中国修复重建外科杂志

中国修复重建外科杂志

近侧骨折段向前成角移位的股骨粗隆间骨折治疗经验

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目的探讨近侧骨折段向前成角移位的股骨粗隆间骨折的特点及治疗措施。方法2015 年 3 月—2016 年 3 月采用手术切开复位、髓内钉固定治疗 40 例近侧骨折段向前成角移位的股骨粗隆间骨折患者。男 11 例,女 29 例;年龄 56~87 岁,平均 75.7 岁。致伤原因:交通事故伤 1 例,摔伤 39 例。体质量指数 18.9~33.8 kg/m2,平均 24.3 kg/m2。受伤至入院时间 2~360 h。骨折按照 AO-OTA 分型:A1.2 型 7 例,A1.3 型 1 例,A2.1 型 6 例,A2.2 型 9 例,A2.3 型 12 例,A3.2 型 2 例,A3.3 型 3 例。记录患者入院时、术前以及术后最低血红蛋白(haemoglobin,Hb)值,住院期间输血量和手术显性出血量。采用简明健康调查量表(SF-36 量表)评估患者伤前及术后 12 周生活质量,疼痛视觉模拟评分(VAS)评估入院时及术后 2 d 疼痛程度。根据术后 X 线片及临床检查判断骨折愈合情况。术后 12 周采用 Harris 评分评价患侧髋关节功能。结果患者入院时 Hb 为(114.33±14.93)g/L,术前最低 Hb 为(99.10±16.48)g/L,差异有统计学意义(t=9.134,P=0.000)。11 例术前输血(520.00±269.98)mL。手术显性出血量(373.08±154.68)mL,术中输血量为(569.23±207.94)mL。术后患者最低 Hb 为(105.41±13.36)g/L,8 例患者术后再次输血(500.00±185.16)mL。术后 3 d 按照改良 Baumgaertner 法评价骨折复位情况:优 16 例,良 18 例,差 6 例。40 例获随访,随访时间 12~15 周,平均 12.8 周。术后切口无感染发生。术后 2 d VAS 评分为(3.2±0.5)分,较入院时的(8.2±0.5)分显著改善(t=37.500,P=0.000)。术后 12 周骨折均愈合;患侧髋关节 Harris 评分为(82.5±6.9)分;SF-36 量表评分为(51.4±11.5)分,较伤前(54.9±11.5)分显著降低(t=18.901,P=0.000)。术后 4 例出现谵妄,8 例感染肺炎,5 例泌尿系统感染,2 例出现静脉血栓形成,均经相应处理后治愈。结论近侧骨折段向前成角移位的股骨粗隆间骨折是一种难复位、不稳定型骨折,术中需要通过辅助器械达到骨折良好复位,解剖对位是取得良好疗效的首要条件,同时需注意及时纠正患者贫血。

ObjectiveTo explore the characteristics and treatment of intertrochanteric fracture, which the proximal part displaced forwardly and angularly.MethodsBetween March 2015 and March 2016, 40 patients with intertrochanteric fracture with forwardly and angularly displaced proximal part were treated with open reduction and intramedullary nailing fixation. There were 11 males and 29 females with the age of 56-87 years (mean, 75.7 years). The causes of injury included traffic accident in 1 case and fall in 39 cases. The body mass index was 18.9-33.8 kg/m2 (mean, 24.3 kg/m2). The time from injury to admission was 2-360 hours. The type of fracture according to AO-OTA classification was A1.2 type in 7 cases, A1.3 type in 1 case, A2.1 type in 6 cases, A2.2 type in 9 cases, A2.3 type in 12 cases, A3.2 type in 2 cases, and A3.3 type in 3 cases. The haemoglobin (Hb) value at admission and the lowest values before and after operation were recorded; the amount of transfused-blood during hospital stay and visible blood loss around operation were recorded. The short-form 36 health survey scale (SF-36) before injury and at 12 weeks after operation were recorded for evaluating the quality of living; the visual analogue scale (VAS) score at admission and at 2 days after operation were recorded for evaluating the degree of pain, the fracture union was evaluated by X-ray film and clinical examination, and the Harris hip scale were used to evaluate the injuried hip function at 12 weeks.ResultsThe lowest Hb value before operation was (99.10±16.48) g/L, which was significantly lower than that at admission[(114.33±14.93) g/L](t=9.134, P=0.000). Eleven patients were treated with blood transfusion at amount of (520.00±269.98) mL before operation. The amount of transfused-blood during operation was (569.23±207.94) mL, and intraoperative blood loss was (373.08±154.68) mL. The lowest Hb value was (105.41±13.36) g/L after operation, and 8 patients were treated with second blood transfusion at amount of (500.00±185.16) mL. The reduction of fracture was rated as excellent in 16 cases, good in 18 cases, and poor in 6 cases according to the modified Baumgaertner criteria at 3 days after operation. Forty cases were followed up 12-15 weeks (mean, 12.8 weeks). No infection occurred. The VAS score at 2 days after operation was 3.2±0.5, which was significantly improved when compared with the value at admission (8.2±0.5) (t=37.500, P=0.000). At 12 weeks after operation, all the fractures healed; the Harris score was 82.5±6.9; and the SF-36 score was 51.4±11.5, which was significantly decreased when compared with the score before injury (54.9±11.5) (t=18.901, P=0.000). There were delirium in 4 cases, pneumonia in 8 cases, urinary infection in 5 cases, and venous thrombosis in 4 cases after operation. And all patients cured after corresponding treatment.ConclusionIntertrochanteric fracture with forwardly and angularly displaced proximal part is a type of unstable fracture, and it is difficult to reduction. It is necessary to achieve a good fracture reduction by means of auxiliary instrument. The anatomical alignment is the primary condition for the good effectiveness, and the anemia before and after the operation must be corrected.

关键词: 股骨粗隆间骨折; 向前成角移位; 解剖对位; 复位

Key words: Intertrochanteric fracture; forward and angular displacement; anatomical alignment; reduction

引用本文: 王敬博, 于树军, 李辰, 臧加成, 王裕民. 近侧骨折段向前成角移位的股骨粗隆间骨折治疗经验. 中国修复重建外科杂志, 2018, 32(9): 1162-1166. doi: 10.7507/1002-1892.201711099 复制

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