NHAN XET KET QUA DIEU TR!
GAY KHUNG CHAU KHONG VUNG BANG KHUNG CO DjNH NGOAI
Pham Dang Ninh*, D6 Dure Binh*, Nguyen Ba Ngoc*, Nguyen Ngoc Toan*
TOMTAT
Tac gia bao cao ke't qua ufng dung phuong phap co' djnh ngoai mot ben bang cpe ep ren ngupc chieu de dieu trj cap cifu cho 35 benh nhan gay khung chau khdng viing tai khoa Chan thuang chinh hinh Benh vien 103 trong thdi gian tir thang 5/2003 de'n 6/2010. Ke't qua thu dupc la kha quan: ngay sau khi dupc cd djnh benh nhan dd dau nhieu, tinh trang toan than nhanh chdng di vao on djnh, c6 the trd minh va tap ngoi day sdm, tranh dupc cac bie'n chimg do nam bat dpng lau ngay. DSc biet thuan Ipi cho cong tac san sdc hp 1^ va dieu trj cac thuong tdn ke't hop nhU chan thuong bung, chan thuang v9 bang quang, cac thUdng tdn viing khdp hang va tang sinh mdn...
SUMMARY
REMARKS ON TREATMENT UNSTABLE FRACTURES OF THE PELVIC RING BY EXTERNAL FIXATION
From May, 2003 to June 2009, 35 patients with unstable fractures of the pelvic ring were treated by external fixation in Traumatic and Orthopeadic Department in Hospital 103. The results was rather well: immediately after fixation, the patients can sit early, excercise gently.
Therefore, they can avoid the complications of lying for long time. Especially, it was very convemient for taking care and treating patients who also had combine lesion as loss soft- tissue, abdomen traumatic, break of vesica...
TCf khoa: Gay khung chau khdng vOfng, Khung cd djnh ngoai. Unstable fractures of the pelvic ring , external fixation
I. OAT VAN OE
Gay khung chau la mdt ton thuang nang i ne, cd ty le tir vong cao, trong dd nguyen ; nhan chu yeu la do tai nan giao thdng.
Benh nhan gSy khung chau cd the bi cac ! thuang ton ket hap khac nhu cha'n thuong ! bung kin, chain thuang bang quang, gSy nhilu \ xuang, vet thuang rach t^ng sinh mdn ... nSn j rat di. sdc va cd nguy ca tit vong rat cao. i
Phuang phap dieu tri kinh dien lau nay ^ vSn duoc ap dung la phdng chdng sdc tich i cue va di benh nhan nam bat ddng gac chSn ! tren gia Braun trong 5- 6 tuSn. Mdt sd tac gia j cho benh nhan dieu trj treo vdng d6' ep va c6' : dinh khung chau hoac keo lien tuc. Tuy nhi6n \ cac bien phap nay khdng thuan lai trong dieu \ tri cap cihi cac benh nhan gay khung chau co i
nhieu thuang ton ket hop khac. \ Do gly khung chau ch^y nhilu mau va '
ra't dau nen de phdng chdng sd'c cd hieu qua i thi can phai cd dinh chac 6 gSy va ep 2 mat j gSy vdi nhau de cdm mau. Xua't phat tiJ I nhirng ly do tren day, trfen the gidi va Vi6t I nam da cd nhieu phau thuat vien nghien ciiu : sir dung khung cd dinh ngoai vao dilu tri cS'p ; cuu gay khung chau nham muc dfch phong chdng sdc, tao thuan lai cho xix tri cac t6n thuang ket hap va du phdng cac bie'n chiing '•
do nSm lau. Nhilu nam qua, Bp mdn khoa i Chfo thuang chinh hinh Benh vien 103 da I ling dung phuang phap cd dinh ngoai mdt ] ben bang bp cpe ep ren nguac chilu cua j Nguydn Van Nhan de dieu tri cho cac gay 1 khung chau, biiac dSu thu duprc ket qua kha [
Y HOC VIET NAM THANG 12 - SO 2/2010
quan. Chiing tdi tien hanh de tai nghien ciiu nay nham hai muc tieu:
- Ddnh gid ke't qud dieu tri cua phuang phdp tren cdc mat phdng chdng sdc, ldm
lien xuang vd phuc hoi chdc ndng.
