自拟下肢损伤熏洗方治疗髌骨骨折术后钢丝断裂进关节腔1例

2018-11-25 杜伟斌 沈福祥 陈荣良 中国现代医生

髌骨被认为是人体中最大的籽骨,其可通过增强股四头肌作用力,联动保护股骨髁处,进而保持膝关节的有限稳定,临床上其骨折发生率约占全身各部骨折的1.05%,20~50岁人群常见,男女比例约为2∶1。其损伤机制主要分为直接和间接暴力。强大的外力直接撞击是直接暴力的主要成因,其引发的骨折类型包括粉碎型、星状型和横型骨折。近年来对髌骨骨折的内固定治疗有了不小的发展,如张力带钢丝环扎内固定、不同材料的髌骨爪内固

髌骨被认为是人体中最大的籽骨,其可通过增强股四头肌作用力,联动保护股骨髁处,进而保持膝关节的有限稳定,临床上其骨折发生率约占全身各部骨折的1.05%,20~50岁人群常见,男女比例约为2∶1。其损伤机制主要分为直接和间接暴力。强大的外力直接撞击是直接暴力的主要成因,其引发的骨折类型包括粉碎型、星状型和横型骨折。近年来对髌骨骨折的内固定治疗有了不小的发展,如张力带钢丝环扎内固定、不同材料的髌骨爪内固定、加压螺钉内固定等方式。早年张力带钢丝环扎内固定是治疗髌骨骨折主流方式,术后由于患者高强度或长时间患膝活动磨损钢丝断裂现象偶有发生,但术后钢丝断裂进关节腔案例较罕见。发挥中医药优势,促进钢丝断裂进关节腔术后的康复值得推广。本文介绍自拟下肢损伤熏洗方,促进治疗髌骨骨折术后钢丝断裂进关节腔1例,并对髌骨骨折内固定提出展望。

临床资料

典型病例:患者女,60岁。7年前因摔倒致右髌骨骨折,在我院行切开复位张力带钢丝内固定术。术后恢复良好,膝关节功能康复正常,出院后未定期复查,且一直未取出内固定物。于此次入院前1个月,突然出现右侧膝关节疼痛,走路时有偶发“疼痛”感,但无明显“绞锁”现象,上下楼梯时疼痛不适加重。后再次就诊于我院,行X线片检查显示:右髌骨骨折愈合良好,内固定断裂,有一小段位于髁间嵴,进膝关节考虑(见图1a、1b)。2017年7月10日入院后行内固定物取出术,按原切口充分显露钢丝张力带,取出膝关节表面张力带钢丝后屈曲膝关节,翻开髌韧带,在C臂机透视下,在关节腔前缘取出游离钢丝。术后予以常规抗凝、消肿、止痛等对症治疗。术后一周指导功能锻炼,拆线后予以下肢损伤熏洗方(桑枝10g、桂枝10g、透骨草10g、葛根15g、乳香5g、没药5g、独活10g、元胡15g、怀牛膝10g、补骨脂10g)熏洗患处,将上述药物煎成汤剂,放入熏蒸治疗机的蒸盆内,接通电源,调节温度约40℃,患者取仰卧位,将患膝距离熏蒸机喷头约40CM,每次30~45min,每天1次,熏蒸完毕注意保暖,避风寒。7d为一个疗程,2个疗程后患膝恢复良好,切口愈合良好,患者无明显疼痛,无肿胀,活动功能良好,效果满意。


讨论

临床上修复髌骨骨折时,不仅要达到骨折的解剖复位,还需十分注意修复其周围因直接或间接暴力牵拉所造成的软组织损伤。总的来说是应注意修复骨折关节面的平整,无塌陷形成,以及重建膝关节附属装置。这两点相互促进,缺一不可。因此临床工作中对于治疗髌骨骨折,应牢记以上两点原则,才能指导早期功能锻炼,加快骨折愈合及功能恢复。

髌骨骨折采用张力带钢丝内固定治疗是最常用的方法,其可以早期脱离石膏等外固定,尽早进行功能锻炼,防止膝关节僵直的发生。价格低廉、取材方便快捷,减少患者经济负担。能将张力转化成对愈合骨折有益压力,加速骨折愈合等。但过度活动或长时间内未取出内固定,常见导致钢丝断裂,而小段钢丝断裂后形成游离体侵犯膝关节附属结构,直接影响活动功能则较为少见。究其钢丝断裂原因可能是长期股四头肌作用下,导致疲劳断裂;断裂后的钢丝进一步分离成小段,随膝关节的活动逐步游走,累及膝关节附属结构,甚至进入关节腔内。因此,对于髌骨骨折应用张力带钢丝内固定的患者,在骨折愈合后应定期复查及时取出内固定物,避免长期留在体内,出现关节软骨磨损、创伤性关节炎等并发症。

古代医家对髌骨称之为“连骸骨”,其附近软组织结构在《医宗金鉴·正骨心法要旨》一书中有了较为深刻的描述,而对于髌骨骨折的治疗,古代医家的治疗方式也多样。现代医学认为骨折手术后由于疼痛、肿胀等原因,不能早期进行锻炼,后期容易引发创伤性关节炎。目前临床上治疗髌骨骨折术后疼痛和水肿,促进患肢早期功能锻炼,加速患肢康复的方法多样,如半导体激光照射、中药冷热交替疗法等。近年来,应用于骨科、普外科、心胸外科、妇产科的加速康复外科理念(ERAS)已逐渐被认可,而注重整体观念的中医理论和ERAS理念十分契合,在促进患者患处康复、改善预后等方面存在独特优势。因此,中医药方法治疗结合ERAS原则成为了目前骨科康复研究的重点之处。

