Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
PHAN II: NGOAI KHOA
DANH GIA KET QUA OIEU TRI GAY H 6 DO I, II 1/3 DI/6I 2 XLfONG CANG CHAN BANG DINH NOI TUY CO CHOT NGANG IME
TAI BENH VIEN VIET TIEP HAI PHONG
• • • • a
Nguyen Viet Dung*, Vu Diic Chuyen*
Dinh The Hung*. Vu Nhat Dinh**
TOM TAT
Dieu tri gay hd do I, I I than xUOng chay bang dinh npi tuy co chot ngang da dUdc nliieu tac gia quan tam nghien ciru. Ket hdp xUdng bang dinh noi tuy co chot ngang da the hien nhCTng Uu diem noi trpi hdn so vdi ket hdp xUdng bang nep vi't d nhij'ng tru'dng hdp 6 gay 6 vj trf 1/3 dUdi xUdng chay.
TLT nam 2008 den nay, Benh vien Viet Tiep Hai Phong da dieu tri cho 83 trUdng hdp gay hd dp I, II doan 1/3 dUdi xUdng chay bang phu'dng phap dong dinh npi tuy co chot ngang. Ket qua tUdng doi l<ha quan, gop phan tra lai chCrc nang van dpng sdm, rut
! ngan thdi gian dieu tri va giam dang ke ti le bien chu'ng cho benh nhan.
S U M M A R Y
; Treatment of open Tibial shaft fracture of I, II
! degree with intramedullary nailing was interested a lot
• of authors. Surgery to insert an intramedullary rod has 1 showed more advantages compared to the combined
< by screws and bands in cases that has broken position in 1 / 3 below part of the tibia.
( From 2008 to now, Hai Phong Viet Tiep hospital has treated 83 cases of open Tibial shaft fracture of I,
; II degree with intramedullary nailing, and the results ( are quite good such as contributing to the return of , motor function early, and shorten treatment time, and significantly reduce the rate of complications in patients.
I. OAT VAN OE
Khoang 10 nam gan day a Vict Nam, dieu tri ga\ 2 xuang cang chan bang dinh noi tuy CO chot ngang dugc ap dung kha rong rai.
Da CO nhieu cong trinh nghien cuu cho thay tinh uu viet ciia phuang phap dong dinh noi tuy CO chot so vai cac dung cu ket hgp xuong khac nhu: nep vit, dinh Kurtscher... Doan 1/3 duai xuang chay long ong tuy loe rong dan nen sir dung dinh Kuntscher a doan nay khong phu hgp vi khong dat dugc hieu qua CO dinh xuang gay, dinh de hi di lenh xoay, gap goc, lech true...Dong dinh noi tuy co chot ngang da khac phuc dugc cac nhugc dilm cua dinh thong thuang a vj tri nay va khong pha huy phan mem nhieu nhu ket hgp xuang bang nep vit...
Bao cao nay nham danh gia ket qua phiu thuat kit hgp xuang chay gay ha do I, 11 doan 1/3 duai bang dinh npi tuy co chot ngang tai Benh vien Viet tiep Hai Phong. Tir do rut ra mgt so nhan xet va chi dinh dieu tri.
II. o 6 l TUONG VA PHaONG PHAP NGHIEN COU
1. Doi tuong nghien ciiu
Chung toi nghien cuu tren 83 truang hgp gay ha do 1, II doan 1/3 duai 2 xuang cang chan dugc dieu tri bang phau thuat ket hgp xuang chay dung dinh ngi tuy co chot ngang
* Benh vien Hihi Nghi Viet Tiep ** Hoc vien Qudn Y
HOI NGHI KHOA HOC BENH VIEN HLfU NGHI VI$T TIER H A I PHONG LAN THLf 37
IME tai Benh vien Vicl Tiep Ilai phong tu nam 2008 den nay. Trong do co: 5H Benh nhan nam \'a 25 Benh nhan nfr co do luoi tu
18 den 72.
2. Phuong phap nghien ciiu :
Benh nhan dugc tham kham lam sang va xct nghiem can lam sang, chup phim X quang cang chiin ben hcnh thang, nghieng.
