法救治的31例严重多发伤合并骨折患者的临床资料作回顾性分析.结果18例严重多发伤伴骨盆骨折大出血,早期双侧髂内动脉结扎17例,早期骨盆外固定支架使用12例.11例严重多发伤伴开放性股骨骨折初期仅作清创和简单外固定,后期确定性内固定手术.2例脊柱骨折伴脊髓压迫,早期经后路行简单椎板减压.ICU治疗时间为1～11 d,平均4.3 d.本组患者死亡1例,其余30例全部生存.结论DCO更符合外伤后患者的病理生理特点,早期针对性控制处理及后期的一体化治疗是提高严重多发伤生存率的关键.     

损伤控制骨科技术在严重多发伤合并骨折治疗中的应用

目的 探讨严重多发伤时损伤控制骨科(damage control orthopedics,DCO)技术应用的可行性、适应证和疗效.方法 对1998-2008年应用DCO方法救治的31例严重多发伤合并骨折患者的临床资料作回顾性分析.结果18例严重多发伤伴骨盆骨折大出血,早期双侧髂内动脉结扎17例,早期骨盆外固定支架使用12例.11例严重多发伤伴开放性股骨骨折初期仅作清创和简单外固定,后期确定性内固定手术.2例脊柱骨折伴脊髓压迫,早期经后路行简单椎板减压.ICU治疗时间为1～11 d,平均4.3 d.本组患者死亡1例,其余30例全部生存.结论DCO更符合外伤后患者的病理生理特点,早期针对性控制处理及后期的一体化治疗是提高严重多发伤生存率的关键.

Abstract：

Objective To probe the feasibility, indications and efficacy of damage control orthopedics (DCO) in treating severe multiple injuries combined with fractures. Methods A retrospective analysis was done on the clinical data of 31 patients with severe multiple injuries combined with fractures treated by DCO from 1998 to 2008. Results Of all patients, 18 patients were combined with pelvic fractures and hemorrhage. Bilateralis hypogastric artery ligation was performed early in 17 patients and nonage pelvis external fixation was performed in 12. Eleven multiple trauma patients combined with femoral fractures received primary debridement and temporal external fixation for further definitive internal fixation. Two patients with spinal fractures combined with spinal cord compression received primary simple decompression. All patients received resuscitation in ICU for average 4.3 days (1-11 days). There was one death due to hemorrhagic shock. Conclusions DCO well conforms to pathophysiological character of the wounded. Early DCO and later integrated treatment are key to enhancement of the survival rate of the multiple trauma patients.     

几种固定方式急诊治疗多发伤合并胫腓骨开放性骨折的疗效分析

目的 比较四种固定方法早期固定开放性胫腓骨骨折对严重多发伤患者治疗和预后的影响.方法 回顾性分析243例存在胫腓骨开放性骨折的严重多发伤患者(ISS≥16分)的资料,其中对胫腓骨骨折采用跟骨牵引加夹板治疗48例,带锁髓内钉治疗69例,钢板螺钉治疗54例,外固定支架治疗72例.从病死率、ARDS、脂肪栓塞综合征(FES)、MODS、ICU监护时间等近期指标,以及创面愈合时间、骨折愈合时间、关节功能恢复优良率、骨折并发症等远期指标,对比分析四种早期固定方法对骨折本身和多发伤治疗的疗效.结果 带锁髓内钉治疗胫腓骨骨折在多项指标方面较其他固定方法为优(P<0.05,0.01).结论 带锁髓内钉治疗严重多发伤并胫腓骨中段开放性骨折(Gustilo Ⅰ型、Ⅱ型和Ⅲa型),明显减少并发症发生率,术后骨折愈合较为理想.

Abstract：

Objective To comparethe effects of four different emergency fixation methods for the open tibiofibular fractures on the treatment and prognosis of the multiple trauma patients. Methods A comparative study was carried out on the effect offour different early fixation methods on the fracture and the multiple trauma in aspects of the short-term indicators including mortality rate,acute respiratory distress syndrome(ARDS),fat embolism syndrome(FES),multiple organ dysfunction syndrome (MODS),ICU stay and the long-term indicators including wound healing time,fracture healing time,rate of joint function recovery and fracture complications in 43 multiple trauma patients. Results The locked intramedullary nail wag better than the other fLxation methods including the calcaneal traction,the gypsum external fixation and the internal fixation with steel plate and extemal fixation support in most indexes(P<0.05,0.01). Conclusion The locked intramedullary nail can significantly decrease the incidence rate of complications and obtain sound fracture healing for the patients with multiple trauma combined with open tibiofibular fractures(types Gnstilo Ⅰ,Ⅱ and Ⅲa).     

