60例多发性肋骨骨折患者手术与非手术治疗效果对比
发布时间：2018-09-11 20:11
【摘要】：目的探讨多发性肋骨骨折的表现形式,明确术前诊断、评估疾病预后,指导临床治疗,并比较多发性肋骨骨折手术治疗及非手术治疗效果。通过其比较结果,讨论手术治疗与传统治疗的优劣,是否临床值得推广。方法回顾分析我院普胸外科自2011年8月至2013年9月间选择60例多发性肋骨骨折患者的临床资料,男41例,女19例;年龄30~70岁,平均(50.6±10.0)岁;住院时间10~35天,平均(21.7±6.8)天,其中交通事故伤为23例,重物压砸伤7例,摔伤23例,高处坠落伤5例,打架伤1例,机器挤压伤1例;60例患者术前均拍摄胸部X线,CT及三维重建示多发性肋骨骨折,骨折端错位较明显,左侧肋骨骨折34例,右侧肋骨骨折31例,双侧肋骨骨折5例,并合并不同程度的肺挫伤13例。为尽可能满足比较需要,采集的病例满足条件:①胸部CT三维重建示肋骨骨折至少三根以上,无明显开放性骨折;②无明显肺挫裂伤形成血胸及其他专科需处理的合并伤;③排除70岁以上的高龄患者;④神志清楚,可自主咳痰;⑤在我科完成主要治疗,排除胸腹联合伤,颅内出血,肱骨骨折以及需要相关科室手术或共同诊治的患者,无需转当地医院继续治疗。术前根据其病因,临床表现,症状和影像学表现诊断为多发性肋骨骨折。在就诊的患者中,告知患者及其家属各项治疗方案及利弊后,充分尊重患者及家属的意愿,选择手术或保守治疗,并满足上述条件,随机选择其中30例作为观察组,采用镍钛记忆合金环抱器(TiNi环抱式接骨器,兰州西脉记忆合金股份有限公司)手术治疗,30例作为对照组,采用保守治疗,常规胸部绷带加压固定,以及近年来采用胸部护板外固定处理,同时抗炎,排痰,镇痛,加强呼吸道管理。手术采用复合麻醉或全身麻醉,术前根据ct三维重建,用记号笔标出肋骨骨折断端走形,相应选择手术切口,一般是后外侧横切口或腋下纵向切口,游离骨折断端骨膜,避免损伤肋间神经和血管,选择相对应的镍钛记忆合金环抱器,塑形,安装。直观了解多发性肋骨骨折的病情,并进一步与ct三维重建相印证。两组患者主要从住院时间、疼痛视觉模拟评分(vas)、自主下床活动时间、住院费用、胸廓成形程度及肺通气功能对病情进行评价并比较。其方法采用:采用视觉模拟评分(visualalqaloguescale,vas)。0分:无痛;3分以下:有轻微的疼痛,能忍受;4~6分:患者疼痛并影响睡眠,尚能忍受;7~10分:患者有渐强烈的疼痛,疼痛难忍,影响食欲,影响睡眠。术前vas评分由术前当天记录,术后vas评分为术后第6天疼痛主观评分的平均值,比较两组vas下降程度。肋骨骨折治疗疗效标准:优:胸壁无疼痛、呼吸正常、影像学检查肋骨解剖对位、双侧胸廓对称;良:与优相比影像学检查肋骨非解剖对位、移位在2mm以内,双侧胸廓基本对称;可:胸壁略有疼痛、影像学检查示少数肋骨对位差,但移位在3mm以内,胸廓稍有塌陷或不对称;差;胸壁疼痛、肋骨移位在3mm以上。所有数据分析采用spss19.0软件进行统计分析。计量资料以sx±表示,组间比较采用t检验,计数资料组间比较采用c2检验及秩和检验。比较两组住院时间,术后疼痛下降程度,以及自主下床时间比较,两组肺功能比较,以及患者伤后1月复查肋骨复位疗效比较,p0.05有统计学差异。结果本观察60例患者术后均获随访,伤后1-2个月均在我院复查胸部x线观察肋骨复位情况,进一步比较手术及传统治疗效果对比。发现从两组住院时间,术后疼痛下降程度,以及自主下床时间比较,观察组明显优于对照组,但从住院费用来看,观察组的治疗费用明显高于对照组,两组比较差异有统计学意义。两组患者均于入院时常规测定肺功能,同时对观察组术后第7天及对照组保守治疗后第7天复查肺功能,以最大自主通气量(mvv)、第1秒用力呼气肺活量(fev1)所占百分比等作为评估指标,见两组患者入院时MVV%及FEV1%比较差异无统计学意义,治疗后7 d复查:观察组MVV恢复明显优于对照组,但FEV1所占百分比变化不明显,考虑为患者外伤引起的肺限制性通气对其无明显影响。两组比较差异有统计学意义。门诊随诊观察肋骨骨折愈合情况及胸廓形状,观察组和对照组两组整体疗效比较差异有统计学意义。结论通过两组患者的对比及术后的随访比较,更加全面了解多发性肋骨骨折患者的临床特点,术中视野全面,清楚,直观面对肋骨骨折的部位进行处理,手术针对性强,处理结果满意,且复位效果佳。总体来说,在住院时间,在疼痛指数下降及治疗满意度上,手术组患者较为满意,但治疗费用偏高。手术复位内固定对多发性肋骨骨折的治疗有重要的应用价值。
[Abstract]:Objective To investigate the manifestations of multiple rib fractures, make clear the preoperative diagnosis, evaluate the prognosis of the disease, guide the clinical treatment, and compare the surgical treatment and non-surgical treatment of multiple rib fractures. From August 2011 to September 2013, 60 patients with multiple rib fractures were selected, including 41 males and 19 females, 30-70 years old, with an average age of (50.6 65 X-ray, CT and three-dimensional reconstruction showed multiple rib fractures in all the patients before operation. The fracture ends were dislocated obviously. 34 cases of left rib fractures, 31 cases of right rib fractures, 5 cases of bilateral rib fractures, and 13 cases of pulmonary contusion were found. At least three rib fractures, no obvious open fractures; no obvious pulmonary contusion and laceration of the formation of hemothorax and other specialized treatment of combined injuries; excluding elderly patients over 70 years old; clear mind, can cough sputum; _in my department to complete the main treatment, excluding thoracoabdominal combined injuries, intracranial hemorrhage, humeral fractures and the need for relevant departments Patients undergoing surgery or co-treatment need not be transferred to local hospitals for further treatment.Preoperative diagnosis of multiple rib fractures is based on etiology, clinical manifestations, symptoms and imaging findings. Thirty of them were randomly selected as the observation group and treated with TiNi memory alloy embracing fixator (TiNi embracing fixator, Lanzhou Ximai Memory Alloy Co., Ltd.) and 30 as the control group. They were treated with conservative treatment, routine compression and fixation of chest bandage, and external fixation of chest guard plate in recent years. Anti-inflammation, expectoration, analgesia, strengthen the management of respiratory tract. Operation using compound anesthesia or general anesthesia, preoperative according to the three-dimensional reconstruction of CT, marking the fracture of the ribs with a marker pen out the shape of the broken end, the corresponding choice of surgical incision, generally posterolateral transverse incision or axillary longitudinal incision, free fracture of the periosteum, to avoid injury of intercostal nerves and blood vessels, choose the phase. The patients in the two groups were assessed and compared by length of stay in hospital, visual analogue score of