Tien hdnh phdu thudt.
Kiem tra dinh ky sau phau thuat 1 thang, 3 thang. 6 thang \a den khi thao phuang ticn ket hgp xuang.
Md td k}> thudt phdu thudt:
Tat ca cac b$nh nhdn deu dugc vo cam bang te tuy s6ng (MARCAIN 0,5%)
Dat ga ro 1/3 giua dui.
Sat khuan toan bg cang chan tu tren goi tra xuong den ngon chan.
Dat chan tren gia da dui - de dui ngang mat ban mo. Cang chan vuong goc vai dui.
Cat lgc vet thuang phan mem cho gay ha.
Rua sach bang 6 xy gia va betadin.
Rach da duai xuang banh che c khoang 4CITI.
Rach dgc gan banh che, bgc 16 ma chay.
Dui tao lo v^o long ong tuy a chinh gii mam chay, phia truac day chang ma.
Luon guide vao long ong tuy doan tmr tam, chinh true 6 gay va tiep tuc dua gui(
xuong dau ngoai vi.
Khoan long ong tuy bang khoan me;
bat dau tir khoan so 8 ...
Dong dinh theo guide vao long ong ti (chieu dai dinh do truac ben chan lanh I chom xuang mac den tren diem cuoi mat ( ngoai 1,5cm. Duong kinh dinh bang c khoan cuoi).
Bat chot ngang theo khung ngam. B;
nap day dau dinh.
Nai ga ro kiem tra cam mau va kha phuc hoi.
Danh gia ket qua dieu tri theo tieu chua Ter-schiphort.
Ket qua phuc hoi chuc nang theo Ter schiphort
MuTcdd
Rat tot
Tot
Trung binh
Kem
Mu'c do iren xitting
Lien xu'dng vu'ng, thSng true nhU xUdnq lanh
Lien xu'dng vu'ng nhu'ng con di lech md goc ra ngoai, ra trUdc <5°, vao trong, ra sau < 10°, ngSn chi < 1cm Lien xUdng di lech qua mu'c tren
Khong lien xUdng ho3c Hen xu'dng d mu'c trung binh + di lech xoay
Dau tai cac khdp CO chan, goi Khong dau
Oau khi gSng sire
Dau lien tuc nhung chju dUdc
Dau lien tuc khong chiu dUdc
Van dpng khdp goi
Binh thudng
Gap goi 90- 120° duoi 0 - 1 0 °
Gap <90°, duoi >90°
Cutig khdp
Van dong khdp CO
chan Binh thudng
Gap mu = 0°
Chan thuong
CuTig khdp
Teocd vung dui
Khong
Khong dar ke
Teo cd nhie
Teo cd nhi!
Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
I. KET QUA
Nguyen nhan:
Nguyen nhan So LUdng
Ty le %
TNGT 63 75,90
TNSH 8 9,53
TNLD 12 14,57
Qua ket qua ngliien cuu chung toi nhan thSy:
Tai nan giao thong la nguyen nhan chu yhu chihn\ 75,90%, tai nan lao dgng chilm
14,57%, con lai la do tai nan lao dgng.
Ga>' 2 xuong cang chan P 43 truang hgp chilm 51.80°o.
Gay 2 xuong cing chan T 40 trirofng hgp chilm 48.20%.
Benh nhan nam gap nhieu hon benh nhan niJ (Benh nhan nam 58 truong hgp va benh nhan nir la 25 truong hgp).
- Thoi diem phau thuat: Co 66 truong hgp dugc phau thuat trong lOh dau sau tai
- Phan loai Ket qua theo Ter - schiphort
nan chiem 79,52%. Con 17 truang hgp chiing toi ticn hanh phau thuat mugn (tu ngay thu 5 den nga\ thu 15 sau tai nan) chiem 20,48%.
Do dieu kien benh loan than benh nhan chua cho phep phau thuat va do benh nhan den mugn sau 10 gio.
