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可吸收髓内钉在多发性肋骨骨折内固定中的应用

【摘 要】 目的 回顾分析可吸收髓内钉在多发性肋骨骨折内固定中的应用方法、指征和疗效。 方法 2005 年9 月－ 2007 年2 月，使用可吸收髓内钉行内固定治疗16 例多发性肋骨骨折患者。男12 例，女4 例；年龄18 ～ 43 岁。患者均有3 根以上肋骨骨折，均合并血胸，其中10 例为血气胸；11 例合并肺挫伤；9 例合并脾破裂、锁骨骨折、骨盆骨折等其他部位的损伤。病程30 min ～ 7 d。手术均采用全身麻醉，健侧卧位，经标准外侧位切口进行。术后定期随访，观察骨折愈合情况。 结果 患者均获随访6 ～ 20 个月。除1 例因切口感染行二期缝合外，余患者均Ⅰ期愈合，未发生脓胸等并发症。胸廓塌陷畸形纠正，完整性良好，外观饱满。术后6 个月骨折端全部达骨性愈合。 结论 可吸收髓内钉具有良好的组织相容性，可自行降解吸收无需二期手术取出，手术操作简便，创伤小、愈合时间短，是一种理想的方法。

SU,s全胸腔镜下肋骨骨折骨板骨钉胸腔内植入固定技术的临床应用

目的　探讨全胸腔镜下肋骨骨折骨板骨钉胸腔内植入固定技术的操作方法及适应证。 方法　2009年10月至2011年10月赤峰学院附属医院3例有移位的肋骨骨折患者，其中男2例、女1例，平均年龄36岁；采用SU , s全胸腔镜下肋骨骨折骨板骨钉胸腔内植入固定技术进行手术，3例均有胸腔内活动性出血和胸内凝血块，术中应用自主设计专利器械进行操作，针对如何控制肋间血管出血、游离显露肋骨断端、牵开骨折断端、对位固定、腔镜下肋骨板内植入等阶段设计了全新的手术方法。 结果　采用胸腔镜下内植入式镍钛记忆合金肋骨板胸腔内植入1例，固定肋骨1根，手术时间125 min；采用可吸收肋骨钉固定2例，1例固定2根肋骨，手术时间110 min；1例固定1根肋骨，手术时间90 min。 3例患者手术顺利，恢复良好，无并发症发生，痊愈出院，随访3个月骨折无移位。结论　SU , s全胸腔镜下肋骨骨折骨板骨钉胸腔内植入固定技术从技术角度在部分选择的患者中可行，但还不能取代在重症复合胸外伤常规开胸手术，还需进一步改进。

Electronic Bronchoscope Lavage Lung Segment for Traumatic Atelectasis Caused By Rib Fractures

目的探讨肋骨骨折导致的创伤性肺不张治疗中应用电子支气管镜肺段灌洗治疗的效果 方法回顾性分析新疆医科大学第六附属医院2009年10月至2013年4月肋骨骨折导致创伤性肺不张73例行电子支气管镜肺段灌洗治疗患者的临床资料，其中男52例、女21例，年龄29～83（36± 5）岁。按治疗方式将患者分为两组：灌洗组（37例）行电子支气管镜肺段灌洗，对照组（36例）采用肺不张的常规治疗。比较两组临床效果。 结果灌洗组呼吸频率及心率减慢，动脉血氧饱和度升至95%以上，肺复张明显好于对照组，差异有统计学意义（P < 0.05）。 结论电子支气管镜肺段灌洗治疗肋骨骨折导致的创伤性肺不张直视下诊断明确，起效快，创伤小，疗效确切。

