伴发直肠肛管损伤的开放性骨盆骨折的治疗
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摘要
目的总结伴有直肠肛管损伤的开放性骨盆骨折的临床治疗经验。
方法1998年10月-2008年10月山东省立医院创伤骨科收治的482例骨盆骨折患者,48例为开放骨盆骨折,其中45例伴有不同程度的直肠肛管损伤,回顾分析其治疗方法与临床效果。患者入院后,临床治疗按四步流程开展:1、急救复苏:抢救生命和控制出血;2、结肠造瘘与清创处理;3、骨盆骨折的治疗;4、后期创面处理。
1、急救复苏:抢救生命和控制出血是关键。患者入院后,按照高级创伤生命支持(Advanced Trauma Life Support ATLS)原则立即实施复苏。确保气道通畅并维持良好的通气,注意患者的血流动力学参数,迅速建立2条以上大的静脉通道。如果患者血压低,寻找出血原因,对显性创面出血通过压迫等进行有效止血,同时快速补液,迅速交叉配血,视病情进行输血。升压药物可酌情应用。血压极低很快危及生命的紧急情况,可给予非交叉配血的O型血,以稳定患者的血液动力学,阻止休克的发展,为其进一步剖腹探查、外固定架固定等手术止血赢得机会。即刻初步评估生命体征,注意颅脑、胸腹部等伴发损伤情况。插导尿管,观察尿道是否通畅及尿液情况,肛门指检、阴道检查等同时进行,避免对各种伴发伤的漏诊。达到挽救生命,降低死亡率,成功复苏的目的。本组45例患者我们按照晶胶结合原则进行扩容,扩容后根据血流动力学情况,均进行了输血,输血400～8000 ml不等,平均2600 ml。以上抢救我们在2～4小时内,平均2.5小时完成。急救复苏过程中3例因失血性休克死亡,42例血流动力学及生命体征获得并维持平稳,进入下一步的结肠造瘘及清创处理。
2、造瘘及清创处理:常规全麻,请普外科医师协助行剖腹探查,若估计生命体征仍会失稳,可先行暂时性腹主动脉阻断术。方法:行股动脉穿刺或纵行切开,置入Forgarty导管,置入导管长度以距腹股沟韧带20～25cm(肾动脉以下)为宜,导管气囊充水10～15ml阻断腹主动脉。对直肠肛管损伤的处理原则为:1、对7例腹膜内直肠损伤的处理:修补直肠破损、乙状结肠造瘘、直肠后间隙引流;2、对23例腹膜外直肠损伤的处理:及时清创,修补直肠破损,乙状结肠造瘘及充分骶前引流;3、对12例肛管损伤的处理:视损伤与污染严重程度,9例单纯性括约肌断裂者用肠线将括约肌断端按层次Ⅰ期缝合,放置引流。3例因损伤及污染严重或并发血肿感染,估计易导致括约肌修补失败,行清创引流及结肠造瘘术后,留待Ⅱ期处理。对直肠肛管损伤以外的伴发伤,亦联合相关科室医师积极处理。本组其他伴发损伤处理情况:胸腔闭式引流5例,脾切除5例,小肠修补5例,膀胱修补28例,早期尿道会师牵引19例,膀胱造瘘34例,阴道修补8例,髂内动脉结扎7例,四肢血管修补、吻合8例。开放创面均经彻底、细致的清创,根据情况争取Ⅰ期、延迟Ⅰ期闭合,创面污染重、条件差时行皮瓣转移或Ⅱ期植皮闭合。
3、骨盆骨折的治疗:造瘘、清创及相关损伤获得有效处理,根据病情特点:7例行一期骨盆外固定架临时固定稳定血流动力学。1例Tile A稳定型骨折行清创、保守治疗。41例行骨盆骨折切开复位内固定术(open reduction and internalfixation,ORIF)的患者,占97.62%,对于Tile B、Tile C不稳定型骨盆骨折手术时机选在病情稳定后3～7天,最长离受伤时不超过2周。术前或术中均行影像学检查,明确骨折类型,以及骨牵引等相关术前准备。21例伴发的四肢骨折亦先后切开复位内固定术。
4、后期创面处理:严格有效清创术后,争取Ⅰ期闭合创面,情况差时可考虑转移皮瓣处理或留待Ⅱ期植皮。保持术中留置引流管的通畅,根据药敏使用广谱敏感抗生素,严格按照无菌原则更换敷料,保持创面的清洁,避免继发感染,促进创面的早期修复。
结果本组45例患者,42例存活并接受后续治疗,且获得了12—48个月(平均18个月)的随访。急救复苏:3例死于失血性休克死亡。直肠肛管损伤:39例治愈,3例改善。骨盆骨折:按Majeed疗效评价,获优8例,良26例,中6例,差2例,优良率为80.95%。创面愈合:23例创面于Ⅰ期、延迟Ⅰ期闭合,16例经转移皮瓣处理或Ⅱ期植皮及顺利愈合。2例创面有不同程度感染,经加强换药、引流及抗炎后愈合。1例Ⅰ期行双侧睾丸移位置于腹部皮下及右股骨中上段截肢转移皮瓣覆盖会阴创面,Ⅱ期再造阴囊,复位睾丸。
结论对于伴发直肠肛管损伤的开放性骨盆骨折,应重视急救复苏,加强多学科协同诊疗,积极处理直肠肛管损伤,正确治疗骨盆骨折,才能获得良好效果。
Objective To investigate the clinical treatment options and manage experience of open pelvic fractures associated with anorectal injuries.