- Dua ra mot sd nhdn xet ve chi dinh vd bien chiing
II. 061 TUONG VA PHUdNG PHAP N G H I I N CCfU 2.1. Ddi tuang nghien curu gom 35 benh nhan gay khung chau dupc caip cunr dieu tri bang khung cd dinh ngoai tai BV 103 trong thdi gian til thang 5/ 2003 den thang 6/2010.
Bao gdm 25 nam va 10 nii tudi tir 13 de'n 54, tuoi trung binh la 31,75.
Nguyen nhan gay xuang: TNGT: 29 BN;
TNLD: 6 BN.
Phan loai gay khung chau theo bang phan loai ciia Tile (1988): tat ca ddu gay khung chau mix. vutig gdm 12 BN gay loai B va 23 BN gay loai C (chi gdm CI, C2 khdng cd gay loai C3).
- Ton thuang kd't hop: cd 18 benh nhan.
-t- Chan thuang bung km : 6 BN + Vd bang quang, diit nieu dao: 4 BN + Rach tSng sinh mdn: 4 BN -I-Gay hd xuang dui: 2 BN + Gay kin 2 xuang cang chan: 1 BN -H Sai khdp hang ben phai the chau, Idc da rpng vung mdng va diii ben phai: 1 BN.
+ Bdng lira dp 2 va dp 3 ndng toan bd viing lung va 2 mdng: IBN .
+ Gay CO phau thuat xuang canh tay, gSy xuang sudn, tran khf tran mau khoang mang phoi: 1 BN.
Cd 1 benh nhan vita cha'n thuang bung kfn vira gay xuang diii va 1 benh nhan vita cha'n thuang bung kfn vira vd bang quang.
2.2. Phuofng phap nghien curu
Nghien ciiu tien ciioi 20 benh nhan, hdi cuu 15 benh nhan.
2.2.1 Dung cu: Bd cpe ep ren ngupc
chi6u (CERNC) cua Nguydn Van Nhan loai dai 35 cm.
Dinh Schanz cd dudng kfnh 4,5mm dai 125mm. Khoan dien, khoan tay va mui khoan dan dudng cd DK 3,0mm. Hai doan dinh Steinmann DK 5mm, dai 60 mm de' lien ket 2 cpe vdi nhau.
2.2.2. Phuang phdp vd cam.
Neu lam tai giudng chi can gay te tai vi trf bat cac dinh Schanz bang dung dich Lidocain 1% + 0,3 ml Adrenalin 0,001; kd't hop vdi thudc giam dau toan than.
2.2.3. Ky thuat xuyen dinh lap khung cd dinh ngodi
Thuc hien tai giudng benh khoa hdi siic cap ciiu hoac sau khi ddng xong vet mo cap ciiu giai quyet cac thuang ton d bung.
Benh nhan nam ngira, hai diii gac tren hai gia Braun tu the con ech .
-I- Xac dinh vi trf xuyen cac dinh: 2 dinh dau tien dat d mao chau 2 ben, each gai chau trudc tren tir 1,0 -1,5 cm. Gay te tai chd va sau dd rach dai 5mm tai cac vi tri bat dinh Schanz. Khoan bang mui khoan dk 3,5 mm theo hudng tir trudc ra sau, tir ngoai chech vao trong. Dimg khoan tay de bat 2 dinh Schanz theo Id 'vira khoan, sau dd lap cpe ep ren ngupc chi6u thii nha't ke't ndi 2 dinh nay, dimg cd le 10 de van dan dan ep khung chau nham thu hep khoang each 2 gai chau trudc tren trudc khi khoan va bat 2 dinh sau. •" . : •
Khoan va bat 2 dinh Schanz tiep theo each dinh dau tit 5-6 cm, hudng di song song vdi hai dinh ddu. Lap tiep cpe ep ren ngupc chieu thii 2 sau dd lien ket 2 cpe vdi nhau bang hai doan dinh Steinmann. Can cii vao miic dp di lech ma't viing cua khung chau, tinh trang doang ciia khdp mu tren phim XQ d6 van ep cho 2 mat gay ap vdi nhau va lam cho khung chau vung ban. Chup lai XQ sdm khi toan than benh nhan on dinh va dua vao
CHUYEN DE: BENH VIEN 103 - HOC VIEN QUAN Y <- CHAO MLfNG 60 NAM NGAY TRUYEN THONG 1
dd de van chinh tiep ep cho khung chau trd chiing tdi xuyen dinh keo lien tuc de 2 canh ; vd binh thudng. chau ve vi tri binh thudng rdi mdi thuc hifin |
Cd 6 BN khi vao cd gay khung chau loai cd dinh ngoai. j C2, mdt nira khung chau bi keo len tren.
