有限内固定联合外固定支架治疗不稳定近侧指间关节骨折脱位

近侧指间关节骨折脱位在临床上较常见,其受伤机制复杂,处理棘手.当骨折块不超过中节指骨基底关节面的30%时,近侧指间关节常较稳定,可采取闭合复位外固定;但当骨折块超过关节面的40%～50%时,关节出现不稳定,则需切开复位内固定.2003年2月～2005年11月,我们应用切开复位、有限内固定联合外固定支架(Orthofix)治疗12例不稳定近侧指间关节骨折脱位患者,取得了较满意的效果.

正确认识与合理使用外固定支架

1840年,Malgaigne首先使用外固定支架治疗骨折,开启了外固定支架临床应用的先河.20世纪50年代,Ilizarov报告了其设计的用于下肢骨牵引延长的器械,并相继就其在动物实验与临床应用上的经验做了讨论,提出了一种张力-应力法则,即建立在组织自身对损伤的再生反应基础上的"张应力理论".这成为20世纪矫形外科的里程碑.目前,外固定支架的理论基础和临床应用已日趋完善,并广泛应用于骨折固定、肢体延长、四肢骨缺损、骨不愈合、畸形矫正、肢体功能重建等治疗.

Objective: To explore the clinical ef-fects of external fixation associated with limited internal fixa-tion on treatment of Gustilo grade Ⅲ leg fractures.Methods: From July 2006 to December 2008, 40 cases of Gustilo grade Ⅲ leg fiactures were emergently treated in our unit with external fixation frames.Soft tissue injuries were grouped according to the Gustilo classification as ⅢA in 17 cases, ⅢB in 13 cases, and ⅢC in 10 cases.All the patients were debrided within 8 hours, and then fracture reposition was preformed to reestablish the leg alignment.Limited internal fixation with plates and screws were per-formed on all the Gustilo Ilia cases and 10 Gustilo ⅢB cases at the first operation.But all the Gustilo ⅢC cases and 3 Gustilo ⅢB cases who had severe soft tissue injuries and bone loss only received Vacuum-sealing drainage (VSD).Broad-spectrum antibiotics were regularly used and VSD must be especially maintained easy and smooth for one week or more after operation.Limited internal fixation and transplanted free skin flaps or adjacent musculocutaneous flaps were not used to close wounds until the conditions of the wounds had been improved.Results: The first operations were completed within 90-210 minutes (170 minutes on average).The blood trans-fusions were from 400 ml to 1500 ml (those used for anti-shock preoperatively not included).All the 40 patients in this study were followed up for 6-28 months, 20.5 months on average.The lower limb function was evaluated accord-ing to the comprehensive evaluation standards of leg func-tion one year after operation and the results of 28 cases were excellent, 9 were good and 3 were poor.Conclusion: External fixation associated with limited internal fixation to treat Gustilo grade Ⅲ leg fractures can get satisfactory early clinical therapeutic effects.