不稳定骨盆后环损伤的手术治疗

Operative treatment of unstable pelvic posterior ring lesion

目的探讨如何选择不稳定骨盆后环损伤的内固定方法，为临床内固定的选择提供依据。方法选择2003年6月-2008年3月收治的不稳定骨盆后环损伤患者53例，其中男39例，女14例；年龄10～69岁，平均39．5岁。致伤原因：交通伤36例，高处坠落伤12例，挤压伤5例。骨盆后环损伤情况：髂骨后部纵向骨折7例；不稳定骶骨骨折27例，按Denis分型标准：Ⅰ区14例，Ⅱ区11例，Ⅲ区2例；不稳定骶髂关节脱位19例，其中伴髂骨翼骨折的骶髂关节脱位7例，经耳状关节与韧带的骶髂关节脱位2例，伴骶骨翼骨折的骶髂关节脱位10例。外伤至手术时间3～28d，平均6．7d。采用前侧重建钢板固定7例，经皮骶髂螺钉内固定26例，经皮后方跨骶骨重建钢板内固定20例。结果本组53例均获12～36个月（平均17．2个月）随访。无切口感染、术中血管神经损伤、内固定松动或断裂，无骨不愈合或明显双下肢不等长。术后根据Matta评分标准：优19例，良27例，可7例，优良率为87％。功能恢复根据Majeed功能评分：优19例，良27例，可7例，优良率为87％。5例骶丛损伤患者鞍区感觉减退或膀胱排尿困难的症状均基本消失，2例骶丛损伤患者遗留会阴部麻木和足下垂。结论手术重建骨盆后环的稳定性可获得良好的功能康复。应根据骨折的类型、内固定技术的适用范围、手术者的经验、设备条件等具体情况，选择合适的内固定方法。

Objective To explore selection of appropriate internal fixation methods for unstable pelvic posterior ring lesions in order to provide the basis for clinical internal fixation. Methods The study involved 53 patients with unstable pelvic posterior ring lesions treated with reconstruction plate and sacroiliac screws from June 2003 to March 2008. There were 39 males and ld females, at age range of 10- 69 years （mean 39.5 years）. Injury causes included traffic accidents in 36 patients, fall from height in 12 and crush in five. As for the state of injury to the pelvic posterior ring, seven patients had vertical fracture of the ilium and 27 had unstable sacral fractures （14 with Ⅰ section sacral fracture, 11 with Ⅱ section sacral fracture and 2 with Ⅲ section sacral fracture）. Of 19 patients with unstable sacroiliac dislocations, 10 patients were accompanied with fracture of the ala sacralis, seven with ala iliac fracture and two ear-shaped joint and ligament lesions. The period from injury to operation was 3-28 days （ mean 6.7 days）. Of all patients, seven patients were treated with reconstruction plate via anterior approch, 26 with percutaneous reconstruction plate via posterior approach and 20 with percutaneous sacroiliac screws. Results All patients were followed up for 12-36 months （mean 17.2 months） , which showed no incisional infection, nerve injuries, loosening or breakage of the screw. All patients attained bone union, with equal lower limbs. According to Matta criterion for fracture reduction, the results were excellent in 19 patients, good in 27 and fair in seven, with excellence rate of 87%. According to the Majeed functional scoring, the results were excellent in 19 patients, good in 27 and fair in seven, with excellence rate of 87%. The hypoesthesia at saddle area or dysuria in five patients were alleviated but two patients with sacriplex injury resulted in perineal numbness and footdrop. Conclusions Surgical reconstruction of the pelvic posterior ring can attain sound functional recovery. For unstable pelvic posterior ring lesions, appropriate internal fixation methods may be selected according to fracture types, serviceable range of internal fixations, experiences of the operator and equipment support.