骨盆骨折合并骶髂关节前脱位的临床治疗

Clinical treatment of pelvic fracture complicated with anterior sacroiliac joint dislocation

目的探讨骨盆骨折合并骶髂关节前脱位的临床诊疗经验。方法回顾性分析2013年6月至2019年9月收治的19例骨盆骨折合并骶髂关节前脱位患者资料,男12例,女7例;年龄9~67岁,平均28.0岁;车祸伤11例,高空坠落伤6例,挤压伤2例;根据Tile分型,C1型8例,C2型2例,C3型9例;6例改良肢体严重创伤评分(mangled extremity severity score,MESS)≥7分,其中2例行髋关节离断术,4例行半侧骨盆离断术;13例患者行保肢手术,其中3例行外固定架手术,10例行切开复位钢板内固定术。根据Matta影像学骨盆标准评价复位质量,根据视觉模拟评分法(visual analogue scale,VAS)评估疼痛情况,根据Majeed评分评估骨盆功能。结果手术时间为2~4 h,平均3.2 h;术中出血量400~1200 ml,平均768.4 ml。18例存活患者均获得随访,随访时间6~24个月,平均11.6个月。6例截肢患者中1例因感染性休克多器官功能衰竭于术后1周死亡,患者术后总体生存率为94.7%(18/19),截肢率31.6%(6/19)。18例存活患者骨盆骨折均愈合,骨折愈合时间3~6个月,平均4.2个月,无一例发生骨折延迟愈合及不愈合。18例存活患者末次随访时,VAS评分(2.4±1.9)分(范围0~6分),其中无痛3例,轻度疼痛9例,中度疼痛6例。13例保肢患者末次随访时,Matta影像学评价,优6例、良4例、可2例、差1例,优良率为76.9%(10/13);Majeed功能评分(81.8±11.9)分(范围53~95分),其中优6例、良5例、可1例、差1例,优良率为84.6%(11/13)。保肢治疗中4例患者腰骶神经损伤致髋关节活动功能受限,单侧下肢感觉、运动减弱,经神经松解及营养支持治疗,感觉、运动功能明显改善。结论骨盆骨折合并骶髂关节前脱位的病死率及致残率高,应早期判断肢体损伤情况,及早介入手术,以挽救患者生命为重,必要时选择髋关节离断术或半骨盆离断术。

Objective To explore the clinical diagnosis and treatment experience of pelvic fracture complicated with anterior sacroiliac joint dislocation.Methods The data of 19 patients with pelvic fracture and anterior sacroiliac joint dislocation admitted from June 2013 to September 2019 were retrospectively analyzed.There were 12 males and 7 females;aged 9-67 years,with an average of 28.0 years.There were 11 cases of traffic accident injury,6 of falling injury and 2 of crashing injury caused by machine extrusion.According to the Tile classification,there were 8 cases of type C1,2 of type C2,and 9 of type C3;6 cases of modified mangled extremity severity score(MESS)were greater than or equal to 7,of which 2 cases underwent hip amputation,4 cases underwent king-steelquis semipelvectomy.13 cases underwent limb-salvage surgery,of which 3 cases underwent external fixation surgery,and the remaining 10 cases underwent open reduction and internal fixation with steel plate.The reduction quality was evaluated according to the Matta imaging criteria of pelvis,the pain was evaluated according to the visual analogue scale(VAS),and the pelvic function was evaluated according to the Majeed score.Results The operation time was 2 to 4 hours,with an average of 3.2 hours;the intraoperative blood loss was 400 to 1200 ml,with an average of 768.4 ml.The 18 surviving patients were followed up for 6 to 24 months,with an average of 11.6 months.One of the 6 amputation patients died one week after the operation due to septic shock and multiple organ failure.The overall survival rate of the patients was 94.7%(18/19),and the amputation rate was 31.6%(6/19).The pelvic fractures of the 18 surviving patients were all healed,and the fracture healing time was 3 to 6 months,with an average of 4.2 months.No delayed union or nonunion occurred.At the last follow-up of the 18 surviving patients,the VAS was 2.4±1.9 points(range,0-6 points).Among them,there were no pain in 3 cases,mild pain in 9 cases and moderate pain in 6 cases.At the last follow-up,13 patients undergoing limb salvage treatment evaluated the quality of reduction according to Matta imaging criteria.Among them,6 cases were excellent,4 were good,2 were fair,and 1 was poor.The excellent and good rate was 76.9%(10/13).The Majeed functional score was 81.8±11.9 points(range,53-95 points).Among them,6 cases were excellent,5 were good,1 was fair,and 1 was poor.The excellent and good rate was 84.6%(11/13).In the limb salvage treatment group,4 patients with lumbosacral nerve injury caused limited hip joint movement function,and unilateral lower limb sensation and movement were weakened.After neurolysis and nutritional support treatment,the patient's sensorimotor function was significantly improved.Conclusion The mortality and disability rate of pelvic fractures combined with anterior sacroiliac joint dislocation is high.In order to save the patient's life,early diagnosis of limb injury and early surgical intervention should be performed.If necessary,hip disarticulation or king-steelquis should be selected.