下肢骨折患者合并深静脉血栓的早期筛查诊断

Screening and diagnosis of deep vein thrombosis in patients with lower extremity fractures

目的通过分析北京积水潭医院2005～2006年间收治的下肢骨折合并深静脉血栓（deep vein thrombosis，DVT）病例，总结出有效的早期筛查诊断方法。方法对于在2005—2006年间入我院骨科治疗的下肢骨折早期（7d）患者，根据临床表现和血清D-二聚体（D-dimer）值和纤维蛋白原（Fibrinogen，FIB）值筛选出可疑DVT病例，经多普勒超声和／或静脉造影确诊。结果共收治早期下肢骨折患者398例，其中可疑DVT患者275例（69．1％），经多普勒超声和／或静脉造影确诊DVT患者共56例（20．4％）。56例患者中4l例患者（73、2％）D-二聚体大于正常值（400μg／L），38例患者（67、9％）FIB高于正常值（4g／L）。15例D-二聚体正常的DVT患者中，其近端骨折和远端骨折患者病例数相近（53．3％，46．7％），有13例（86．7％）伴发有FIB升高。D-二聚体和FIB对于DVT的敏感性接近（73．2％，69、1％）。结论骨折患者的DVT发生率较正常人群明显升高。在该类人群中，有效的DVT早期诊断筛选方法为常规监测血清D-二聚体和FIB值，如二者中有一项升高，都需要及时进行多普勒超声和／或静脉造影来确诊。

Objective To explore an effective and efficient method for screening and diagnosing deep vein thrombosis （DVT） in patients with lower extremity fractures. Methods Subjects were 398 patients with new lower extremity fractures （less than 7 days） who underwent surgery in our hospital from 2005 to 2006. Results Among 398 Patients, 275 patients （69.1% ） were suspected of DVT before surgery and were further investigated for having DVT symptoms （ swollen, Homan＇ s）, elevated D-dimer level （ 〉 400 μg/L）, or elevated fibrinogen （FIB） level （ 〉4 g/L）. Subsequently, the DVT diagnoses were confirmed in 56 patients （20.4%） by Doppler ultrasonography and/or venography. Among all 56 DVT patients, there were 41 cases （73.2%） with elevated blood D-dimer level and 38 cases （67.9%） with elevated blood FIB level. In those DVT patients with a normal D-dimer value, 13 （86.7%）cases demonstrated an elevation in FIB value. The locations of the fractures in these 15 patients were not significantly different： 8 eases （53.3%） had proximal femur fractures and 7 cases （46.7%） had distal fractures. Conclusions Our results demonstrated that compared to normal population, the incidence of DVT was much higher in patients with lower extremity fractures （20.4%）. Thus for those patients, the D-dimer assay and FIB assay should be both used to exclude DVT. If either parameter is elevated, then the Doppler uhrasonography and/or venography should be performed to confirm the diagnosis.