McHenry Timothy P, Holcomb John B, Aoki Noriaki, Lindsey Ronald W
Joint Trauma Training Center, Ben Taub General Hospital, Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
J Trauma. 2002 Oct;53(4):717-21. doi: 10.1097/00005373-200210000-00016.
The sequence of surgical repair for penetrating extremity injuries requiring both vascular repair and fracture fixation is controversial. The optimal determination of repair order and its consequences is the purpose of this study.
A retrospective review was performed of 27 patients over a 10-year period requiring acute revascularization and fracture fixation for isolated gunshot wound injuries. Injuries to the brachial artery and the femoral and popliteal vessels with accompanying fractures requiring operative stabilization were considered. The Mangled Extremity Severity Score, surgical sequence, limb viability, fasciotomy, incidence of iatrogenic vascular repair disruption, and length of hospitalization were analyzed.
There were 17 lower and 10 upper extremity injuries, with a mean Mangled Extremity Severity Score of 4.1. Fracture fixation preceded vascular repair in five cases, whereas revascularization preceded bone fixation in 22 cases. A temporary vascular shunt was used in 13 and definitive vascular repair with used in 9 patients. There were no cases of vascular repair, shunt disruption, or amputation after fracture fixation. Four of five (80%) patients with orthopedic fixation before revascularization required fasciotomies, whereas 8 of 22 (36%) patients with revascularization before fixation required fasciotomies, and this difference approached significance (p = 0.10). Patients with fasciotomies had a significantly longer mean length of hospitalization, 18.3 +/- 8.6 days compared with 10.8 +/- 8.1 days (p = 0.03). CONCLUSION For patients with combined injuries, priority should be given to revascularization before orthopedic fixation because of shorter hospitalization and a trend toward lower fasciotomy rates. Revascularization before fracture fixation did not result in iatrogenic disruption of the vascular repair.
对于需要同时进行血管修复和骨折固定的穿透性肢体损伤，手术修复顺序存在争议。本研究旨在确定修复顺序的最佳选择及其后果。
回顾性分析了27例在10年期间因孤立性枪伤需要急性血管再通和骨折固定的患者。研究对象包括伴有骨折且需要手术稳定的肱动脉、股动脉和腘血管损伤。分析了肢体损伤严重程度评分、手术顺序、肢体存活情况、筋膜切开术、医源性血管修复中断的发生率以及住院时间。
下肢损伤17例，上肢损伤10例，平均肢体损伤严重程度评分为4.1。5例患者先进行骨折固定，再进行血管修复；22例患者先进行血管再通，再进行骨折固定。13例患者使用了临时血管分流术，9例患者进行了确定性血管修复。骨折固定后未发生血管修复、分流中断或截肢病例。血管再通前进行骨科固定的5例患者中有4例（80%）需要进行筋膜切开术，而血管再通前进行骨折固定的22例患者中有8例（36%）需要进行筋膜切开术，这种差异接近显著性（p = 0.10）。接受筋膜切开术的患者平均住院时间显著更长，为18.3±8.6天，而未接受筋膜切开术的患者为10.8±8.1天（p = 0.03）。结论：对于合并损伤的患者，由于住院时间较短且筋膜切开率有降低趋势，应优先进行血管再通，然后进行骨科固定。骨折固定前进行血管再通不会导致医源性血管修复中断。
