Y HOC VIET NAM THANG 10 - SO 2/2010
NGHIEN CLfu DAC DIEM LAM SANG, CAN LAM SANG VA DIEU TRI TON THl/ONG DONG MACH L 6 N
KEM THEO GAY Xl/ONG, SAI KHClP CHI DI/6I
Le Minh Hoang*, Nguyen Thai Son*', Vu Nhat Djnh'**, Vu Dure Chuyen', Le Minh Son*, Dinh The Hiing*
TOMTAT
16 benh nhan bj tdn thgdng ddng mach chi du'di kem theo gay xUdng, sai khdp dugc dleu trj tai Benh vien Viet Tiep Hai Phdng tir Thang 5 nam 2009 den Thang 6 nam 2010.
l.Dac diem doi tUdng nghien cu'u:
Nguyen nhan: TNGT: 15; TNLO: 1;
Tudi: nhd nhat: 17; Idn nhat: 60;
Gidi: Nam/NO': 11/5.
2. Ton thu'dng giai phau benh:
- Vj tri td'n thu'dng: DM khoeo: 8/ 16; DM chay tru'dc: 4/ 16; DM chay sau: 4/ 16; Gay xu'dng diii: 1/ 16; Sai khdp gdi: 1/16; gay xUdng cang chan: 14/ 16. '"'•
• Tinh chat ton thu'dng DM: Dung dap dirt rdi: 6/ 16; Dung dap tac: 5/ 16; Chen ep va raeh thanh ben: 5/ 16.
3. Lam sang, can lam sang: sdc chan thu'dng 16/ 16; gay xu'dng kin: 4/ 16; sai khdp hd: 1/ 16; gay xu'dng hd: 11/ 16; Mach ngoai vi mat: 10/16; Mach ngoai vi yeu: 6/16; Dau hieu thieu mau ngoai vi dien hinh: 10/16; Dau hieu thieu mau ngoai vi khdng dien hinh: 5/16; Hdi chiing chen ep khoang: 3/16.
Oo do bao hoa dxy( SPO2): giam 1/16, mat:
15/16. « i
Sieu am Doppler mach(4/16): mat tin hieu dong chay: 4/4.
4. Ky thuat dieu trj
+ Thii tli: xii trf td'n thu'dng xu'dng khdp tru'dc: 16/ 16.
+ Phu'dng phap xir trf td'n thu'dng xUdng Benh vien Viet Tiep Hdi Phdng
** B^nhvien Saint Paul , .
*** Hoc vien Qudn Y
khdp: Cd djnh ngoai: 7/ 16; Odng dinh ndi tiiy:
3/16; Xuyen kim Kirschner: 5/16; Budc vdng day thep: 1/16;
+ Phu'dng phap xu' trf td'n thgdng dgng mach: Ghep bang doan tTnh mach hien tu" than:
5/16; Ndi: 6/16; Giai phdng chen ep va khau vet thu'dng ben: 5/16.
+ Ket qua gan: tir vong: 0; Bao tdn chi:
14/16; Cat cut chi thi 2: 2/16; Tac mach phai mo lai: 1/16.
SUMMARY
16 patients that had injuries of arterial leg with bones fracture, dislocation had been treated at Viet Tiep Hospital since May 2009 to June 2010
1. Characteristics of object of study - Causes: traffic accident: 15 cases; accident at work: 1 case.
- Age: from 17 to 60
- Sex: Male: 11 cases. Female: 5 cases.
2. Pathologico-anatomlc injuries Fracture shinbones 14/16; Femoral fracture 1/16; Dislocation of knee joint: 1/16.
Arterial injuries: Popliteal artery: 8/16;
anterior tibial artery: 4/16; posterior tibial artery:
4/16; Interrupted contusion artery: 6/16;
obstructed contusion artery: 5/16; compression and chapped wall of artery: 5/16
3. Clinical and paradinical:
Close bone fractures: 4/16; Open bone fractures: 11/16; Open dislocation: 1/16; weak
HOI CHAN THUONG CHINH HINH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN THLf IX pulse of peripheral arteries: 6/ 16; disappeared
pulse of peripheral arteries: 10/16; signs of symbolic anaemia 10/16; signs of non-symbolic anaemia 6/16; compress syndrome: 3/16.
