难复性PipkinⅠ、Ⅱ型股骨头骨折的特征及其临床意义

Characteristics and clinical significance of irreducible Pipkin typeⅠandⅡfemoral head fracture-dislocations

目的探讨难复性PipkinⅠ、Ⅱ型股骨头骨折的临床特征、影像学表现及临床意义。方法筛选2010年1月—2019年12月收治的4例难复性PipkinⅠ、Ⅱ型股骨头骨折患者临床资料。男2例,女2例;年龄24~41岁,平均33.5岁。致伤原因:交通事故伤3例,摔伤1例。Pipkin分型:Ⅰ型2例,Ⅱ型2例。受伤至手术时间1~2 d。临床特征为患肢髋关节呈锁定状态,被动活动度差,髋关节轻度屈曲,患肢明显缩短,呈中立位或仅存在轻度内收、内旋。影像学表现为股骨头向后上方脱位,髋臼后缘的坚硬皮质嵌入股骨头松质骨,二者互相挤压嵌顿。病例1~3分别于伤后3、1、3 h行髋关节闭合复位1~2次后,发生股骨颈骨折,损伤类型转变为PipkinⅢ型,遂行切开复位内固定术;病例4未行闭合复位,直接行切开复位内固定术。结果病例1~3分别获随访14、17、12个月,分别于术后9、5、10个月发生股骨头坏死,均行人工全髋关节置换术。病例4获随访24个月,无髋关节疼痛及活动受限;影像学检查示内固定物位置良好,骨折愈合,股骨头未见塌陷变形,未发现股骨头坏死迹象。结论临床医生需要提高对难复性PipkinⅠ、Ⅱ型股骨头骨折独特临床特征及影像学表现的认识;建议对此类损伤直接采取切开复位并同期固定股骨头骨折治疗,以减少股骨头坏死的发生。

Objective To summarize the characteristics and clinical significance of irreducible Pipkin typeⅠandⅡfemoral head fracture-dislocations.Methods The clinical data of 4 patients with irreducible Pipkin typeⅠandⅡfemoral head fracture-dislocations between January 2010 and December 2019 were collected.There were 2 males and2 females and the age ranged from 24 to 41 years,with an average age of 33.5 years.The cause of injury included traffic accident in 3 cases and falling in 1 case.Pipkin classification was 2 cases of typeⅠand 2 cases of typeⅡ.The time from injury to operation was 1-2 days.The clinical features were that the hip joint of the affected limb was in a locked position,and the passive range of motion was poor.The affected limb was slightly flexed at the hip joint and shortened,in a state of neutral position or slight adduction and internal rotation.The imaging data suggested that the femoral head dislocated backward and upward,and the hard cortex of the posterior edge of the acetabulum was embedded in the cancellous bone of the femoral head,and the two were compressed and incarcerated.Patients of cases 1-3 underwent closed reduction of hip dislocation 1-2 times at 3,1,and 3 hours after injury respectively,and femoral neck fracture occurred.The injury types changed to Pipkin typeⅢ,and open reduction and internal fixation were performed.Patient of case 4 did not undergo closed reduction,but underwent open reduction and internal fixation directly.Results Patients of cases 1-3 were followed up 14,17,and 12 months,respectively.They developed osteonecrosis of the femoral head at 9,5,and 10 months after operation respectively,and all underwent total hip arthroplasty.Patient of case 4 was followed up 24 months and had no hip pain and limited mobility;the imaging data indicated that the internal fixator position was good and the fracture healed;no collapse or deformation of the femoral head was seen,and no osteonecrosis of the femoral head occurred.Conclusion Clinicians need to improve their understanding of the unique clinical features and imaging findings of irreducible Pipkin typeⅠandⅡfemoral head fracture-dislocations.It is suggested that open reduction and simultaneous fixation of femoral head fracture should be directly used to reduce the incidence of osteonecrosis of the femoral head.