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[不稳定胸壁的骨固定术]

[Osteosynthesis of the unstable thoracic wall].

作者信息

Spering Christopher, von Hammerstein-Equord Alexander, Lehmann Wolfgang, Dresing Klaus

机构信息

Klink für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.

Klinik für Thorax‑, Herz- und Gefäßchirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland.

出版信息

Oper Orthop Traumatol. 2021 Jun;33(3):262-284. doi: 10.1007/s00064-020-00688-2. Epub 2020 Dec 8.

DOI:10.1007/s00064-020-00688-2
PMID:33289872
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7722258/
Abstract

OBJECTIVE

Surgical stabilization of patients with flail chest, dislocated serial rib and sternal fractures, posttraumatic deformities of the thorax, symptomatic non-unions of the ribs and/or sternum, and weaning failure to biomechanically stabilize the thorax and avoid respirator-dependent complications.

INDICATIONS

Combination of clinically and radiologically observed parameters, such as pattern of thoracic injuries, grade of fracture dislocation, pathological changes to breathing biomechanics, and failure of nonsurgical treatment.

CONTRAINDICATIONS

Acute hemodynamical instability and signs of systemic infection.

SURGICAL TECHNIQUE

Detailed preoperative planning. Open, minimally invasive reduction and osteosynthesis using precontoured, low-profile locking plates and/or intramedullary splints. Careful reduction drilling/implantation of screws due to proximity of the pleura, lungs and pericardium.

POSTOPERATIVE MANAGEMENT

Weaning from respirator as early as possible and early therapy of pneumothorax perioperatively. Removal of implants usually not necessary.

RESULTS

In a retrospective study, 15 polytraumatized patients with flail chest benefitted from an early interdisciplinary surgical treatment strategy within 24-48 h. Early osteosynthesis after severe thoracic trauma significantly reduced ventilator dependency and lowered the risk of pneumonia compared to patients who underwent surgery at a later time point. Patients with severe thoracic injury and life-threatening polytrauma, who meet the indication criteria for open reduction and surgical stabilization of the thorax, are in need of a throughly planned and interdisciplinary synchronized priorization and strategy. Longer intensive care unit stay, overall prolonged duration of admission in hospital, and higher level of respirator-associated complication should be expected in patients with life-threatening severe thoracic trauma (Abbreviated Injury Score (AIS) ≥ 3) compared to patients without thoracic trauma.

摘要

目的

对连枷胸、肋骨及胸骨连环脱位骨折、创伤后胸廓畸形、有症状的肋骨和/或胸骨不愈合以及脱机失败的患者进行手术固定，以实现胸廓的生物力学稳定并避免依赖呼吸机的并发症。

适应症

临床和影像学观察参数的综合考量，如胸部损伤模式、骨折脱位程度、呼吸生物力学的病理变化以及非手术治疗失败情况。

禁忌症

急性血流动力学不稳定和全身感染迹象。

手术技术

详细的术前规划。采用预塑形、低轮廓锁定钢板和/或髓内夹板进行开放或微创复位及骨固定。由于胸膜、肺和心包距离较近，需谨慎进行复位钻孔/螺钉植入。

术后管理

尽早脱机，并在围手术期对气胸进行早期治疗。通常无需取出植入物。

结果

在一项回顾性研究中，15例连枷胸多发伤患者在24 - 48小时内受益于早期多学科手术治疗策略。与较晚接受手术的患者相比，严重胸部创伤后早期骨固定显著降低了呼吸机依赖程度，并降低了肺炎风险。符合胸廓切开复位和手术固定适应症标准的严重胸部损伤及危及生命的多发伤患者，需要经过全面规划和多学科同步的优先处理及策略。与无胸部创伤的患者相比，危及生命的严重胸部创伤（简明损伤评分（AIS）≥3）患者预计在重症监护病房停留时间更长、住院总时长延长且呼吸机相关并发症发生率更高。

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