损伤控制理论在合并骨折多发伤中的临床应用研究
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摘要
目的
本研究旨在通过筛选临床大量的病例,以取得完整资料,总结和分析合并骨折多发伤的病情特点及损伤控制处理的临床疗效,为临床上此类病人的病情评估、治疗选择、手术时机、手术方式及预后提供初步依据。
方法
回顾性分析我院2007年1月～2010年4月救治的98例合并骨折严重多发伤患者临床资料,另采用ISS评分对病人进行评估,术前ISS评分按ISS值16～24分为A组,25～34分为B组,≥35分为C组,通过年龄、ISS评分、损伤部位、手术部位、伤后确定性手术时间、输血量、住院时间、并发症发生率、死亡率等指标进行统计学分析,对患者进行疗效评估。
结果
1、其中男性75例,女性23例,男女比例3.26：1。年龄4～80岁,平均年龄为(31.44±15.02)岁。高发年龄为21～30岁和31～40岁,分别占30.61%和29.59%。道路交通伤为首位致伤原因,共53例(54.1%),其次为高处坠落伤,共18例(18.4%),其余分别为重物砸伤13例(13.3%)、刀伤7例(7.1%),机器伤5例(5.1%),爆炸伤2例(2.0%)。损伤部位共284处,平均伤处2.90处,其中以颅脑损伤39处,面部34处,颈部8处,胸部29处、腹部26处,脊柱24处、上肢49处,下肢69处,体表其他6处。ISS评分16～75分,平均(27.10±9.24)分。痊愈和好转共81例,总抢救成功率为82.65%；死亡和病危放弃治疗出院共17例,合计死亡率17.35%。死亡与存活患者两组各指标比较,死亡组高处坠落伤患者的比例明显高于存活组,颅脑损伤为最主要的受伤部位,死亡组ISS评分平均值明显高于存活组。主要死因为出血性休克、多器官功能不全综合征和中枢性呼吸衰竭。
2、按ISS评分值分为3组：A组16～24分41例,年龄33.49±15.84岁,平均ISS评分19.22±2.89分,损伤部位数2.82±0.62,手术部位数1.18±0.83,伤后确定性手术时间7.31±6.23天,输血量182.49±262.25ml,住院时间31.98±12.56天,并发症率9.76%,死亡率4.88%；
B组25～34分38例,年龄32.16±13.63岁,平均ISS评分28.79±3.11分,损伤部位数2.91±0.48；手术部位数1.63±0.46,伤后确定性手术时间14.78±7.03天,输血量462.89±488.73ml,住院时间45.50±16.72天,并发症率43.56%,死亡率7.89%；
C组≥35分19例,年龄30.16±15.42岁,平均ISS评分40.74±8.84分,损伤部位数3.10±0.51；手术部位数2.15±0.71,伤后确定性手术时间19.21±6.45天,输血量815.79±964.95ml,住院时间18.89±21.40天,并发症率84.21%,死亡率63.16%。
3、统计学分析,A、B、C三组年龄、损伤部位比较无显著性差异(P＞0.05),输血量、住院天数、手术部位、确定性手术时间,并发症及死亡率比较具有显著差异(P<0.05)。
结论
1.合并骨折多发伤患者高发年龄为21～30岁和31～40岁,道路交通伤为首位致伤原因,总抢救成功率为82.65%。致伤原因高处坠落伤、合并颅脑损伤的骨折合并多发伤患者具有较高的死亡率。
2.随着ISS评分增加,患者救治过程更复杂,病程更长。ISS值25～34组,并发症发生率43.56%,ISS值≥35病例死亡率达到63.16%,因此我们应当将更多的治疗注意力放在ISS值25以上的病例,以降低并发症及进一步改善患者预后情况。
3.采用损伤严重度评分法有助于临床上对合并骨折多发伤患者的伤情评估、手术时机确定、治疗选择及预后判定。患者全身情况稳定性及病情需要决定确定性手术时机。
4.合并骨折多发伤的合理处理需充分了解患者病理生理状态、正确的伤员分类和时间选择,以合理计划治疗。多发伤应作为全身性疾病处理,其首要目的是挽救生命。先尽可能减少生理状态干扰,损害控制,再进行确定性手术。损害控制理论救治合并骨折多发伤这一复杂创伤,能提高救治成功率。
Objective
To analyze, summarize the characteristics of polytrauma with fractures and clinical curativie effect of damage control by screening mass clinical cases and other related datas, for the purpose of providing preliminary foundation for the evaluation of traumatic conditions, treatment preferences, operative occasion, operative technique and prognosis.