Methods We retrospectively reviewed the medical charts and images of 45 patients who sustained a open pelvic fracture associated with anorectal injuries and were treated at our department between October 1998 and October 2008. The treatment protocols were divided into four steps. First of all, rescuing block and controlling massive hemorrhage were the key points of rescue. Subsequently, sigmoid colon ostomy and debridement were used to deal with anorectal injuries and wounds. The next step was the treatment of pelvic fractures. Last but not least, wounds treatings were dealt with.
1, first-aid recovery: To save lives and control of bleeding are the keypoints. Patients after admission, first-aid recovery was implemented immediatly in accordance with ATLS principles. To ensure airway patency and maintain good ventilation, attention should be paid to hemodynamic parameters of patients and two or more large vein channels were set up rapidly. If patients with low blood pressure, we looked for the causes of bleeding carefully and stopped bleeding on the overt wound with oppression in order to ensure effective hemostasis. At the same time, the rapid rehydration, rapid cross matching of blood, and a blood transfusion were done depending on the conditions . Medicines for elevating blood pressure were applied if necessary. As for low life-threatening blood pressure emergencies ,non-cross matching type O blood may be granted to patients in order to obtain hemodynamic stability and prevent the development of shock.Measures taken formerly win the opportunity to further exploratory laparotomy, external fixation, and surgery to stop bleeding. While immediate preliminary assessment of vital signs which including paying attention to head, chest and abdomen injuries, etc was executed. Observeing whether the patency of urethra by catheter inserting ,vaginal examination and urine anal examination were conducted at the same time.It was important to avoid missed diagnosis of injuries associated with pelvic fractures.To save the lives of patients and reduce mortality was the success of first-aid recovery. 45 cases of patients in this group are all received blood transfusion which varied from 400 to 8000 ml,average 2600ml in accordance with the principles of crystal plastic combination .It took us 2～4 hours which was at an average of 2.5 hours to accomplish first-aid recovery. First aid in the recovery process ,there were three cases of death due to hemorrhagic shock, 42 cases which obtained stable hemodynamics and vital signs and entered the next phase of colon ostomy and debridement treatment.
2, ostomy and debridement treatment: Under conventional anesthesia, exploratory laparotomy was executed with the help of general surgery doctors.If there were still unstable vital signs, a temporary abdominal aortic cross-clamping techniques was received in advance. Methods: After the femoral artery puncture or longitudinal incision , we placed Forgarty catheter into abdominal aorta whose insertion length was approximately 20～25cm from the inguinal ligament to renal artery below.A balloon filled with 10～15ml water blocked abdominal aorta. The principles of anorectal injury treatment are: 1, 7 cases of intraperitoneal rectal injuries: repairing the damaged recta, making a sigmoid ostomy, and keeping retrorectal space drainage ;
2, 23 cases of extraperitoneal rectal injuries:debriding in time,repairing the damaged recta, making a sigmoid ostomy and keeping fully presacral drainage; 3, 12 cases of anal injuries :9 cases of simple sphincter fractures sutured at stage I and kept continuous drainage. 3 cases of serious polluted injuries were debrided and kept fully drainage at stage I and other repairs were left at stage II. Besides anorectal injuries, other injuries treatment in this group included: 5 cases of closed thoracic drainage, splenectomy in 5 cases ,5 cases of small intestinal repair, 28 cases of bladder repair, early urethral realignment traction in 19 cases, 34 cases of cystostomy, 8 cases of vaginal repair,7 cases of internal iliac artery ligation , 8 cases of limb vascular patch or anastomosis. After thorough and careful debridement, open wounds were closed at stage I, delayed stage I depending on the circumstances . Wounds with heavy pollution and bad conditions were closed in stage II.
3, pelvic fractures: According to the characteristics of the pelvic fractures,the treatments were executed:a temporary pelvic external fixator fixed in 7 cases. One Tile A stable fracture case received conservative therapy after ostomy and debridement. 41eases with ORIF, accounting for 97. 62 percent of all patients. As for Tile B or Tile C unstable pelvic fractures which were in stable condition through 3～7 days recoveries, the longest from the injury was not more than two weeks,surgical reductions and fixations were executed. They were all performed imaging examinations to define a clear fracture type as well as skeletal tractions and other related pre-operative preparations. 21 cases associated with limb fractures were also received ORIF.
4, the latter wound treatment: It was essential for wounds early repairs to maintain the patency of indwelling drainage tube, to use broad-spectrum and drug-sensitive antibiotics, to replace dressings in strict accordance with the principle sterile , and to keep the wounds clean without secondary infections.
Results There were 3 deaths of all cases. A total of 42 patients were followed up. The follow up period ranged from 12 to 48 months with an average of 18 months. For anorectal injuries,39 cases obtained satisfactory therapeutic results except 3 cases which had an improvement . According to the Majeed evaluation, the results of pelvic fractures were as followes: 8 cases were excellent, 26 cases were good, 6 cases were fair, and only 2 cases was a failure. The rate of excellency and goodness was 80. 95%. As far as the results of the wound healing: 23 cases were healed at the stage of I or delayed I,16 patients were healed with transferring of skin or flaps of their own at stage II ,2 cases which suffered various degrees of wound infections,obtained acceptable results by intensive dressing changes, drainages and the anti-inflammatory. One patient was dealt with transfering of the right upper femur myocutaneous flap formed by amputation to cover the exposed perineum and translocation bilateral testes translocation into abdominal subcutis respectively at stage I . Scrotum reconstruction and testes reduction were accomplished at stage II .