股骨骨折合并颅脑损伤48例治疗

目的 探讨股骨骨折合并颅脑损伤治疗的时机及疗效.方法 回顾分析48例股骨骨折合并颅脑损伤病例,比较死亡率、手术时间、手术失血量、住院时间、骨不连例数、骨折愈合时间,观察急诊行内固定手术(≤48小时)、早期外固定延期内固定(＞48小时)对股骨骨折合并颅脑损伤的治疗效果.结果 早期外固定延期内固定手术时间更短、手术失血量更...     

经髋动力螺钉侧孔注入骨水泥强化技术治疗高龄不稳定型转子间骨折

目的 观察经动力髋螺钉(DHS)侧孔注入骨水泥强化固定技术治疗高龄骨质疏松性不稳定型股骨转子间骨折的疗效. 方法 2006年1月～2007年12月收治高龄骨质疏松性不稳定型股骨转子间骨折15例,均采用带侧孔 DHS固定和经DHS侧孔注入甲基丙烯酸甲酯(PMMA)骨水泥的加强技术治疗.术后观察早期活动能力及手术并发症的发生情况,随访至骨折愈合,按照Harris标准评价手术治疗效果. 结果 手术时间、出血量等手术创伤指标与单纯DHS手术相同;所有患者术后2～3 d即行髋关节屈伸锻炼和完全坐起,6例患者术后1周可利用助行器锻炼行走功能,围术期未发生卧床和PMMA方面的并发症;骨折于术后3～6个月愈合,随访期间未出现内固定松动、切割破坏股骨头等并发症.术后半年14例患者恢复到手术前的生活能力,Harris评分:优4例,良10例,中1例,平均83分. 结论 采用DHS固定和经DHS侧孔注入PMMA的加强技术治疗可增强DHS在股骨头中的固定强度,且手术创伤小,固定可靠,可以早期功能锻炼,适合高龄骨质疏松性不稳定型股骨转子间骨折患者.     

下肢多发骨折合并多发损伤的处理

报告102例下肢多发骨折患者，骨折共258处。56．8%合并颅脑、胸、腹多发损伤。经救治无急性死亡。下肢多发骨折处理以股骨骨折为主，合并同侧髋、膝关节损伤及脊柱骨盆损伤者，强调内固定处理。下肢功能恢复良好率达85．4％。     

External skeletal fixation of the tibial shaft fractures

AIM: To present the possibility of a succesfful use of external skelatal fixation in treating the open and closed tibial shaft fractures with Mitkovi?'s external fixator. METHODS: External fixation was used in 115 patients with 118 fresh tibial shaft fractures, 82 males (71.3%) and 33 females (28.7%), average age 43.92 years (16-84). Open tibial shaft fractures were present in 37 (31.36%). All the fractures were treated with Mitkovi?'s external fixator type M 20. RESULTS: The results of external fixation were excellent or good in 94.07% of the cases, and bad in 5.08%. Pin tract infection appeared in 7 (5.93%) patients. In only 3 cases an external fixator was removed and treatment continued with the functional braces. Nonunion occurred in 6 (5.08%) patients, of which 4 were with open fractures (2 Gustilo type IIIB, 1 Gustilo type IIIA, 1 Gustilo type II) and 2 with the segment fractures. Compartment syndrome was observed in 1 (0.85%) patient with closed fracture. Malunion was found in 2 (1.69%) patients. CONCLUSION: External fixation of tibial shaft fractures is a simple and effective method to enable the safe healing of fractures, early mobilization of the patients, early weight-bearing, as well as early rehabilitation. Fixation of tibial shaft fractures was unilateral with convergent pins orientation, and there was also a possibility of compression and distraction.     

External fixation combined with limited internal fixation in the treatment of pilon tibia fractures

