Nghien cmi Y hpc Y Hpc TP. Ho Chi Minh * Phu Ban Tap 19 * So 5 * 2015
NHAN XET 03 TRl/ONG HOP TON THl/ONG GOI BAP BENH (FLOATING KNEE) 6 TRE EM TAI BENH VIEN NHI DONG NAI
Pham Dong Doai*, Nguyen Bd Minh Phuac*, Pham Vdn Khuang*
TOMTAT
Tm thieang goi bgp IJenh (floating knee) dtre em la tan thuang hian gap nhtrng rat nang zn thuang trang benh cdnh da di&i thieang phoi hap vd hay gap kem theo dimt thuang so ndo, ton thieang phan mem nang zm gay xitang ha.
Trong thai gian tir 05/2012 dat 04/2015 chiing tdi dd dieu tri 03 truang hap tm thtamg ndy. Cd03cadeu dteac hoi siit tich arc, truyen mau dion dinh huyei dong, uu tien can thiep phdu thuat cap cuu cho ton thttang de doa tilth mang nhuphau thuqt vei thi/ang sg nao, phSu thuqt cat lgc vei thuang.
Lua dign phuang phdp dieu tri tmt thuang ndy a tre em la kho khdn. Chung tdi da dieu tri2 ca bang phau thuat kH hgp xieang kni du&i C-arm xuyen dinh Rush ngi ti'iy cd xntang diii zm xteang chdy. 01cadoz>el tlntang sg nao nang nen chiing tdi lua chgn phieang phdp dOu tri bao ton keo lien tuc.
Hai ca pliau thuqt ket hap xteang dto kH qud lanh xitang va phuc hdi toi theo doi sau 06 thdng. Ca kw Uin tiu: cimg dto kei qua lanh xteang toi va phuc Iwi hodn todn khi toil titcnig ndo Hoi phuc dii trong benh cdnh da dmi thieang cd tail thumig sg nao rdt nqng.
Tuy nhieit, dtiing ldi chua ddnh gid diegc cdc di chung lau dai do roi loqn tdng tntdng xuang do thai gian theo doi ngdn. Can theo doi lau dai zm soai lan hon mai ddnh gid hii cdc van de cua tan thucmg nay.
ABSTRACT
03 CASES OF "FLOATING KNEE" IN CHILDREN IN DONG NAICHUDREN'S HOSPTTAL Pham Dong Doai, Nguyen Ba Minh Phuoc, Pham Van Khucng
* Y Hoc TP. Ho Chi Minh * Supplement of Vol. 19 - No 5 - 2015:230 - 235 The "floating knee" in duldren is rare hut lifo-threatening injury because this injury is ustudly concomitant injury associated zoith head injury, severe soft-tissue damage and open fractures.
Ehiring the period from 05/2012 to 04/2015 zoe treated 03 cases of this mjury.
All 03 cases zvere mtensely cared; given blood tran^ion to stabilize haemodyimmic, referred to emergency surgery on life-threatenhig injury siuh as surgery on head trauma, loound ddnidement surgery.
Choosing ti-eatinent for this injury in children is quite difficidt. We treated 02 cases withclosed mti-amedullary nailing using Rush nails under C-arm of both bonefomur and tibia, but we used Bryant's traction for the third because of severe head trauma.
Two cases treated leith dosed inti-ameduUary nailing showed bony union and fidl recovery after being follawedfljr 6 months. Case ti-eated zoith ti-action dso showed bony unim u^ten the brain injury recovered, despite thefoct that this case is a severe multi-trauma case.
Hazoever, zoe camwt assess long-term sequelae caused by bone grozoth disorder because of a short follow-up period. There should be a Umger follaw-up period and more cases so as to assess all problems of this injury
•Benh vifn Nhi Ddng Nai. ** Bfnh vifn Nhi Ddng 2.
Tdcgid lien Inc. Bs Pham Dong Doai, DT: 0913 989 239, Email: doaiphamdong^^mail mm
Chuyen De Ngoai Nhi
Y Hpc TP. Ho Chi Minh * P h u Ban Tap 19 * So 5 * 2015 Nghien cihi Y hoc D A T V A N D E
Tdn tiiucmg goi bap benh (floating knee) la ton thucmg gay xuong diii va xuong chay cimg ben lam cho khdp goi ldng leo, bap benh do khdng cdn diem tua dau ^ n va dau xa d chi dudi.