Measurement of Saturation of Peripheral Oxygen(
SPO2): reduce 1/16; disappear 15/16 Doppler ultrasound( 4/16): disappearance of signal flow:
4/4.
4. Treatment: Firstly osteosynthesis and then intervention vascular injuries: 16/16.
Osteosythesis: External fixation: 7/16; Kuntcher nail: 3/16; Kirschner nail: 5/16; Steel wires: 1/
16.
Injurie artery intevention: Transplant by oneself saphenous vein: 5/ 16; anastomosis of artery: 6/16; release compression and suture the lateral wall of wound: 5/16. Results: Die: 0;
conservative leg: 14/16; amputation: 2/16;
blocked artery that must be reoperated: 1/16.
I. OAT V A N OE
Tdn thucmg ddng mach cd kem theo gay xuong, sai khdp d chi dudi la mdt tdn thuang nang ne bdi cd the nguy hiem den tinh mang, su sdng cua chi cQng nhu anh hudng tdi chiic nang chi ve sau.
Van de chan doan sdm tdn thuang dgng mach ludn la ddi hdi cap bach nhung ciing gap khdng it khd khan bdi benh canh lam sang ciia gay xuang, sai khdp, nhat la da chan thuang che lap.
Theo nghien cuoi ciia Gustilo R.B. nam 1984 [6], vdi 87 benh nhan gay do III, cac trudng hgp gay hd do Ilia, Illb chi ddu dugc bao tdn, trong khi 42% gay hd IIIc phai cat cut, cac trudng hgp cdn lai cdn lai hoac la nhiem trimg md mem, viem xuang hoac cham lien xuong. Mgt nghien ciiu khac cua Perry M.O nam 1989 [9], cho thiy tdn thuang mach mau phdi hgp gay xuang cd ty le cat cut la 28%, trong khi khdng cd gay xuang la 0,6%.
Viec xir tri loai ton thuang phoi hgp ddng mach - xuang khdp cdn cd nhieu y kien khac nhau. Tuy nhien ngay nay cd dinh gay xuang, sai khdp ket hgp phuc hdi tdn thuang mach mau la viec lam dugc dai da sd cac phlu thuat vien d cac nudc tien tien [2], [3],
[9], [10] lua chgn.
Tgi Viet Nam, theo bang thdng ke cua mgt sd benh vien [2], sd benh nhan bi chan thuang cd xu hudng ngay cang tang ciing vdi su phat trien cua cac phuang tien giao thong, tdn thuang dgng mach do gay xuang, sai khdp chi dudi ciing nam trong tinh hinh chung dd. Nhieu trudng hgp nan nhan dugc cuu chua kip thdi da khdi benh, trd lai cong ddng lao dgng, sinh boat binh thudng. Mot s6 nhugc diem can khac phuc nhu bd sdt ton thuang mach mau hoac chan doan mugn, co dinh gay xuang chua dugc coi trgng truoc khi xir tri tdn thuang mach mau dS lam anh hudng khdng tdt den ket qua dieu tri
Xuat phat tir tinh hinh thuc te tren chiing tdi thuc hien nghien ciiu nham 2 muc tieu:
1. Nghiin cieu dgc diim ton thuang giai phau binh, lam sdng, can lam sdng cm ton
thuang dong mgch l&n kem theo gay xuang, sai kh&p chi du&i.