Co 2 truong hgp do co chan thuang sg nao ket hgp, nen chung toi tien hanh phau thuat sau tai nan 15 ngay- khi tinh trang chan thuang sg nao on dinh.
Phau thuat som cQng la yeu to thuan lgi cho qua trinh phuc hoi chuc nang van dgng hoi phuc ciia benh nhan
Ket qua so lu'dng ty le%
Rat tot 75 90,36
Tot 8 9,64
Qua tieu chudn ciia Ter-schiphort chiing toi thay kit qua rit t6t dat kha cao 90,36%.
Khong CO truong hgp nao nhilm trung vit m6 khong co truong hgp nao viem xuong.
Thoi gian benh nhan phuc hoi van dgng chan gay sau 3 thang la 74 truong hgp, (co 1 truong hgp gay xuong chay 2 tang 3 doan.
chiing toi huong din benh nhan di bang 2 nang trong 2 thang dau).
Khong CO truong hgp nao bi chen ep khoang sau mo.
Thoi gian mo trung binh la 45 phiit (truong hgp nhanh nhat la 35 phiit, truong hgp cham nhat la 80 phiit).
Khong CO truong hgp nao that bai phai chuyen phuong phap phau thuat khac S6 lugng vit ch6t dhu ngoai vi.
So vit chdt So lUdng
Ty le%
01 vit 35 42,17
02 vit
48 57,83
HOI NGHI KHOA HOC BENH VIEN HUfU NGHI VIET TIEP H A I PHONG LAN THLf 37
Do chi dinh chiing toi lira chgn nhrrng dinh dii do dai dc dam bao do viing chac cho benh nhan gay 1/3 diroi 2 xirirng cang chan 6 pay. Duong kinh dinh chiing toi dong bang CO duong ga\ ircn khop ch;i\ sen 3cm cho so klioan cuoi. Su dung nhieu nhat la dinh iKMi CO 3.^ truong hop bai mgl \ it chot dau <)\ "^2 (.S3 Inrang hop chicMTi 63,86%).
ngoai \i bang 42,17"u, con 48 Iruong hop hai llicn nay c() rat nhieu Igai dinh noi tuy 2 \ it chot dan ngoai \ i. kin co chol diing dc ket hgp xuong chay,
Co 0> hcnh nhan dugc heit ihC'iii vii Chiing loi chgn dinh IMF, \i dinh nay la loai chot dau trung uim do o g;i\ nhicu manh. dinh rong, dong theo guide, mat khac dinh ngu> CO mat \irng \a nuan chi. IMF, cung phong phii \c chiing loai va gia
- Thai gian nam \ ien Irung binh: 12,3 thanh cung thap hon cac loai dinh ciing tinh nga>. nang.
Sau mo chiing toi cho hcnh nhan ke chan IV. BAN LUAN cao lien gia Braun \a bat dau lap phuc hoi
Nhiing truang hgp khong phau thuat kcl ehirc nang lir nga\ thii 2 sau mo. Luyen tap hgp xuong cap ciiu (17 iruimg hgp), chiing \'oi cirang do lang dan \a bat dau tap ti de toi lien hanh cat lgc xir 1>' vit thuong phAn tren chan gay \ ao ngay thir 5 sau mo. Chung mem. dat nep bgt diii cang ban chan. Den khi loi khuyen cao bcMih nhan sir dung nang de toan trang on dinh- phau thuat kit hgp lap \ an dgng trong ihang dau nham dam bao xuong. an toan cho benh nhan.
Chiing toi chii truong han chi bill \ it Tuy dieu tri tren nhung truong hgp benh chot o dau trung tain do duong ga} thap \a nhan ga>' ho do 1. II chimg toi da han che toi dau dinh co duong kinh Ion hon than dinh da ton thuong phan mctn o xune quanh 6 gay nen rat kho di lech dan each. trong qua trinh phau thuat. Dieu do cung gop
Ca 83 truong hgp chimg toi diu khoan phan lam giam cac bien chimg trong qua long ong tuy bang khoan mim de tranh tSc trinh dieu tri sau mo. giam ngu\ ca nhiem dinh va cung thong nhat voi nghien ciru ciia khuan. nil ngan thoi gian dieu tri tai Benh Nguyen Tien Binh la chua thdy sir khac biet N ien.
