连枷胸保守治疗与手术治疗对比研究

Comparison between surgical and conservative treatment for flail chest

目的探讨连枷胸的优化救治方案，降低肺功能损害，提高救治成功率。方法回顾性分析1991年2月～2008年12月我院收治的35例连枷胸病例。分为保守治疗组[巾钳肋骨悬吊牵引和（或）呼吸机气体内固定]13例，手术内固定组22例。手术组除行止血、肺修补等处理外，还采用“钢丝＋克氏针”或记忆合金肋骨环抱接骨器内固定。结果（1）治愈率97．1％（34／35），保守组1例死于多器官功能衰竭（MOSF）。（2）手术组与保守组ISS值（25．7±6．9VS29．8±8．5）、双侧肋骨骨折数（11．8±3．5vs9．8±1．8）差异无统计学意义（P〉0．05，0．05）；大量血胸发生率手术组明显高于保守组（40．9％vs7．7％）（P〈0．05），呼吸系统并发症及胸廓畸形发生率手术组显著低于保守组（36．4％vs84．6％，27．3％vs92．3％）（P〈0．01，0．01）；需呼吸机支持率手术组（4／22，18．2％）与保守组（3／13，23．1％）差异无统计学意义（P〉0．05）。（3）记忆合金肋骨环抱接骨器内固定呼吸并发症（4／16，25％）明显低于“钢丝＋克氏针”内固定（4／6，66．7％）（P〈0．05）；手术组后遗胸廓畸形均为“钢丝＋克氏针”内固定组，记忆合金肋骨环抱接骨器恢复胸廓形态、纠正胸壁软化满意。结论连枷胸肋骨骨折内固定可以迅速稳定胸壁、改善连枷胸对呼吸功能的影响，尤其记忆合金肋骨环抱接骨器内固定可达到恢复胸壁完整形态，明显优于保守治疗组。

Objective To investigate the therapeutic strategies, decrease the damage of pulmonary function and improve survival rate for severe chest trauma with flail chest. Methods The 35 patients with severe chest trauma and flail chest,admitted from Feb. 1991 to Dec. 2008 in Chongqing Emergency Medical Center,were retrospectively analyzed. The patients were divided into conservative treatment group （ 13 cases ） and surgical internal fixation group （ 22 cases ）. Results The survival rate was 97.1% （ 34/35 ）. One case died of MOSF in conservative treatment group. There was no statistical difference in the value of ISS and the number of fractured ribs in both sides （25.7±6.9 vs29.8±8.5;11.8±3.5 vs9.8±1.8）（P〉0.05,0.05）. The incidence of massive haematotborax in surgical internal fixation group was significantly higher than that of conservative treatment group （40.9% vs 7.8% ）（P 〈0.05）. But the complications of respiratory system and the deformity of chest wall in surgical internal fixation group were significantly lower than those in conservative treatment group （ 36.4% vs 84.6% ,27.3% vs 92. 3%）（P 〈0.01,0.01）. There was no statistical significance in both groups for ventilator support （ 18.2% vs 23.1% ）（ P 〉 0.05 ）. The respiratory complications in the group of using Ni-Ti shape memory alloy of embracing internal fixator were much lower than those in group of using steel-wire and Kirschner wire（ 25% vs 66.7% ）（ P 〈 0.05）. The deformity of chest wall after operation was only existed in group of fixation using steel-wire and Kirsehner wire. The shape of thoracic cage was recovered completely for all of the patients using Ni-Ti shape memory alloy of embracing internal fixator. Conclusion The surgical internal fixation group is much better than the conservative treatment. It can stabilize the chest wall rapidly and improve the respiratory function in patients with severe flail chest. The results suggest that Ni-Ti shape memory alloy of embracing internal fixator is one of the best suitable choices for correction of chest wall floating.