延误诊治的下肢大血管损伤的临床救治

目的　总结延误诊治的下肢大血管损伤的救治经验和教训。方法　对本组延误诊治的 1 7例病例均行小腿骨筋膜室切开 ,并根据不同情况分别行对侧大隐静脉移植修复血管 8例 ,血管吻合 3例 ,血管结扎 6例。本组 1 7例中 ,Whitman功能分级为好 5例 ;6例下肢功能于术后 8～ 1 2个月恢复 ;截肢 6例。结论强调血管损伤的早期诊治 ,若基层医院无血管修复条件 ,早期行小腿骨筋膜室切开减压 ,及时转送上级医院。强调修复下肢大静脉的必要性。小腿肌肉缺血是决定修复动脉或是果断截肢的主要依据之一。     

52例下肢大血管损伤的诊治

目的 总结下肢大血管损伤的诊治经验。方法 1994年5月-2000年12月收治下肢大血管损伤52例,ISS-90评分9-26倒退,平均13分,Ⅰ期血管吻合39例,其中自体静脉移植6例,血管端-端吻合22例;血管修补6例,切开取血栓5例,结扎2例,结果 术后随访3个月,47例下肢循环良好,其中39例按Whitman分级为好（伤肢行走不同支具）,8例因神经损伤及骨折因素,分别于伤后6-12个月功能恢复良好。5例截肢。结论 采用多普勒技术早期诊断,正确掌握手术时机并行皮肤小切口,深筋膜充分切开减压,能减少下肢大血管损伤致残率和截肢率。     

Arthroscopic treatment of acromioclavicular joint injuries and results

Injuries and conditions that affect the AC joint are common. Low-grade separations, degenerative conditions, and osteolysis of the distal clavicle are frequently dealt with by the treating physician. Proper assessment requires a thorough history, examination, and radiologic work-up. An injection of bupivicaine into the AC joint can be a very useful test to evaluate the source of pain about the symptomatic shoulder. Most conditions affecting the AC joint can be treated conservatively, but patients who do not respond to these treatments or athletes who do not wish to modify their activities may require resection of the distal clavicle and the AC joint. Operative intervention can be performed as an open procedure with good results. Recent advances in operative arthroscopic procedures allow us to replicate and exceed the results of the open resection. Arthroscopic resection can be undertaken via a direct approach that does not violate the subacromial space or via an indirect or bursal approach. The indirect approach allows you to assess both the subacromial space and the AC joint because impingement pathology and subacromial compromise are frequently associated with AC change. The advantage of an arthroscopic resection is its ability to be performed as an outpatient procedure with less compromise of musculotendinous structures, shorter rehabilitation, and quicker return to activity. The amount of bone resection necessary is less than with the open procedure because of the ability to preserve the stabilizing properties of the superior AC ligaments. Resection of 4 mm to 8 mm of bone is all that may be required to give uniformly good results. Arthroscopic resection of the distal clavicle is technically demanding and requires skill and familiarity with other arthroscopic shoulder procedures. Complications related to this procedure are relatively infrequent and include infection, residual pain, lack of adequate bone resection, and instability, particularly in patients with previous grade 1 and 2 separations. Less commonly noted is the symptomatic development of heterotopic bone. To the accomplished arthroscopic shoulder surgeon, arthroscopic resection of the symptomatic AC joint gives excellent clinical results that allow a compromised athlete a relatively quick return to desired sport activities.     

Operative treatment of acromioclavicular joint injuries and results

A variety of pathological conditions affect the acromioclavicular joint and the surrounding structures. For each of these, different procedures have been described with varying degrees of success. This article focuses on contemporary procedures. The acromioclavicular joint can be reapproximated using one of three stabilization techniques: (1) primary fixation across the acromioclavicular joint, (2) secondary stabilization of the joint by recreating the anatomic linkage between the distal clavicle and the coracoid process, or (3) dynamic stabilization of the joint by creating an inferiorly directed force on the distal clavicle. These methods are not mutually exclusive and may be combined in a single operative setting to produce a final construct with superior mechanical stability.     

