骨盆骨折合并阴道损伤的早期诊断和治疗

Early diagnosis and treatment of pelvic fracture with vaginal injury

目的探讨骨盆骨折合并阴道损伤的早期诊断和治疗策略。方法回顾性分析2000年1月至2010年7月收治的13例骨盆骨折合并阴道损伤患者的病历资料，年龄17-52岁，平均31．7岁。按Tile骨盆骨折分类系统分类：B1型4例、B2型1例（Tilt骨折）、B3型4例、C1型3例、C2型1例。3例急诊行阴道损伤修复、骨盆骨折切开复位内固定术；5例血流动力学不稳定者，积极抗休克治疗，病情稳定后急诊行阴道修复、骨盆骨折外固定支架固定术；2例延迟诊断阴道损伤，确诊后及时行阴道修复术，1例行骨盆骨折切开复位内固定术，另1例行外固定支架固定术；2例因外院漏诊阴道损伤，形成盆腔脓肿，行彻底清创、骨盆骨折外固定支架固定术，待感染控制后二期行阴道重建术。结果12例存活，1例人院后6h死亡。11例获得随访，平均随访17个月（8-36个月）。阴道损伤一期修复的9例患者中已婚者6例，5例性生活正常，1例存在性交时疼痛；未婚者3例，月经正常。阴道损伤二期重建的2例患者，均存在性交时疼痛。末次随访时Majeed骨盆骨折术后功能评分平均82．2分（56-06分），优6例、良3例、可2例。结论女性骨盆骨折存在骨盆前环损伤，应高度怀疑阴道损伤的可能。早期诊断并修复阴道损伤是处理的关键，可获得较好的临床效果；延误诊断和治疗可导致严重的并发症，临床效果差。

Objective To investigate the early diagnosis and treatment of pelvic fracture with vagi- nal injury. Methods From January 2000 to July 2010, 13 patients suffered from pelvic fracture with vagi- nal injury were treated in our hospital, whose average age was 31.7 years. According to the Tile classifica- tion, there were 4 cases of type B1, 1 case of type B2, 4 cases of type B3, 3 cases of type C1, and 1 case of type C2. Emergency repair of vagina together with open reduction and internal fixation of pelvic fracture was performed in 3 patients. After the patients condition became stable, 5 patients with shock were treated with emergency repair of vagina together with primary external fixation of pelvic fracture. Prompt repair of vagina together with open reduction and internal fixation or primary external fixation of pelvic fracture was per- formed in 2 patients who underwent delayed diagnosis. Two cases of extensive pelvic abscess due to missed diagnosis of vaginal laceration were treated with debridement and external fixation of pelvic fracture, and re- constructions of vagina were performed after infection control. Results Twelve patients survived, and 1 pa- tient died 6 h after admission. Eleven patients were followed up for 8 to 36 months （average, 17 months）. A- mong 9 patients who underwent one-stage repair of vagina, 5 married patients had normal sexual life, 1 suf- fered from pain during sexual intercourse, and 3 unmarried patients had normal menses. Two patients who underwent second-stage reconstruction of vagina suffered from pain during sexual intercourse. At final follow- up, the mean Majeed score was 82.2 （range, 56 to 96）, and the results were excellent in 6 cases, good in 3 cases, fair in 2 cases. Conclusion Vaginal injury should be highly suspected in females with anterior pelvic ring fracture. Early diagnosis and repair of vaginal injury is crucial to good clinical outcomes. Delayed diagnosis and treatment may lead to severe complications.