60例多發(fā)性肋骨骨折患者手術(shù)與非手術(shù)治療效果對比
發(fā)布時間：2018-09-11 20:11
【摘要】：目的探討多發(fā)性肋骨骨折的表現(xiàn)形式,明確術(shù)前診斷、評估疾病預(yù)后,指導(dǎo)臨床治療,并比較多發(fā)性肋骨骨折手術(shù)治療及非手術(shù)治療效果。通過其比較結(jié)果,討論手術(shù)治療與傳統(tǒng)治療的優(yōu)劣,是否臨床值得推廣。方法回顧分析我院普胸外科自2011年8月至2013年9月間選擇60例多發(fā)性肋骨骨折患者的臨床資料,男41例,女19例;年齡30~70歲,平均(50.6±10.0)歲;住院時間10~35天,平均(21.7±6.8)天,其中交通事故傷為23例,重物壓砸傷7例,摔傷23例,高處墜落傷5例,打架傷1例,機器擠壓傷1例;60例患者術(shù)前均拍攝胸部X線,CT及三維重建示多發(fā)性肋骨骨折,骨折端錯位較明顯,左側(cè)肋骨骨折34例,右側(cè)肋骨骨折31例,雙側(cè)肋骨骨折5例,并合并不同程度的肺挫傷13例。為盡可能滿足比較需要,采集的病例滿足條件:①胸部CT三維重建示肋骨骨折至少三根以上,無明顯開放性骨折;②無明顯肺挫裂傷形成血胸及其他專科需處理的合并傷;③排除70歲以上的高齡患者;④神志清楚,可自主咳痰;⑤在我科完成主要治療,排除胸腹聯(lián)合傷,顱內(nèi)出血,肱骨骨折以及需要相關(guān)科室手術(shù)或共同診治的患者,無需轉(zhuǎn)當?shù)蒯t(yī)院繼續(xù)治療。術(shù)前根據(jù)其病因,臨床表現(xiàn),癥狀和影像學(xué)表現(xiàn)診斷為多發(fā)性肋骨骨折。在就診的患者中,告知患者及其家屬各項治療方案及利弊后,充分尊重患者及家屬的意愿,選擇手術(shù)或保守治療,并滿足上述條件,隨機選擇其中30例作為觀察組,采用鎳鈦記憶合金環(huán)抱器(TiNi環(huán)抱式接骨器,蘭州西脈記憶合金股份有限公司)手術(shù)治療,30例作為對照組,采用保守治療,常規(guī)胸部繃帶加壓固定,以及近年來采用胸部護板外固定處理,同時抗炎,排痰,鎮(zhèn)痛,加強呼吸道管理。手術(shù)采用復(fù)合麻醉或全身麻醉,術(shù)前根據(jù)ct三維重建,用記號筆標出肋骨骨折斷端走形,相應(yīng)選擇手術(shù)切口,一般是后外側(cè)橫切口或腋下縱向切口,游離骨折斷端骨膜,避免損傷肋間神經(jīng)和血管,選擇相對應(yīng)的鎳鈦記憶合金環(huán)抱器,塑形,安裝。直觀了解多發(fā)性肋骨骨折的病情,并進一步與ct三維重建相印證。兩組患者主要從住院時間、疼痛視覺模擬評分(vas)、自主下床活動時間、住院費用、胸廓成形程度及肺通氣功能對病情進行評價并比較。其方法采用:采用視覺模擬評分(visualalqaloguescale,vas)。0分:無痛;3分以下:有輕微的疼痛,能忍受;4~6分:患者疼痛并影響睡眠,尚能忍受;7~10分:患者有漸強烈的疼痛,疼痛難忍,影響食欲,影響睡眠。術(shù)前vas評分由術(shù)前當天記錄,術(shù)后vas評分為術(shù)后第6天疼痛主觀評分的平均值,比較兩組vas下降程度。肋骨骨折治療療效標準:優(yōu):胸壁無疼痛、呼吸正常、影像學(xué)檢查肋骨解剖對位、雙側(cè)胸廓對稱;良:與優(yōu)相比影像學(xué)檢查肋骨非解剖對位、移位在2mm以內(nèi),雙側(cè)胸廓基本對稱;可:胸壁略有疼痛、影像學(xué)檢查示少數(shù)肋骨對位差,但移位在3mm以內(nèi),胸廓稍有塌陷或不對稱;差;胸壁疼痛、肋骨移位在3mm以上。所有數(shù)據(jù)分析采用spss19.0軟件進行統(tǒng)計分析。計量資料以sx±表示,組間比較采用t檢驗,計數(shù)資料組間比較采用c2檢驗及秩和檢驗。比較兩組住院時間,術(shù)后疼痛下降程度,以及自主下床時間比較,兩組肺功能比較,以及患者傷后1月復(fù)查肋骨復(fù)位療效比較,p0.05有統(tǒng)計學(xué)差異。結(jié)果本觀察60例患者術(shù)后均獲隨訪,傷后1-2個月均在我院復(fù)查胸部x線觀察肋骨復(fù)位情況,進一步比較手術(shù)及傳統(tǒng)治療效果對比。發(fā)現(xiàn)從兩組住院時間,術(shù)后疼痛下降程度,以及自主下床時間比較,觀察組明顯優(yōu)于對照組,但從住院費用來看,觀察組的治療費用明顯高于對照組,兩組比較差異有統(tǒng)計學(xué)意義。兩組患者均于入院時常規(guī)測定肺功能,同時對觀察組術(shù)后第7天及對照組保守治療后第7天復(fù)查肺功能,以最大自主通氣量(mvv)、第1秒用力呼氣肺活量(fev1)所占百分比等作為評估指標,見兩組患者入院時MVV%及FEV1%比較差異無統(tǒng)計學(xué)意義,治療后7 d復(fù)查:觀察組MVV恢復(fù)明顯優(yōu)于對照組,但FEV1所占百分比變化不明顯,考慮為患者外傷引起的肺限制性通氣對其無明顯影響。兩組比較差異有統(tǒng)計學(xué)意義。門診隨診觀察肋骨骨折愈合情況及胸廓形狀,觀察組和對照組兩組整體療效比較差異有統(tǒng)計學(xué)意義。結(jié)論通過兩組患者的對比及術(shù)后的隨訪比較,更加全面了解多發(fā)性肋骨骨折患者的臨床特點,術(shù)中視野全面,清楚,直觀面對肋骨骨折的部位進行處理,手術(shù)針對性強,處理結(jié)果滿意,且復(fù)位效果佳�？傮w來說,在住院時間,在疼痛指數(shù)下降及治療滿意度上,手術(shù)組患者較為滿意,但治療費用偏高。手術(shù)復(fù)位內(nèi)固定對多發(fā)性肋骨骨折的治療有重要的應(yīng)用價值。
[Abstract]:Objective To investigate the manifestations of multiple rib fractures, make clear the preoperative diagnosis, evaluate the prognosis of the disease, guide the clinical treatment, and compare the surgical treatment and non-surgical treatment of multiple rib fractures. From August 2011 to September 2013, 60 patients with multiple rib fractures were selected, including 41 males and 19 females, 30-70 years old, with an average age of (50.6 65 X-ray, CT and three-dimensional reconstruction showed multiple rib fractures in all the patients before operation. The fracture ends were dislocated obviously. 