HOI CHAN THUONG CHJNH HJNH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H O IX
NHAN XET KET QUA DIEU TRj
GAY KHUNG CHAU KHONG VOfNG BANG KHUNG CO DINH NGOAI
Pham Dang Ninh*, Dd DurcBinh*, Nguyin Ba Ngoc*, Nguyin Ngoc Toan*
TOM T A T
Tac gia bao cao ket qua iing dung phu'dng phap cd djnh ngoai mgt ben bang cgc ep ren ngu'dc chieu de dieu trj cap cu'u cho 24 benh nhan gay khung chau khdng vUng tai khoa Chan thUdng chinh hinh Benh vien 103 trong thdi gian tir thang 5/ 2003 den 6 / 2009. Ket qua thu du'dc la kha quan: ngay sau khi du'dc cd djnh benh nhan dd dau nhieu, tinh trang toan than nhanh chdng di vao dn dinh, cd the trd minh va tap ngoi day sdm, tranh du'dc cac bien chu'ng do nam bat dgng lau ngay. Oac biet thuan ldi cho cdng tac san sdc hd ly va dieu trj cac thu'dng tdn ket hdp nhu' chan thu'dng bung, chan thu'dng v5 bang quang, cac thu'dng ton viing khdp hang va tang sinh mdn...
SUMMARY
REMARKS ON TREATMENT UNSTABIe 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 convernient for taking care and treating patients who also had combined lesion as loss soft- tissue, abdomen traumatic, break of vesica...
Tli khoa: Gay khung chau khdng vCi'ng,
Khung cd djnh ngoai.
Unstable ftactures of the pelvic ring, external fixation
I. OAT VAN OE
Gay khung chau la mdt tdn thuong nang ne, cd ty le tir vong cao (chi sau chan thuang sg nao), trong dd nguyen nhan chii yeu la do tai nan giao thdng.
Benh nhan gay khung chau cd the bi cac thuong tdn ket hgp khac nhu chan thuang bung kin, chan thuong bang quang, gly nhieu xuong, vet thuong raeh tang sinh mon
... nen rat de sdc va cd nguy co tii vong rat cao.
Phuong phap dieu tri kinh dien lau nay vin dugc ap dung la phdng chdng sdc tich cue va de benh nhan nam bat ddng gac chan tren gia Braun trong 5-6 tuan. Mdt sd tac gia cho benh nhan dieu tri treo vdng de ep va co dinh khung chau hoac keo lien tuc. Tuy nhien cac bien phap nay khdng thuan lgi trong dieu tri cap eim cac benh nban gay khung chau co nhieu thuong tdn ket hgp khac.
Do gay khung chau chay nhieu mau va rat dau nen de phdng chdng sdc cd hieu qua thi can phai cd dinh chac d gay va ep 2 mat gay vdi nhau de cam mau. Xuat phat tir nhiing ly do tren day, tren thi gidi va Viet nam da cd nhieu phau thuat vien nghien ciru sir dung khung cd dinh ngoai vao dieu tri cap ciiu gay khung chau nham muc dich phong chdng sdc, tao thuan lgi cho xir tri cac ton thuong k6t hgp va du phdng cac biSn chiing do nSm lau. Nhieu nam qua, Bd mdn khoa Chan thuong chinh hinh Benh vien 103 da
* Khoa CTCH Benh vien 103
Y HOC VIET NAM THANG 10 - SO 2/2010
img dung phuong phap cd dinh ngoai mdt ben bang bd cgc ep ren ngugc chieu ciia Nguyin Van Nhan dk didu tri cho cac gay khung chau, buoc dhu thu dugc kdt qua kha quan. Chiing tdi tidn hanh dd tai nghien cuu nay nham hai muc tieu: i •-, ;M
- Ddnh gid kit qud dieu tri cda phieang phdp trin cdc mat phong chong soc, lam
liin xuang vdphuc hoi chuc ndng.
- Dua ra mot so nhan xet vi chi dinh vd biin chieng
II. 001 TUONG VA PHUONG PHAP NGHIEN COU
2.L Doi tuong nghien cuu gdm 35 benh nhan gay khung chau dugc cap cuu dieu tri bang khung cd dinh ngoai tai BV 103 trong thdi gian tir thang 5/ 2003 den thang 6 / 2010. Bao gdm 15 nam va 10 nii tudi tir 13 den 54, tudi trung binh la 31,75.
Nguyen nhan gay xuong: TNGT: 29 BN;
TNLD: 6 BN.
Phan loai gay khung chau theo bang phan loai ciia Tile (1988): tdt ca ddu gay khung chau mat virng gdm 12 BN gay loai B va 23 BN gay loai C (chi gdm Cl, C2 khdng cd gay loai C3).