Ton thuong nay it gip d tie em, nhung benh canh rat n|ing \T thudng co cac ton thuong da ch&i thuong phdi hop nhu c h ^ thuong dau, nguc, bung, gay hd va ton thucmg phan mem nang cd the de dpa den tinh m ^ g .
Viec xu tri ton thuong nay nam trong t)f nh canh da chan tiiucmg, nen luu y den nhimg van de xu tri cap cuu, hoi siic tich aic nham cuu sdng benh nhi can duoc uu tien.
Ton thuong nay, theo khuynh hudng hifn nay, can phai dupc nhanh chdng can thiep phau thuat. Tuy nhien, hifn it c6 nhung bao cao tdng CA LAM SANG
Ca lam sang 1
ket ve loai ton thuong nay, va cang it hon niia, nhimg bao cao cac trudng hop o tre em
Tu 05/2012 den 04/2015, chung tdi gap 03 trudng hpp. Ca 3 ca da duoc cuu song va dieu tri ton ttiuong "Floating knee" vai 2 ca ket hpp xuong va 1 ca bao ton, xin dupc trinh bay d day.
Muc tieu nghien cuu
Md ta ca lam sang ve mat chain doan, tdn thucmg phdi hpp, phan loai, each thiic dieu tii, ket qua, bien chiing va di chiing.
DOI T l / O N G & PHU'ONG PHAP Phmmg phap
Hdi cuu, bao cao lo^t ca.
Doi tuong
Cac ca cd ton thuong goi b | p benh dieu tri tai t>enh vifn Nhi Dong Nai.
Tu 05/2012 den 04/2015.
Be trai; 5,5 tudi.
Be di bp bi xe gan may dyng true chen. Bi chah thucmg dau, chah thuong dui va cang chan phai.
Nhap vien tiong tinh trang: tri giac lo mo, Qasgow 13 diem, mach 120 lan/phiit huyet ap 90/60 mmHg. Vet thuong dau vimg thai duong 3 cm. Bien dang va sung dau 1/3 tren diu va cang ch&i phai. Mach mu chan ro. Chah thuong phan men vimg tran, co, ben va tang sinh mdn ben phai. Ngyc bung chua phat hien ton thuong. CT-
scan sp nao chua phat hifn ton thuong. X-cjuang gay 1/3 tien xuong dui va 1/3 giua xuong chay phai. Het 30%.
Chan doan: da chah thuong, chj&i thuong dau, gay kin 1/3 tien tiian xuong diii va gay kin 1/3 giiia than xuong chay cung ben phai - TYPE A (phan loai Letts), ton thuong phian men vung dau, cd, tang sinh mdn.
Xii tii: hdi sue tich cue, dich truyen, giam dau, nep bat ddng.
Nghien ctru Y hoc Y Hpc TP. Ho Chi Minh * Phu Ban T a p 19 * So 5 * 2015 Sang ngaj' thii 2, benh nhi cd dau hieu mat
mau cap, da xanh, niem nhot, mach 140 lan/phiit, huyet ap 100/60 mmHg, het giam xuraig cdn 18%. Chi djiih truyen 150 ml mau crimg nhdm. Sau truyen, sinh hieu on, Hd 24%,
Ngay thii 3, truyen them 150 ml mau cimg nhdm. Sau truyen, Het len 32%. Benh nhi dii dieu kien phau thuat ket hpp xuong,
Tudng tiinh phlu thuat benh nhi dupc keo 2 chan tren ban chinh hinh, keo nan va luon 2 dinh Rush vao ndi tiiy xuong dui tu dau dudi xucmg dui qua d gay, ludn 1 dinh Rush vao npi tiiy xuong chay tir dau tren qua d" gay, khdng md 2 d gay, kiem tia dudi man tang sang.
Ket qua: Xuong diii va xucmg chay dupc nan het di lech, dinh ndi tuy vung.
Hau phau ngay 3, benh nhan tiep tuc cd daii hifu tiiieu mau cap, nen dupc truyen them 150ml mau cung nhdm. Bfnh nhi duoc xuat vifn sau 12 ngay hau phau.