34 cases of left rib fractures, 31 cases of right rib fractures, 5 cases of bilateral rib fractures, and 13 cases of pulmonary contusion were found. At least three rib fractures, no obvious open fractures; no obvious pulmonary contusion and laceration of the formation of hemothorax and other specialized treatment of combined injuries; excluding elderly patients over 70 years old; clear mind, can cough sputum; _in my department to complete the main treatment, excluding thoracoabdominal combined injuries, intracranial hemorrhage, humeral fractures and the need for relevant departments Patients undergoing surgery or co-treatment need not be transferred to local hospitals for further treatment.Preoperative diagnosis of multiple rib fractures is based on etiology, clinical manifestations, symptoms and imaging findings. Thirty of them were randomly selected as the observation group and treated with TiNi memory alloy embracing fixator (TiNi embracing fixator, Lanzhou Ximai Memory Alloy Co., Ltd.) and 30 as the control group. They were treated with conservative treatment, routine compression and fixation of chest bandage, and external fixation of chest guard plate in recent years. Anti-inflammation, expectoration, analgesia, strengthen the management of respiratory tract. Operation using compound anesthesia or general anesthesia, preoperative according to the three-dimensional reconstruction of CT, marking the fracture of the ribs with a marker pen out the shape of the broken end, the corresponding choice of surgical incision, generally posterolateral transverse incision or axillary longitudinal incision, free fracture of the periosteum, to avoid injury of intercostal nerves and blood vessels, choose the phase. The patients in the two groups were assessed and compared by length of stay in hospital, visual analogue score of pain (vas), time of ambulation, hospitalization expenses, degree of thoracoplasty and pulmonary ventilation function. Methods: Visual analogue scale (vas) was used. 0 points: no pain; below 3 points: slight pain, tolerable; 4-6 points: patients with pain and affect sleep, can tolerate; 7-10 points: patients with gradual intense pain, pain intolerable, affecting appetite, affecting sleep. The results of rib fracture treatment were as follows: excellent: no pain in chest wall, normal breathing, radiographic examination of rib anatomical contraposition, bilateral chest symmetry; good: compared with excellent imaging examination rib non-anatomical contraposition, displacement within 2 mm, bilateral chest symmetry; can: All data were analyzed by SPSS 19.0 software. The measurement data were expressed as SX (+), t test was used for comparison between groups, and C2 test for comparison between groups. Rank sum test. Comparing the length of hospitalization, the degree of postoperative pain reduction, and the time to get out of bed independently, the pulmonary function of the two groups, and the effect of rib reduction after 1 month of injury, there were statistical differences between the two groups. Results All the 60 patients were followed up after operation, and the rib reduction was observed by chest X-ray after 1-2 months of injury in our hospital. It was found that the observation group was superior to the control group in terms of the length of hospital stay, the degree of postoperative pain reduction, and the time to get out of bed independently, but from the cost of hospitalization, the treatment cost of the observation group was significantly higher than that of the control group, the difference between the two groups was statistically significant. Pulmonary function was measured routinely at admission. At the same time, pulmonary function was reexamined on the 7th day after operation in