2. Nghiin cieu ky thudt dieu tri vd riit ra nhgn xet cdc yiu to liin quan den ket qud diiu tri.
II. Odi TUdNG VA PHUONG PHAP NGHIEN COU
1- Doi tuang nghiin cieu
16 benh nhan tdn thuang ddng mach chi dudi kem theo gay xuong, sai khdp dugc dieu tri tai Khoa Chdn thuang Chinh hinh va Khoa phlu thuat Ldng nguc Tim mach Benh vien Viet- Tiep Hai Phdng tir thang 5.2009 den thang 6.2010.Cac trudng hgp bi diit lia chi thi hoac dap nat chi thd hoac ddn muon da hoai tir khdng nam trong nghien ciiu nay.
Y HOC VIET NAM THANG 10 - 5 0 2/2010
2- Phuang phdp nghiin cieu: md ta cat ngang, tien ciiu.
+ Nghien ciiu dac diem tdn thuang giai phau benh.
+ Nghien ciiu dac didm lam sang.
-I- Nghien ciiu dac diem can lam sang.
^- Nghien ciiu ky thuat dilu tri va cac yeu td lien quan den ket qua dieu tri.
-I- Ket qua dieu tri:
Ddnh gid ket qud gdn: Trong 3 tuan dau sau md dua vao phan loai:
-1- Rdt tot: Mach mu chan va dng gdt dap ro, ban chan, ngdn chan hdng, am, cam giac tdt.
+ Tdt: Mach mu chan va dng gdt dap rd, ban ngdn chan am nhung sung ne, cam giac giam it, giam van ddng ban chan va ngdn chan.
-I- Trung binh: Mach mu chan va dng gdt dap yeu hoac khdng sd thay, ban ngdn chan sung ne nhieu, nhgt, cam giac giam nhieu cd hoai tir mdt phan da va co.
+ Kem: Mach ngoai vi khdng sd thay, ban chan lanh, tim va cd mang tim hoai tii thdi phai cat cut thi 2.
Ddnh gid ket qud xa: Sau 3, 6 va 9 thang. Dua vao bang phan loai chiic nang chi ciia Katsamouris A.N. [8] va Harrell D.J. [7]
cd 4 mire do:
Rdt tot: Chiic nang chi, van ddng khdp binh thudng, mach ha luu dap rd, ban chan hdng am, khdng bien chirng.
Tot: Chiic nang van ddng khdp gan binh thudng, cd bien chiing dugc xir li kip thdi khdng phai phau thuat lai.
Trung binh: Chiic nang chi van ddng khdp giam nhieu, cd bien chiing nhilm triing, mach ha luu yeu, cd rdi loan dinh dudng.
Kem: Chiic nang chi bi anh hudng nghiem trgng, mat kha nang di lai (rdi loan dinh duong nang, teo co, ciing khdp, te budt thudng xuyen)
III. KET QUA NGHIEN COU
3.1. Ddc diim doi tuang nghiin cuu - Nguyen nhan: tai nan giao thdng: 15/
16; tai nan lao ddng: 1/16;
- Tudi nhd nhat: 17, ldn nhat: 60, tap trung d do tudi lao ddng tir 20 den 59;
- Gidi: Nam: 11 BN; Nir: 5 BN.
3.2. Ton thuang gidi phau binh
Bang 1: vi tri tdn thuong dgng mach va xuong khdp
V Td'n thu'dng DM khoeo
Ton thu'dng OM chay tru'dc
Ton thu'dng DM chay sau
tri ton thu'dng Gay xu'dng diii Sai khdp gdi
Gay 1/ 3 tren xu'dng cang chan Gay 1/ 3 tren xu'dng cang chan Gay 1/ 3 giO'a xu'dng cang chan Gay 1/ 3 dgdl xu'dng cang chan Gay 1/ 3 tren xu'dng cang chan Gay 1/ 3 giCa xu'dng cang chan
Tong cpng
SoBN 1 1 6 1 1 2 2 2 16
Ti le o/o 6,25 6,25 37,50
6,25 6,25 12,50 12,50 12,50 100
HOI CHAN THUONG CHJNH H I N H VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN THlf IX
Ton thuang DM khoeo chiem ti li 50% • 'M <'. .P. ";•":'?