Methods
Ninety-eight cases of severe polytrauma with fractures admitted in our department from January 2007 to April 2010 were in this retrospective study. The patients were analyzed and evaluated by Injury Severity Score(ISS). They were divided into three groups according to ISS before the operation:Group A (I-SS'values from 16 to 24), Group B(ISS'values from 25 to 35), Group C(ISS'v-alues above 35). To evaluate the curative effect, the three groups were quan-titative analyzed in ISS, injured sites, operation sites, transfusion, deter-ministic operation time, length of stay, mortality rate, complications rate.
Result
1. There were 75 male and 23 female patients, male to female ratio was 3.26:1. They aged from 4 to 80 years old, the average age was 31.44±15.02 years old. The high incidence of age were 21 to 30 years old and 31 to 40 years old, accounting for 30.61%and 29.59%. Traffic accident injury was the leading cause in all with a total of 53 cases(54.1%), following by High Fall Injury,18 cases all together(18.4%),and the remaining 13 cases were Bruise (13.3%),7 cases of Wounds (7.1%), Machinery injuries in 5 cases (5.1%), Traumatic in 2 cases (2.0%). There were 284 injured sites in total, with the average were 2.90 sites. Among them, there are 39 cases of craniocerebral injury,34 of face,8 of neck, 29 of chest,26 of abdomen,24 of spine,49 of upper extremity,69 of lower extremity and 6 of the other body surface. The ISS valued from 16 to 75, the average was 27.10±9.24. A number of 81 patients were cured and improved. The total success rate was 82.65%.17 cases had been died or give up the treatment to discharged dying of an illness with the mortality rate was 17.35%to add up. To compare the indexes of death group and survival group, the proportion of High Fall Injury patients in death group was significantly higher than survival group, with craniocerebral injury was the main injuried site. The ISS score of death group was much higher than survival Group, and the other was showed in Table 1. Most of them died of hemorrhagic shock, MODS and central respiratory failure.
2. The patients were divided into 3 groups according to ISS:there were 41 cases in group A (ISS'values from 16 to 24), aged 33.49±15.84 years old, and transfusion were 182.49±262.25ml, the average ISS score was 19.22±2.89, the number of injured sites was 2.82±0.62, the number of surgical sites was 1.18±0.83, definitive operation time after operation were 7.31±6.23 days, length of stay were 31.98±12.56 days, complications rate was 9.76%, mortality rate was 4.88%.
Group B(ISS'values from 25 to 34), aged 32.16±13.63 years old, the average ISS score was 28.79±3.11, and transfusion were 462.89±488.73ml, the number of surgical sites was 1.63±0.46, definitive operation time after operation were 14.78±7.03 days, the number of injured sites was 3.10±0.51, length of stay were 45.50±16.72 days, complications rate was 43.56%, mortality rate was 7.89%.
Group C(ISS'values above 35), aged 30.16±15.42 years old, the average ISS score was 40.74±8.84, and transfusion were 815.79±964.95ml, the number of surgical sites was 2.15±0.71, definitive surgery time after operation were 19.21±6.45 days, the number of injured sites was 3.10±0.51, length of stay were 18.89±21.40 days, complications rate was 84.21%, mortality rate was 63.16%.
3. By statistical analysis, there was no significant difference among three groups in the age, injured sites (P>0.05). There was significant difference in transfusion, length of stay, operative sites, definitive surgery time, complications rate and mortality rate among the three groups (P<0.05).
Conclusion
1. The high incidence age of multiple traumas with fractures is 21to 30 years old and 31 to 40 years old. Traffic accident injury is the leading cause in all causes of trauma. The total success rate is 82.65%. The cases which are caused by High Fall Injury or associated with craniocerebral injury have higher mortality rate in the causes of trauma.
2. With the ISS score increasing, treatment process becomes more complex and the course of disease is longer. Complications rate of group 25 to 34 of ISS is 43.56%, mortality rate of ISS above 35 group reaches 63.16%。So we should be focus more attention on the cases which is valued more than 25 by ISS,in order to reduce complications and improve the prognosis of patients.
3. ISS is helpful for the evaluation of traumatic conditions, treatment preferences, operative occasion, operative technique and prognosis. Operative occasion depends on the pathogenetic condition needs and the stability of the patients'general condition.
4. Polytrauma with fractures should be considered as a systemic disease. The cognition of Pathology, Physiology, acurate injury classification and elaborative therapeutic plan was the key of successful treament. In order to save the lives of polytrauma patients and improve the physiological state, the damage control surgery should be considered first. It's valuable for improving the success rate if the treatment of polytrauma with fractures such complex trauma following the principles of damage control.