pain (vas), time of ambulation, hospitalization expenses, degree of thoracoplasty and pulmonary ventilation function. Methods: Visual analogue scale (vas) was used. 0 points: no pain; below 3 points: slight pain, tolerable; 4-6 points: patients with pain and affect sleep, can tolerate; 7-10 points: patients with gradual intense pain, pain intolerable, affecting appetite, affecting sleep. The results of rib fracture treatment were as follows: excellent: no pain in chest wall, normal breathing, radiographic examination of rib anatomical contraposition, bilateral chest symmetry; good: compared with excellent imaging examination rib non-anatomical contraposition, displacement within 2 mm, bilateral chest symmetry; can: All data were analyzed by SPSS 19.0 software. The measurement data were expressed as SX (+), t test was used for comparison between groups, and C2 test for comparison between groups. Rank sum test. Comparing the length of hospitalization, the degree of postoperative pain reduction, and the time to get out of bed independently, the pulmonary function of the two groups, and the effect of rib reduction after 1 month of injury, there were statistical differences between the two groups. Results All the 60 patients were followed up after operation, and the rib reduction was observed by chest X-ray after 1-2 months of injury in our hospital. It was found that the observation group was superior to the control group in terms of the length of hospital stay, the degree of postoperative pain reduction, and the time to get out of bed independently, but from the cost of hospitalization, the treatment cost of the observation group was significantly higher than that of the control group, the difference between the two groups was statistically significant. Pulmonary function was measured routinely at admission. At the same time, pulmonary function was reexamined on the 7th day after operation in observation group and the 7th day after conservative treatment in control group. Maximum voluntary ventilation volume (mvv) and percentage of forced expiratory capacity (fev1) in the 1st second were taken as evaluation indexes. There was no significant difference in MVV% and FEV1% between the two groups at admission. The recovery of MVV in the observation group was obviously better than that in the control group, but the percentage of FEV1 had no significant change, and there was no significant difference between the two groups. Conclusion Through the comparison of the two groups of patients and postoperative follow-up comparison, more comprehensive understanding of the clinical characteristics of multiple rib fracture patients, intraoperative visual field is comprehensive, clear, intuitive facing the rib fracture site for treatment, surgery targeted, satisfactory treatment results, and reduction effect. In terms of pain index and treatment satisfaction, the operation group was more satisfied, but the treatment cost was higher. Surgical reduction and internal fixation had important application value in the treatment of multiple rib fractures.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3
本文编号：2237736
[Abstract]:Objective To investigate the manifestations of multiple rib fractures, make clear the preoperative diagnosis, evaluate the prognosis of the disease, guide the clinical treatment, and compare the surgical treatment and non-surgical treatment of multiple rib fractures. From August 2011 to September 2013, 60 patients with multiple rib fractures were selected, including 41 males and 19 females, 30-70 years old, with an average age of (50.6 65 X-ray, CT and three-dimensional reconstruction showed multiple rib fractures in all the patients before operation. The fracture ends were dislocated obviously. 