四肢高能量骨折分期治疗策略

Staged management in patients with high-energy extremities fractures

目的高能量损伤常引起患者四肢粉碎性骨折,严重的软组织损伤,皮肤坏死,以及合并血管神经损伤、伤面感染和多脏器损伤等,一次性骨折内固定的风险大,如何分期治疗值得探讨。方法自2004年2月至2007年3月共收治29例四肢高能量骨折病例,初期治疗选用单臂外固定支架(Orthofix)以及Hoffmann外固定支架(Stryker)。患者全身情况改善和伤面皮肤存活后,再转换为切开复位内固定或微创闭合内固定。结果29例患者初次外固定治疗,平均外固定支架使用时间为13.2d(7～49d),转换为牢固内固定治疗。所有病例无骨筋膜室综合征发生。1例开放性Pilon骨折外固定后并发感染,在抗菌治疗7周后更换内固定,同时放置庆大霉素珠链,术后正常骨折愈合。结论高能量损伤的骨折治疗中,合理分期治疗、适当时机更换内固定和良好保护受损软组织能有效减少并发症发生。

Objective To explore the strategies of staged management in patients with high-energy extremities fractures. Methods Twenty-nine patients with high-energy fractures were managed from Feb 2004 to Mar 2007. All patients were operated with external fixations of singlearm external fixator （Orthofix） or Hoffmann external fixator （Stryker） in the very early stage. After well controlled the general conditions and reepithelialization of skin injury, transferred to strong internal fixations through open reduction or close reduction with the technique of Minimally Invasive Percutaneous Plate Oesteosynthesis （MIPPO）. Results External fixations were initially used for 29 high-energy fractures,and the mean interval was 13.2 days（range 7 to 49 days）,then transferred to internal fixations. No case of compartment syndrome occurred in this study. But one case of open Pilon fracture suffered with infection after external fixation,and 7 weeks later he was transferred to internal plate fixation locally treated together with Gentamycin-released beads. The infection was controlled and also the bone reunited. Conclusions Proper staged management, right timing of fixation changing and well protecting of soft tissue may reduce the complications of high-energy fractures.