- Tdn thuong ket hgp: cd 18 benh nhan.
+ Chan thuong bung kin : 6 BN + Vo bang quang, diit nieu dao: 4 BN + Raeh tang sinh mdn: 4 BN
+ Gay hd xuong dui: 2 BN
Cd 1 benh nhan vira chan thuong bung kin vira gay xuong diii va 1 benh nhan vira chan thuong bung kin vira vo bang quang.
+ Gay 2 xuong cang chan: 1 BN + Sai khdp hang ben phai thg chau, ldc da rgng vimg mdng va diii ben phai: 1 BN.
+ Bdng lira do 2 va do 3 ndng toan bd vimg lung va 2 mdng: IBN .
+ Gay cd phau thuat xuong canh tay, gay xuong sudn, tran khi tran mau khoang mang phdi: 1 BN
2.2. Phuotig phap nghien cihi
Nghien ciiu tien ciiu 20 benh nhan, hdi ciiu 15 benh nhan.
2.2.1 Dung cu.
Bd cgc ep ren ngugc chieu (CERNC) cua Nguyen Van Nhan loai dai 35 cm.
Dinh Schanz cd dudng kinh 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 d8 lien kk 2 cgc vdi nhau.
2.2.2. Phuang phdp vo cdm.
Neu lam tai giudng chi can gay te tai vi tri bat cac dinh Schanz bang dung dich Lidocain 1% + 0,3 ml Adrenalin 0,001; k6t hgp vdi thudc giam dau toan than.
2.2.3. Ky thudt xuyen dinh ldp khung co dinh ngodi
Thuc hien tai giudng benh khoa hdi siic cap ciiu hoac sau khi ddng xong vet md cap ciiu giai quyet cac thuong tdn d bung.
Benh nhan nam ngira, hai diii gac tren hai gia Braun tu the con ech .
-I- Xac dinh vi tri xuyen cac dinh: 2 dinh dau tien dat d mao chau, each gai chau trudc tren tir 1,0 -1,5 cm. Gay te tai cho va sau do raeh dai 5mm tai cac vi tri bat dinh Schanz.
Khoan bang mQi khoan 3,5 mm theo hudng tir tren xudng dudi, tir trudc ra sau, tir ngoai chech vao trong. Dimg khoan tay de bat 2 dinh Schanz theo Id vira khoan, sau dd lap cgc ep ren ngugc chieu thii nhat ket 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 tiep 2 dinh Schanz cdn lai a mao chau, each vi tri dinh dau tir 5-6 cm.
HOI CHAN THUONG CHINH HINH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN THLf IX
hudng dinh song song vdi hai dinh dau. Lap tiep cgc ep ren ngugc chieu thii 2 sau dd lien ket 2 cgc vdi nhau bang hai doan dinh
Steinmann. Can cir vao miic do di lech mat virng cua khung chau, tinh trang doang ciia khdp mu tren phim XQ de van ep cho 2 mat gay ap vdi nhau va lam cho khung chau virng hon. Chup lai XQ sdm khi toan than benh nhan dn dinh, dua vao dd de van chinh tiep ep cho khung chau trd ve binh thudng.
Cd 6 BN khi vao cd gay khung chau loai C2, mdt nira khung chau bi keo len tren, chiing tdi xuyen dinh keo lien tuc de 2 canh chau ve vi tri binh thudng rdi mdi thuc hien cd dinh ngoai.
2.2.4. Thai diem thuc Men ky thudt + Thuc hien ngay sau khi md cap ciiu: 4 BN (2 BN md chan thuong bung kin va 2 benh nhan vo bang quang).
+ Thuc hien tir ngay thii 2 den ngay thii 4:19BN
-I- Thuc hien vao ngay thii 5: IBN, do chuyen mudn tir noi khac den.
Thdi gian mang khung: tir 5 - 6 tuan.
2.3. Ddnh gid kit qud : dua theo nhung tieu chuan ve tac dung giam dau, phdng chdng sdc, ket qua lien xuong 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. Kit qud gdn: tat ca cac benh nhan deu do dau d khung chau ngay sau khi xuyen dinh va lap khung cd dinh ngoai. Trir 4 BN md bung ket hgp phai dgi khi tinh lai mdi thay khung chau do dau.
Ket qua XQ kiem tra thay tat ca cac benh nhan deu dugc nan chinh phuc hdi vd hinh the giai phau tir miic kha trd len. Cac dinh Schanz dugc bat diing vi tri, nam trong
xuong mao chau. Khdng cd BN nao bi xuyen dinh trugt ra ngoai.