Bang 2: Tinh chat tdn thuang ddng mach
Tinh chat Raeh thanh ben
Chen ep va raeh thanh ben Dung dap dirt rdi
Dung dap tac Tdng cgng
SoBN 2 3 6 5 16
Ti le % 12,50 18,75 37,50 31,25 100
3.3. Ddc diim lam sdng vd can lam sdng
Bang 3: Dau hieu lam sang
Dau hieu
Sdc chan thu'dng Trung binh
Nang Gay xu'dng kin Gay xu'dng hd Trat khdp hd Mach ngoai vi
Dau hieu thieu mau ngoai vi
Yeu Mat Khdng dien hinh
Dien hinh Hdi chu'ng chen ep khoang
SoBN 11
5 4 11
1 6 10
6 10
3
Tl le o/o 68,75 31,25 25,00 68,75 6,25 37,50 62,50 37,50 62,50 18,75
Bang 4: Phuang phap tham dd xac dinh tdn thuang ddng mach trudc md
Phu'dng phap Do do bao hda oxy (Sp02)
Sieu am Doppler mach ( 4 BN)
Ket qua Giam
Mat
Mat tfn hieu mach
SofBN 1 15 4
3.4. Phuang phdp diiu tri
Bang 5: Thdi gian tir khi BN bi tai nan den khi phau thuat Thdi gian
SdBN Ti le %
< 6 gid 11 68,75
6 den < 12 gid 3 18,75
12 den 24 gid 2 12,50
Da so BN duac mo sam truac 6 gia.
Y HOC VIET NAM THANG 10 - SO 2/2010
Bang 6: Phuong phap Phu'dng phap
Cd dinh nqoai Ddng dinh ndi tuy Xuyen kim Kirschner Budc vdnq day thep Cdng
cd dinh xuong SoBN
7 3 5 1 16
khdp Ti leo/o
43,75 18,75 31,51 6,25
100 Tdt cd BN duac kit hap xuang truac, CDN chiem ti le cao nhdt 48,75%.
Bang 7: Phuang phap xir tri tdn thuong mach
Phifdng phap Ghep doan TM hien t g than dao chieu Cat ndi
Giai phdng chen ep va khau VT ben Cdng
SdBN 5 6 5 16
Tl1e%
31,25 37,50 31,25
ioo
Tdt cd cdc ton thuang mach deu duoc phuc hoi lieu thong, khong co truang hap ndo bi thdt mach.
3.5. Kit qud diiu tri
Bang 8: Kit qua ghn (16 BN)
Ket qua Bao ton chi Cat cut thi 2 Tac mach Td vong
SdBN 14
2 1 0
Ti leo/o 87,50 12,50 6,25
0
Bang 9: Kit qua xa ( j BN)
Ket qua Rat tdt Tdt Trung binh Xau
SdBN
* 3 1 3 0
Ti leo/o 14,30 42,85 42,85
0
Ddnh gid kit qud xa: Chi co 7 BN duac theo doi > 3 thdng.
IV. BANLUAN
4.1. Gidiphdu binh:
- Vi tri tdn thuang: Tdn thuang ddng mach khoeo hay gap nhat (chiem 50%). Do cau tao giai phlu ddng mach khoeo nam cd djnh d vi tri cd nhieu td chiic xo it ehun gian, phia trudc sat ldi cau xuong diii va dau tren xuang chay nen rdt dl bi tdn thuang khi trat khdp gdi hoac gly xuang vung nay. Vi vay khi gay dhu duai xuong diii, sai khdp gdi.
gly dau tren xuang cang chan can tim tdn thuang dgng mach khoeo.
- Tinh chat tdn thuang: chii yeu la dung dap tac mach hoac mat doan do do tren lam sang thudng gap hdi chiing thieu mau ngoai vi, it cd dau hieu chay mau d at va ti le phai cat doan ddng mach > 2cm va'ghep mach tu than la 31,25%.