Choice of Surgical Pathway and Incision for Multiple Fractured Ribs

目的探讨多发性肋骨骨折切口及手术入路选择 方法回顾性分析赤峰学院附属医院2000年6至2013年12月手术治疗58例多发性肋骨骨折患者的临床资料，其中开胸组46例，胸腔镜组12例，男43例、女15例，年龄36（15～61）岁。 结果开胸手术组平均手术时间152 min，平均住院时间16 d；腔镜镜手术组平均手术时间125 min，平均住院时间12.5 d。46例开胸手术患者中44例术后胸壁稳定，自主呼吸排痰良好，16例肺挫伤较重有呼吸综合征（ARDS）倾向，术后经12～148 h呼吸机支持后恢复，1例死于合并食管下段破裂，术后第3 d突发腹腔大出血，分析为外伤性腹主动脉瘤破裂。3例患者切口部分裂开，均为环抱器骨板，1例胸骨骨折胸大肌皮瓣拉拢缝合治愈，另2例中1例取出裸露骨板，1例换药及二期缝合治愈。45例患者返院及电话随访6个月至3年，开胸组39例胸壁稳定，胸部X线片固定处均有骨伽形成，全组无难以耐受的肋间神经痛，腔镜手术组切口及固定肋骨处愈合良好。 结论实际操作中可根据骨折形态特点以后外侧“～”切口及垂直切口为基础做多种变形。胸腔镜下手术切口设计时要根据骨折断端位置，可能出现的胸内脏器血管损伤，综合考虑切口布局；最好操作孔及进镜孔处有骨折断端，方便内外结合固定，节省手术时间；同时要考虑出血脏器损伤的部位，方便止血修补或中转开胸；操作孔可以3～5个。

Assisted Thoracic Rib Internal Fixation for Flail Chest

目的探讨胸腔镜辅助肋骨内固定术治疗连枷胸的优势及合理性。 方法纳入我院2006年1月至2012年1月因外伤导致连枷胸行肋骨内固定手术40例患者，采用胸腔镜辅助对多发性肋骨骨折连枷胸行NiTi合金肋骨环抱器内固定术20例为胸腔镜辅助组，其中男14例、女6例，年龄（44.8±7.7）岁；常规开胸切口进胸探查暴露肋骨骨折并行NiTi合金肋骨环抱器内固定术20例为传统手术组，其中男15例、女5例，年龄（43.0±4.7）岁；比较两组临床结果。 结果与传统手术组相较，胸腔镜辅助组无再出血，患者能较早脱离呼吸机并适当活动，术后疼痛症状较轻，住院时间短，6个月后随访无慢性胸痛，伤侧胸部切口无麻木感。 结论胸腔镜辅助肋骨内固定术较常规开胸手术治疗多发性肋骨骨折有优势，值得推广。

Effectiveness of conservative treatment and open reduction with internal fixation for the treatment of multiple rib fractures: a systematic review

Objectives To systematically review the efficacy of conservative treatment and open reduction with internal fixation for multiple rib fractures. Methods We searched WanFang Data, CNKI, VIP, PubMed, EMbase, The Cochrane Library and Web of Science from inception to December 2017 to collect studies on conservative treatment and open reduction with internal fixation for multiple rib fractures. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of included studies. RevMan 5.3 software was used for meta-analysis. Results A total of 16 studies were included, involving 1 374 patients, 723 patients in the surgical group and 651 patients in the conservative group. The meta-analysis showed that the length of stay in the ICU (MD=–3.41, 95%CI –4.92 to –2.43, P<0.000 01), total length of stay (MD=–7.60, 95 %CI–10.67 to–4.53,P<0.000 01), incidence of pulmonary arylene (RR=0.40, 95%CI 0.29 to 0.54,P<0.000 01), incidence of lung infections (RR=0.43, 95%CI 0.30 to 0.61,P<0.000 01), and incidence of chest wall malformation (RR=0.05, 95%CI 0.03 to 0.11,P<0. 0.000 01) in the surgical group were superior to the conservative group. Conclusions Compared with conservative treatment, open reduction with internal fixation can significantly improve the recovery time of patients with multiple rib fractures, reduce hospitalization time, the incidence of perioperative complications, and significantly enhance the prognosis of patients, which is more conducive to the rehabilitation of patients.

创伤性肋骨骨折的处理：广东胸外科行业共识（2017 年版）

Surgical and traditional methods for the treatment of multiple rib fractures: A systematic review and meta-analysis of randomized controlled trials