voi cac nghien cim khong khoan long i)ng Uiy. Chimg toi da thao phuong tien ket xuong Do dong khong diing man tang sang nen cho 69 truong hgp thoi gian thao dinh trung van de trugt 16 \ it dau xa cung nit dugc qium Uim. binh la sau 9.3 thang
Chimg toi dimg guide kiem ira nga>' Can cir thao dinh dua vao cac dau hien trong mo xem vit chot co qua lo chol ciia hen xuong tren lam sang \a hinh anh can dinh hay khong, nen khong co truong hgp xuong tren X quang. Chua gap trudng hop nao trugt 16 vit dau xa. nao ga\ lai 6 gay sau thao phuong tien ket
Cac truong hgp gay thap chi bat dugc 1 hop xuong.
vit ch6t dau xa, chiing toi bo bgt tang cuong
sau m6 1 thang nham dam bao sir vCrng chhc V. KE'T LUAN
cho 6 gay. ^ Di^u ^f^ ggy ^^ ^5 j^ U ^o^n 1/3 duoi 2 Chieu dai dinh chung t6i lira chgn bang xuong cing chan bang dinh ngi tuy kin co each do tren chan lanh. Tir chom xuong mac chot ngang da mang lai kit qua t6t cho benh den tren dau duoi mat ca ngoai 1,5cm. Chgn nhan giam thilu cac nguy co, biln chimg
Y HOC VIET NAM THANG 10 - SO DAC BIET/2G11
trong va sau phau thuat, phuc h6i chirc nang van dgng t6t cho chi thi. Rut ngdn thai gian dilu tri, thai gian nam vien trung binh: 12,3 ngay. Dat tinh tham my cao.
Diing dinh ngi tiiy co chit dilu tri gay ho do I, 11 doan 1/3 duoi 2 xuong cdng chan CO the thay the phuong phap kit hgp xuong bang nep vis.
Tap van dgng phuc hoi chirc nang som sau mo cGng gop mgt phan quan trgng \ao ket qua dieu tri. Do 6 gay dugc co dinh viing chac nen chiing t6i chu truong cho benh nhan tap van dgng som, tu> nhien rat can su huong dan cua can bg chuyen khoa phuc hoi chiic nang cho timg nguoi benh cu the.
TAI LIEU T H A M KHAO
1. Nguyen Tien Binh. Phuong phap ket xuong dinh ngi tu\ kin. Mgt s6 van de co ban trong chan thuong chinh hinh, trang.
167- 177
2. Nguyen Viet Dung. Danh gia ket qua dilu tri gay kin 1/3 duoi 2 xuong cang chan tai Benh vien Viet Tiep Hai Phong.
Tap chi y hgc Viet Nam thang 5 - s6 2/2009, trang 44.
3. Do Xuan Ho'p. (iiai phau thuc dung ngoai khoa chi tren va duai. Dai hgc Quan y. trang. 337-338
4. Nguyen Diix Phuc 2004. Gay than xuong cang chan. Chan thuang chinh hinh. NXB Y hgc. Ha Ngi, trang. 447- 452
.S. Nguyen Quang Hanh, Nguyen Dac Nghia 2003. Nhan xcl ket qua dong dinh ngi lu\ kin co chot khong doa nong 6ng Ui> trong dieu tri gay ho moi 2 xuong cang chan tai Benh \'ien Saint - paul.
Chuyen de hgi nghi chan thuang chinh hinh toan qu6c lan thir nhat. So dac biet trang 168-171.
6. Shah R.K, Moehving H.D, Singh R.P, Dhakal 2004. Surgical Implant Generation Network (Sign) intranedullary nailing of open fracture of the tibia. Int orthop. 28 (3): 163-6.
7. Zbigniew. Gwgala, Arvind Nana Roral wlindzey 2001. Interlocking screw placemet. Comprison Fixation free - hard resus disttally - based targeting derice techniques.