伴会阴部损伤的开放性骨盆骨折治疗

目的探讨伴会阴部损伤的开放性骨盆骨折治疗方法及疗效。方法 2000年8月-2010年7月,收治16例伴会阴部损伤的开放性骨盆骨折患者。男12例,女4例;年龄17～69岁,平均41岁。致伤原因:交通事故伤9例,高处坠落伤6例,重物砸伤1例。受伤至入院时间为5～20 min,平均8 min。骨盆骨折按照Tile分型标准:A型2例,B型6例,C型8例。创面范围5 cm×3 cm～15 cm×12 cm。会阴部损伤部位:腹膜内直肠损伤2例,腹膜外直肠肛管损伤14例。按创伤严重度评分标准(injury severity score,ISS)评分为25～48分,平均29分。入院后按创伤骨折流程急救处理,主要包括急救复苏、结肠造瘘、外固定架固定、创面多次清创、冲洗、持续封闭式负压引流技术(vacuum sealingdrainage,VSD)。结果入院4 d内死亡5例,其中3例死于失血性休克,2例死于多器官功能衰竭。余11例存活患者均获随访,随访时间6～46个月,平均14个月。X线片检查示骨盆骨折于术后2～4个月达骨性愈合。术后会阴部损伤创面均有不同程度感染,经扩创、VSD治疗后,其中10例创面直接拉拢缝合后Ⅱ期愈合,1例行股薄肌皮瓣移位修复后愈合。直肠肛管损伤患者随访期间无失禁表现。结论对于伴会阴部损伤的开放性骨盆骨折,应早期积极抗休克、保护重要脏器功能、处理合并症,后期抗感染、恢复骨盆环稳定性、修复重建直肠肛管及尿道功能,以获得较好疗效。

Clinical treatment of open pelvic fractures associated with perineal injury

Objective To investigate the method and the effectiveness of open pelvic fractures associated with perineal injury. Methods Between August 2000 and July 2010,16 cases of open pelvic fractures associated with perineal injury were treated.There were 12 males and 4 females with an average age of 41 years(range,17-69 years).Injury was caused by traffic accidents in 9 cases,by falling from height in 6 cases,and by crushing in 1 case.The mean time between injury and admission was 8 minutes(range,5-20 minutes).According to Tile classification,2 cases were rated as type A,6 as type B,and 8 as type C.The wound size ranged from 5 cm × 3 cm to 15 cm × 12 cm.The perineal injured location included intraperitoneal rectal injury in 2 cases and extraperitoneal anorectal injury in 14 cases.The average injury severity score(ISS) was 29(range,25-48).The main treatments included emergency resuscitation,colostomy,external fixation of fractures,repeated debridement with pulsatile irrigation followed by intravenous antibiotics,and vacuum sealing drainage(VSD). Results In 5 deaths,3 cases died of hemorrhagic shock and 2 cases died of multiple system organ failure within 4 days of admission.The other 11 cases were followed up 6-46 months(mean,14 months).The X-ray films showed that bone union was achieved after 2-4 months of operation.Infection in varying degree occurred at perineal wounds;second stage healing of wounds was achieved in 10 cases after debridement and VSD treatment,and wound healed in 1 case after gracilis muscle flap repair.No anal incontinence occurred in the patients having anorectal injury during follow-up.Conclusion For patients with perineal injury and open pelvic fractures,the following treatments should be carried out so as to obtain good effectiveness: early anti-shock,protection of important organ function,treatment of complications,late resistance to infection and stability restoration of the pelvic ring,functional repair and reconstruction of rectum and anal canal and urinary tract.