骨科损伤控制在不稳定骨盆骨折的应用研究

发布时间：2018-06-27 10:00

本文选题：骨科损伤控制 + 不稳定骨盆骨折　；参考：《郑州大学》2015年硕士论文

【摘要】：背景和目的当今社会,随着医学的进步与变革,对创伤控制、尤其是多发伤的诊治理念有了长足的进步,骨科损伤控制理念也应运而生:指创伤骨科用来控制病情进展的手段,不是立即实施确定性的创伤修复,当时提出这一理论弥补了美国广泛使用枪支引起创伤救治的需要。20世纪80年代Stone等选择17例严重多发伤患者实施早期简化手术,重症监护病房复苏,后期行确定性治疗手术,获得了良好的效果。创伤早期实施简化控制手术进行控制损伤,挽救原来以为难以救治的危重患者,从而提出损伤控制外科(damage control surgery,DCS)的概念。近些年来损伤控制广泛被使用于严重创伤及多发伤的救治,获得了较大的进展。不稳定骨盆骨折由高处坠落、挤压、车祸等高能量损伤引起,往往伴有邻近部位损伤,如膀胱、直肠、尿道等相应盆腔内脏器损伤,可致大出血和休克,继而引发低体温、DIC和代谢性酸中毒,是致命性的骨折。因此在极端创伤状态下引入骨科损伤控制是必要的。骨科损伤控制理念(damage control orthopedics,DCO)是指在围手术期综合应用多学科的方法,合理有效地改良一系列诊疗措施,如手术方式,最大限度地减少病人死亡率、术中应激、手术风险及并发症,以达到加速患者功能恢复,提高康复质量的目的。骨科损伤控制理念核心内涵是尽可能的减少甚至阻断以手术操作为主的各种有创诊疗操作导致的机体应激反应。作为目前创伤医学界最新的治疗理念和原则之一,骨科损伤控制理念应用于临床实践即显示出较传统理念更为优越的治疗效果,同时在外科学的各个学科迅速传播开来,逐步拓展到几乎所有外科领域。但迄今为止仍骨科损伤控制主要应用于危重创伤,本文拟探讨骨科损伤控制在不稳定骨盆骨折中应用价值及前景。方法自2013年1月至2014年6月按照连续采样的方法于郑州大学第一附属医院急诊外科收集以不稳定骨盆骨折为诊断急诊入院并采取手术治疗的患者。按治疗方案不同将纳入研究的患者进行分组,并按照拟采取手术方式不同将每组患者随机分为骨科损伤控制(damage control orthopedics,DCO)组和传统手术(conservative treatment surgery,CTS)组。收集患者在院的相关生化指标及临床指标。经治的不稳定骨盆骨折患者院外均获随访,随访时间最短6个月,最长24个月,平均14个月。患者术后定期进行复查,进行Matta评分,然后比较组间上述指标的差异。统计处理采用spss17.0软件进行统计处理,计量资料用x±s表示;计量资料采用t检验;重复测量资料采用单因素方差分析;组间率比较采用2c检验;等级资料采用秩和检验;P0.05认为差异有统计学意义。结果1.参与本研究的在院患者中DCO组2例(4%),CTS组6例(10%)因伤情较重,在治疗期间死亡,成功随访99例,随访时间(14±4.9)月。随访中5例死亡病例(死因均与原发疾病无明显相关)。2.患者入院PH值、BE、T、FDP、D-DT、WBC、ESR、PCT、CRP、组间性别构成,年龄相比差异无统计学意义(P0.01)。3.DCO组患者术后PH值、BE、T、FDP、D-DT、WBC、红细胞沉降量、PCT、CRP等水平改善情况均较CTS组好,组间差异有统计学意义(P0.05)。4.DCO组术后患者胃肠功能恢复时间较短,术后床上功能锻炼及护理开始时间较早,术后并发症发生率较低,住院时间较短,住院费用较少,组间差异有统计学意义(P0.05)。5.组间术后WHO疼痛分级相比,DCO组术后疼痛分级较CTS组低,组间相比差异有统计学意义(P0.05)。6.DCO组术后优良率较CTS组高,组间相比差异有统计学意义(P0.05)。结论骨科损伤控制理念在不稳定骨盆骨折治疗中的应用,能够以简化方式控制大出血,阻断死亡三联征的恶性循环,减轻患者全身应激及炎症反应。骨科损伤控制应用不稳定骨盆骨折治疗中能够降低患者死亡率,减少术后并发症的发生,减轻患者的经济负担,提高患者术后肢体功能康复质量。
[Abstract]:Background and objective today's society, with the progress and change of medicine, the concept of diagnosis and treatment of trauma, especially multiple injuries has made great progress. The concept of injury control in Department of orthopedics has emerged as the times require: refers to the means that the traumatic Department of orthopedics is used to control the progress of the disease. It is not the immediate implementation of the definitive repair of trauma, and the theory made up the beauty at that time. The need for extensive use of firearms in the country was required for the treatment of trauma in the 80s.20 Stone and other 17 cases of severe multiple injuries. The early simplified operation was performed, the intensive care unit resuscitation, and the later period of deterministic treatment. The concept of damage control surgery (DCS) is put forward in critically ill patients. In recent years, damage control has been widely used in the treatment of severe trauma and multiple injuries, and great progress has been made. The injury of the corresponding pelvic viscera, such as the rectum and urethra, can cause massive hemorrhage and shock, and then cause hypothermia, DIC and metabolic acidosis, which are fatal fractures. Therefore, it is necessary to introduce the Department of orthopedics injury control under the extreme trauma condition. The concept of damage control orthopedics (DCO) is the comprehensive application of the comprehensive application in the perioperative period. The method of discipline, rational and effective improvement of a series of diagnosis and treatment measures, such as surgical methods, to minimize patient mortality, intraoperative stress, surgical risk and complications, in order to accelerate the recovery of the patient's function and improve the quality of rehabilitation. The connotation of the concept of the Department of orthopedics damage control concept is to reduce or even block operation operation as possible. As one of the latest treatment