四肢主干动脉伤外科处理后并发症防治的临床观察

目的　分析6 2例四肢主干血管伤的临床治疗效果,探讨四肢主干动脉伤的早期处理方法,减少术后伤残率和死亡率。方法　回顾分析6 2例四肢主干血管伤用不同方法处理的临床效果,探讨其原因。结果　单纯血管吻合组9例,发生缺血性肌挛缩5例;采用血管吻合 切开减压(前臂或小腿深筋膜切开)组共4 7例,发生缺血性肌挛缩4例。单纯行血管吻合比血管吻合 切开减压更易发生缺血性肌挛缩(P <0 .0 5 )。8例通血后高钾血症均以血液透析处理后取得良好效果。截肢5例;死亡1例。长时间缺血易发生骨筋膜室综合征、高钾血症、急性肾功能衰竭。结论　对四肢主干血管损伤,及时行缺血肢体的切开减压,防止缺血性肌挛缩发生,密切监测血钾水平、每小时尿量,及时处理高钾血症、急性肾功能衰竭,对降低伤残率、杜绝死亡病例非常重要。     

Percutaneous transcatheter embolization in arterial injuries of the lower limbs

Purpose: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries.

Material and Methods: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate.

Results: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67±0.91 days.

Conclusion: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.     

Medicolegal evaluation of vascular injuries of limbs in Turkey

This study evaluated 372 cases of post-traumatic extremity vessel lesions, for which the Forensic Medicine Council, Istanbul, Turkey prepared medicolegal evaluation reports between 1998 and 2000. The study group (n = 372) comprised of 346 men (93.0%) and 26 women (6.9%), and their ages ranged between 6 and 73 years (30.18 +/- 6.13). There were 378 artery (74.5%), and 131 vein injuries (25.5%) out of a total of 509 limb vascular injuries. The most frequently injured arteries and veins were the femoral artery (n = 73), and the deep femoral vein (n = 41), respectively. The causes of injuries were as follows: cutting and stabbing complements, in 160 cases (43.0%); gunshots in 136 cases (36.6%); traffic accidents in 52 cases (14%); work accidents in 23 cases (6.2%); and blunt trauma in one case (0.3%). These injuries were accompanied by local nerve lesions (27.1%), local bone lesions (37.1%), and injuries to other organs (11.0%). The medicolegal assessments by the Forensic Medicine Council showed that there were risk of death in 371 cases. Additionally, there was 'organ dysfunction' in 37 (9.9%) and 'organ loss' in 53 (14.2%) cases. The results of this study suggested that the main causes of severe vascular injuries (i.e. those accompanied by bone and nerve lesions) had serious consequences such as amputation, permanent disorders or loss of function and were caused by gunshot and traffic accidents.     

Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete

The long-term results of 25 patients treated nonoperatively with isolated posterior cruciate ligament (PCL) injuries were evaluated. Mean followup was 6.2 years (range, 2.2 to 16 years). All patients were evaluated both subjectively (questionnaire) and objectively (clinical examination, x-ray films, Cybex II dynamometer, and KT-1000 Knee Arthrometer). At followup, 80% of the patients were satisfied with their knees and 84% had returned to their previous sport (68% at the same level of performance, 16% at a decreased level of performance). Mean torque Cybex II quadriceps values for three velocities of testing (45, 90, and 180 deg/sec) in patients fully returned to sport and satisfied with their knees was greater than 100% of uninvolved quadricep; conversely, those not satisfied with their knees all had values less than 100% of uninvolved knee. The amount of knee instability as determined by the KT-1000 Arthrometer was not related to the patient's return to sport nor to knee satisfaction. We concluded that the majority of athletes with isolated PCL injuries who maintain strength in musculature return to sports without functional disability.     

Combined PCL-ACL lateral and medial side injuries: treatment and results

The multiple ligament-injured knee is a complex problem in orthopedic surgery. These injuries may or may not present as acute knee dislocations, and careful assessment of the extremity vascular and neurologic status is essential because of the possibility of arterial and/or venous compromise, and nerve injury. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Surgical timing depends on the injured ligaments, vascular status of the extremity, reduction stability, and the overall health of the patient. The use of allograft tissue is preferred because of the strength of these large grafts, and the absence of donor site morbidity.     