Conclusions As for an open pelvic fracures associated with anorectal injuries case,a good outcome may only be achieved on the basis of the first aid and resuscitation ,aggressive managements of anorectal injuries and proper managements of pelvic fractures taken by orthopaedists in cooperation with multidisciplinary specialists.
方法1998年10月-2008年10月山东省立医院创伤骨科收治的482例骨盆骨折患者,48例为开放骨盆骨折,其中45例伴有不同程度的直肠肛管损伤,回顾分析其治疗方法与临床效果。患者入院后,临床治疗按四步流程开展:1、急救复苏:抢救生命和控制出血;2、结肠造瘘与清创处理;3、骨盆骨折的治疗;4、后期创面处理。
1、急救复苏:抢救生命和控制出血是关键。患者入院后,按照高级创伤生命支持(Advanced Trauma Life Support ATLS)原则立即实施复苏。确保气道通畅并维持良好的通气,注意患者的血流动力学参数,迅速建立2条以上大的静脉通道。如果患者血压低,寻找出血原因,对显性创面出血通过压迫等进行有效止血,同时快速补液,迅速交叉配血,视病情进行输血。升压药物可酌情应用。血压极低很快危及生命的紧急情况,可给予非交叉配血的O型血,以稳定患者的血液动力学,阻止休克的发展,为其进一步剖腹探查、外固定架固定等手术止血赢得机会。即刻初步评估生命体征,注意颅脑、胸腹部等伴发损伤情况。插导尿管,观察尿道是否通畅及尿液情况,肛门指检、阴道检查等同时进行,避免对各种伴发伤的漏诊。达到挽救生命,降低死亡率,成功复苏的目的。本组45例患者我们按照晶胶结合原则进行扩容,扩容后根据血流动力学情况,均进行了输血,输血400～8000 ml不等,平均2600 ml。以上抢救我们在2～4小时内,平均2.5小时完成。急救复苏过程中3例因失血性休克死亡,42例血流动力学及生命体征获得并维持平稳,进入下一步的结肠造瘘及清创处理。
2、造瘘及清创处理:常规全麻,请普外科医师协助行剖腹探查,若估计生命体征仍会失稳,可先行暂时性腹主动脉阻断术。方法:行股动脉穿刺或纵行切开,置入Forgarty导管,置入导管长度以距腹股沟韧带20～25cm(肾动脉以下)为宜,导管气囊充水10～15ml阻断腹主动脉。对直肠肛管损伤的处理原则为:1、对7例腹膜内直肠损伤的处理:修补直肠破损、乙状结肠造瘘、直肠后间隙引流;2、对23例腹膜外直肠损伤的处理:及时清创,修补直肠破损,乙状结肠造瘘及充分骶前引流;3、对12例肛管损伤的处理:视损伤与污染严重程度,9例单纯性括约肌断裂者用肠线将括约肌断端按层次Ⅰ期缝合,放置引流。3例因损伤及污染严重或并发血肿感染,估计易导致括约肌修补失败,行清创引流及结肠造瘘术后,留待Ⅱ期处理。对直肠肛管损伤以外的伴发伤,亦联合相关科室医师积极处理。本组其他伴发损伤处理情况:胸腔闭式引流5例,脾切除5例,小肠修补5例,膀胱修补28例,早期尿道会师牵引19例,膀胱造瘘34例,阴道修补8例,髂内动脉结扎7例,四肢血管修补、吻合8例。开放创面均经彻底、细致的清创,根据情况争取Ⅰ期、延迟Ⅰ期闭合,创面污染重、条件差时行皮瓣转移或Ⅱ期植皮闭合。
3、骨盆骨折的治疗:造瘘、清创及相关损伤获得有效处理,根据病情特点:7例行一期骨盆外固定架临时固定稳定血流动力学。1例Tile A稳定型骨折行清创、保守治疗。41例行骨盆骨折切开复位内固定术(open reduction and internalfixation,ORIF)的患者,占97.62%,对于Tile B、Tile C不稳定型骨盆骨折手术时机选在病情稳定后3～7天,最长离受伤时不超过2周。术前或术中均行影像学检查,明确骨折类型,以及骨牵引等相关术前准备。21例伴发的四肢骨折亦先后切开复位内固定术。
4、后期创面处理:严格有效清创术后,争取Ⅰ期闭合创面,情况差时可考虑转移皮瓣处理或留待Ⅱ期植皮。保持术中留置引流管的通畅,根据药敏使用广谱敏感抗生素,严格按照无菌原则更换敷料,保持创面的清洁,避免继发感染,促进创面的早期修复。
结果本组45例患者,42例存活并接受后续治疗,且获得了12—48个月(平均18个月)的随访。急救复苏:3例死于失血性休克死亡。直肠肛管损伤:39例治愈,3例改善。骨盆骨折:按Majeed疗效评价,获优8例,良26例,中6例,差2例,优良率为80.95%。创面愈合:23例创面于Ⅰ期、延迟Ⅰ期闭合,16例经转移皮瓣处理或Ⅱ期植皮及顺利愈合。2例创面有不同程度感染,经加强换药、引流及抗炎后愈合。1例Ⅰ期行双侧睾丸移位置于腹部皮下及右股骨中上段截肢转移皮瓣覆盖会阴创面,Ⅱ期再造阴囊,复位睾丸。
结论对于伴发直肠肛管损伤的开放性骨盆骨折,应重视急救复苏,加强多学科协同诊疗,积极处理直肠肛管损伤,正确治疗骨盆骨折,才能获得良好效果。
Objective To investigate the clinical treatment options and manage experience of open pelvic fractures associated with anorectal injuries.