concepts and principles in the field of trauma medicine, as one of the latest treatment concepts and principles in the field of trauma medicine, the concept of injury control in the Department of orthopedics is applied to clinical practice, which shows a more superior treatment effect than the traditional concept, and is spreading rapidly in various disciplines of the external science and gradually expanding to almost all of them. There is a surgical field. But to date, Department of orthopedics damage control is mainly used in critical trauma. This paper intends to explore the value and Prospect of the Department of orthopedics injury control in unstable pelvic fractures. Methods from January 2013 to June 2014, the unstable pelvic fractures were collected at the First Affiliated Hospital of Zhengzhou University in accordance with the continuous sampling method. Patients who were admitted to the hospital for the diagnosis of emergency hospitalization were divided into groups according to the different treatment schemes, and the patients in each group were randomly divided into the Department of orthopedics (damage control orthopedics, DCO) and the traditional surgery (conservative treatment surgery, CTS). The patients with unstable pelvic fractures were followed up, the shortest 6 months, the longest 24 months, an average of 14 months. The patients were reexamined after the operation, the Matta score was carried out, and then the differences between the above indexes were compared. Statistical processing was carried out with SPSS17.0 software for statistical processing and measurement. The material was expressed with x + s; the measurement data were tested by t test; the repeated measurement data were analyzed with single factor variance; the rate of inter group was compared with 2C test; the rank data was tested by rank sum test; P0.05 thought the difference was statistically significant. Results 1. in this study, 2 cases (4%) were involved in the hospital patients, and 6 cases (10%) in the CTS group were seriously injured and died during the treatment period. Follow up 99 cases, follow-up time (14 + 4.9) months. 5 cases of death in the follow-up (no significant correlation with the primary disease),.2. patients were hospitalized with pH, BE, T, FDP, D-DT, WBC, ESR, PCT, CRP, and there was no statistical difference between the groups (P0.01).3.DCO group. The improvement was better than that of the CTS group. The difference between the groups was statistically significant (P0.05) the recovery time of the gastrointestinal function in the group.4.DCO was shorter, the postoperative bed functional exercise and nursing began earlier, the incidence of postoperative complications was low, the hospitalization time was shorter, the hospitalization cost was less, and the difference between the groups was statistically significant (P0.05) WHO pain between the.5. group after the.5. group. The classification of pain in group DCO was lower than that of group CTS, and there was significant difference between groups (P0.05) compared with group.6.DCO (P0.05), there was a higher rate in group.6.DCO than that in group CTS, and there was a significant difference between groups (P0.05). Conclusion the application of the concept of injury control in the treatment of unstable pelvic fractures can control massive bleeding and block death by three In the treatment of unstable pelvic fracture, injury control in Department of orthopedics can reduce the mortality of the patients, reduce the incidence of postoperative complications, reduce the economic burden of the patients, and improve the rehabilitation quality of the postoperative limb function.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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