上肢严重创伤保肢失败的原因探讨

Cause discussion of limb salvage failure in severe upper limb trauma

目的通过对上肢严重创伤保肢失败患者的回顾性分析,探讨保肢失败的原因及相应对策。方法自2015年1月至2020年12月我院共收治上肢严重创伤患者87例(完全离断18例,不完全离断32例,GustiloⅢC型骨折37例),其中67例保肢成功,20例保肢失败(完全离断8例,GustiloⅢC型骨折12例)。20例患者中年龄≤50岁7例,年龄>50岁13例;损伤平面为前臂下段4例,前臂中、上段11例,上臂中、下段5例;中度贫血16例,轻度贫血4例,接诊时有休克13例。创伤类型:13例机器绞伤,4例重物砸伤,1例挤压伤,1例热压伤,1例电锯切割伤。分别对这20例患者的截肢原因、受伤至急诊清创的时间、受伤至肢体通血的时间、创面修复的时间及术式、细菌培养结果及首诊医生职称进行统计分析。结果20例患者受伤至急诊清创的时间为7~13h,平均10.3h;受伤至肢体通血的时间为10~16h,平均13.2 h。创面修复术式为游离皮瓣2例,带蒂皮瓣4例,皮肤移植5例,直接缝合9例。创面覆盖时间为2~32 d,平均11.9 d;首诊医生职称为主治医师6例,高年资住院医师14例。最终截肢原因为感染的11例,其中单种细菌感染6例,多种细菌感染5例,感染菌种多为铜绿假单胞菌、鲍曼不动杆菌、金黄色葡萄球菌等耐药细菌;因肢体血供障碍而截肢的有7例;因经济原因放弃治疗的有2例。结论上肢严重创伤的保肢失败与综合考量手术指征、早期彻底清创、及时建立肢体血液循环和有效的创面早期覆盖等因素密切相关,其中感染、缺血时间和经治医师的临床经验是主要原因。

Objective To discuss the causes and corresponding countermeasures of limb salvage failure through the retrospective analysis of patients with severe upper limb trauma and limb salvage failure.Methods From January 2015 to December 2020,87 patients with severe upper limb trauma were treated in our hospital(18 cases of complete amputation,32 cases of incomplete amputation and 37 cases of GustiloⅢC fracture),of which 67 cases were successful and 20 cases failed(8 cases of complete amputation and 12 cases of GustiloⅢC fracture).Among the 20 patients,7 were younger than or equal to 50 years old and 13 were older than 50 years old.The injury plane was the lower segment of forearm in 4 cases,the middle and upper segments of forearm in 1l cases,and the middle and lower segments of upper arm in 5 cases.There were 16 cases of moderate anemia,4 cases of mild anemia and 13 cases of shock.Types of trauma:13 cases of machine injury,4 cases of heavy object injury,1 case of crush injury,1 case of thermal compression injury and 1 case of electric saw cutting injury.The causes of amputation,the time from injury to emergency debridement,the time from injury to limb blood circulation,the time and operation method of wound repair,the results of bacterial culture and the title of the first doctor were statistically analyzed.ResultsThe time from injury to emergency debridement was 7 to 13 hours,with an average of 10.3 hours.The time from injury to limb blood circulation was 10 to 16 hours,with an average of 13.2 hours.The wound repair methods were free skin flap in 2 cases,pedicled skin flap in 4 cases,skin transplantation in 5 cases and direct suture in 9 cases.The covering time of wound was 2 to 32 days,with an average of 11.9 days.The title of the first doctor was the attending surgeon in 6 cases and senior resident in 14 cases.The final cause of amputation was infection in 11 cases,including 6 cases of single bacterial infection and 5 cases of multiple bacterial infection.Most of the infection strains were drug-resistant bacteria such as Pseudomonas aeruginosa,Acinetobacter baumannii and Staphylococcus aureus.Seven cases were amputated due to limb blood supply disorder.Two cases gave up treatment for economic reasons.ConclusionThe failure of limb salvage in severe upper limb trauma is closely related to the comprehensive consideration of surgical indications,early thorough debridement,timely establishment of limb blood circulation and effective early wound coverage,among which infection,ischemia time and clinical experience of doctors are the main reasons.