- Tinh chat tdn thuong xuang va phan mem: do luc chan thuang tuong ddi manh nen xuong bi gly phiic tap, co, can, da bi dap
HOI CHAN THUONG CHJNH HJNH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN THlf IX
nat nhieu nen sau md chi sung ne cang, nguy CO nhiem triing rat cao.
4.2. Lam sdng vd can lam sdng: sdc chan thuang la dau hieu thudng gap do dau, mdt mau, tdn thuang phdi hgp. Tai chd chan bi chin thuong thudng sung ne bien dang, phan mem bi dap nat bong ldc rdng, cd the kem theo hdi chiing chen ep khoang la nguyen nhan lam bd sdt tdn thuong mach mau. Do do can tham kham can than, nhieu lln va dac biet phai cd phan xa tim tdn thuang mach mau trudc mdt gay xuong phirc tap hoac trat khdp ldn. Neu cd nghi ngd tdn thuong mach can do do bao hda oxy ca 2 chi dl so sanh, bdi vi day la phuong phap rat don gian cd the lam thudng quy. Trong sd 16 BN bi tdn thuang ddng mach dugc do do bao hda oxy deu cho ket qua giam hoac mat. Sieu am Doppler mach trong 4 trudng hgp gay xuong kin nghi tdn thuang ddng mach cho thay mat tin hieu mach dudi tdn thuang giiip chan doan va xir tri sdm. Chup Xquang xuong khdp de danh gia mire do tdn thuang va chuan bi phuong tien ket hgp xuong phii hgp.
Trong nghien ciiu nay chiing tdi chua tien hanh chup mach de chan doan Theo mdt sd tac gia [3], [8], [10], day la mdt phuang phap tham dd cho thay chinh xac vi tri, tinh chat tdn thuang tuy nhien cd cac nhugc dilm nhu huyet khdi gay tac mach, suy than, sdc phan ve va keo dai thdi gian thieu mau ngoai vi.
4.3. Phuang phdp diiu tri:
Muc dich: dam bao tinh mang BN, ciiu chi va phuc hdi chiic nang chi.
Hdi siic tich cue phdng chdng sdc trudc, trong va sau md bang truyen dich, cao phan tir, truyen mau, giam dau. Khdng cd BN tir vong trong nghien eim.
Md cap ciiu: chiing tdi chgn dudng md thich hgp vira ket hgp xuong vira xir tri tdn
thuong mach. Trudng hgp nghi ngd tdn thuang ddng mach khoeo chiing tdi chgn dudng md phia trong khdp gdi vdng ra phia trudc trong cing chan. Mdt sd tac gia chgn dudng md phia sau dl xir tri tdn thuong ddng mach khoeo, nhugc dilm la gay khd khan khi cham sdc vet md va phuc hdi chirc nang chi.
Cd 6 benh nhan den mudn bi thieu mau chi keo dai, chung tdi tien hanh rira chi bang 1000 ml dung dich NaCI 9%o cd pha 20.0000 dv Heparin (bom qua vet thuang ddng mach va mau dugc lay qua vet md tinh mach ciing mire hoac tinh mach bi diit) nham muc dich loai bd mdt phan san pham chuyen hda ki khi [5]. Bang each nay chiing tdi da lam giam nguy CO nhiem ddc cho ca the sau khi tai lap tuan hoan va cac benh nhan nay dugc theo ddi thay khdng cd suy than sau md.