Bfnh nhi tai kham va tap VLTL hang thang, nit dinh sau 04 thang, xuong dui va xuong ciiay cai Ianh tdt benh nhi di 1^ binh thudng, tai thdi Ca lam sang 2
diem nit dinh, khdng cd bien chiing cung khop hoac dai chi.
Bdn luan
Day la mdt trudng hpp tdn thuong gdi b | p benh rat nang va phiic tap, Bfnh nhi cd tdn tiiuong "floating knee" ti-ong benh canh da chah thuong nang anh hudng den tinh mang, nen hdi sue tich cue de dieu chinh cac chi so sinh tdn va huyet ddng la then chdt benh nhi ndi bat len vah de mat mau cap do da chah thucmg va da phai truyen 03 don vi mau nham phuc hdi huyet ddng.
Ve phuong tiiiic dieu tii gay xuong diii va xuong chay. Chiing tdi da ket hop ca xuong diii va xucmg chay bSng dinh RUSH kin dudi C-arm, uu diem la tranh dudng mo ldn, giam mat mau, ket hop xuong viing chac, giai phdng khdp sdm.
Ve ket qua, chiing tdi mdi danh gia dupc lanh xutmg va phuc hdi kha nang di lai ciia benh nhi deh thdi diem nit dinh (5 thang), chua danh gia dupc bioi chiing lau dai la dai chi ho|ic bien dang khac.
Be gai: 7 tud'i.
Be di bp bi xe gan may dung true difn. Bi chah thuong dau, chah thucmg dui va cang chan tiai.
Nhap vifn trong tinh tiang: huyet ddng dn dinh, sung he va bam tim vimg tran, bieh dang diii va cang chan trai, tudi mau ban chan tiai
binh thudng, mach quay trai rd, Khdng cd tdn thucmg phan mem hoac co quan khac kem them.
Can lam sang dupc chi dinh: CT-scan sp nao binh tiiudng, x-quang tiiay gay 1/3 giiia xuong dui drai (AO/ASIF type 32-A3), gay 1/3 giua xuong chay (cd manh rdi)va xuong mac tiai{AO/ASIF type 42-B3).
Chuyen De Ngoai Nhi
Y Hpc TP. Hb Chi Minh * Phu Ban Tap 19 * So 5 * 2015 Nghien cuu Y hoc Chan doan: da chah thuong, chah thuong
dau, gay kin 1/3 giira than xuong dui va gay kin 1/3 giua than xucmg chay va xuong mac cimg ben tiai - TYPE A (phan loai Letis).
Benh nhi nay liic nhap vien cd huyet ddng on dinh, nhung sau 24 gjd, cd giam huyet ddng bieu hien tren huyet dd, Het liic nhap vien la 31%, sau dd giam dan xuong 28% va 16%, nen cd chi dinh truyen 250 ml mau cimg nhdm.
Ve dieu tri ton thuong xuong, chung tdi da thuc hien phau thuat ket hpp xuong dui bSng 2 dinh Rush npi tiiy vdi dudng md tdi tiiieu va ket hpp xuong chay bing 2 dinh Rush kin dudi C- arm.Ly do md md toi thieu: do khdng keo het duoc di Ifch chong ngan xucmg dui, vi luc keo tang len chi cd the qua duoc mdt d gay (d gay cang chan).
Ket qua: xuong dui va xuong chaj' dupc nan het di Ifch, dinh npi tuy vung.benh nhan xuat vien sau 10 ngay nam vien.
Ca lam sang 3
Tai kham mdi tuan tiong thang dau tien, tap gap goi va di nang chdng chan dau. Sau 01 thang x-quang kiem tra da cd cai xuong. Sau 02 thang, bfnh nhi di lai binh thudng, han che gap goi, x- quang cai xuong vimg chic. Rut dinh sau 05 thang.
Bfnh nhi tai kham sau 06 thang, di lai binh thudng, khdng han che van ddng khdp goi.
Bdn luan
Bfnh nhi nay tuy khdng n|ing bling ca dau tien, nhung cung phai truyen 01 don vi mau trudc md. Chiing tdi dong lua chon each thiic dieu tri phau thuat ket hop x-uong kin diroi C- arm cho trudng hop nay, nhung d gay xuong diu phai mo md toi thieu do luc keo nan khdng the truyen qua 2 o gay, nen nan kin tJii dupc mpt d gay xuong chay ma khdng the nan d gay xuong diii.
