损伤控制骨科理论在严重肢体骨折合并腹部创伤中的应用

Application of damage control orthopedics in treatment of severe polyfractures with abdominal injuries

背景：严重肢体骨折常合并有腹部创伤,正确的诊断和处理是提高患者生存率的重要保障。损伤控制骨科理论（DCO）符合严重肢体骨折合并腹部创伤患者的病理生理特点,正确地应用DCO理论是提高患者救治成功率的关键。目的：探讨DCO理论在严重肢体骨折合并腹部创伤中的应用。方法：回顾性分析2009年1月至2013年6月收治的38例严重肢体骨折合并腹部创伤患者的临床资料。骨折情况：单纯四肢骨折20例,骨盆骨折6例,骨盆合并四肢骨折4例,脊柱骨折4例,脊柱合并四肢骨折4例;闭合性骨折21例,开放性骨折17例。腹部损伤情况：脾破裂20例,肝破裂8例,肝脾破裂5例,肠破裂3例,肝破裂＋肠破裂1例,肝破裂＋肾破裂1例。损伤严重度（ISS）评分平均39.3分。结果：本组38例患者经DCO理论救治后死亡2例,36例患者病情稳定后行骨折确定性手术,实施确定性手术的时间为6~62 d,平均12.5 d。其中12例发生各种并发症。除2例死亡、4例失随访外,其余32例均获得随访,随访时间为10~25个月,平均15.4个月。其中28例骨折正常愈合,愈合时间为12~25周,平均21.2周;3例骨折出现延迟愈合,经石膏外固定后愈合,总愈合时间为10~12个月;1例骨折术后10个月发现骨不连,经二期手术并植骨后愈合。所有随访者均部分或完全恢复正常工作生活。结论：DCO理论符合严重肢体骨折合并腹部创伤患者的病理生理特点,尽早进行针对性的损伤控制手术和ICU复苏是实施DCO的关键,可提高严重此类患者的救治成功率。

Background： Abdominal injuries are often found in severe polyfracture patients. It is very important to improve the survival rate of patients by correct diagnosis and management for the patients. Damage control orthopedics （DCO） theory well con- forms to pathophysiological character of severe ployfracture patients with abdominal trauma. How to correctly apply DCO is the key to improve the treatment of severe polyfractures with abdominal injuries. Objective： To evaluate the feasibility and efficacy of DCO theory in severe polyfractures combined with abdominal injuries. Methods： A retrospective analysis was done in 38 patients treated by DCO from January 2009 to June 2013. There were 20 cases of extremity fractures, 6 of pelvic fractures, 4 of pelvic and extremity fractures, 4 of spine fracture and 4 of spine and extremity fractures. There were 21 closed fractures and 17 open fractures. All the patients suffered from abdominal injuries： 20 of splenic ruptures, 8 of hepatic ruptures, 5 of splenic and hepatic ruptures, 3 of bowel ruptures, 1 of hepatic and bowel rupture, and 1 of hepatic and kidney rupture. The average injury severity score （ISS） was 39.3. Results： Two cases died after DCO. The other 36 cases received internal fixation after resuscitation in ICU. The mean duration between injury and internal fixation was 12.5 d （range, 6-62 d）. Complications occurred in 12 patients. After internal fixation, 4 patients were not followed up. The mean duration of follow-up in the other 32 patients was 15.4 months （range, 10-25 months）. Altogether 28 cases revealed fractures healing after a mean time of 21.2 weeks （range, 12-25 weeks）. Delayed union occurred in 3 patients who were cured after plaster external fixation and the healing time ranged from 10 to 12 months. Non- union happened in one patient for 10 months after surgery, and secondary operation and bone graft were performed. Conclusions： DCO well conforms to pathophysiological character of severe ployfracture combined with abdominal injuries.Quick and effective damage control operation and resuscitation in ICU are the key in DCO, which can improve the survival rate of severe polytrauma patients.