ObjectiveTo evaluate the effect of surgical and traditional treatments for multiple rib fractures through systematic review and meta-analysis.MethodsCNKI, Wanfang, VIP, PubMed, OVID, EMbase, The Cochrane Library, Thieme and Springer Link database for information from inception to July 2019 were screened by computer. Randomized controlled trials (RCTs) of surgical and conventional methods for the treatment of multiple rib fractures were screened, assessed and extracted. RevMan 5.3 software was used for meta-analysis.ResultsTwelve studies were included, including 1 039 patients. There were 512 patients in the operation group and 527 patients in the traditional treatment group. The results of meta-analysis showed that there was a significant difference between the two groups in the incidence of pneumonia (RR=0.41, 99%CI 0.29 to 0.58, P<0.000 01), incidence of atelectasis (RR=0.24, 99%CI 0.06 to 0.94, P=0.007), duration of mechanical ventilation (SMD=–2.64, 99%CI –4.38 to –0.91, P<0.000 1), duration of intensive care unit stay (SMD=–1.33, 99%CI –2.26 to –0.40, P=0.000 2), duration of hospital stay (SMD=–2.25, 99%CI –3.30 to –1.19, P<0.000 01)and incidence of chest wall deformity (RR=0.08, 99%CI 0.04 to 0.17, P<0.000 01). There was no significant difference between the two groups in the hospital mortality (RR=0.75, 99%CI 0.23 to 2.46, P=0.53), incidence of tracheostomy (RR= 0.69, 99%CI 0.39 to 1.21, P=0.09), ventilator support rate (RR=0.65, 99%CI 0.41 to 1.05, P=0.02) and chest drainage time (SMD=–2.58, 99%CI –6.41 to 1.25, P=0.08).ConclusionSurgical treatment of multiple rib fractures can reduce pulmonary complications, shorten hospital stay, and reduce the incidence of chest wall deformity, which is conducive to rapid recovery and improves quality of life.

胸腔镜辅助爪形接骨板内固定手术治疗多发性肋骨骨折24例

目的　探讨胸腔镜辅助爪形接骨板内固定手术治疗多发性肋骨骨折的临床疗效。　方法　回顾性分析2007年7月至2011年9月河北省沧州市中心医院收治24例多发性肋骨骨折患者的临床资料，男18例，女6例；中位年龄37.3 （17～53） 岁；肋骨骨折6 （3～14）处。交通伤19例，高空坠落伤3例，挤压伤2例。全组患者均在全身麻醉，胸腔镜辅助下行肋骨骨折复位爪形接骨板内固定手术治疗。　结果　全组患者术后胸廓外观正常，反常呼吸消失，复查胸部X线片显示两肺膨胀良好，骨折对位满意。其中14例术后呼吸机辅助治疗32 h （6 h～7 d），所有患者均痊愈出院，平均住院时间18 d，随访23例，随访时间3～13个月，患者恢复良好。　结论　胸腔镜辅助爪形接骨板内固定手术治疗多发性肋骨骨折疗效满意，可有效弥补传统开胸行肋骨骨折内固定手术的不足，但应严格掌握手术适应证。

Fast Track Surgery in Rib Fracture Fixation

ObjectiveTo investigate the feasibility and effectiveness of fast track surgery (FTS) in rib fracture fixation. MethodsFifty-two patients with chest trauma who underwent rib fracture fixation surgery in Mingji Affiliated Hospital of Nanjing Medical University from October 2010 to June 2013 were enrolled in this study. All the patients were divided into FTS group and control group. In the FTS group, there were 26 patients including 22 males and 4 females with their age of 45.62±8.20 years, who received FTS strategies. In the control group, there were 26 patients including 21 males and 5 females with their age of 46.42±7.60 years, who received traditional treatment strategies. Postoperative visual analogue scale (VAS), gastrointestinal function recovery time, postoperative hospital stay and hospitalization cost were compared between the 2 groups. ResultsVAS at 6 hours, 24 hours and 48 hours postoperatively of FTS group (4.5±0.3, 4.2±0.2, 3.2±0.1) were significantly lower than those of the control group (6.5±0.1, 6.1±0.3, 4.8±0.2) respectively (P < 0.05). Gastrointestinal function recovery time of FTS group (0.8±0.2 days) was significantly shorter than that of the control group (1.5±0.5 days, P < 0.05). Length of hospital stay (21.0±2.6 days) and hospitalization cost (5.18±0.75 ten thousand yuan) of FTS group were significantly shorter or lower than those of the control group (26.2±3.4 days and 5.78±0.64 ten thousand yuan) respectively (P < 0.05). ConclusionFTS strategies can effectively reduce postoperative VAS, shorten length of hospital stay, decrease hospitalization cost, and promote postoperative recovery of rib fracture patients.