Methods We retrospectively reviewed the medical charts and images of 45 patients who sustained a open pelvic fracture associated with anorectal injuries and were treated at our department between October 1998 and October 2008. The treatment protocols were divided into four steps. First of all, rescuing block and controlling massive hemorrhage were the key points of rescue. Subsequently, sigmoid colon ostomy and debridement were used to deal with anorectal injuries and wounds. The next step was the treatment of pelvic fractures. Last but not least, wounds treatings were dealt with.
1, first-aid recovery: To save lives and control of bleeding are the keypoints. Patients after admission, first-aid recovery was implemented immediatly in accordance with ATLS principles. To ensure airway patency and maintain good ventilation, attention should be paid to hemodynamic parameters of patients and two or more large vein channels were set up rapidly. If patients with low blood pressure, we looked for the causes of bleeding carefully and stopped bleeding on the overt wound with oppression in order to ensure effective hemostasis. At the same time, the rapid rehydration, rapid cross matching of blood, and a blood transfusion were done depending on the conditions . Medicines for elevating blood pressure were applied if necessary. As for low life-threatening blood pressure emergencies ,non-cross matching type O blood may be granted to patients in order to obtain hemodynamic stability and prevent the development of shock.Measures taken formerly win the opportunity to further exploratory laparotomy, external fixation, and surgery to stop bleeding. While immediate preliminary assessment of vital signs which including paying attention to head, chest and abdomen injuries, etc was executed. Observeing whether the patency of urethra by catheter inserting ,vaginal examination and urine anal examination were conducted at the same time.It was important to avoid missed diagnosis of injuries associated with pelvic fractures.To save the lives of patients and reduce mortality was the success of first-aid recovery. 45 cases of patients in this group are all received blood transfusion which varied from 400 to 8000 ml,average 2600ml in accordance with the principles of crystal plastic combination .It took us 2～4 hours which was at an average of 2.5 hours to accomplish first-aid recovery. First aid in the recovery process ,there were three cases of death due to hemorrhagic shock, 42 cases which obtained stable hemodynamics and vital signs and entered the next phase of colon ostomy and debridement treatment.
2, ostomy and debridement treatment: Under conventional anesthesia, exploratory laparotomy was executed with the help of general surgery doctors.If there were still unstable vital signs, a temporary abdominal aortic cross-clamping techniques was received in advance. Methods: After the femoral artery puncture or longitudinal incision , we placed Forgarty catheter into abdominal aorta whose insertion length was approximately 20～25cm from the inguinal ligament to renal artery below.A balloon filled with 10～15ml water blocked abdominal aorta. The principles of anorectal injury treatment are: 1, 7 cases of intraperitoneal rectal injuries: repairing the damaged recta, making a sigmoid ostomy, and keeping retrorectal space drainage ;
2, 23 cases of extraperitoneal rectal injuries:debriding in time,repairing the damaged recta, making a sigmoid ostomy and keeping fully presacral drainage; 3, 12 cases of anal injuries :9 cases of simple sphincter fractures sutured at stage I and kept continuous drainage. 3 cases of serious polluted injuries were debrided and kept fully drainage at stage I and other repairs were left at stage II. Besides anorectal injuries, other injuries treatment in this group included: 5 cases of closed thoracic drainage, splenectomy in 5 cases ,5 cases of small intestinal repair, 28 cases of bladder repair, early urethral realignment traction in 19 cases, 34 cases of cystostomy, 8 cases of vaginal repair,7 cases of internal iliac artery ligation , 8 cases of limb vascular patch or anastomosis. After thorough and careful debridement, open wounds were closed at stage I, delayed stage I depending on the circumstances . Wounds with heavy pollution and bad conditions were closed in stage II.
3, pelvic fractures: According to the characteristics of the pelvic fractures,the treatments were executed:a temporary pelvic external fixator fixed in 7 cases. One Tile A stable fracture case received conservative therapy after ostomy and debridement. 41eases with ORIF, accounting for 97. 62 percent of all patients. As for Tile B or Tile C unstable pelvic fractures which were in stable condition through 3～7 days recoveries, the longest from the injury was not more than two weeks,surgical reductions and fixations were executed. They were all performed imaging examinations to define a clear fracture type as well as skeletal tractions and other related pre-operative preparations. 21 cases associated with limb fractures were also received ORIF.
4, the latter wound treatment: It was essential for wounds early repairs to maintain the patency of indwelling drainage tube, to use broad-spectrum and drug-sensitive antibiotics, to replace dressings in strict accordance with the principle sterile , and to keep the wounds clean without secondary infections.
Results There were 3 deaths of all cases. A total of 42 patients were followed up. The follow up period ranged from 12 to 48 months with an average of 18 months. For anorectal injuries,39 cases obtained satisfactory therapeutic results except 3 cases which had an improvement . According to the Majeed evaluation, the results of pelvic fractures were as followes: 8 cases were excellent, 26 cases were good, 6 cases were fair, and only 2 cases was a failure. The rate of excellency and goodness was 80. 95%. As far as the results of the wound healing: 23 cases were healed at the stage of I or delayed I,16 patients were healed with transferring of skin or flaps of their own at stage II ,2 cases which suffered various degrees of wound infections,obtained acceptable results by intensive dressing changes, drainages and the anti-inflammatory. One patient was dealt with transfering of the right upper femur myocutaneous flap formed by amputation to cover the exposed perineum and translocation bilateral testes translocation into abdominal subcutis respectively at stage I . Scrotum reconstruction and testes reduction were accomplished at stage II .
