髋部骨折患者远端深静脉血栓的解剖分布及变化规律

Anatomical distribution and change of distal deep venous thrombosis in patients with hip fracture

目的探讨髋部骨折患者远端深静脉血栓的解剖分布及变化规律,为下肢深静脉超声检查及髋部骨折患者深静脉血栓的预防和治疗提供依据。方法回顾性分析2014年7月—2018年4月西安交通大学附属西安市红会医院创伤骨科收治的383例术前远端深静脉血栓的髋部骨折患者的临床资料,其中男性122例,女性261例;年龄范围17~94岁,中位数为78岁,四分位数间距为12岁。股骨颈骨折154例,股骨粗隆间骨折208例,股骨粗隆下骨折21例;分别在术前及术后3~5d进行双下肢静脉超声判断深静脉血栓的发生情况,对远端深静脉血栓形成的解剖位置及变化情况进行分析。偏态分布资料用中位数和四分位数间距表示,下肢各静脉解剖位置发生的深静脉血栓例数占总数的比例用百分率表示。结果383例术前远端深静脉血栓的髋部骨折患者中,孤立性远端深静脉血栓(IDDVT)占89.30%(342/383),IDDVT中以肌间静脉血栓为最多,无胫前静脉血栓出现;累及多支静脉血栓占10.70%(41/383),其中以肌间静脉、胫后静脉和腓静脉中的2支或3支同时受累较为多见。术后有28例(7.31%)患者出现远端血栓向近端延伸(其中累及腘静脉21例,累及股浅静脉7例);孤立性远端血栓(IDDVT)占61.88%(237/383),累及多支静脉血栓占16.19%(62/383);其中62.40%(239/383)的远端血栓位置并未发生变化,有14.62%(51/383)的远端血栓消失。结论对于髋部骨折患者,肌间静脉为远端深静脉血栓形成最常累及的部位;胫前静脉没有必要进行B超检查。在抗凝的情况下,有7.31%的远端深静脉血栓可能向近端延伸,有14.62%的远端深静脉血栓消失。对于髋部骨折远端深静脉血栓患者在住院期间,无抗凝禁忌证者应早期进行药物抗凝治疗远端深静脉血栓,预防血栓向近端进展或脱落,降低远端深静脉血栓的危险性。

Objective To investigate the anatomical distribution and change of distal deep venous thrombosis in patients with hip fracture, to provide evidence for prevention and treatment of deep vein thrombosis in patients with hip fracture and lower limb deep vein ultrasound examinatio. Methods The clinical data of 383 patients with hip fractures who were admitted in Department of Orthopaedics Trauma, Xi′an Jiaotong University Medical College Red Cross Hospital from July 2014 to April 2018 were analyzed retrospectively. There were 122 males and 261 females, the age range was 17 to 94 years, the median was 78 years, and the interquartile range was 12 years. There were 154 cases of femoral neck fracture, 208 cases of femoral intertrochanteric fracture, and 21 cases of femoral subtrochanteric fracture. Deep venous thrombosis was assessed by ultrasonography before and 35 days after operation, and the anatomical location and changes of deep vein thrombosis were analyzed. The skewed distribution data were represented by the median and interquartile range. The proportion of the number of deep venous thrombosis case in the anatomical position of the lower extremities was expressed as a percentage. Results Of the 383 patients with hip fracture who had distal deep venous thrombosis before surgery, isolated distal deep vein thrombosis (IDDVT) accounted for 89.30%(342/383), and multivessel thrombosis accounted for 10.70%(41/383). In IDDVT, intermuscular venous thrombosis was the most common, and no anterior venous thrombosis occurred. In multivessel thrombosis, two or three of the intermuscular vein, the posterior tibial vein, and the iliac vein were more common. Twenty-eight (7.31%) patients had distal thrombus extension to the proximal end (including 21 cases involving the iliac vein and 7 cases involving the superficial femoral vein), IDDVT accounted for 61.88%(237/383). The involvement of multiple venous thrombosis accounted for 16.19%(62/383), 62.40%(239/383) of the distal thrombus position did not change, and 14.62%(56/383) of the distal thrombus disappeared. Conclusions For patients with hip fracture, the intermuscular vein is the most common site of distal deep venous thrombosis, ultrasound examination of anterior tibial vein is not necessary. Under anticoagulation, 7.31% of distal deep venous thrombosis may extend to the proximal and 14.62% of distal deep venous thrombosis disappear. For patients with hip fracture complicated with distal deep venous thrombosis in hospital, patients without contraindication of anticoagulation should be treated with anticoagulation at an early stage to prevent the proximal progression or fall off of thrombosis and reduce the risk of distal deep venous thrombosis.