2.2.4. Thdi diem thuc Men ky thuat + Thuc hien ngay sau khi mo cap ciiu: 4 BN (2 BN mo cha'n thuang bung kfn va 2 benh nhan vd bang quang).
+ Thuc hien tir ngay thir 2 ddn ngay thii 4: 20 BN
4- Thuc hi6n vao ngay thii: 5: IBN, do chuyen mudn tir nai khac de'n.
Thdi gian mang khung: tit 5 - 6 tuan.
2.3. Ddnh gid ket qud : dua theo nhOng tieu chuan ve tac dung giam dau, phdng chdng sdc, ke't qua lidn xuang va cac bien chiing, chiing tdi xay dung mdt bang phan loai ket qua gdm 4 miic tdt, kha, trung binh va kem. . ,,
III. KET QUA NGHIEN CCfU
3.1. Ket qud gan: tat ca cac benh nhan deu dd dau d khung chau ngay sau khi xuy6n dinh va lap khung cd dinh ngoai. Trtr 8 BN mo bung ket hap phai dpi khi tinh lai mdi tha'y khung chau dd dau.
Ke't qua XQ kiem tra thay ta't ca cac benh nhan deu dupc nSn chinh phuc hdi ve hinh the giai phiu tit miic kha trd len. Cac dinh Schanz dupc bat diing vj trf, nam trong xuang mao chau. Khdng cd BN nao bi xuyen dinh truot ra ngoai.
Bie'n chiing nhidm khu^n chan dinh:
lOBN (28,57%).
Cac benh nhan cd thuang ton ket hop : j -H 6 BN chain thuang bung kin trudc khi ; cd dinh ngoai 6 gSy khung chau deu dupc xtt \ tri bung on djnh trong dd cd 4 BN mo bung i cap ciiu va 2 BN mau tu sau phiic mac khSng i phai mo, khdng benh nhan nao cd bo sot ;
thuang ton. i -t- 2 benh nhan ton thuong bang quang ;
va 2 BN diit nieu dao tang sinh mdn dupc m6 I cap ciiu til gid thii 4 de'n gid thii 6, dat sonde j nieu dao va dan luu bang quang tren xirong j mu. Di6n bien sau mo td't.
+ 4 benh nhan cd rach iing sinh m6n ; deu dupc xir trf cat loc vet thuang, thay bang ;
ket qua li6n vet mo ky hai. : + 2 BN gay xuang diii hd:
Mdt benh nhan dupc mo kdt xuong ' nep vft ngay thii 10, vet mo lien ky dau. \
Mdt BN duac ket xuong dui bang | khung cd djnh ngoai, hien nay BN da liSn i
xuong va thao khung. I + Benh nhan cd sai khdp hang ben phai i
duoc keo lien tuc nan chinh ke't hop cd djnh | ngoai 6 gay khung chau. Ke't qua benh nhSn i dupc nan chinh bet sai khdp hang va dieu trj i
lien vet thuong loc da d dui. 4
Y HOC VIET NAM THANG 12 - SO 2/2010
+ BN gSy kfn 1/3 giiia 2 xuong cang chan sau khi toan than dn djnh dupc mo ddng dinh SIGN kin
-I- Benh nhan gSy cd phSu thuat xuong canh tay, gSy xuong sudn, tran khf tran mau khoang mang ph6i xir tri ca'p cuu dSn luu dich mau khoang mang phoi va cd dinh xuong sudn gSy + cd djnh ngoai khung chau.