BACKGROUND/AIM: Intraarticular fractures of the tibial plafond (pilon fractures) belong to the group of most severe fractures. They are usually caused by high-energy trauma and frequently associated with a marked soft-tissue damage. Surgical treatment has replaced the traditional nonoperative treatment. The aim of this study was to present the results of the treatment of distal tibial intraarticular fracture by the use of internal fixation, as well as the combination of minimal internal fixation and external fixation. METHODS: The study included 47 patients with pilon tibia fractures who went through at the Clinic for Orthopedics and Traumatology, School of Medicine, Nis (1995-2004). Within the analayzed group there were 33 (70.2%) males and 14 (29.8%) females. The patients mean age was 45.8 years. In the first group, which consisted of 22 patients, open reduction and internal fixation of both the tibia and the fibula was performed in the two separate incisions. The second group consisted of 25 patients managed with external fixation by external fixator "Mitkovi?" with limited internal fixation. Besides external fixation, a minimal internal fixation was performed by the use of Kirschner wires and screws. The patients were followed-up inside a 24-months-period. Results. The obtained was a substantially high number of complications after open reduction and internal fixation in the group of patients. There was no difference in a long-term clinical outcome. Postoperative osteitis, as the most severe complication in the management of closed pilon tibia fractures, was not registered in the second group. CONCLUSION: Considering the results obtained in this study, it can be concluded that external fixation by the "Mitkovi?" external fixator with the minimal internal fixation is a satisfactory method for the tratment of fractures of the tibial plafond causing less complications than internal fixation.     

小儿颅脑外伤合并股骨干骨折23例救治分析

目的探讨小儿颅脑外伤合并股骨干骨折损伤机制、救治措施及预后。方法总结我科近4年来住院病例。探讨股骨受暴力后颅脑损伤的机制,股骨干骨折手术时机的选择以及预后。结果此类患儿系暴力撞击大腿后,头部着地造成减速伤,颅脑受伤机制中有剪切力存在。除2位轻型颅脑外伤患儿外,中重型颅脑外伤患儿入院CT大都表现白质及灰白质交界处、基底节及胼胝体处多发点灶样挫伤。患儿昏迷时间为5～178天,平均23.1±4.2天。患儿吞咽功能恢复后行弹性髓内钉固定术效果好,肺部并发症较轻。结论收住神经外科颅脑外伤合并股骨干骨折患儿颅脑受伤机制大都伴有剪切力存在。虽然颅脑损伤严重,但大部分患儿经过正确的治疗仍可获得较好的预后。     

撬拨辅助钉道控制在闭合治疗股骨转子下骨折中的意义

目的 评估术中使用斯氏针撬拨辅助钉道控制闭合复位的效果. 方法 23例股骨转子下骨折,术中用斯氏针置入股骨大转子后部协助复位,闭合复位后股骨近端髓内钉(PFN)或抗旋股骨近端髓内钉(PFNa)固定. 结果 23例患者手术时间30～55 min,平均39 min,出血量50～120 ml,平均76 ml.术中透视、术后X线复查骨折对位对线优良,骨折全部获得愈合,无严重并发症. 结论在髓内钉治疗股骨转子下骨折时,股骨近侧置入斯氏针撬拨辅助钉道控制能较好纠正和控制股骨转子下骨折近端骨折块的移位,手术时间短,创伤小,固定可靠.     

不等距无头加压螺纹钉治疗Hoffa骨折

目的探讨不等距无头加压螺纹钉治疗Hoffa骨折的效果。方法 2010年6月-2012年12月,我院共收治Hoffa骨折5例,其中外髁骨折3例,内髁骨折1例,双髁骨折1例。患者均为男性;年龄17-54岁,平均年龄35.8岁。5例行前正中切口切开复位,不等距无头加压螺纹钉内固定治疗,术后第2d拔管,开始主动和被动活动锻炼,术后2个月逐渐下地负重行走。结果 5例均获随访,随访时间4-30个月,平均15个月。骨折均获骨性愈合,功能恢复参照Letenneur方法进行评估,优良4例,可1例。本组无深部感染、内固定松动和关节僵直发生。结论临床上Hoffa骨折比较少见,股骨外髁发生率高于股骨内髁,双髁骨折更少见。不等距无头加压螺纹钉把持力强,无头结构适合股骨髁部骨折,可以达到骨折端解剖复位、坚强稳定的内固定及早期功能锻炼,术后临床效果良好。     

Surgical treatment of pertrochanteric fractures using dynamic methods of internal and external fixation

Pertrochanteric fractures usually occur in patients over 65 years of age, with greater loss of skeletal mass (osteoporosis). Nonsurgical methods of treatment are accompanied by relatively high lethality rate. Moreover, they do not produce satisfactory anatomical and functional results. Surgical treatment by using dynamic implants represents a method of choice in the fixation of pertrochanteric fractures. This paper presents the treatment results of 110 patients, 61 with pertrochanteric fractures, who were surgically treated by the dynamic method of internal fixation, and 49 patients who were treated by the method of external fixation. Dynamical implants enabled both dynamization and compression of the fracture in the axis of the neck, as well as the diaphysis of the femur, which lowered the risk of mechanical complications, and, at the same time, provided effective healing of the fracture, early activation, and mobilization of the patients on whom the surgery was performed. In patients infected by various diseases, for whom surgical trauma represents a life threat, the external fixation is recommended as a method of choice.     