Conclusions As for an open pelvic fracures associated with anorectal injuries case,a good outcome may only be achieved on the basis of the first aid and resuscitation ,aggressive managements of anorectal injuries and proper managements of pelvic fractures taken by orthopaedists in cooperation with multidisciplinary specialists.
引文
1. Brenneman FD, Kaytal D, Boulanger BR, et al. Long term outcome in open pelvic fractures. J Trauma 1997, 42:773-777.
2. Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe haemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001, 15:468-474.
3. Rommens PM, Hessmann MH. Staged reconstruction of pelvic ring disruption: differences in morbidity, mortality,radiologic results and functional outcomes between B1,B2/B3 and C-type lesions. J Orthop Trauma 2002, 16:92-98.
4. Rommens PM. Pelvic ring injuries: a challenge for the trauma surgeon. Acta Chir Belg 1996, 96:78-84.
5. Tucker MC, Nork SE, Simonian PT, Routt Jr ML. Simple anterior pelvic external fixation. J Trauma 2000, 49:989-994.
6.Tile M Acute pelvic fractures 1 Causation and Classification [J ] .Am Acad Orthop Surg ,1996 ,4 (1) :1432-1461
7 Majeed SA.Grading outcome of pelvic fractures[J].J Bone Joint Surg (Br),1989,71(2):304-306.
8 Ber MY,Cddwell DM ,Young JWR ,etal.Hemorrhage associated pelvic fractures : causes ,diagnosis ,and emergent management [J] . Am J Roentgenol ,1991 ,157(8):10052-10111
9 Bolter S , Haueisen H ,Renner N , et al.Inferior epigastric artery : An atypical source of bleeding in pelvic fracture [J] .Unfallchirurg ,2000 ,103 (4) :3182-3211
10 Davidson BS, Simmons GT, Williamson PR, et al. Pelvic fractures with open perineal wounds: a survivable injury. J Trauma 1993;35:36-39.
11 Ferrera PC, Hill DA. Good outcomes of open pelvic fractures. Injury 1999;30:187-90.
12 Hanson PB, Milne JC, Chapman MW. Open fractures of the pelvis, review of 43 cases. J Bone Joint Surg 1991;74:325-329.
13 Govender S, Sham A, Singh B. Open pelvic fractures. Injury 1990;21:373-376.
14 Leenen LP, van der Werken C, Schoots F, Goris RJ. Internal fixation of open pelvic fractures. J Trauma 1993;35:220-225.
15 Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for trauma centers. Am J Surg 1992; 163:283-287.
16 Poka A , Libby EP. Indications and techniques for external fixation of the pelvis. Clin Orthop , 1996 , (329) :56 - 59.
17 Matta J , Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop , 1989 , (242) :83 -97.
18 周东生,主编.骨盆创伤学.第1版.济南：山东科学技术出版社,2003. 139-143.
19 Pohlemann T. Internal stabilization of pelvic ring fractures. SICOT V VIE World Congress. Montreal, 1990. 353.
20 Katsoulis E ,Giannoudis PV.Impact of timing of pelvic fixation on functional outcome.Injury,2006,37(12):1133-1142.
21 周东生,穆卫东,王鲁博等.多排螺旋CT三维血管成像技术在不稳定骨盆骨折中的应用[J].中华骨科杂志,2006,26(6):424-426.
22 ZHU Li-jun,GU Li-qiang,PEI Guo-xian.Damage control orthopaedics:state of the art mangement of polytrauma,Zhonghua Chuangshang Guke Zazhi(Chin J Orthop Trauma),2004,6(4):439-442
23 Giannoudis PV.Surgical priorities in damage control in polytrauma.J Bone Joint Surg(Br),2003,85:478-483.
24 周东生,黄涛,王鲁博.术中导航三维影像系统辅助置入骶骨钉微创治疗骶髂关节脱位[J].临床骨科杂志,2007,10(1):1-3.
25 周东生,主编.实用骨科导航技术.第1版.济南:山东科学技术出版社,2007.162-177.
26 Davidson BS,Simmons GT,Williamson PR,et al.Pelvic fractures associated with open perineal wounds:a survivable injury[J].Journal of Trauma,1993,35(1):362-431.
1.Brenneman FD,Kaytal D,Boulanger BR,et al.Long term outcome in open pelvic fractures.J Trauma 1997,42:773-777.
2.Ertel W,Keel M,Eid K,Platz A,Trentz O.Control of severe haemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption.J Orthop Trauma 2001,15:468-474.
3.Rommens PM,Hessmann MH.Staged reconstruction of pelvic ring disruption:differences in morbidity,mortality,radiologic results and functional outcomes between B1,B2,B3 and C-type lesions.J Orthop Trauma 2002,16:92-98.
4.Rommens PM.Pelvic ring injuries:a challenge for the trauma surgeon.Acta Chir Belg 1996,96:78-84.
5.Tucker MC,Nork SE,Simonian PT,Routt Jr ML.Simple anterior pelvic external fixation.J Trauma 2000,49:989-994.
6周东生,黄涛,王鲁博.术中导航三维影像系统辅助置入骶骨钉微创治疗骶髂关节脱位[J].临床骨科杂志,2007,10(1):1-3.
7周东生,主编.实用骨科导航技术.第1版.济南:山东科学技术出版社,2007.162-177.
