损伤控制骨科技术在重型颅脑损伤合并四肢骨折救治中的效果分析

Clinical efficacy of damage control orthopaedics in treatment of patients with severe traumatic brain injury combined with limb fracture

目的探讨损伤控制骨科技术(DCO)在重型颅脑损伤(sTBI)合并四肢骨折救治中的适用范围及效果。方法收集2011年1月至2018年12月山东大学齐鲁医院急诊外科收治的sTBI合并闭合性四肢骨折患者149例,2013年3月及之前采用一期骨折内固定手术,纳入常规治疗组(A组,47例),2013年4月及之后采用一期外固定架或支具固定,颅脑损伤平稳后行内固定手术,纳入损伤控制组(B组,102例)。对两组一般资料、入院格拉斯哥昏迷评分(GCS评分)、影像学资料、术中及术后颅内压、凝血功能障碍、住院天数和伤后3个月格拉斯哥预后评分(GOS评分)等进行回顾性研究,并根据颅脑术后颅内压增高危险程度将两组均分为颅内压增高低危亚组和高危亚组,对其术后颅内压、住院天数和GOS评分等进行统计学分析。结果两组性别、年龄、术前GCS评分、影像学类型及术中初始颅内压差异均无统计学意义。A组术后即刻颅内压值[(17.1±4.6)mmHg]和凝血功能障碍发生率[29.8%(14/47)]均高于B组[(15.0±4.3)mmHg,13.7%(14/102)],P<0.05,而住院时间和GOS评分预后良好率差异均无统计学意义(P值分别为0.475和0.097)。亚组统计分析显示,颅内压增高低危亚组术后即刻颅内压和GOS评分差异无统计学意义,而B组住院时间较A组明显延长(P<0.05),颅内压增高高危亚组A组术后即刻颅内压较B组明显升高(P<0.01),A组GOS评分预后良好率明显低于B组(P<0.05),而住院时间差异无统计学意义(P=0.667)。结论sTBI合并四肢骨折的患者,应根据患者颅脑损伤的实际情况考虑是否应用DCO。对存在术后颅内压增高高危因素的患者,应用DCO可显著改善患者的预后。

Objective To explore the clinical efficacy of damage control orthopaedics in treatment of patients with severe traumatic brain injury combined with limb fracture.Methods Total 149 patients with sTBI combined with limb fracture treated in Emergency Surgery Department of Shandong University Qilu Hospital from January,2011 to December,2018 were collected.Patients that were treated with immediate definitive fixation before March 31st,2013 were included into the routine treatment group(group A,47 cases),and that were treated with damage control orthopaedics(DCO)after April 1st,2013 were included into the DCO group(group B,102 cases).The clinical data during hospitalization and prognosis 3 months after injury was analyzed retrospectively.Then according to the risk of postoperative ICP increase,the two groups were divided into low risk subgroup and high risk subgroup.The postoperative ICP,length of stay and GOS score were statistically analyzed.Results There were no statistically significant differences in sex,age,preoperative GCS score,imaging type of lesion and initial intraoperative ICP between the two groups.The postoperative ICP and incidence of coagulation dysfunction were significantly higher in group A[(17.1±4.6)mmHg,29.8%]than that in group B[(15.0±4.3)mmHg,13.7%]separately(P<0.05),and there was no significant difference of length of stay and GOS score between the two groups(P=0.475 and 0.097,respectively).As for the subgroup with low risk of postoperative ICP increase,there was no significant difference in postoperative ICP and GOS score between group A and B,and the length of stay of group B was significantly longer than that of group A(P<0.05).As for the subgroup with high risk of postoperative ICP increase,there was no significant difference in the length of stay between group A and B(P=0.667),and for group A the postoperative ICP was higher and GOS score was lower than that of group B(P<0.05).Conclusions For patients with sTBI combined with limb fracture,the application of DCO should be based on the severity of traumatic brain injury.For patients with high risk of postoperative ICP increase,DCO can significantly improve the prognosis of patients.