切开复位内固定治疗股骨远端骨折

目的探讨切开复位内固定股治疗骨远端骨折的方法和临床疗效。方法切开复位内固定治疗股骨远端骨折47例,根据AO/ASIF分型：A型10例,B型12例,C型25例,分别采用股骨髁支持钢板、L-梯形钢板、逆行带锁髓内钉、拉力螺钉进行固定,术后经15～96个月随访。结果5例骨不愈合、3例出现伤口及骨折部位化脓性感染、3例出现钢板断裂,根据Kolmenrt股骨远端功能评定标准：优22例,良17例,一般4例,差4例,优良率82.9%。结论切开复位内固定治疗股骨远端骨折能最大限度获得骨折复位和关节早期功能锻炼,是治疗股骨远端骨折较理想的方法。     

空心加压螺钉内固定术治疗股骨颈骨折的疗效

目的：探讨研究空心加压螺钉内固定术治疗股骨颈骨折的疗效及安全性。方法选取2013年1月～2015年2月骨科收治的70例股骨颈骨折患者,采用随机数字法分为治疗组和常规组,对照组采用DHS进行固定,观察组采用空心加压螺钉内固定治疗,并对两组患者康复情况满意度、两组患者术后发生的愈合率、两组患者股骨头坏死情况进行比较。结果观察组的患者康复情况满意度、两组患者术后发生的愈合率、两组患者股骨头未坏死情况均高于对照组,差异具有统计学意义（ P＜0．05）。结论空心加压螺钉内固定术手术的创伤面积小,无需进行术后的特殊护理,是一种较可靠、安全、理想的内固定法,值得临床的广泛推广和应用。     

内外联合固定治疗不稳定性骨盆骨折

目的探讨切开复位内固定结合骨盆外固定架在不稳定性骨盆骨折治疗中的应用及效果。方法对2003年12月~2013年12月获得随访的29例不稳定性骨盆骨折患者进行回顾性分析,男性18例,女性11例;年龄18~57岁,平均32.5岁。按Tile分型的不稳定性骨盆骨折,均采用切开复位内固定结合外固定架技术治疗不稳定性骨盆骨折。结果随访6~18个月,29例均获得骨性愈合,恢复原来工作。术后功能评定按Majeed评分标准:优18例,良8例,可3例。结论切开复位内固定结合外固定架固定技术是治疗不稳定性骨盆骨折的有效方法。     

外固定支架下经皮有限内固定加肠造瘘术治疗开放性骨盆骨折伴盆底撕裂伤

目的 探讨开放性骨盆骨折伴盆底撕裂伤的治疗方法,介绍采用外固定支架下经皮有限内固定加肠造瘘术治疗开放性骨盆骨折伴盆底撕裂伤的方法、要点.方法 对9例开放性骨盆骨折伴盆底撕裂伤患者行外固定支架下有限经皮内固定加肠造瘘术,总结治疗经验.结果 9例患者骨盆骨折均满意愈合,盆底撕裂伤9例中7例未发生感染,2例轻度感染经治疗后痊愈,半年后复查患者创面愈合良好,功能良好.结论 采用外固定支架下有限经皮内固定加肠造瘘术治疗开放性骨折骨盆骨折伴盆底撕裂伤可获得较满意的效果.

Abstract：

Objective To introduce the methods and key points for the external fixation combinel with limited percutaneous internal fixation plus colostomy in the treatment of open pelvic fracture concomitant with perineal laceration.Methods Nine patients with open pelvic fractures concomitant with perineallaceration were treated by external fixator combined with limited percutaneous internal fixer plus colostomy. Data including injury details, management and outcomes were collected for comparison.Results All the patients survived and attained bony union except for two patients with local infection that was healed several days after repeated wound debridement and use of wide spectrum antibiotics. All the patients had good extremity function at the latest follow-up. Conclusion External fixation combined with limited percutaneous internal fixation plus colostomy is a reliable, safe and less invasive procedure for the treatment of open pelvic fractures concomitant with perineal open wound.     