四肢软组织损伤的评估与治疗

软组织损伤通常是指皮肤、皮下组织、筋膜、肌肉、肌腱、韧带、滑膜、关节囊等软组织及周围神经、血管的损伤。四肢软组织损伤在临床工作中常会遇到,处理不当会使治疗周期大大延长,增加致残率和病死率,降低患者生活质量,对患者和社会造成严重影响。对软组织损伤严重性的评估,不仅是对患者整体评价的一个重要组成部分,而且也影响着骨折的处理。随着科技的迅速发展和机械化程度的不断提高,使得机械化因素在各类致伤因素中成为主要因素,尤其是交通事故等引起的各类高能量损伤,往往都是多发伤,伤情大多较严重。因此,充分认识软组织的损伤程度并正确处理,是创伤和骨折得以有效治疗的基础。     

十二指肠损伤的处理及死亡原因分析

目的 十二指肠损伤及处理中应注意的问题及应吸取的教训。方法 对十二指肠损伤早期临床特征,处理方法及造成死亡的原因进行分析。结果 ２７例均进行手术治疗,治愈２３例,死亡４例。死亡率为１４．８％,术后并发症发生率为４４．４％。结论十二指肠损伤治疗成败的关键是掌握好早期手术探查指征和选择的合适的术式。     

Phlebography in recent injuries of the lower limbs. Its role in operative decisions

67 patients were transferred to a traumatology centre within a mean period of 8 days following an accident in order to envisage treatment of their fractures. Routine pre-operative phlebography was undertaken in 37 patients. It detected the presence of thromboses in 46% of cases. Anticoagulant treatment was started immediately and the date of orthopaedic surgery delayed because of the risk of pulmonary embolism.     

交通事故致下肢大面积皮肤撕脱伤的治疗

目的 探讨交通事故致下肢大面积皮肤撕脱伤的治疗。方法 回顾分析我科收治的30例（34处）交通事故致下肢大面积皮肤撕脱伤的诊治。本组8例截肢;7例皮肤原位缝合;2例中厚皮片游离植皮;10例（12处）去脂全厚皮片开窗回植;1例皮下置管引流,加压包扎;1例穿刺抽吸加压包扎;1例I期腓肠神经营养逆行岛状皮瓣转移;1例自体表皮细胞复合同种异体皮肤覆盖创面。同时处理合并损伤。结果 平均随访21个月。本组1期全部/大部皮片和皮瓣成活共23处,成功率67.6%。4例大面积皮片坏死,Ⅱ期行局部皮瓣或肌皮瓣转移,全厚皮片、皮瓣或肌皮瓣成活后功能良好。结论 准确判断伤情和正确选用创面修复方法是确保治疗成功的关键。     

开放性腹部外伤102例救治分析

目的探讨开放性腹部外伤的早期诊断和救治方法。方法回顾性总结2001年2月—2011年12月收治的102例开放性腹部外伤患者的临床资料。结果 102例患者治愈98例,死亡4例(2例失血性休克死亡,1例术后腹腔严重感染死亡,1例术后多器官功能衰竭死亡),救治成功率96.1%。结论开放性腹部外伤的救治重点在于早期正确判断是否存在穿透伤、腹腔内脏器损伤及是否需要急诊剖腹探查。应当根据患者受伤过程、腹部体征结合必要的检查来把握剖腹探查指征。一旦发现剖腹探查指征,应尽早手术探查。仔细、全面、有序的剖腹探查是手术成功的关键。开放性腹部外伤腹腔镜探查具有早期诊断、治疗和创伤小、并发症少等优点,但应严格掌握适应证。     

游离皮瓣修复小儿肢体严重损伤的术后护理

近年来,皮神经营养皮瓣很大程度上代替了吻合血管的游离皮瓣,而游离皮瓣对局部血供的主动改善是皮神经营养皮瓣无可比拟的[1].小腿内侧皮瓣可在止血带下快速切取,含全套深浅血管、皮神经,可用于桥接重建循环,修复方便,针对小儿肢体创伤可进行Ⅰ期修复,具有良好外形及功能修复以及减轻患儿痛苦、经济负担等特殊意义.1999年1月～2006年7月我院对10例合并软组织缺损的小儿严重肢体损伤运用吻合血管的小腿内侧皮瓣修复,取得满意疗效,现将护理体会报告如下.1 临床资料