股骨转子间骨折中头颈骨块“鸟嘴样”向前翘起的形态特征及复位技巧

Morphological characteristics and reduction techniques of sagittal beak-like deformity of head-neck fragment in femoral intertrochanteric fractures

目的总结股骨转子间骨折中头颈骨块在矢状面呈“鸟嘴样”向前翘起的形态特征和复位技巧。方法回顾性分析2021年5月—2023年4月收治的31例头颈骨块在矢状面呈“鸟嘴样”向前翘起的股骨转子间骨折患者临床资料。男13例,女18例;年龄68~83岁,平均76.2岁。受伤至手术时间36~76 h,平均51.2 h。骨折按国际内固定研究协会/美国骨创伤协会(AO/OTA)-2018分型标准分型:A1.2型10例、A1.3型11例、A2.2型6例、A2.3型4例;按中国康复医学会修复重建外科专业委员会“老年髋部骨折”研究小组提出的新综合分类法分型:A1.3型10例,A2.1型11例,A2.2型6例,A2.3型2例,A2.4型2例。术前经X线片、CT扫描及三维重建,将骨折分为两种类型:第1类14例,骨折形态不复杂但有严重骨性交锁和(或)软组织嵌顿;第2类17例,骨折粉碎严重、骨块之间明显分离错位、软组织铰链破坏。患者均经闭合手法复位失败,选择经前方小切口拧入空心螺钉辅助复位头颈骨块,再按常规进行股骨近端防旋髓内钉内固定。记录手术时间、术中透视次数、术中显性失血量、住院时间及并发症;术后即刻X线透视下评估骨折复位质量及内固定术后稳定性,定期复查X线片观察骨折愈合情况及愈合时间;术后48 h行疼痛视觉模拟评分(VAS)评定疼痛程度;术后3个月按Parker-Palmer活动能力评分进行功能评定。结果手术时间39~58 min,平均46.3 min;术中透视13~38次,平均23.5次;术中显性失血量45~90 m L,平均65.3 m L。术后即刻影像判断骨折复位质量及内固定术后稳定性评分均为优29例、良2例。术后48 h VAS评分为2~6分,平均3.1分。术后11例发生下肢深静脉血栓形成,无其他并发症发生。患者住院时间6~10 d,平均7.3 d。术后均获随访,随访时间5~8个月,平均6.5个月。X线片复查示骨折均愈合,愈合时间3.5~8.0个月,平均4.5个月。术后3个月Parker-Palmer活动能力评分达9分28例、6分3例。结论股骨转子间骨折中,头颈骨块在矢状面呈“鸟嘴样”向前翘起时手法复位困难,经前方导针结合空心螺钉辅助复位,简单有效,能取得满意疗效。

Objective To summarize the morphological characteristics of sagittal beak-like deformity of headneck fragment in femoral intertrochanteric fractures and to investigate the technical skills in fracture reduction.Methods A clinical data of 31 patients with femoral intertrochanteric fractures between May 2021 and April 2023 was retrospectively analyzed.The fractures had sagittal beak-like deformity of head-neck fragment in all patients.There were 13 males and 18 females,with an average age of 76.2 years(range,68-83 years).The time from injury to operation was 36-76 hours(mean,51.2 hours).Fractures were classified as type A1.2 in 10 cases,type A1.3 in 11 cases,type A2.2 in 6 cases,and type A2.3 in 4 cases according to the AO/Orthopaedic Trauma Association(AO/OTA)-2018 classification;and as type A1.3 in 10 cases,type A2.1 in 11 cases,type A2.2 in 6 cases,type A2.3 in 2 cases,and type A2.4 in 2 cases according to a novel comprehensive classification for femoral intertrochanteric fractures proposed by the“Elderly Hip Fracture”Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association.Based on preoperative X-ray films,CT scan and three-dimensional reconstruction,the fractures were classified into two types:type 1(14 cases),with uncomplicated fracture morphology,severe bone interlocking and(or)soft tissue incarceration;type 2(17 cases),with severe fracture crushing,obvious dissociation between bone blocks,and severe soft tissue hinge destruction.After the failure of the closed reduction,all patients underwent fracture reduction assisted with instrument via anterior minimal incision and proximal femoral nail antirotation nails internal fixation.The operation time,intraoperative fluoroscopy,intraoperative visible blood loss,length of hospital stay,and incidence of complications were recorded.The fracture reduction quality and stability score were assessed at immediate after operation under fluoroscopy.The fracture healing was evaluated and healing time was recorded by X-ray films.The pain visual analogue scale(VAS)score was performed at 48 hours after operation and Parker-Palmer activity score at 3 months after operation for function evaluation.Results The operation time was 39-58 minutes(mean,46.3 minutes);fluoroscopy was performed 13-38 times(mean,23.5 times)during operation;the intraoperative visible blood loss was 45-90 mL(mean,65.3 mL).The fracture reduction quality and stability score were rated as good in 29 cases and acceptable in 2 cases.The pain VAS score was 2-6(mean,3.1)at 48 hours after operation.Eleven patients developed deep vein thrombosis of the lower limbs after operation.Patients were hospitalized for 6-10 days(mean,7.3 days).All patients were followed up 5-8 months(mean,6.5 months).All fractures healed at 3.5-8.0 months after operation(mean,4.5 months).Parker-Palmer activity score at 3 months after operation was 9 in 28 cases and 6 in 3 cases.Conclusion The femoral intertrochanteric fracture with sagittal beak-like deformity of head-neck fragment is difficult to manually reduce.The pin combined with cannulated screw insertion to the neck cortex can hold the fragment and assist fracture reduction,which is a simple and effective technique.