Ca nay lanh xuong tot bfnh nhan di lai binh thudng sdm, chua phat hifn di chiing gi sau 06 thang.
Be gai. 5 tuui.
Be dung ben le dudng bi xe tai dung, sau tai nan be bi hdn me, chah thuong so nao, chan thuong dui va cang chan phai.
Tmh trang nhap vien: hdn me, Glasgow 7 diem, rdi loan huyet ddng, dpa soc, vet thucmg ldm sp cham tiai, chay mau va dd dich nao tuy ra tai, bien dang 1/3 tien dui va gay hd 1/3 tren
cang chiin phai- CT-scan sp nao co lun sp cham, nhdi mau tieu nao. X-quang gay lien mail chuyeh dm (AO/ASIF tj'pe 31-A3) va gay vimg hanh xuong 1/3 tien 2 xuong cang chan(AO/ASIF type 41-A2), het 26%.
Chan doan: da chah thucmg nang dpa soc, vet thuang sp nao ldm sp, gay kin lien mau
Nghien a r u Y hpc Y Hpc TP. Hd Chi M i n h * P h u Ban Tap 19 * So 5 * 2015 chuyen xuong diii\'a gay hd dp II 1/3 tren 2
xuong cang chan -TYPE D (phan loai Letts).
Xu fri: hdi siici tnij-en 750 ml mau. Phau tiiuat md sp cat lpc; nang sp bi ldm, cam mau.
TOT thuong "floating kr»ee" dupc xu tri cat lpc vet thuong gay hd cang chan, xuj'en dinh Idi cau diii, keo ta chan phai tren khung Braun.
Bfnh nhi nay sau md hdn me, thd may keo dai Hoi sue ti'ch cue keo dai sau 02 tuan mdi cai dupc may thd va tri gjac mdi tinh hoi phuc;
nhung di dning nao khdng hoi phuc.
Rieng ton tiiuong "floating knee", dupc dieu tri bao ton biing keo lien tyc, sau 03 tuan Idem tra, tiiay cai xuong tot thing true Benh nhi xuat vien sau 01 thang, vcJi di chiing nao.
Bfnh nhi tai kham sau 06 thang, tdn thuong nao hoi phuc hoan toan, x-quang kiem tra thay d gay xuong dui va xucmg chay cai lanh tot khdng cd bieu hifn ngan chi, bfnh nhi di lai \'a hoat dpng binh tiiudng.
Bdn luan
Day Cling la mdt ca da chah thuong rat nang t>ao gidm vet thucmg sp nao va "floating knee"
type D. Theo Letts, tdn thucmg type D nay cd chi dinh can thiep md md ket hpp xuong, vi ti le khdng lanh xuong cao. Nhung chiing tdi da dieu tri bing bao ton keo lien hjc vi tinh trang benh nhi qua nang, uu tien cho dieu tri ciiu song va nhan xet thay ket cjua la lanh xucmg tot tren x- {{uan^ kha nang di lai va sinh hoat binh fhudng sau khi ton thuong nao hoi phuc.
BANLUAN
Qua 3 trudng hpp tii (6/2012 den 04/2015, chung tdi tiiay ton thuong "floating knee" khdng gap nlueu d tre em. Tuy nhien, day la ton thuong nang de dpa d&i tinh mang benh nhi, vi thudng cd ton thuong phdi hpp, nhat la chloi thuong sp nao. Ca 03 ca deu phai truyen mau trudc hoac sau phau thuat va ca thii ba de lai ch chiing nao nang ne. Ket cjua nay cung gidng nhan xet ciia cac tac gia Letts & Vincent (Canada), Bohn & Durbin (Hoa Ky).
Theo cac nghien a i u tiea khac biet giiia tdn ttiuong nay o ngudi ldn va tre em la ti« em khdng cd bi&i chiing tic mach do md mac du tdn tiiuong nang, nen cd tiie tiiuc hifn ket hgp xuong kin sdm ca 2 d gay xuong. Tuy nhien, ca tiiii 1 do cSng chan chi gay xucmg chay, khdng gay xucmg mac, khi keo nin kin luc keo tiTiyen qua xuong mac deh d gay xuong diu nen tiiuc hien duoc ket hpp xuong khdng phai md d gay.