Xir tri tdn thuang xuong khdp trudc khi xir tri tdn thuang mach mau. Tuy theo tinh chat tdn thuang, tat ca gay xuong, sai khop dugc nan chinh va cd dinh nhanh chong bang khung cd dinh ngoai mgt ben-mdt binh dien (khung F.E.S.S.A., cgc ep rang ngugc chieu) [1],[4], ddng dinh ndi tiiy, xuyen kim Kirschner hoac budc vdng day thep. Nhd ket hgp xuong viing chac, viec xir tri tdn thuong mach, theo ddi va cham sdc BN sau md co nhilu thuan lgi. Chiing tdi khdng sir dung nep vit vi mat nhieu thdi gian gay thieu mau ngoai vi keo dai, khdng ap dung phuang phap bd bdt hoac keo lien tuc vi cd dinh xuong khdng virng cd the gay tdn thuang mieng ndi mach va khd khan khi cham soc BN saumd.
Ddi vdi mach mau tiiy theo mire do ton thuang dugc khau, ndi hoac ghep doan bing tinh mach hien tu than dao chilu, khdng co trudng hgp nao dugc thit mach. Nhumg trudng hgp ddng mach bi dung dap, tic mach dugc cit bd tdn thuang ndi mac din td chiic
Y HOC VIET NAM THANG 1 0 - 3 0 2/2010
lanh va sir dung xdng Fogarty dl liy hit huyet khdi trong ldng mach trudc khi khau ndi hoac ghep mach. Vat lieu dl ghep mach la doan tinh mach hiln trong cua chi ddi dien dao chieu. De phdng chen ep khoang sau md, vit md dugc de hd can, khau da thua hoac de hd da. Mdt sd tac gia cho rang neu thdi gian thieu mau ngoai vi trudc 6 gid nen xir tri tdn thuang xuong khdp trudc. Ngugc lai can tien hanh xir tri tdn thuang mach trudc de nhanh chdng cap mau cho ngoai vi, nhung mudn xir tri tdn thuong mach trudc phai sir dung shunt bac cau dgng mach de tudi mau ngoai vi trong thdi gian KHX.
4.4. Kit qud diiu tri
- Ket qua gan: khdng cd BN tir vong. Cd 2 BN bi cit cut chi thi 2 (chilm 12,50%).
Nguyen nhan: 1 BN tdn thuang dap nat phan mem nang gay nhiem triing nhiem ddc sau md, 1 BN bi md mugn sau 24 gid gay thieu mau ngoai vi khdng hdi phuc. Cd 1 BN bi tac mach sau md (chiem 6,25 %) do tdn thuang noi mac chua dugc cat bd het trudc khi ghep mach gay huyet khdi. Xir tri: md lai cat bd phan ddng mach bi dung dap ndi mac va ghep doan ddng mach bang tinh mach hien tu than dao chieu ket qua tdt.
- Ket qua xa: chi cd 7 BN dugc theo ddi tren 3 thang do thdi gian nghien ciiu. Ket qua CO 4/ 7 BN dat kit qua tdt va rit tot, 3/ 7 BN dat ket qua trung bmh.
V. KET LUAN
5.1. Dgc diim tdn thuang gidi phdu benh, lam sdng vd can lam sdng:
- Dac dilm tdn thuang giai phau benh:
Vi tri tdn thuang: DM khoeo: 8/ 16; DM chay trudc: 4/ 16; DM chay sau: 4/ 16. Gly xuong diii: 1/ 16; Sai khdp gdi: 1/16; gly xuong cang chan: 14/16.
Tinh chat tdn thuang DM: Raeh thanh ben: 2/ 16; chen ep va raeh th^nh ben; 3/16;
Dung dap dirt rdi: 6/ 16; Dung dap tac: 5/16.
- Lam sang: sdc chan thuang 16/16; gay xuong kin: 4/16; sai khdp hd: 1/16; gay xuong hd: 11/16. Mach ngoai vi mat: 10/16;
Mach ngoai vi yeu: 6/16; Dau hieu thieu mau ngoai vi dien hinh: 10/16; Dau hieu thieu mau ngoai vi khdng dien hinh: 6/16; Hdi chiing chen ep khoang: 3/16.
- Can lam sang: Do do bao hda oxy (SPO2): giam 1/16, mit: 15/16.
Sieu am Doppler mach (4/16): mat tin hieu ddng chay: 4/4.