8朱立军,顾立强,裴国献.伤害控制骨科学-多发伤治疗最新观点[J].中华创伤骨科杂志,2004,(04)
9 Ertel W,Eid K,Keel M,et al.Therapeutical strategies and outcome of polytraumatized patients with pelvic injuries:a six - year experience.Euro J Trauma,2000,26:278-286.
10 Pohlemann T,Culemann U.Summary of controversial debates during the 5th "Homburg pelvic Course" 13-15 September 2006.Injury,2007,38(4):424-30.
11 Ertel W,Keel M,Eid K,et al.Control of severe hemorrhage using C - clamp and pelvic packing in multiply injured patients with pelvic ring disruption.J Orthop Trauma,2001,15:468- 474.
12 周东生,穆卫东,王鲁博等.多排螺旋CT三维血管成像技术在不稳定骨盆骨折中的应用[J].中华骨科杂志,2006,26(6):424-426.
13 高劲谋,胡平,田显扬,李昌华,赵山弘,杨俊,林曦.髂内动脉断血术在创伤急救中的应用[J]中华急诊医学杂志,2005,(08).
14 吴伟军,朱少俊,郑志强.双侧髂内动脉结扎治疗骨盆骨折及盆底创伤大出血[J]浙江医学,2001,(06).
15 梁庆芝,陈鸿儒.双侧髂内动脉结扎治疗骨盆骨折大出血[J]中华创伤杂志,1996,(04).
16 Key NS,Aledort LM,Beardsley D,et al.Home treatment of mild to moderate bleeding episodes using recombinant factor VIIa(Novo-Seven) in haemophiliacs with inhibitors.Thromb Haemost,1998,80:912.
17 Davidson BS,Simmons GT,Williamson PR,et al.Pelvic fractures with open perineal wounds:a survivable injury.J Trauma 1993;35:36-39.
18 Ferrera PC,Hill DA.Good outcomes of open pelvic fractures.Injury 1999;30:187-190.
19 Hanson PB,Milne JC,Chapman MW.Open fractures of the pelvis,review of 43cases.J Bone Joint Surg 1991;74:325-329
20 Govender S,Sham A,Singh B.Open pelvic fractures.Injury 1990;21:373-376.
21 Leenen LP,van der Werken C,Schoots F,Goris RJ.Internal fixation of open pelvic fractures.J Trauma 1993;35:220-225.
22 Sinnott R,Rhodes M,Brader A.Open pelvic fracture:an injury for trauma centers.Am J Surg 1992;163:283-287.
23 Kim S,Linden B,Cendron M,etal.Pediatric anorectal impalement with bladder rup ture:case report and review of the literature[J].J Pediatr Surg,2006,41(9):E1- E3.
24 Devine PC,Devine CJ.Posterior urethral injuries associated with pelvic fractures.Urology,1982,20:467-469.
25 Tauber M,Joos H,Karpik S,etal.Urogenital injuries accompanyingpelvicringfractures[J].Unfallchirurg,2007,110(2):116 - 123.
26 Tayal V S,Nielsen A,Jonesa E,et al.Accuracy of trauma ultrasound in major pelvic injury[J].J Trauma,2006,61(6):1 453 - 1 457.
27 Herschorn S,Thijssen A,Radomski SB.The value of immediate or early catheterization of the traumatized posterior urethra[J].J Urol,1992,148:1428 -1431.
28 王良,郑伟,蔡玉群,张伟江.骨盆骨折合并会阴、阴道损伤八例临床分析.中华妇产科杂志,2004,39(3):191
29 Davidson BS,Simmons GT,Williamson PR,et al.Pelvic fractures with open perineal wounds:a survivable injury.J Trauma 1993;35:36-39.
30 Ferrera PC,Hill DA.Good outcomes of open pelvic fractures.Injury 1999;30:187-90.
31 Hanson PB,Milne JC,Chapman MW.Open fractures of the pelvis,review of 43cases.J Bone Joint Surg 1991;74:325-329.
32 Govender S,Sham A,Singh B.Open pelvic fractures.Injury 1990;21:373-376.
33 Leenen LP,van der Werken C,Schoots F,Goris RJ.Internal fixation of open pelvic fractures.J Trauma 1993;35:220-225.
34 Sinnott R,Rhodes M,Brader A.Open pelvic fracture:an injury for trauma centers.Am J Surg 1992;163:283-287.
35 周东生,穆卫东,王鲁博等.多排螺旋CT三维血管成像技术在不稳定骨盆骨折中的应用[J].中华骨科杂志,2006,26(6):424-426.
36 Poka A,Libby EP.Indications and techniques for external fixation of the pelvis.Clin Orthop,1996,(329):56 - 59.
37 Matta J,SaucedoT.Internal fixation of pelvic ring fractures.Clin Orthop,1989,(242):83 -97.
38 周东生,主编.骨盆创伤学.第1版.济南:山东科学技术出版社,2003.139-143.
39 Pohlemann T.Internal stabilization of pelvic ring fractures.SICOT Ⅴ Ⅷ World Congress.Montreal,1990.353.
40 Katsoulis E,Giannoudis PV.Impact of timing of pelvic fixation on functional outcome.Injury,2006,37(12):1133-1142.
41 ZHU Li-jun,GU Li-qiang,PEI Guo-xian.Damage control orthopaedics:state of the art mangement of polytrauma,Zhonghua Chuangshang Guke Zazhi(Chin J Orthop Trauma),2004,6(4):439-442
42 Giannoudis PV.Surgical priorities in damage control in polytrauma.J Bone Joint Surg(Br),2003,85:478-483.
43 周东生,黄涛,王鲁博.术中导航三维影像系统辅助置入骶骨钉微创治疗骶髂关节脱位[J].临床骨科杂志,2007,10(1):1-3.