Sau 10 ngay khi toan than on dijnh da md ket xuong CO phau thuat xuong canh tay . , -
3.2 Ke't qud xa.
Chiing tdi da kiem tra dupc ke't qua xa dupc 28 BN (80%) vdi thdi gian theo ddi tir 7 thang de'n 5 nam, trung binh la 16,4 thang.
2 benh nhan khdng theo ddi dupc ket qua xa do tha't lac dja chi va 5 BN chua du thdi gian theo ddi tren 6 thang.
Ke't qua tdt cd 22 benh nhan (78,57%), kha 4 benh nhan (14,28%) va trung binh 2 benh nhan (7,14%). Khdng cd ke't qua kem.
Cd mdt BN bien chiing nhiem khuan chan dinh rd mil keo dai tdi 3 thang. BN nay da xir trf gay te tai chd, nao bet phdn xuong viem, ke't qua he't viem rd. Bdnh nhan ket qua trung binh do gay khung chau phiic tap, cdn ngan chi 3cm.
IV. BAN LUAN
Vdi nhiing kd't qua di^u trj thu dupc, chung tdi xin dua ra mdt sd nhan xet nhu sau.
4.1. Ve chi dinh cua phuang phdp cd dinh ngodi trong dieu tri gay khung chdu
Theo Tile, Letoumel, Judet va Muller, viec chpn mdt phuong phap didu trj cho benh nhan gay khung chau trudc he't phai can cii vao tinh trang toan than ciia benh nhan va phan loai gay khung chau. Hai bang phan loai ciia Muller va ciia Tile hien dang dupc nhieu phau thuat vien ap dung. Dd'i vdi gay loai A, la cac gay khung chau nhung la gay viing, neu khdng cd cac thuong ton ke't hop chi can cho benh nhan nam bat ddng gac
chan tu the' dui e'ch trong 4 tuan. Vdi cac gay loai B va loai C, la nhiing gay khdng viing.
Khai niem khdng viing d day khdng phai la dudng gSy ma ndi dd'n su ma't viing ciia vdng chau (gSy ca cung trudc va cung sau). Ddi vdi loai gSy nay cac tac gia ddu chii truong phlu thuat ke't xuong lam virng khung chau.
Chiing tdi chpn phuong phap cd dinh ngoai v i :
- Trudc he't day la phuong phap cd dinh 6 gay •viing chac.
- Thao tac ky thuat don gian, chain thuong phau thuat khdng Idn ndn dp an toan rSit cao. Vl the' cd the lam ngay tai phdng hdi siic va lam sdm trong ngay dau sau khi da loai trii tinh trang bung ngoai khoa.
- Viec cd dinh 6 gay -viing chac vira cd tac dung giam dau -vita cd tac dung cdm mau ddi vdi 6 gay xuong chau va ra't tien lpi cho viec thuc hien cac cdng tac cham sdc hd ly cho BN sdm, an toan hon.
Ke't qua dieu trj 24 BN vdi nhiing thuang tdn nang ne va phuc tap deu thoat sdc, lidn xuong va PHCN tdt da chiing td su lua chpn ciia chiing tdi la diing.
4.2. Ve ky thuat ke't xuang cd mot sd diem chung tdi mudn trao ddi.
• Ve thdi diem tien hanh: chiing tdi cho rang ndn lam sdm, cang sdm cang td't vi muc tieu quan trpng la giam dau va cdm mau de phdng chdng sd'c. Do dd, ne'u benh nhan cd thuong ton ke't hpp cSn phai mo thi se d^
BN len nha mo va cd djnh khung chau sau khi ddng vd't mo bung. Ne'u BN khdng cd thuang ton ket hpp trong 6 bung thi nen lam ngay tai giudng benh va cung can lam sdm khi loai trir cap ciiu bung ngdai khoa.
