Nieto H, Baroan C
Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France.
Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France.
Orthop Traumatol Surg Res. 2017 Feb;103(1S):S61-S66. doi: 10.1016/j.otsr.2016.11.006. Epub 2016 Nov 15.
Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without reaming are preferable.
长骨骨折内固定的替代方法包括根据骨折部位采用外固定或关节置换。其局限性包括感染风险和功能预后质量，这些会因技术不同而有所差异。本研究基于比较性或大规模研究中得出的某些显著结果，对这些局限性进行了探讨。研究涉及四个主要问题：（1）锁定钢板目前的作用；（2）Gustilo IIIb型开放性骨折髓内钉固定的条件；（3）小腿开放性骨折从外固定转换为髓内钉固定的局限性；（4）以及多发伤中确定性顺行股骨髓内钉固定的局限性。在任何有高质量比较分析的解剖部位，锁定钢板固定尚未证明其临床优越性。如果伤口护理和清创有效、迅速开始抗生素治疗且在7天内恢复皮肤覆盖，那么Gustilo IIIb型开放性小腿骨折采用髓内钉固定或外固定时感染风险相当。如果外固定器安装时间少于28天且在7天内恢复皮肤覆盖，则可以从初次外固定转换为髓内钉固定。多发伤中周围损伤或股骨骨折确定性顺行髓内钉固定对肺部和全身的影响需要谨慎对待，即所谓的“损伤控制骨科”（DCO），这一术语涵盖了初始创伤及其治疗的总体后果。因此，在出现失血性休克（血压<90mmHg）、体温过低（<33°C）、凝血障碍（血小板计数<90,000）或周围损伤如多发长骨骨折、肢体挤压伤或原发性肺挫伤的情况下，禁忌进行股骨髓内钉固定。在这种情况下，外固定或采用小直径髓内钉且不扩髓的逆行髓内钉固定更为可取。