44 周东生,主编.实用骨科导航技术.第1版.济南:山东科学技术出版社,2007.162-177.
2. Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe haemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001, 15:468-474.
3. Rommens PM, Hessmann MH. Staged reconstruction of pelvic ring disruption: differences in morbidity, mortality,radiologic results and functional outcomes between B1,B2/B3 and C-type lesions. J Orthop Trauma 2002, 16:92-98.
4. Rommens PM. Pelvic ring injuries: a challenge for the trauma surgeon. Acta Chir Belg 1996, 96:78-84.
5. Tucker MC, Nork SE, Simonian PT, Routt Jr ML. Simple anterior pelvic external fixation. J Trauma 2000, 49:989-994.
6.Tile M Acute pelvic fractures 1 Causation and Classification [J ] .Am Acad Orthop Surg ,1996 ,4 (1) :1432-1461
7 Majeed SA.Grading outcome of pelvic fractures[J].J Bone Joint Surg (Br),1989,71(2):304-306.
8 Ber MY,Cddwell DM ,Young JWR ,etal.Hemorrhage associated pelvic fractures : causes ,diagnosis ,and emergent management [J] . Am J Roentgenol ,1991 ,157(8):10052-10111
9 Bolter S , Haueisen H ,Renner N , et al.Inferior epigastric artery : An atypical source of bleeding in pelvic fracture [J] .Unfallchirurg ,2000 ,103 (4) :3182-3211
10 Davidson BS, Simmons GT, Williamson PR, et al. Pelvic fractures with open perineal wounds: a survivable injury. J Trauma 1993;35:36-39.
11 Ferrera PC, Hill DA. Good outcomes of open pelvic fractures. Injury 1999;30:187-90.
12 Hanson PB, Milne JC, Chapman MW. Open fractures of the pelvis, review of 43 cases. J Bone Joint Surg 1991;74:325-329.
13 Govender S, Sham A, Singh B. Open pelvic fractures. Injury 1990;21:373-376.
14 Leenen LP, van der Werken C, Schoots F, Goris RJ. Internal fixation of open pelvic fractures. J Trauma 1993;35:220-225.
15 Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for trauma centers. Am J Surg 1992; 163:283-287.
16 Poka A , Libby EP. Indications and techniques for external fixation of the pelvis. Clin Orthop , 1996 , (329) :56 - 59.
17 Matta J , Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop , 1989 , (242) :83 -97.
18 周东生,主编.骨盆创伤学.第1版.济南：山东科学技术出版社,2003. 139-143.
19 Pohlemann T. Internal stabilization of pelvic ring fractures. SICOT V VIE World Congress. Montreal, 1990. 353.
20 Katsoulis E ,Giannoudis PV.Impact of timing of pelvic fixation on functional outcome.Injury,2006,37(12):1133-1142.
21 周东生,穆卫东,王鲁博等.多排螺旋CT三维血管成像技术在不稳定骨盆骨折中的应用[J].中华骨科杂志,2006,26(6):424-426.
22 ZHU Li-jun,GU Li-qiang,PEI Guo-xian.Damage control orthopaedics:state of the art mangement of polytrauma,Zhonghua Chuangshang Guke Zazhi(Chin J Orthop Trauma),2004,6(4):439-442
23 Giannoudis PV.Surgical priorities in damage control in polytrauma.J Bone Joint Surg(Br),2003,85:478-483.
24 周东生,黄涛,王鲁博.术中导航三维影像系统辅助置入骶骨钉微创治疗骶髂关节脱位[J].临床骨科杂志,2007,10(1):1-3.
25 周东生,主编.实用骨科导航技术.第1版.济南:山东科学技术出版社,2007.162-177.
26 Davidson BS,Simmons GT,Williamson PR,et al.Pelvic fractures associated with open perineal wounds:a survivable injury[J].Journal of Trauma,1993,35(1):362-431.
1.Brenneman FD,Kaytal D,Boulanger BR,et al.Long term outcome in open pelvic fractures.J Trauma 1997,42:773-777.
2.Ertel W,Keel M,Eid K,Platz A,Trentz O.Control of severe haemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption.J Orthop Trauma 2001,15:468-474.
3.Rommens PM,Hessmann MH.Staged reconstruction of pelvic ring disruption:differences in morbidity,mortality,radiologic results and functional outcomes between B1,B2,B3 and C-type lesions.J Orthop Trauma 2002,16:92-98.
4.Rommens PM.Pelvic ring injuries:a challenge for the trauma surgeon.Acta Chir Belg 1996,96:78-84.
5.Tucker MC,Nork SE,Simonian PT,Routt Jr ML.Simple anterior pelvic external fixation.J Trauma 2000,49:989-994.
6周东生,黄涛,王鲁博.术中导航三维影像系统辅助置入骶骨钉微创治疗骶髂关节脱位[J].临床骨科杂志,2007,10(1):1-3.
7周东生,主编.实用骨科导航技术.第1版.济南:山东科学技术出版社,2007.162-177.
8朱立军,顾立强,裴国献.伤害控制骨科学-多发伤治疗最新观点[J].中华创伤骨科杂志,2004,(04)
9 Ertel W,Eid K,Keel M,et al.Therapeutical strategies and outcome of polytraumatized patients with pelvic injuries:a six - year experience.Euro J Trauma,2000,26:278-286.
