血浆D-2聚体预测学龄期儿童下肢骨折后发生深静脉血栓的意义

Plasma D-dimer in the prediction of deep vein thrombosis after the fracture in the school-age children

目的探讨学龄期下肢骨折患儿血浆D-2聚体对下肢深静脉血栓(deep venous thrombosis,DVT)的诊断和治疗措施。方法选取2013年1月至2016年6月我科收治的4岁及4岁以上下肢骨折患儿127例,年龄4~14.5岁,平均11.8岁。患儿入院后常规抽血化验血浆D-2聚体浓度及行双下肢深静脉彩色多普勒超声检查。对查出有DVT的患儿进行抗凝溶栓治疗,治疗方法主要是使用低分子肝素钙皮下注射及我院自制制剂活血化瘀汤治疗,定期复查血浆D-2聚体浓度和彩超检查,治疗疗程2~4周;对于D-2聚体浓度超过500μg/L,行下肢深静脉彩超检查无血栓者,不予抗凝治疗,给予定期复查D-2聚体及下肢深静脉彩超,直至D-2聚体浓度下降至500μg/L以下。结果本组中共查出血浆D-2聚体浓度超过500μg/L者127例,其中彩超查出DVT 6例,1例骨盆骨折合并股骨骨折,3例股骨干骨折,1例股骨髁部粉碎骨折,1例股骨部粉碎骨折合并髌骨骨折,血栓位于静脉和(或)胫后静脉。经2~4周抗凝溶栓治疗,血栓消失,术后复查未见血栓再形成。结论术前筛查血浆D-2聚体十分必要,围手术期血浆D-2聚体浓度的动态监测对术后并发DVT早期诊断和治疗具有重要意义。

Objective To determine the incidence and mechanism of deep vein thrombosis （ DVT ） in the school-age children, and to propose the prevention and treatment measures. Methods A total of 1367 cases of 4 years or older children underwent the treatment for fractures of lower limbs from January 2013 to June 2016. There were 26 cases of pelvic fractures, 811 cases of femur the （ including femoral neck, femoral spine, femoral condyle ）, 376 cases of lower leg fractures, and 154 cases of foot fractures. The children were at the ages ranging from 4 years to 14 years and 5 months, with the average age 10 years and 10 months. After the children were admitted to the hospital, a regular blood test and the detection of plasma D-dimer levels and the deep venous color doppler ultrasonography were performed. Anticoagulatory thrombolytic therapy was performed for children with deep vein thrombosis. The main treatment methods included subcutaneous injection of low molecular weight heparin calcium and oral traditional Chinese medicine decoction. The plasma D-dimer levels and color Doppler ultrasound were monitored and treatment persisted for 2 - 4 weeks. If the plasma D-dimer levels were greater than 500 μg / L, deep vein ultrasonography of Double lower limb was performed, if no clots were found, no anticoagulants were given, and monitoring was given by regular plasma D-dimer levels and the deep venous color doppler ultrasonography until the plasma D-dimer levels droped to below 500 μg / L. Results D-dimer levels of 127 patients were over 500 μg / L. Six cases had deep vein thrombosis confirmed by Doppler ultrasonography, including three femoral fractures, one femoral condyle fracture, and one femoral fracture with fracture of the femur. The thrombus was located in the popliteal vein and / or the posterior tibial vein, after 2 - 4 weeks of anticoagulation / thrombolytic therapy, the clot disappeared, and the blood clots were not seen again. Conclusions Deep vein thrombosis is rare in children after fracture, but there are still risks for thrombosis. Preoperative screening active anticoagulation and essential. Preventing the clot from falling is very important since are falling of clot may cause pulmonary embolism, which can even be life-threatening. Dynamic plasma D-dimer monitoring is critical to the timely diagnosis of DVT for early diagnosis and treatment.