Letoumel, Ruedi, Murphy, Nguyin Vinh Thdng, Nguyin Ngpc Toan, khi gay khung chau, muc dfch cd djnh 6 gay va khung chau la de giam dau, cam mau va tao didu kien thuan tien cho viec di chuyen BN khi can thiet va do cha'n thuong phau thuat
khdng nhieu ndn cac tac gia nay ddu chu truong lam sdm hon. Cd benh nhan khi vao caip ciiu, sau khi thuc hien cac bien phap chdng sd'c co ban nhu tiem giam dau, truydn dii djch va man ma vSn chua thoat sd'c, chiing tdi da thucjj hien cd dinh ngoai ngay va ket qua la benh nhan on djnh. Ruedi cho rang khung cd djnh ngoai cd tac dung ep chat 2 mat gay xuong chau nen cd tac dung cam mau d xuong khi dang chay mau.
- Vj tri xuyen dinh: chiing tdi chpn mao chau la vi trf xuydn dinh. Vi trf nay sd thay ngay dudi da, de lam va khdng sp cd tdn thuong mach mau, tdn thuong tang trong 6 bung. Mdt sd tac gia cdn xuydn ca 2 dinh vao nganh chau - mu, lam nhu vay luc ep dan deu ban nhung can phai de phdng bie'n chiing ton thuong tang d phfa dudi.
- Phai khoan trudc bang mui khoan cd dudng kfnh 3,5mm qua 2 vd xuong chau, sau dd dung khoan tay di hk cac dinh cd ren.
Lam nhu vay de bat cac dinh chfnh xac va chac vao thanh xuong chau. Khi dung dinh Schanz cd dau nhpn, thi cd the lap true tie'p dinh va khoan rat cham ma khdng can khoan trudc bang mui khoan. Lam the' nao de bat cac dinh nam gpn chfnh giiia xuong canh chau, khdng bj trupt sang bdn la diiu cSn chii y vi neu khoan trucrt sang ben phai khoan lai thi dinh khdng cdn cdm chac vao xuong niia.
Thdng thudng sau khi rach da, chiing tdi dung ngay dau dinh de tham dd bi dfiy ciia xuong canh chau trudc khi khoan va dat dau dinh d chfnh giiia.
- Khi lap cpe ep nen de' cpe each da thanh bung 4-5 cm la du de thay bang cac vet mo bung ne'u cd.
4.3. Tgi sao Igi chpn bp cpe ep ren ngugc chieu :
Chpn khung cd dinh ngoai la coc ep ren nguoc chieu cua Nguyin Van Nhan co loi diem vl: day la bd khung ma cac bac sy quan
y da quen sir dung, thao tac don gian, cd djnh chac. Day ciing la loai khung dang cd san 6 i cac benh vien quan y. Bd cpe ep ren nguoc \ chieu cd the sir dung cho nhiiu vj trf gay i xuong, ndn ra't tien cho viec bao quan, sir ] dung d tuyen trudc trong diiu kien chiin d& i
hoac cini chiia hang loat. \
\ V. KET LUAN
Diiu tri cac gay khung chau khdng viing (loai B va C theo phan loai ciia Tile) bang phuong phap cd dinh ngoai vdi bd cpe ep ren ngupc chiiu cho ket qua kha quan. Nhd tac j dung CO djnh viing chac 6 gay, dm mau kip i
thdi nen gdp phan chdng sdc tdt. i Day la phuang phap an toan, tien loi 1
cho viec cham sdc cac BN cd cac thuong t6n | ket hop, nhd dd cd the trd minh sdm cho BN, j tap van ddng sdm, tranh cac bie'n chiing do i
nam lau. j Kit qua xa vi liin xuong va phuc h6i \
chiic nang td't dat 78,57%, kha dat 14,28% va trung binh la 1,\A%. Bidn chiing nhiim khuan chan dinh la 28,57%.
Chi djnh cua phuong phap la cac gay \ khung chau ma't vimg loai B, C. (theo phan j loai ciia Tile)
TAI LIEU THAM KHAO
1. Nguyin Ngpc Toan (2005). Danh gia ke't qua dieu tri gay khung chau khdng viJng bang khung cd djnh ngoai. Luan van Thac sy.
HVQY.
2. Ruedi T.P., MurphyW.M (2001). Pelvic ring injuries: assessment and concepts of surgical management. AO principles of fracture management, p 395- 417.
3. Larry D.I., Marc F.S., (1994). fracture of the pelvis, sarum and coccyx. Manual of acute orthopeadic therapeutic 4 th. 1994. p 2007 - 220.