10 Pohlemann T,Culemann U.Summary of controversial debates during the 5th "Homburg pelvic Course" 13-15 September 2006.Injury,2007,38(4):424-30.
11 Ertel W,Keel M,Eid K,et al.Control of severe hemorrhage using C - clamp and pelvic packing in multiply injured patients with pelvic ring disruption.J Orthop Trauma,2001,15:468- 474.
12 周东生,穆卫东,王鲁博等.多排螺旋CT三维血管成像技术在不稳定骨盆骨折中的应用[J].中华骨科杂志,2006,26(6):424-426.
13 高劲谋,胡平,田显扬,李昌华,赵山弘,杨俊,林曦.髂内动脉断血术在创伤急救中的应用[J]中华急诊医学杂志,2005,(08).
14 吴伟军,朱少俊,郑志强.双侧髂内动脉结扎治疗骨盆骨折及盆底创伤大出血[J]浙江医学,2001,(06).
15 梁庆芝,陈鸿儒.双侧髂内动脉结扎治疗骨盆骨折大出血[J]中华创伤杂志,1996,(04).
16 Key NS,Aledort LM,Beardsley D,et al.Home treatment of mild to moderate bleeding episodes using recombinant factor VIIa(Novo-Seven) in haemophiliacs with inhibitors.Thromb Haemost,1998,80:912.
17 Davidson BS,Simmons GT,Williamson PR,et al.Pelvic fractures with open perineal wounds:a survivable injury.J Trauma 1993;35:36-39.
18 Ferrera PC,Hill DA.Good outcomes of open pelvic fractures.Injury 1999;30:187-190.
19 Hanson PB,Milne JC,Chapman MW.Open fractures of the pelvis,review of 43cases.J Bone Joint Surg 1991;74:325-329
20 Govender S,Sham A,Singh B.Open pelvic fractures.Injury 1990;21:373-376.
21 Leenen LP,van der Werken C,Schoots F,Goris RJ.Internal fixation of open pelvic fractures.J Trauma 1993;35:220-225.
22 Sinnott R,Rhodes M,Brader A.Open pelvic fracture:an injury for trauma centers.Am J Surg 1992;163:283-287.
23 Kim S,Linden B,Cendron M,etal.Pediatric anorectal impalement with bladder rup ture:case report and review of the literature[J].J Pediatr Surg,2006,41(9):E1- E3.
24 Devine PC,Devine CJ.Posterior urethral injuries associated with pelvic fractures.Urology,1982,20:467-469.
25 Tauber M,Joos H,Karpik S,etal.Urogenital injuries accompanyingpelvicringfractures[J].Unfallchirurg,2007,110(2):116 - 123.
26 Tayal V S,Nielsen A,Jonesa E,et al.Accuracy of trauma ultrasound in major pelvic injury[J].J Trauma,2006,61(6):1 453 - 1 457.
27 Herschorn S,Thijssen A,Radomski SB.The value of immediate or early catheterization of the traumatized posterior urethra[J].J Urol,1992,148:1428 -1431.
28 王良,郑伟,蔡玉群,张伟江.骨盆骨折合并会阴、阴道损伤八例临床分析.中华妇产科杂志,2004,39(3):191
29 Davidson BS,Simmons GT,Williamson PR,et al.Pelvic fractures with open perineal wounds:a survivable injury.J Trauma 1993;35:36-39.
30 Ferrera PC,Hill DA.Good outcomes of open pelvic fractures.Injury 1999;30:187-90.
31 Hanson PB,Milne JC,Chapman MW.Open fractures of the pelvis,review of 43cases.J Bone Joint Surg 1991;74:325-329.
32 Govender S,Sham A,Singh B.Open pelvic fractures.Injury 1990;21:373-376.
33 Leenen LP,van der Werken C,Schoots F,Goris RJ.Internal fixation of open pelvic fractures.J Trauma 1993;35:220-225.
34 Sinnott R,Rhodes M,Brader A.Open pelvic fracture:an injury for trauma centers.Am J Surg 1992;163:283-287.
35 周东生,穆卫东,王鲁博等.多排螺旋CT三维血管成像技术在不稳定骨盆骨折中的应用[J].中华骨科杂志,2006,26(6):424-426.
36 Poka A,Libby EP.Indications and techniques for external fixation of the pelvis.Clin Orthop,1996,(329):56 - 59.
37 Matta J,SaucedoT.Internal fixation of pelvic ring fractures.Clin Orthop,1989,(242):83 -97.
38 周东生,主编.骨盆创伤学.第1版.济南:山东科学技术出版社,2003.139-143.
39 Pohlemann T.Internal stabilization of pelvic ring fractures.SICOT Ⅴ Ⅷ World Congress.Montreal,1990.353.
40 Katsoulis E,Giannoudis PV.Impact of timing of pelvic fixation on functional outcome.Injury,2006,37(12):1133-1142.
41 ZHU Li-jun,GU Li-qiang,PEI Guo-xian.Damage control orthopaedics:state of the art mangement of polytrauma,Zhonghua Chuangshang Guke Zazhi(Chin J Orthop Trauma),2004,6(4):439-442
42 Giannoudis PV.Surgical priorities in damage control in polytrauma.J Bone Joint Surg(Br),2003,85:478-483.
43 周东生,黄涛,王鲁博.术中导航三维影像系统辅助置入骶骨钉微创治疗骶髂关节脱位[J].临床骨科杂志,2007,10(1):1-3.
44 周东生,主编.实用骨科导航技术.第1版.济南:山东科学技术出版社,2007.162-177.