按照骨折损伤传统中医药“舒筋活络、活血化瘀、消肿止痛、补肝益肾”的机制,下肢损伤洗方的原方四肢损伤洗方,出自《中医伤科学讲义》一书。《中医骨伤科学》记录四肢损伤洗方具有温通经络,活血祛风,强筋骨之功,多用于四肢骨折、脱位、扭挫伤后筋洛挛缩酸痛等症。本文将此方加减,形成下肢损伤洗方(桑枝、桂枝、透骨草、葛根、乳香、没药、独活、元胡、怀牛膝、补骨脂),桑枝性平和,与桂枝相合,温经散寒、祛风除痹效佳;透骨草辛散温化,与葛根合用,通阳气,利脉络;乳香配没药,活血散瘀、行气舒筋;独活对元胡,祛下里之痹,镇瘀结之痛;怀牛膝与补骨脂相须二用,补肝肾,强筋骨。对于目前研究,辨证运用中药方剂局部熏洗,药力与热力可通过患处皮肤渗透直达病所,从而改变疾病的病理生理过程。究其现代机理,能使患处毛细血管扩张,改善膝关节周围微循环,使局部肌肉、韧带等组织的营养和代谢增强,加速组织水肿减退,促进组织渗出吸收,对消除缓解肌紧张和肌痉挛,松解患处软组织粘连,恢复患膝关节功能效果显著。

预防髌骨骨折术后引发的创伤性关节炎等并发症,尽早恢复患膝关节功能有着积极的作用。中药方剂不论内服外用,对骨折、筋伤、软组织损伤等病种在康复期运用价值已显而易见,本例患者因病情较为特殊,具有典型及警示意义。警示临床工作者要不断创新医疗技术,实时作好长期随访工作,尽可能提高患者认知和依从性等,从而降低不良案例发生,改善患者生活质量。本文术后采用自拟下肢损伤洗方熏洗,对症用药,发挥中医药特色,加速患肢康复,促进了患肢运动功能改善。相信祖国医学在特殊病种、急危症等运用发挥的作用会越来越突出。当然,随着医疗技术及内固定材料的不断改善,如关节镜、机器人导航等入路手术方式,选用高分子可吸收材料内植物,髌骨骨折的远期治疗效果会大大改善,并发症也会愈来愈低。

原始出处:

杜伟斌;沈福祥;陈荣良;岳振双; 自拟下肢损伤熏洗方治疗髌骨骨折术后钢丝断裂进关节腔1例分析并文献复习. 《中国现代医生》2018年第04期 

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    2018-11-27 zsyan
  4. [GetPortalCommentsPageByObjectIdResponse(id=1924671, encodeId=2c8e19246e159, content=<a href='/topic/show?id=6cec10209670' target=_blank style='color:#2F92EE;'>#髌骨骨折#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=102096, encryptionId=6cec10209670, topicName=髌骨骨折)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f49517, createdName=xinmeili, createdTime=Sat Feb 16 19:52:00 CST 2019, time=2019-02-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1814949, encodeId=eec318149491c, content=<a href='/topic/show?id=c397964662f' target=_blank style='color:#2F92EE;'>#钢丝断裂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96466, encryptionId=c397964662f, topicName=钢丝断裂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a35a460, createdName=fengyi812, createdTime=Wed May 22 14:52:00 CST 2019, time=2019-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1363572, encodeId=0aec13635e24b, content=<a href='/topic/show?id=d23f10209183' target=_blank style='color:#2F92EE;'>#髌骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=102091, encryptionId=d23f10209183, topicName=髌骨)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dab8203, createdName=zsyan, createdTime=Tue Nov 27 01:52:00 CST 2018, time=2018-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1397672, encodeId=b300139e67240, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Tue Nov 27 01:52:00 CST 2018, time=2018-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=353627, encodeId=449e35362e39, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Nov 25 12:05:52 CST 2018, time=2018-11-25, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1924671, encodeId=2c8e19246e159, content=<a href='/topic/show?id=6cec10209670' target=_blank style='color:#2F92EE;'>#髌骨骨折#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=102096, encryptionId=6cec10209670, topicName=髌骨骨折)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f49517, createdName=xinmeili, createdTime=Sat Feb 16 19:52:00 CST 2019, time=2019-02-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1814949, encodeId=eec318149491c, content=<a href='/topic/show?id=c397964662f' target=_blank style='color:#2F92EE;'>#钢丝断裂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96466, encryptionId=c397964662f, topicName=钢丝断裂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a35a460, createdName=fengyi812, createdTime=Wed May 22 14:52:00 CST 2019, time=2019-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1363572, encodeId=0aec13635e24b, content=<a href='/topic/show?id=d23f10209183' target=_blank style='color:#2F92EE;'>#髌骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=102091, encryptionId=d23f10209183, topicName=髌骨)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dab8203, createdName=zsyan, createdTime=Tue Nov 27 01:52:00 CST 2018, time=2018-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1397672, encodeId=b300139e67240, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Tue Nov 27 01:52:00 CST 2018, time=2018-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=353627, encodeId=449e35362e39, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Nov 25 12:05:52 CST 2018, time=2018-11-25, status=1, ipAttribution=)]
    2018-11-25 天地飞扬

    了解一下,谢谢分享!

    0