5.2. Ky thuat diiu tri vd cdc yiu to liin quan din kit qud diiu tri
- Ky thuat dieu tri:
-I- Thii tu: xir tri tdn thuang xuong khdp trudc: 16/16.
-I- Phuang phap xir tri tdn thuong xuong khdp: Cd dinh ngoai: 7/16; Ddng dinh ndi tuy: 3/16; Xuyen kim Kirschner: 5/16; Budc vdng day thep: 1/16;
-I- Phuang phap xir tri tdn thuong ddng mach: Ghep bang doan tinh mach hien tu than: 5/16; Ndi: 6/16; Giai phdng chen ep va khau vet thuong ben: 5/16.
+ Ket qua dieu tri:
Ket qua gan: tir vong: 0; Bao tdn chi:
14/16; Cat cut chi thi 2: 2/16; Tac mach phai md lai: 1/16.
- Cac yeu td lien quan den ket qua dilu tri:
-I- Thdi gian: BN dugc md sdm trudc 6 gid ke tir khi bi tai nan ket qua tdt hon nhd thdi gian thieu mau ngoai vi ngan. Ngugc lai cac trudng hgp dugc md mugn cd nguy co hoai tir chi, nhiem ddc toan than do chuyin hda ky khi va anh hudng nghiem trgng din chiic nang chi ve sau.
HOI CHAN THUONG CHJNH HINH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN THLf IX
+ Miic do tdn thuang: tdn thuong xuong khdp, mach mau, than kinh va phan mem nang de gay nhiem triing tai chd ciing nhu suy than cap sau md.
+ Phuong phap dieu tri: hdi sire trudc md de eim tinh mang BN, phau thuat va dieu tri sau phau thuat cd vai trd quyet dinh dam bao su sdng ciia chi ciing nhu phuc hdi chuc nang chi.
TAI LIEU THAM KHAO
1. Nguyen Tien Binh "Ky thuat va cac hinh thiic su' dung co dinh ngoai trong gay xuong hd". Mgt sd van de ca ban trong Chan thuang Chinh hinh.Bg mon khoa CTCH Benh vien Trung uong Quan dgi 108. Ha Ngi 2003.Trangl57-166
2. Nguyen Sinh Hien va cong sir "Ton thuong mach khoeo trong chan thirong kin: nhung khd khan trong chan doan va dieu trj" Tap chi ngoai khoa. So 3 nam 2000. Trang 29 - 37.
3. Frederic B., Jean Michel C. "Chin thuang dgng mach khoeo". Hoi nghi khoa hgc Viet Phap 2000. Ngudi djch Doan Quoc Hung.
4. Nguyen Dang Ninh "Nhan xet ket qua budc dau su dung khung cd djnh ngoai tir tao kieu F.E.S.S.A. trong dieu tri gay hd hai xucng cang chan" Luan van Thac sT y hgc. Hgc vien
quan y1995.
5. Nguyin Hiru tTo-c "Tic chac ba chu chau cap tinh". Phlu thuat d p ciiu tim mach va long nguc. Nha xuit ban Y hgc. Ha Noi 2001. Trang 202-207.
6. Gustilo R.B., Mendoza R.M., Williams D.N. "Problemes in the management of tye 111 (severe) open Fractures: A new classification of tye 111 open Fractures".J trauma, 1984, Aug, 24 (8), 228 -232.
7. Harrell D.J., Spain D.A., Bergamini T.M., Miller F.B., Richardson J.D. "Blunt poplieal artery trauma: a challenging injury".
Am-Surg, 1997, Mar, 63 (3), 228 - 232.
8. Katsamouris A.N., Steriopoulos K., Katomim P., Chiston K. "Limb Arterial injeries Associated with limb Fractures:
Clinical presentasion. Assessment and Management". Eur. J. Vase. Endovas. Surg., 1995,Jan, 9(1), 6 4 - 7 0 .
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