Biln chung nhi§m khuan chan dinh:
lOBN (28,57%).
Cac benh nhan cd thuong tdn ket hgp : + 6 BN chan thuong bung kin trudc khi cd dinh ngoai d gly khung chau deu dugc xir tri bung dn dinh trong dd cd 4 BN md bung cap ciiu va hai BN mau tu sau phiic mac khdng phai md, khdng benh nhan nao cd bo sdt thuong tdn.
-I- 2 benb nhan tdn thuong bang quang va 2 BN diit nieu dao tang sinh mdn dugc m6 cap ciiu tir gid thii 4 den gid thu 6, dat sonde nieu dao va dan luu bang quang tren xuong mu. Dien bien sau md tdt.
-I- Bdn benh nhan cd raeh tang sinh mdn deu dugc xir tri cat lge vet thuong, thay bang ket qua lien vet md ky hai.
-I- Hai BN gay xuong diii hd:
Mgt benh nhan dugc md ket xuong nep vit ngay thii 10, vet md lien ky dau.
Mgt BN dugc ket xuong diii bang khung cd dinh ngoai, hien nay BN da lien xuong va thao khung.
-t Benh nhan cd sai khdp hang ben phai dugc keo lien tuc nan chinh ket hgp cd dinh ngoai d gay khung chau. Ket qua benh nhan dugc nan chinh het sai khdp hang va dieu tri lien vet thuong ldc da d dui.
3.2 Kit qud xa.
Chiing tdi da kiem tra dugc ket qua xa dugc 28 BN (80%) vdi thdi gian theo ddi tir 7 thang den 5 nam, trung binh la 16,4 thang.
2 benh nhan khdng theo ddi dugc ket qua xa do that lac dia chi va 5 BN chua dii thdi gian theo ddi tren 6 thang.
Kit qua tdt cd 22 benh nhan (78,57%), kha 4 benh nhan (14,28%) va trung binh 2 benh nhan (7,14%). Khdng cd kit qua kem.
Y HOC VIET NAM THANG 1 0 - 3 0 2/2010
Cd mdt BN biln chiing nhilm khuin chan dinh rd mu keo dai tdi 3 thang. Xir tri gay te tai cho, nao hit phin xuong viem, ket qua het viem rd. Benh nhan kit qua trung binh do gay khung chau phiic tap, cdn ngan chi 3 cm.
IV. BAN LUAN
Vdi nhimg kit qua dilu tri thu dugc, chiing tdi xin dua ra mdt sd nhan xet nhu sau.
4.1. Vi chi dinh cda phuang phdp co dinh ngodi trong diiu tri gdy khung chau
Theo Tile, Letoumel, Judet va Muller, viec chgn mdt phuong phap dieu tri cho benh nhan gay khung chau trudc het phai can cii vao tinh trang toan than ciia benh nhan va phan loai gay khung chau. Hai bang phan loai ciia Muller va cua Tile hien dang dugc nhieu phau thuat vien ap dung. Ddi vdi gay loai A, la cac gay khung chau nhung la gay viJng, neu khdng cd cac thuong tdn kit hgp chi can cho benh nhan nam bat ddng gac chan tu the diii ech trong 4 tuan. Vdi cac gay loai B va loai C, la nhiing gay khdng viing.
BChai niem khdng viing d day khdng phai la dudng gly ma ndi den su mat virng cua vdng chau (gay ca cung trudc va cung sau). Ddi vdi loai gay nay cac tac gia deu chii truong phau thuat ket xuong lam viing khung chau.
Chiing tdi chgn phuang phap cd dinh ngoai vi:
- Trudc het day la phuong phap cd dinh 6 gay viing chSc.
- Thao tac ky thuat don gian, chin thuong phlu thuat khdng ldn nen dg an toan rat cao. Vi thi cd the lam ngay tai phdng hdi siic va lam sdm trong ngay dau sau khi da loai tru tinh trang bung ngoai khoa.
- Viec cd dinh d gay viing chic vua cd tac dung giam dau vira cd tac dung cam mau ddi vdi d gly xuong chau va rat tien lgi cho
viec thuc hien cac cdng tac cham sdc hd ly cho BN sdm, an toan hon.
Ket qua dieu tri 24 BN vdi nhiing thuong tdn nang nl va phiic tap deu thoat sdc, lien xuong va PHCN tdt da chiing td su lira chgn cua chiing tdi la diing.