observation group and the 7th day after conservative treatment in control group. Maximum voluntary ventilation volume (mvv) and percentage of forced expiratory capacity (fev1) in the 1st second were taken as evaluation indexes. There was no significant difference in MVV% and FEV1% between the two groups at admission. The recovery of MVV in the observation group was obviously better than that in the control group, but the percentage of FEV1 had no significant change, and there was no significant difference between the two groups. Conclusion Through the comparison of the two groups of patients and postoperative follow-up comparison, more comprehensive understanding of the clinical characteristics of multiple rib fracture patients, intraoperative visual field is comprehensive, clear, intuitive facing the rib fracture site for treatment, surgery targeted, satisfactory treatment results, and reduction effect. In terms of pain index and treatment satisfaction, the operation group was more satisfied, but the treatment cost was higher. Surgical reduction and internal fixation had important application value in the treatment of multiple rib fractures.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R687.3
本文編號：2237736
[Abstract]:Objective To investigate the manifestations of multiple rib fractures, make clear the preoperative diagnosis, evaluate the prognosis of the disease, guide the clinical treatment, and compare the surgical treatment and non-surgical treatment of multiple rib fractures. From August 2011 to September 2013, 60 patients with multiple rib fractures were selected, including 41 males and 19 females, 30-70 years old, with an average age of (50.6 65 X-ray, CT and three-dimensional reconstruction showed multiple rib fractures in all the patients before operation. The fracture ends were dislocated obviously. 34 cases of left rib fractures, 31 cases of right rib fractures, 5 cases of bilateral rib fractures, and 13 cases of pulmonary contusion were found. At least three rib fractures, no obvious open fractures; no obvious pulmonary contusion and laceration of the formation of hemothorax and other specialized treatment of combined injuries; excluding elderly patients over 70 years old; clear mind, can cough sputum; _in my department to complete the main treatment, excluding thoracoabdominal combined injuries, intracranial hemorrhage, humeral fractures and the need for relevant departments Patients undergoing surgery or co-treatment need not be transferred to local hospitals for further treatment.Preoperative diagnosis of multiple rib fractures is based on etiology, clinical manifestations, symptoms and imaging findings. Thirty of them were randomly selected as the observation group and treated with TiNi memory alloy embracing fixator (TiNi embracing fixator, Lanzhou Ximai Memory Alloy Co., Ltd.) and 30 as the control group. They were treated with conservative treatment, routine compression and fixation of chest bandage, and external fixation of chest guard plate in recent years. Anti-inflammation, expectoration, analgesia, strengthen the management of respiratory tract. Operation using compound anesthesia or general anesthesia, preoperative according to the three-dimensional reconstruction of CT, marking the fracture of the ribs with a marker pen out the shape of the broken end, the corresponding choice of surgical incision, generally posterolateral transverse incision or axillary