通道螺钉联合皮肤牵张技术治疗骨盆骨折合并严重Morel-Lavallée损伤

Application of channel screw combined with skin-stretching technique in treatment of pelvic fracture with severe Morel-Lavallée lesion

目的探讨通道螺钉联合皮肤牵张技术治疗骨盆骨折合并严重Morel-Lavallée损伤的疗效。方法 2017年1月—2020年5月,应用通道螺钉联合皮肤牵张技术治疗11例骨盆骨折合并严重Morel-Lavallée损伤患者。其中男8例,女3例;年龄28~58岁,平均39.2岁。致伤原因:交通事故伤9例,高处坠落伤2例。受伤至入院时间1~6 d,平均3.7 d。骨盆骨折Tile分型:C1型7例、C2型3例、C3型1例。Morel-Lavallée损伤部位:臀部8例,髋部2例,大腿1例。合并直肠损伤1例、脾破裂1例、颅脑损伤3例、胸部损伤2例、脊柱骨折4例、骶神经损伤6例。术后行X线片检查观察骨折复位及愈合情况,术后1周采用Matta标准评价骨折复位质量;观察创面愈合及并发症发生情况,采用Majeed评分评价髋关节功能,Gibbons骶神经损伤分级评价神经功能恢复情况。结果患者共接受4~7次手术,平均5.8次。首次骨盆骨折固定及清创、安装皮肤牵张器的手术时间为115~275 min,平均186.5 min;术中出血量30~80 mL,平均45.5 mL。患者均获随访,随访时间6~12个月,平均8.3个月。骨折复位质量根据Matta标准,获优7例、良2例、可2例,优良率81.8%;术后3~6个月骨折均愈合,平均4.5个月。末次随访时,髋关节功能根据Majeed评分获优7例、良4例,优良率100%;6例术前合并骶神经损伤患者Gibbons骶神经损伤分级达Ⅰ级4例、Ⅱ级1例、Ⅲ级1例。9例创面经牵张25~32 d后直接缝合,平均28 d;1例发生创面皮缘坏死,行游离植皮修复;1例创面皮肤干性坏死,换药后痂下愈合。结论通道螺钉技术及皮肤牵张技术在骨盆骨折合并严重Morel-Lavallée损伤治疗中发挥了各自优势,联合应用能早期固定骨折和利于创面愈合,获得良好疗效。

Objective To investigate the effectiveness of channel screw combined with skin-stretching technique in treatment of pelvic fracture with severe Morel-Lavallée lesion.Methods Between January 2017 and May 2020,11 patients with pelvic fractures complicated with severe Morel-Lavallée lesions were treated with channel screw combined with skin-stretching technique.There were 8 males and 3 females,with an average age of 39.2 years(range,28-58 years).Causes of injury included traffic accident in 9 cases and falling from hight in 2 cases.The time from injury to hospital admission ranged from 1 to 6 days(mean,3.7 days).According to the Tile classification,the pelvic fractures were rated as type C1 in 7 cases,type C2 in 3 cases,and type C3 in 1 case.The sites of Morel-Lavallée lesions were buttocks in 8 cases,hips in 2 cases,and thigh in 1 case.There was 1 case of rectal injury,1 case of splenic rupture,3 cases of craniocerebral injury,2 cases of chest injury,4 cases of spinal fracture,and 6 cases of sacral nerve injury.X-ray films were performed to observe reduction and healing of fracture.The quality of fracture reduction was evaluated by Matta standard at 1 week after operation.Wound healing and complications were observed.Majeed scoring was used to evaluate hip function and Gibbons sacral nerve injury grading was used to evaluate neurological function recovery.Results The patients underwent 4-7 operations,with an average of 5.8 operations.The time of first operation(pelvic fracture fixation,debridement,and skin distractor installation)was 115-275 minutes,with an average of 186.5 minutes.The amount of intraoperative blood loss was 30-80 mL,with an average of 45.5 mL.All patients were followed up 6-12 months,with an average of 8.3 months.The quality of fracture reduction according to the Matta standard was excellent in 7 cases,good in 2 cases,and fair in 2 cases,with an excellent and good rate of 81.8%.All fractures healed at 3-6 months after operation,with an average of 4.5 months.At last follow-up,the hip functions were excellent in 7 cases and good in 4 cases according to Majeed scoring,with an excellent and good rate of 100%.Among the 6 patients complicated with sacral nerve injury,the Gibbons sacral nerve injury grading reached gradeⅠfor 4 cases,gradeⅡfor 1 case,and gradeⅢfor 1 case.The wounds of 9 cases were sutured directly after skin-stretching treatment for 25-32 days,with an average of 28 days.The dermal edge necrosis occurred in1 case,and the defect was repaired by free skin grafting.The skin superficial dry necrosis of the wound occurred in 1 case,and healed by dressing change.Conclusion In the treatment of pelvic fracture complicated with severe Morel-Lavallée lesion,the channel screw and skin-stretching technique showed their own advantages,which can obtain early fracture fixation and good wound healing.