本研究旨在通过筛选临床大量的病例,以取得完整资料,总结和分析合并骨折多发伤的病情特点及损伤控制处理的临床疗效,为临床上此类病人的病情评估、治疗选择、手术时机、手术方式及预后提供初步依据。
方法
回顾性分析我院2007年1月～2010年4月救治的98例合并骨折严重多发伤患者临床资料,另采用ISS评分对病人进行评估,术前ISS评分按ISS值16～24分为A组,25～34分为B组,≥35分为C组,通过年龄、ISS评分、损伤部位、手术部位、伤后确定性手术时间、输血量、住院时间、并发症发生率、死亡率等指标进行统计学分析,对患者进行疗效评估。
结果
1、其中男性75例,女性23例,男女比例3.26：1。年龄4～80岁,平均年龄为(31.44±15.02)岁。高发年龄为21～30岁和31～40岁,分别占30.61%和29.59%。道路交通伤为首位致伤原因,共53例(54.1%),其次为高处坠落伤,共18例(18.4%),其余分别为重物砸伤13例(13.3%)、刀伤7例(7.1%),机器伤5例(5.1%),爆炸伤2例(2.0%)。损伤部位共284处,平均伤处2.90处,其中以颅脑损伤39处,面部34处,颈部8处,胸部29处、腹部26处,脊柱24处、上肢49处,下肢69处,体表其他6处。ISS评分16～75分,平均(27.10±9.24)分。痊愈和好转共81例,总抢救成功率为82.65%；死亡和病危放弃治疗出院共17例,合计死亡率17.35%。死亡与存活患者两组各指标比较,死亡组高处坠落伤患者的比例明显高于存活组,颅脑损伤为最主要的受伤部位,死亡组ISS评分平均值明显高于存活组。主要死因为出血性休克、多器官功能不全综合征和中枢性呼吸衰竭。
2、按ISS评分值分为3组：A组16～24分41例,年龄33.49±15.84岁,平均ISS评分19.22±2.89分,损伤部位数2.82±0.62,手术部位数1.18±0.83,伤后确定性手术时间7.31±6.23天,输血量182.49±262.25ml,住院时间31.98±12.56天,并发症率9.76%,死亡率4.88%；
B组25～34分38例,年龄32.16±13.63岁,平均ISS评分28.79±3.11分,损伤部位数2.91±0.48；手术部位数1.63±0.46,伤后确定性手术时间14.78±7.03天,输血量462.89±488.73ml,住院时间45.50±16.72天,并发症率43.56%,死亡率7.89%；
C组≥35分19例,年龄30.16±15.42岁,平均ISS评分40.74±8.84分,损伤部位数3.10±0.51；手术部位数2.15±0.71,伤后确定性手术时间19.21±6.45天,输血量815.79±964.95ml,住院时间18.89±21.40天,并发症率84.21%,死亡率63.16%。
3、统计学分析,A、B、C三组年龄、损伤部位比较无显著性差异(P＞0.05),输血量、住院天数、手术部位、确定性手术时间,并发症及死亡率比较具有显著差异(P<0.05)。
结论
1.合并骨折多发伤患者高发年龄为21～30岁和31～40岁,道路交通伤为首位致伤原因,总抢救成功率为82.65%。致伤原因高处坠落伤、合并颅脑损伤的骨折合并多发伤患者具有较高的死亡率。
2.随着ISS评分增加,患者救治过程更复杂,病程更长。ISS值25～34组,并发症发生率43.56%,ISS值≥35病例死亡率达到63.16%,因此我们应当将更多的治疗注意力放在ISS值25以上的病例,以降低并发症及进一步改善患者预后情况。
3.采用损伤严重度评分法有助于临床上对合并骨折多发伤患者的伤情评估、手术时机确定、治疗选择及预后判定。患者全身情况稳定性及病情需要决定确定性手术时机。
4.合并骨折多发伤的合理处理需充分了解患者病理生理状态、正确的伤员分类和时间选择,以合理计划治疗。多发伤应作为全身性疾病处理,其首要目的是挽救生命。先尽可能减少生理状态干扰,损害控制,再进行确定性手术。损害控制理论救治合并骨折多发伤这一复杂创伤,能提高救治成功率。
Objective
To analyze, summarize the characteristics of polytrauma with fractures and clinical curativie effect of damage control by screening mass clinical cases and other related datas, for the purpose of providing preliminary foundation for the evaluation of traumatic conditions, treatment preferences, operative occasion, operative technique and prognosis.