34 cases of left rib fractures, 31 cases of right rib fractures, 5 cases of bilateral rib fractures, and 13 cases of pulmonary contusion were found. At least three rib fractures, no obvious open fractures; no obvious pulmonary contusion and laceration of the formation of hemothorax and other specialized treatment of combined injuries; excluding elderly patients over 70 years old; clear mind, can cough sputum; _in my department to complete the main treatment, excluding thoracoabdominal combined injuries, intracranial hemorrhage, humeral fractures and the need for relevant departments Patients undergoing surgery or co-treatment need not be transferred to local hospitals for further treatment.Preoperative diagnosis of multiple rib fractures is based on etiology, clinical manifestations, symptoms and imaging findings. Thirty of them were randomly selected as the observation group and treated with TiNi memory alloy embracing fixator (TiNi embracing fixator, Lanzhou Ximai Memory Alloy Co., Ltd.) and 30 as the control group. They were treated with conservative treatment, routine compression and fixation of chest bandage, and external fixation of chest guard plate in recent years. Anti-inflammation, expectoration, analgesia, strengthen the management of respiratory tract. Operation using compound anesthesia or general anesthesia, preoperative according to the three-dimensional reconstruction of CT, marking the fracture of the ribs with a marker pen out the shape of the broken end, the corresponding choice of surgical incision, generally posterolateral transverse incision or axillary longitudinal incision, free fracture of the periosteum, to avoid injury of intercostal nerves and blood vessels, choose the phase. The patients in the two groups were assessed and compared by length of stay in hospital, visual analogue score of pain (vas), time of ambulation, hospitalization expenses, degree of thoracoplasty and pulmonary ventilation function. Methods: Visual analogue scale (vas) was used. 0 points: no pain; below 3 points: slight pain, tolerable; 4-6 points: patients with pain and affect sleep, can tolerate; 7-10 points: patients with gradual intense pain, pain intolerable, affecting appetite, affecting sleep. The results of rib fracture treatment were as follows: excellent: no pain in chest wall, normal breathing, radiographic examination of rib anatomical contraposition, bilateral chest symmetry; good: compared with excellent imaging examination rib non-anatomical contraposition, displacement within 2 mm, bilateral chest symmetry; can: All data were analyzed by SPSS 19.0 software. The measurement data were expressed as SX (+), t test was used for comparison between groups, and C2 test for comparison between groups. Rank sum test. Comparing the length of hospitalization, the degree of postoperative pain reduction, and the time to get out of bed independently, the pulmonary function of the two groups, and the effect of rib reduction after 1 month of injury, there were statistical differences between the two groups. Results All the 60 patients were followed up after operation, and the rib reduction was observed by chest X-ray after 1-2 months of injury in our hospital. It was found that the observation group was superior to the control group in terms of the length of hospital stay, the degree of postoperative pain reduction, and the time to get out of bed independently, but from the cost of hospitalization, the treatment cost of the observation group was significantly higher than that of the control group, the difference between the two groups was statistically significant. Pulmonary function was measured routinely at admission. At the same time, pulmonary function was reexamined on the 7th day after operation in observation group and the 7th day after conservative treatment in control group. Maximum voluntary ventilation volume (mvv) and percentage of forced expiratory capacity (fev1) in the 1st second were taken as evaluation indexes. There was no significant difference in MVV% and FEV1% between the two groups at admission. The recovery of MVV in the observation group was obviously better than that in the control group, but the percentage of FEV1 had no significant change, and there was no significant difference between the two groups. Conclusion Through the comparison of the two groups of patients and postoperative follow-up comparison, more comprehensive understanding of the clinical characteristics of multiple rib fracture patients, intraoperative visual field is comprehensive, clear, intuitive facing the rib fracture site for treatment, surgery targeted, satisfactory treatment results, and reduction effect. In terms of pain index and treatment satisfaction, the operation group was more satisfied, but the treatment cost was higher. Surgical reduction and internal fixation had important application value in the treatment of multiple rib fractures.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3
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