当前骨折内固定治疗中的几个基本问题

SomeBasicProblemsintheCurrentTreatmentofFractureswithInternalFixation

自６０年代以来，坚强固定和有关骨折内固定治疗的原则一直被ＡＯ／ＡＳＩＦ学组所推荐．加压钢板和髓内钉的设计和应用技术也有较大进展．然而仍存在些有争议的问题．如坚强固定可引起应力遮挡，无论采用加压钢板或髓内钉治疗长骨粉碎骨折，骨不连和内固定器材破坏的发生率仍然高．在临床和实验研究的基础上，作者强调ＡＯ／ＡＳＩＦ学组提出的某些基本原则有必要修改和（或）补充．在切开复位时如骨折部，特别是压力侧有骨缺损，必须采用髓内、外植骨修复，否则内固定器材承受的应力比无骨缺损时将增加５～１０倍．骨折早期固定应该比较坚强，后期肢体负重时应为弹性固定．这样不仅有利于骨折愈合，而且有利于骨的模造．两者可通过合理使用优化设计的内固定器材结合起来．在骨折治疗中，如练功或负重后骨折断端出现骨吸收，这是固定不牢和骨折端活动太多的一个信号．一旦出现骨吸收，则应限制练功活动并避免负重，直至骨折部形成连续外骨痂再恢复活动．

Since1960'therigidfixationandrelatedprinciplesfortreatmentoffractureswithinter-nalfixationhavebeenrecommendedbyAO/ASIFGroup.Thedesignandtheapplicatedtechniquesofeithercompressionplateorintramedularynailhavealsomaderathergreatprogress.However,somecontroversialproblemsstilremain.Rigidfixation,forinstance,maycausestressshielding.Theinci-denceofnonunionand/orbreakageofimplantwasstilhighinthetreatmentofcomminutedfracturesoflongbones,nomaterwhatkindofimplant,compressionplateorintramedularynailwasused.Basedonclinicalandexperimentalstudies,theauthorsemphasizedthatsomebasicprincipleswhichwerepro-posedbyAO/ASIFGroupshouldberevisedand/orsupplemented.Inopenreduction,ifthereisanybonedefectatthefracturesite,especialyonthecompressionside,shouldberepairedbyonlayandin-laybonegraft.Otherwise,thestresssubjectedtotheimplantisabout5～10foldgreaterthanthatwithoutbonedefect.Immobilizationoffractureshouldberelativelyrigidintheearlystageandelasticinthelaterstageduringweight-bearing.Itisbeneficialnotonlyforfracturehealingbutalsoforbonere-modeling.Bothofthemcanbeintegratedbyrationaluseofoptimaldevices.Duringthetreatment,iftheboneresorptionappearsatthefragmentendsafterdoingexercisesortakingweight-bearing,itisasignalwhichshowsthatthefixationisunstableandthemotionatthefracturesiteistoomuch.Oncetheboneresorptionappears,theexerciseshouldberestrictedandtheweight-bearingmustbeavoided.Ifnecessary,someexternalfixation,castslaborsplints,canbeapplieduntilthecontinuouscalusformsaroundthefracturesite.