Ca thii 2, cing chan gay hoan toan 2 xuong chay mac; luc keo chi qua d gay cang chan ma khdng truyen cjua o gay xuong diii, nen phai md md toi thieu mdi nSn dupc xuong diii. Do dd, chiing tdi de xuat cac tiaidng hpp hiong tu, cd the xuyen 1 dinh qua loi a u diu de tao luc keo true tiep len d gay xuong diii, nham thuc hifn xuyen kim ldn de dang hon.
Ca thii 3, do tdn Ihuong sp nao nang, khdng thpc hifn phlu thuat gay xuong, nhung dieu tri bao ton keo lien tuc van cho ket qua lanh xuong tdt cho fhay khdng phai tat ca cac ca deu phai mo nhung tiiy tinh huong lam sang, van cd the dieu tri bao ^ n dupc.
Theo Bohn & IXubin theo doi thdi gian dai n h | n thay cd cac di chiing thudng gap nhu bien dang dai chi (ddi vdi gay than xucmg), ddng sdm sun tiep hpp (doi vdi gay gan ^ u xucmg), veo goi, long day chang goi va cac bieh chiing Ichac (cham lanh xucmg, khdng lanh xucmg va gay Iai).
Theo bao cao nay, vi thdi gian theo ddi la 06 thang nen chua danh gia dupc bien chiing dai chi mudn do cai qua miic va cac ch chiing ketren.
KETLUAN
Tdn thuong "floating knee" hiem gap d tre em, nhung thudng gap frong benh canh lam sang da chah tiiucmg nang, nguyen nhan thudng do tai nan xe dung vdi toe dp rat ldn, cd tdn tiiuong phdi hpp va hay gap kem tiieo chan tiiuong so nao, tdn ttiuong phan mem nang va gay xuong ho.
Chuyen De Ngoai Nhi
Y Hpc TP. Ho Chi Minh * Phu Ban Tap 19 * So 5 * 2015 Nghien ctru Y hoc Ca 03 ca deu dupc hoi siic tich cue truyen
mau de dn dinh huyet ddng, uu tien can tiiiep phau thuat cap ciiu cho tdn thuong de dpa tinh mang nhu phlu thuat vet thucmg sp nao, phau thuat cat lpc vet thuang,
Lua chpn phuang phap dieu tri ton thucmg floating knee d tre em la khd khan. Chiing tdi da dieu tri 2 ca bang phau thuat ket hpp xuong kin dudi C-arm bang dinh Rush npi tuy ca xucmg dui va xuong chay, cd 1 ca phai md o gay xucmg diii tdi thieu, 01 ca do vet thuong sp nao nang nen chiing tdi lua chpn phucmg phap dieu tri bao ton keo lien tuc.
Hai ca phau thuat ket hpp xucmg cho ket qua lanh xuong va phuc hoi tot theo ddi sau 06 ttiang. Ca keo lien tuc ciing cho ket cjua lanh xuong tot va phuc hdi van ddng hoan toan mac dil cd ton thuong sp nao nang.
Chua danh gja dupc cac di chiing lau dai do rdi loan tang trudng xuong do thdi gian theo ddi ngan, can theo ddi lau dai va so ca ldn hon mdi danh gia het cac van de ciia ton thuong nay.
TAI LIEU THAM KHAO
1 Arslan R Kapukava A. Kesemaili C, ci at (2003) Fbaiing knee in children-J/'aAan-OJAcp.23<4)pp 458-163
•> BohnWW,DurbmRA(!W]) IpsilaKial fractures rfthe femur and bbia m childi^i and adolescents J Bone Joint Surg _-4m,73(3)pp429-139.
3 LeOsM VmcentN C3ouwG(1986) "nie"floaiingknee" in children JBone JoitV Suig Br,68(3) pp 442-446
4 Lund>' DW", Johnson KD (2001). Tloahng knee" iiqunes:
ipsilateral fractures of the femur and tibia. J .*H .icad Orthop Surg Jijl-Aug;9(4).pp-238-45
Ngay nliqn hdi hdo:
Ngdy plidn bien nlian xet bdi bdo- Ngay bai bdo duac dang:
21/0S/2015.
22/08/2015.
01/10/2015
