开放性骨盆骨折:治疗对策与疗效分析

Open pelvic fractures:therapeutic strategy and result

目的探讨开放性骨盆骨折的治疗对策,评价其疗效。方法回顾性分析1998年1月至2008年10月我院收治的42例开放性骨盆骨折病例资料。男23例,女19例;年龄7～73岁,平均45.5岁。致伤原因:车祸伤24例,压砸伤10例,高处坠落伤8例;并发休克27例。按Tile分型:A型3例,B型9例,C型30例。软组织损伤按Gustilo-Anderson分类:Ⅰ类3例,Ⅱ类7例,Ⅲ类32例。骨盆周围皮肤软组织损伤部位:髂前上棘3例,腹股沟区5例,臀骶部5例,腰背、臀骶及大腿根部严重大面积皮肤撕脱1例。伴发其他系统损伤:颅脑损伤5例,胸部和肺部损伤7例,胃破裂2例,脾破裂3例,卵巢破裂1例,腹膜后血肿5例,空回肠破裂5例,直肠乙状结肠损伤7例,泌尿系统挫裂伤23例,会阴挫裂伤19例。运动系统其他合并损伤:坐骨神经损伤3例,股神经损伤2例,骶丛损伤6例,腰椎骨折伴脊髓损伤4例,股骨头骨折2例,股骨颈骨折2例,转子下骨折3例,股骨干骨折6例,胫骨平台骨折4例,胫腓骨骨折8例,胫骨远端骨折1例,内外踝骨折2例,桡骨远端骨折3例。ISS评分9～58分,平均31.5分。结果治愈37例,死亡5例。42例患者中,骨盆骨折以外组织的损伤数量为123处,是骨盆骨折的2.9倍,其中泌尿系统挫裂伤占54.8%,会阴损伤占45.2%,肠道损伤率占28.6%。剖腹探查率42.9%,初期乙状结肠造瘘率26%,延期乙状结肠造瘘率23%。本组死亡率为11.9%,死亡组平均ISS评分为41.5分,且骨折类型均为Tile C型。存活组平均ISS评分为28.2分。骨盆骨折采用外固定支架固定29例,单纯内固定9例,未同定4例。42例开放性骨盆骨折的创面平均手术3.1次,5例出现深部感染,其中1例为会阴、肛周撕裂伤,受粪便污染而导致创面感染形成深部脓肿,经多次清创和乙状结肠造瘘而治愈。3例为内固定术后感染,其中2例形成窦道,经久不愈,最终去除内固定而愈合;另1例术后出现严重感染,因败血症而死亡。1例为剖腹探查术后,未行乙状结肠造瘘,引起腹膜炎,因败血症而死亡。另1例患者死于严重颅脑损伤和2例死于不可控制性出血。37例存活患者中32例获得随访,随访时间12～129个月,平均68.3个月。根据Majeed SA评价方法,本组优15例,良10例,可7例,优良率为78.1%。结论ISS评分、骨折类型、深部感染是影响开放性骨盆骨折死亡率的重要因素,乙状结肠造瘘、骨盆外固定支架固定有利于控制感染和创面的治疗,骨盆内固定术在开放性骨盆骨折的治疗中应谨慎运用。

Objective To investigate the effective therapy of open pelvic fractures.Methods Forty-two cases of open pelvic fractures treated in our hospital between January 1998 and December 2008 were analyzed retrospectively.Of these patients,23 were male and 19 were female.Their ages ranged from 7 to 73 years with the average age of 47.5 years.The causes were all high energy injuries;24 were traffic accidents,10 were crush injuries and 8 were falling injuries. And 27 patients were complicated by shock.The Tile classifications of fractures：3 were type A,9 were type B and 30 were type C.The classifications of soft tissue injuries according to Gustilo-Anderson：3 were TypeⅠ,7 were TypeⅡand 32 were TypeⅢ.The regions of soft tissue injuries：3 anterior superior iliac spine,5 inguinal region,5 sacral region and 1 skin avulsion in lower back sacral region and thighs.The number of patients complicated by injuries in other systems：5 cases of brain trauma,7 cases of chest and lung trauma,2 cases of stomach rupture,3 cases of splenic rupture, 1 case of ovarian rupture,5 cases of retroperitoneal hematoma,5 cases of jejunoilal rupture,7 cases of injuries in rectum and sigmoid colon,23 cases of injuries in the urinary system and 19 contusions in perineum.Other injuries of locomotor system：3 cases of cainjury of sciatic nerve,2 cases of injury of femoral nerve,6 cases of injury of sacral plexus, 4 cases of fracture of lumbar vertebra and spinal cord injury,2 cases of fracture of femur head,2 cases of fracture of femur neck,3 cases of subtrocanteric fractures,6 fracture of shaft of femur,4 cases fracture of tibial plateau,8 cases of tibial and fibula fracture,1 case of fracture of distal end of tibia,2 cases of fracture of medial and lateral malleoles,3 fracture of distal radius.The average injury severity score was 31.5,ranged from 9 to 58.Results Thirty-seven patients were cured,5 patients died.The number of injured regions except pelvic fractures was 123,which was 2.9 times of number of peliv fractures.Of these regions,54.8%were the urinary system,45.2%were perineum,28.6%were injuries intestines The rate of exploratory laparotomy was 42.9%,stoma of sigmoid in initial stage was 26%,delaying stoma was 23%.The mortality of all cases was 11.9%,the average injury severity score of mortality were 41.5.All of the mortalities are Tiles C.The average injury severity score of the survival group was 28.2.And 29 cases underwent external fixation for pelvic fracture,9 internal fixation only and 4 without any fixation.The average frequency of surgeries for wound surfaces was 3.1,5 cases developed severe infections,one was avulsion of perineum,which were contaminate by excrement and developed into deep abscess and cured by repeated debridments and delayed sigmoid stoma.Three cases them had undergone internal fixation surgery and 2 patients were cured after internal fixations were removed and 1 was died of septicemia One case that had undergone exploratory laparotomy without sigmoid stoma,developed into peritonitis and died of septicemia at last.In addition,3 patients died of craniocerebral trauma and uncontroling hemorrhage.Totally 32 survival cases received satisfactory follow-up.The lengths for follow-up ranged from 12 to 129 months with an average length of 45 months.The outcomes of the survival cases：splendid 15,well 10,acceptable 7.Conclusion Ages injury severity score,type of fracture and deep infection affect the mortality of open pelvic fracture cases.Sigmoid stoma and external pelvic fixation profit treatment of infections and wound surfaces.Precaution should be raised when internal fixations would be used.