伴有直肠肛管损伤的开放性骨盆骨折的治疗

Clinical treatment of open pelvic fractures associated with anorectal injury

目的探讨伴有直肠肛管损伤的开放性骨盆骨折的治疗。方法1998年10月至2008年10月共收治35例开放性骨盆骨折患者，其中19例伴有直肠肛管损伤，对此19例患者的资料进行回顾性分析。骨折按Tile方法分类：A型1例，B型5例，C型13例。直肠肛管损伤部位：腹膜内直肠损伤3例，腹膜外直肠损伤11例，肛管损伤5例。患者人院后，临床治疗按四步流程开展：①急救复苏：抢救生命和控制出血，②结肠造瘘与清创，③骨盆骨折的治疗，④后期创面的处理。结果19例患者均存活，并获得12～48个月（平均18个月）随访。直肠肛管损伤治疗结果按Hiltunen标准进行评价：18例治愈（无失禁及部分失禁），1例出现医源性狭窄后经扩肛治疗改善。骨盆骨折按Majeed疗效评价：优3例，良11例，可4例，差1例，优良率为73．7％。创面愈合：18例创面Ⅰ期愈合或Ⅱ期经过植皮及转移皮瓣修复后愈合，其中1例创面有不同程度感染，经换药、引流及加强抗炎后愈合；1例创面损伤及感染严重，行右股骨中上段截肢、转移皮瓣覆盖会阴创面及双侧睾丸移位置于腹部皮下，加强换药后好转，留待Ⅱ期整形处理。结论对于伴有直肠肛管损伤的开放性骨盆骨折，通过术前准确的评估，结合伤情的演变规律，分阶段按照止血与液体复苏、骨科损伤控制、多学科联合、复合固定技术、感染控制等一系列原则序贯而针对性地进行处理，患者可存活，并能取得较满意的效果。

Objective To investigate the clinical treatment of open pelvic fractures associated with anorectal injury. Methods We retrospectively reviewed the medical data of 19 patients who had been treated at our department between October 1998 and October 2008 for open pelvic fractures associated with anorectal injury. By Tile classification, there were 1 type A, 5 type B and 13 type C. Three cases suffered from intraperitoneal rectal injury, 11 from extraperitoneal rectal injury and 5 from injury to the anal canal. Their treatment was carried out in 4 steps. First, emergency resuscitation to rescue life and control massive hemorrhage; second, sigmoid colon ostomy and debridement to handle anoreetal injury; third, management of the pelvic fracture; fourth, later wounds management. Results No death occurred in this group. All the 19 patients were followed up for 12 to 48 （average, 18） months. The anorectal injury was cured in 18 cases and improved in 1 case. According to the Majeed evaluation, the outcome of pelvic fractures was excellent in 3 cases, good in 11, fair in 4, and poor in 1. The good to excellent rate was 73. 7%. The wounds healed at one or two stages after grafting and flap transfer in 18 cases. Conclusion Good outcome of open pelvic fractures associated with anorectal injury may result from timely emergency resuscitation, aggressive management of anorectal injury and proper management of pelvic fractures by orthopaedists in cooperation with specialists from other disciplines.