longitudinal incision, free fracture of the periosteum, to avoid injury of intercostal nerves and blood vessels, choose the phase. The patients in the two groups were assessed and compared by length of stay in hospital, visual analogue score of pain (vas), time of ambulation, hospitalization expenses, degree of thoracoplasty and pulmonary ventilation function. Methods: Visual analogue scale (vas) was used. 0 points: no pain; below 3 points: slight pain, tolerable; 4-6 points: patients with pain and affect sleep, can tolerate; 7-10 points: patients with gradual intense pain, pain intolerable, affecting appetite, affecting sleep. The results of rib fracture treatment were as follows: excellent: no pain in chest wall, normal breathing, radiographic examination of rib anatomical contraposition, bilateral chest symmetry; good: compared with excellent imaging examination rib non-anatomical contraposition, displacement within 2 mm, bilateral chest symmetry; can: All data were analyzed by SPSS 19.0 software. The measurement data were expressed as SX (+), t test was used for comparison between groups, and C2 test for comparison between groups. Rank sum test. Comparing the length of hospitalization, the degree of postoperative pain reduction, and the time to get out of bed independently, the pulmonary function of the two groups, and the effect of rib reduction after 1 month of injury, there were statistical differences between the two groups. Results All the 60 patients were followed up after operation, and the rib reduction was observed by chest X-ray after 1-2 months of injury in our hospital. It was found that the observation group was superior to the control group in terms of the length of hospital stay, the degree of postoperative pain reduction, and the time to get out of bed independently, but from the cost of hospitalization, the treatment cost of the observation group was significantly higher than that of the control group, the difference between the two groups was statistically significant. Pulmonary function was measured routinely at admission. At the same time, pulmonary function was reexamined on the 7th day after operation in observation group and the 7th day after conservative treatment in control group. Maximum voluntary ventilation volume (mvv) and percentage of forced expiratory capacity (fev1) in the 1st second were taken as evaluation indexes. There was no significant difference in MVV% and FEV1% between the two groups at admission. The recovery of MVV in the observation group was obviously better than that in the control group, but the percentage of FEV1 had no significant change, and there was no significant difference between the two groups. Conclusion Through the comparison of the two groups of patients and postoperative follow-up comparison, more comprehensive understanding of the clinical characteristics of multiple rib fracture patients, intraoperative visual field is comprehensive, clear, intuitive facing the rib fracture site for treatment, surgery targeted, satisfactory treatment results, and reduction effect. In terms of pain index and treatment satisfaction, the operation group was more satisfied, but the treatment cost was higher. Surgical reduction and internal fixation had important application value in the treatment of multiple rib fractures.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R687.3
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