髋臼顶柱骨折合并髂外动脉损伤的机制及外科治疗

Mechanism and surgical treatment of acetabular roof column fractures with external iliac arterial injury: analysis of 4 cases

虽然骨盆或髋臼骨折引起的骨盆大动脉损伤很少发生(15%~20%),合并髂外动脉损伤更为罕见,但该类患者死亡率非常高(75%~83%)。然而骨盆或髋臼骨折导致主要动脉损伤机制尚不清楚。我们分享4例髋臼顶柱骨折合并髂外动脉损伤病例外科治疗,试图探讨该类型骨折引起髂外动脉损伤的机制。4例患者入院后行损伤控制复苏及手术治疗,除1例患者死于多器官功能衰竭外,余患者恢复良好。通过分析4例患者受伤经过及骨折类型,我们考虑髋臼顶柱骨折发生后,由于髂外动脉通过髂耻筋膜等软组织与髂腰肌有一定连接,髂外动脉可能随髂腰肌一起被牵拉入骨折端间隙,髂外动脉直接被骨折端割破,或患者在搬运及骨折复位过程中,骨折块刺破髂外动脉。虽然髋臼顶柱骨折合并髂外动脉损伤很少发生,但其损伤后果是灾难性的。临床医生遇到此类病人时,应高度警惕大血管损伤的可能性,必要时可通过CT血管三维重建或动脉介入血管造影术,早期干预、早期治疗以挽救肢体。

Pelvic arterial injuries caused by pelvic or acetabular fractures are rare(15%-20%), and the complication by external iliac artery(EIA) injuries is even rarer, which can result in a mortality rate as high as 75%-83%. The mechanism of major artery damage caused by pelvic or acetabular fractures remains unclear. We report our experience with surgical treatment of 4 patients with acetabular roof column fracture and EIA injury. All the 4 patients underwent injury control resuscitation and surgery after admission. One patient died of multiple organ dysfunction syndrome(MODS), and the other 3 patients recovered smoothly. In these cases, as we presume, the occurrence of acetabular roof column fracture caused the EIA, which was connected to the iliopsoas muscle through soft tissues such as the iliac fascia, to be pulled into the fracture space along with the iliopsoas muscle and was cut directly by the fracture end;the EIA may also be punctured during transport and fracture reduction. Although acetabular roof column fractures with EIA injuries rarely occur, the consequences can be fatal. In such cases, clinicians should be highly vigilant about the possibility of large vessel injuries, and its early detection using threedimensional vascular reconstruction based on CT vessels or arterial interventional angiography can be critical for implementation of early treatment to save the limbs.