距骨颈骨折的治疗分析

目的 研究距骨颈骨折的治疗. 方法 1988年10月-2004年6月,按改良Haw-kins法对66例距骨颈骨折患者分型:Ⅰ型14例,行石膏外固定;Ⅱ型34例,行手法复位石膏外固定、切开复位内固定或关节融合术;Ⅲ型16例,行切开复位内固定或关节融合术;Ⅳ型2例,行切开复位内固定或关节融合术.其中陈旧性骨折4例. 结果 平均随访6.28年,采用Hawkins评分进行评估,优(29%)19例(Ⅰ型13例,Ⅱ型5例,Ⅲ型1例);良(26%)17例(Ⅰ型1例,Ⅱ型12例,Ⅲ型4例);可(27%)18例(Ⅰ型11例,Ⅱ型6例,Ⅳ型1例);差(18%)12例(Ⅰ型6例,Ⅱ型5例,Ⅳ型1例).距骨缺血性坏死25例(38%),踝及距下关节炎分别为20例(30%)和26例(39%). 结论 距骨颈Ⅰ型和Ⅱ型骨折宜石膏外固定,Ⅲ型骨折应切开复位内固定,Ⅳ型和陈旧性骨折宜采用关节融合术.     

髓内扩张自锁钉与外固定架治疗胫骨开放性骨折的疗效评估

目的评估髓内扩张自锁钉(IESN)和外固定架治疗胫骨开放性骨折的疗效。方法自2003年10月—2005年9月采用髓内扩张自锁钉治疗胫骨开放性骨折41例,与38例采用外固定架治疗胫骨开放性骨折疗效进行对比分析。结果全部病例随访12~20个月,平均15.4个月,IESN组手术时间、术后平均发热时间和住院天数,骨折愈合时间分别为45min,2.3d,21d,9.5周,外固定架组分别为63min,3.2d,27d,13.2周。两组相比差异有统计学意义(t值分别为2.775,2.712,2.874,2.869,P均<0.01);IESN组无骨折延迟愈合及畸形愈合,无感染及内固定失败等并发症,而外固定架组出现9例感染,7例畸形愈合。结论髓内扩张自锁钉内固定在治疗胫骨开放性骨折中损伤小,并发症少,固定可靠,同时最大限度地保护骨断端血运,符合生物力学要求,在治疗胫骨开放性骨折中是一种有效的好方法。     

有限切开复位结合前外侧L形锁定加压接骨板内固定治疗胫骨远端干骺端骨折

目的探讨胫骨远端干骺端骨折应用有限切开复位结合前外侧L形锁定加压接骨板(locking compression plate,LCP)内固定治疗的临床疗效。方法 2011年6月~2013年1月共收治15例胫骨远端干骺端骨折患者。骨折按照国际内固定研究协会(AO/ASIF)分型:43A2型3例,43A3型10例,43B1型2例,均合并腓骨下端骨折;胫骨远端干骺端骨折线距踝关节面1.6~4.5cm,平均2.8cm;闭合性骨折8例,开放性骨折7例(GustiloⅠ型2例,Ⅱ型3例,ⅢA型2例)。GustiloⅢA型2例急诊行清创、腓骨内固定及外固定支架固定,余患者术前行跟骨骨牵引。运用有限切开复位结合前外侧L形LCP内固定治疗,术中酌情植骨,术后早期功能锻炼。结果所有患者术后获12~18个月(平均16个月)随访,术后2例切口表皮坏死,经换药处理后愈合,余切口均一期愈合。骨折于术后16~24周(平均20周)获骨性愈合。末次随访时根据美国骨科协会足踝外科分会(American Orthopedic Foot Ankle Society,AOFAS)评分标准:评分为73~95分,平均89.5分,其中优10例,良3例,可2例,优良率86.7%。随访期间无感染、骨不连及内固定松动断裂等并发症发生。结论采用有限切开复位结合前外侧L形LCP内固定治疗胫骨远端干骺端骨折,术中利用微创置板技术,并酌情植骨,术后早期功能锻炼,可获得良好疗效。     

多功能外固定支架结合腓骨内固定治疗胫骨极远端近关节面部位骨折

目的：分析和观察多功能外固定支架结合腓骨内固定治疗胫骨极远端近关节面部位骨折的疗效。方法：采用多功能外固定支架结合腓骨切开复位内固定进行外固定治疗。结果：17例病人经过平均13个月随访全部骨性愈合,平均愈合时间4个月,去除外固定支架时间平均5个月。1例病人针道深部慢性感染,窦道刮除后置管闭合冲洗痊愈。2例病人术后3处针道浅部感染,换药、抗炎愈合。所有病人踝关节、趾间关节功能良好,无畸形。结论：多功能外固定支架结合腓骨内固定治疗胫骨极远端近关节面部位骨折操作简单,效果佳,愈合快。