4.2. Vi ky thudt kit xuang co mot sd diim chiing toi muon trao ddi.
- Ve thdi diem tien hanh: chiing tdi cho rang nen lam sdm, cang sdm cang tdt vi muc tieu quan trgng la giam dau va elm mau dl phdng chdng sdc. Do dd, nlu benh nhan cd thuong ton kit hgp cin phai md thi se dl BN len nha md va cd dinh khung chau sau khi ddng vet md bung. NIU BN khdng cd thuong tdn ket hgp trong d bung thi nen lam ngay tai giudng benh va ciing can lam sdm khi loai trir cap ciiu bung ngoai khoa.
Letoumel, Ruedi, Murphy, Nguyin VTnh Thdng, Nguyin Nggc Toan, khi gly khung chau, muc dich cd dinh d gay va khung chau la de giam dau, cam mau va tao dilu kien thuan tien cho viec di chuyin BN khi cin thiet va do chan thuong phlu thuat khdng nhieu nen cac tac gia nay deu chii truong lam sdm hon. Cd benh nhan khi vao cap eim, sau khi thuc hien cac bien phap chdng sdc co ban nhu tiem giam dau, truyen dii dich va mau ma van chua thoat sdc, chiing tdi da thuc hien cd dinh ngoai ngay va kit qua la benh nhan on dinh. Ruedi cho rang khung cd dinh ngoai cd tac dung ep chat 2 mat gly xuong chau nen cd tac dimg cam mau d xuong khi dang chay mau.
- Vi tri xuyen dinh: chiing tdi chgn mao chau la vi tri xuyen dinh. Vi tri nay sd thiy ngay dudi da, dl lam va khdng sg cd tdn thuong mach mau, tdn thuong tang trong d bung. Mdt sd tac gia cdn xuyen ca 2 dinh vao nganh chau - mu, lam nhu vay lire ep dan
HOI CHAN THUONG CHINH HJNH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN THlf IX
deu hon nhung can phai de phdng biln chiing tdn thuong tang d phia dudi.
- Phai khoan trudc bang miii khoan cd dudng kinh 3,5mm qua 2 vd xuong chau, sau dd dimg khoan tay de bat cac dinh cd ren.
Lam nhu vay de bat cac dinh chinh xac va chic vao thanh xuong chau. Khi dimg dinh Schanz cd diu nhgn, thi cd the lip true tiep dinh va khoan rat cham ma khdng can khoan trudc bang miii khoan. Lam the nao de bat cac dinh nlm ggn chinh giiia xuong canh chau, khdng bi trugt sang ben la dieu can chii y vi neu khoan trugt sang ben phai khoan lai thi dinh khdng cdn cam chac vao xuong niia.
Thdng thudng sau khi raeh da, chiing tdi dimg ngay dau dinh de tham dd be day ciia xuong canh chau trudc khi khoan va dat dau dinh d chinh giiia.
- Khi lap cgc ep nen de cgc each da thanh bung 4-5 cm la du de thay bang cac vet md bung neii cd.
Tai sao lai chgn bd cgc ep ren ngugc chieu:
Chgn khung cd dinh ngoai la coc ep ren ngugc chieu cua Nguyen Van Nhan cd loi diem vi: day la bd khung ma cac bac sy quan y da quen sii dung, thao tac don gian, cd dinh chac. Day ciing la loai khung dang cd sin d cac benh vien quan y. Bd cgc ep ren ngugc chieu cd the sir dung cho nhieu vi tri gay xuong, nen rdt tien cho viec bao quan, sir dung d tuyen trudc trong dieu kien chien dau hoac cuii chira hang loat.
t'X ; 0 f
V. KET LUAN
Dieu tri cac gay khung chau khdng viing bang phuong phap cd dinh ngoai vdi bd coc ep ren ngugc chilu cho ket qua kha quan nhd tac dung cd dinh viing chac d gay, cam mau kip thdi nen gdp phan chdng sdc tdt.
Day la phuong phap an toan, tien lgi cho viec cham sdc cac BN cd cac thuong tdn kit hgp. Nhd dd BN cd thi trd minh, tap van ddng sdm, tranh dugc cac biln chung do nlm lau.
Ket qua xa ve lien xuong va phuc h6i chiic nang tdt dat 78,57%, kha dat 14,28% va trung binh la 7,14%. Bien chiing nhiem khuan chan dinh la 28,57%. -MI^UI
Chi dinh ciia phuong phap la cac gay khung chau mat viing loai B, C. (theo phan loai cua Tile)
TAI LIEU THAM K H A O
1. Nguyen Ngoc Toan ( 2005). Danh gia ket qua dieu tri gay khung chau khong vung 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 207 - 220.
i.irtU
j ' ii^iii l:rf
