骨盆粉碎性骨折伴休克及神经损伤的手术治疗

Operative Treatment of Comminuted Fracture of Pelvis Accompanied by Hemorrhagic Shock and Nerve Injuries

目的探讨骨盆粉碎性骨折伴出血性休克及神经损伤的治疗方法选择。方法骨盆粉碎性骨折伴出血性休克及神经损伤4例,在抗休克基础上整复骶骼关节脱位。CT、MR及三维CT立体成像确诊,分别给予以下手术:①对于有较大动脉损伤,经导管选择性栓塞损伤动脉;②对于闭孔神经、股神经、精索损伤,先前方进行耻骨骨折复位手术,然后CT引导下行双骶髂关节加压螺钉固定术;③对于骶部副交感神经受到压迫、骶骨Ⅱ区纵向骨折移位导致骶神经孔变形损伤,先后方骶管骶骶神经孔扩大减压,再行前路腹膜外减压会师术。结果随访6～39个月。3例运动感觉功能恢复满意。1例除残留右骶神经损伤(右足底感觉麻木和屈拇肌力Ⅳ级)外,阳萎消失,植物神经功能及下肢功能正常。结论放射性介入治疗较大动脉损伤有良好的止血效果;合并神经压迫时,最好在骨盆骨折切开复位、内固定的同时对损伤的腰骶丛进行手术探查、修复,即使当时未能手术,半年后仍应积极手术减压,此为减少合并症、促进康复的有效措施。

Objective To discuss the treatment of comminuted fracture of pelvis accompanied by hemorrhagic shock and nerve injuries.Methods Four cases of comminuted fracture of pelvis accompanied by hemorrhagic shock and nerve injuries were included.The dislocation of sacroiliac joint was first repositioned under anticoagulation,and then the following treatments were given after CT,MR,and 3-D CT examinations.The vessels embolization through angiography was used in one case of major artery bleeding.Two cases of the injuries of left obturator nerve,femoral nerve or spermatic cord were first treated by the reduction of pubis fracture,and then the bilateral sacroiliac joints were fixed by compression screw under the guidance of CT.One case of oppressed parasympathetic nerve and injured sacral nerve was treated by enlarging posterior sacral canal and anterior sacral foramina as well as releasing S1 nerve root.Results All the cases were followed up for 6 to 39 months.Three cases recovered satisfactory in both motion and feeling.One case had a satisfied recovery of ED,autonomic nerve function and low limb function,but the symptom of right sacroiliac nerve injury was remained.Conclusion The vessel embolization by angiography is effective to control acute hemorrhage of major artery.The open reduction and internal fixation are the best ways to treat comminuted fracture of pelvis accompanied by oppressed nerve.Meanwhile,it is necessary to examine and repair the injuries of lumbosacral plexus in operation.To the cases that can't be treated in time,decompression is still significant after half a year.