Methods
Ninety-eight cases of severe polytrauma with fractures admitted in our department from January 2007 to April 2010 were in this retrospective study. The patients were analyzed and evaluated by Injury Severity Score(ISS). They were divided into three groups according to ISS before the operation:Group A (I-SS'values from 16 to 24), Group B(ISS'values from 25 to 35), Group C(ISS'v-alues above 35). To evaluate the curative effect, the three groups were quan-titative analyzed in ISS, injured sites, operation sites, transfusion, deter-ministic operation time, length of stay, mortality rate, complications rate.
Result
1. There were 75 male and 23 female patients, male to female ratio was 3.26:1. They aged from 4 to 80 years old, the average age was 31.44±15.02 years old. The high incidence of age were 21 to 30 years old and 31 to 40 years old, accounting for 30.61%and 29.59%. Traffic accident injury was the leading cause in all with a total of 53 cases(54.1%), following by High Fall Injury,18 cases all together(18.4%),and the remaining 13 cases were Bruise (13.3%),7 cases of Wounds (7.1%), Machinery injuries in 5 cases (5.1%), Traumatic in 2 cases (2.0%). There were 284 injured sites in total, with the average were 2.90 sites. Among them, there are 39 cases of craniocerebral injury,34 of face,8 of neck, 29 of chest,26 of abdomen,24 of spine,49 of upper extremity,69 of lower extremity and 6 of the other body surface. The ISS valued from 16 to 75, the average was 27.10±9.24. A number of 81 patients were cured and improved. The total success rate was 82.65%.17 cases had been died or give up the treatment to discharged dying of an illness with the mortality rate was 17.35%to add up. To compare the indexes of death group and survival group, the proportion of High Fall Injury patients in death group was significantly higher than survival group, with craniocerebral injury was the main injuried site. The ISS score of death group was much higher than survival Group, and the other was showed in Table 1. Most of them died of hemorrhagic shock, MODS and central respiratory failure.
2. The patients were divided into 3 groups according to ISS:there were 41 cases in group A (ISS'values from 16 to 24), aged 33.49±15.84 years old, and transfusion were 182.49±262.25ml, the average ISS score was 19.22±2.89, the number of injured sites was 2.82±0.62, the number of surgical sites was 1.18±0.83, definitive operation time after operation were 7.31±6.23 days, length of stay were 31.98±12.56 days, complications rate was 9.76%, mortality rate was 4.88%.
Group B(ISS'values from 25 to 34), aged 32.16±13.63 years old, the average ISS score was 28.79±3.11, and transfusion were 462.89±488.73ml, the number of surgical sites was 1.63±0.46, definitive operation time after operation were 14.78±7.03 days, the number of injured sites was 3.10±0.51, length of stay were 45.50±16.72 days, complications rate was 43.56%, mortality rate was 7.89%.
Group C(ISS'values above 35), aged 30.16±15.42 years old, the average ISS score was 40.74±8.84, and transfusion were 815.79±964.95ml, the number of surgical sites was 2.15±0.71, definitive surgery time after operation were 19.21±6.45 days, the number of injured sites was 3.10±0.51, length of stay were 18.89±21.40 days, complications rate was 84.21%, mortality rate was 63.16%.
3. By statistical analysis, there was no significant difference among three groups in the age, injured sites (P>0.05). There was significant difference in transfusion, length of stay, operative sites, definitive surgery time, complications rate and mortality rate among the three groups (P<0.05).
Conclusion
1. The high incidence age of multiple traumas with fractures is 21to 30 years old and 31 to 40 years old. Traffic accident injury is the leading cause in all causes of trauma. The total success rate is 82.65%. The cases which are caused by High Fall Injury or associated with craniocerebral injury have higher mortality rate in the causes of trauma.
2. With the ISS score increasing, treatment process becomes more complex and the course of disease is longer. Complications rate of group 25 to 34 of ISS is 43.56%, mortality rate of ISS above 35 group reaches 63.16%。So we should be focus more attention on the cases which is valued more than 25 by ISS,in order to reduce complications and improve the prognosis of patients.
3. ISS is helpful for the evaluation of traumatic conditions, treatment preferences, operative occasion, operative technique and prognosis. Operative occasion depends on the pathogenetic condition needs and the stability of the patients'general condition.
4. Polytrauma with fractures should be considered as a systemic disease. The cognition of Pathology, Physiology, acurate injury classification and elaborative therapeutic plan was the key of successful treament. In order to save the lives of polytrauma patients and improve the physiological state, the damage control surgery should be considered first. It's valuable for improving the success rate if the treatment of polytrauma with fractures such complex trauma following the principles of damage control.
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[54]KossmannT, Trease L, FreedmanI, etal. Damage control surgery for spine trauma[J]. Injury,2004,35:661-670.
[55]Kitchel SH. Current treatment of gunshot wounds to the spine [J]. Clin Orthop Relat Res,2003,408:115119.