Neudeck F, Aufmkolk M, Voggenreiter G, Olivier L C, Majetschak M, Obertacke U
Abteilung für Unfallchirurgie, Universitätsklinikum Essen.
Unfallchirurg. 1998 Oct;101(10):769-74. doi: 10.1007/s001130050336.
The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.
对于多发伤患者，早期手术稳定股骨骨折的益处已得到确立。在过去几年中，尽管存在病理生理学方面的担忧，但非扩髓股骨钉仍受青睐用于股骨骨折的内固定。与钢板固定相比，股骨钉的首要优势在于早期完全负重的可能性。本回顾性研究的目的是，在考虑损伤严重程度、损伤范围及临床病程的情况下，探讨伴有股骨骨折的多发伤患者采用首选的早期负重髓内钉固定是否有益。1271例多发伤患者（损伤严重度评分>17）中有302例（23.8%）伴有股骨骨折。302例患者中有47例为16岁以下儿童，其余255例患者。255例患者中有18例在创伤后21天内死亡，66例患者需要机械通气超过三周（171/255）。30例患者患有严重颅脑损伤（简明损伤定级标准头部评分>3），7例患有严重肺挫伤并伴有腹部损伤（134/255）。2例患者为Ⅲ级开放性股骨骨折并伴有血管损伤。11例患者可见同侧不稳定骨盆骨折，7例患者有同侧股骨关节内骨折，40例患者观察到同侧小腿或足部关节内骨折（74/255）。结果表明，255例多发伤患者（>16岁）中只有74例（29%）理论上能从早期负重中获益。考虑完全负重，70%的患者未从髓内钉固定中获益。鉴于病理生理学方面的担忧，应为这些患者讨论骨折固定的替代方法。外固定器一期骨折固定和二期内固定被证明是一种安全的替代方法。钢板固定的并发症发生率与髓内钉固定相当，但全身风险较轻。股骨骨折一期钢板固定不会延迟大多数多发伤患者的活动。
