应用伤害控制骨科学原则治疗骨科严重多发创伤

摘要

目的 探讨伤害控制骨科学(damage control orthopaedics,DCO)原则治疗骨科严重多发创伤的可行性和有效性.方法 按照DCO原则收治严重多发创伤患者47例,男35例,女12例;年龄17～55岁,平均32.8岁;开放骨折28例,闭合骨折19例;颅脑损伤15例,胸部损伤20例,腹部损伤17例.患者术前损伤严重度评分平均33.4分,系统炎性反应评分平均2.9分,格拉斯哥昏迷评分平均11.4分.结果 一期手术中骨科处理时间平均65 min,术中出血量平均185 ml;一期术后平均7 d行骨折确定性手术,平均手术时间(142±29)min,术中出血量(420±70)ml.一期术后3例患者死亡,其中1例伴严重创伤性颅脑损伤,2例伴严重胸腹部损伤.术后3例出现腹腔内脓肿,经引流冲洗后治愈;2例发生外固定架针道浅表感染和1例深部感染,经治疗后愈合.无一例出现脂肪栓塞、深静脉血栓等其他并发症和与骨科治疗有关的其他系统病情的恶化.39例患者获得随访,随访时间3～14个月,平均9个月.骨折愈合时间5～14个月,未发现畸形愈合及远期并发症.结论 运用DCO原则治疗骨科多发创伤,可减少患者二次打击程度,控制炎性反应水平的增加,降低手术治疗风险,临床结果较好.%Objective To evaluate the feasibility and safety of the damage control orthopedics (DCO) strategy in the treatment of multiple traumas combine with bone injuries. Methods Forty-seven se-vere multiple injuries patients were treated by DCO strategy in our center. There were 35 males, 12 females, with a mean age of 32.8 years (17-55 years). There were 28 for open fractures, and 19 for close fractures. Other system injuries mainly include: brain injury 15 cases, breast injury 20 cases, abdominal injury 17 cases. Mean injury severity score was 33.4, mean glasgow coma score was 11.4, mean systemic inflammatory response syndrome score was 2.9. After the early resuscitation and one-stage of damage control surgery, all patients were send to ICU for a profound resuscitation. Two -stage definitive osteosynthesis were executed when the patients were stabilization. The data of time spend, blood loss, and complications of operations were recorded to evaluation. Results In the one-stage procedure, the mean time spend on bone injury for each patients was 65 min, blood loss during the operation was 185 ml. The two-stage definitive osteosynthesis were performed average 7 days after the one-stage procedure, and the time spend and blood loss during the oper-ation were (142±29) min and (420±70) ml, respectively. Three patients died from the deteriorate after one-stage procedure. Six cases development complications after the operation. Fat embolism, deep vein thrombus and others deteriorate associate with the one-stage procedure were not found. Four patients were all obtained neurologic improvement who has spinal fractures combined with spinal cord injuries. 39 cases were followed up for a mean time of 9 months (range, 3-14 months). No long-term complications were found, and the frac-tures got a satisfactory healing. Conclusion DCO appears to reduce the extent of second-hit, control the in-crease of systematic inflammatory response, deduce the risk of the operation for those severe multiple trauma patients, and have a satisfactory clinical outcome, is a safe, effective, feasible treatment strategy.