胫腓骨远端骨折合并同侧陈旧性股骨粗隆间骨折漏诊1例

2018-08-18 周东明 长治医学院学报

胫腓骨骨折是临床常见的一种骨科疾病,在全身长骨骨折中发生率最高,约占10%,且多为双骨折。询问病史,体格检查,结合X光片、CT等辅助检查,诊断并无困难。但合并同侧陈旧性股骨粗隆间骨折的病例非常少见,由于患者本身的原因和医生的诊断水平,容易发生漏诊。我科最近收治1例左侧胫腓骨远端骨折合并同侧陈旧性股骨粗隆间骨折的病例,其中同侧股骨粗隆间陈旧骨折发生漏诊,现报道如下。

作者:内蒙古科技大学包头医学院第一附属医院骨科周东明

胫腓骨骨折是临床常见的一种骨科疾病,在全身长骨骨折中发生率最高,约占10%,且多为双骨折。询问病史,体格检查,结合X光片、CT等辅助检查,诊断并无困难。但合并同侧陈旧性股骨粗隆间骨折的病例非常少见,由于患者本身的原因和医生的诊断水平,容易发生漏诊。我科最近收治1例左侧胫腓骨远端骨折合并同侧陈旧性股骨粗隆间骨折的病例,其中同侧股骨粗隆间陈旧骨折发生漏诊,现报道如下。

病例资料

女,72岁。以左小腿摔伤后疼痛肿胀畸形3H入院。患者3H扶拐行走时不慎摔倒,左小腿扭伤。当即感左小腿剧痛,小腿中下段畸形,肿胀,无法站立,无外在伤口及出血,无头晕头痛、胸闷气短及腹痛腹泻。家人急送患者于附近乡镇医院就诊,检查X光片显示左胫腓骨远端斜行骨折。患者及家属为求手术治疗转入我院,急诊以“左胫腓骨远端骨折”收入我科。既往高血压病史20年余,口服硝苯地平控释片,10mg,1次/d,血压可控制在130/80mmHg左右。糖尿病史10年余,采取注射诺和灵30R针治疗,三餐前30min注射10U/次,血糖可控制在正常范围内。冠心病史10年余,心绞痛发作时口服救心丸10粒,平素未曾服药。个人史家族史均无特殊记录。查体:体温36.3℃,脉搏84次/min,呼吸21次/min,血压128/78mmHg。神志清晰,表情痛苦,左下肢被动体位。心肺腹及神经系统查体未见明显阳性体征。

专科查体:患者平卧位,左小腿支具固定中,无外在伤口及出血。小腿中下段轻度畸形,肿胀明显,压痛叩痛均阳性,可触及骨擦感,足背动脉搏动较弱,末梢血运存在,左小腿无法自由屈伸活动。余肢体查体未见明显异常。辅助检查:外院X片显示左胫腓骨远端斜行骨折。我院CT显示左胫腓骨远端斜行骨折。化验显示:红细胞计数3.49×1012/L,血红蛋白103g/L,超敏C反应蛋白17.73mg/L,余尿便常规、肝肾功能、血糖、凝血功能及术前九项等检查均未见明显异常。入院后给予患肢抬高,对症消肿用药,1周后左小腿肿胀基本消退,入手术室拟利用MIPPO技术行左胫骨远端骨折钢板内固定手术。腰硬联合麻醉满意后患者平卧位,去除左小腿支具后发现患肢较对侧短缩25px左右,且外旋约60°,即以C型臂透视左髋部,显示左股骨粗隆间骨折。

追问患者及家属病史后得知,患者8个月前有左髋部摔伤史,当时左髋部剧痛,左下肢无法下地活动,患者未就诊医院,亦无任何检查和治疗,卧床1个月余即逐渐扶拐下地活动,但行动极不便,这也是导致此次摔伤的主要原因。再次向患者及家属交代病情及本次手术只进行左胫骨远端骨折钢板内固定治疗,择期完善相关检查后可行左股骨粗隆间陈旧骨折人工股骨头置换手术,家属表示同意。遂选用苏州艾迪尔医疗器械公司提供的胫骨远端内侧钢板,利用MIPPO技术顺利置入,C型臂透视胫骨远端骨折复位满意,钢板位置良好。考虑患者合并多种内科疾病、左小腿皮肤条件较差、C臂透视腓骨骨折复位对位对线可、患者短期无法下地等多种因素,对左腓骨远端骨折行支具外固定治疗。术后预防使用抗生素,换药可见手术切口干燥无渗出,无红肿疼痛。复查术后X片显示左胫骨远端骨折解剖复位,内固定位置无异常,左腓骨远端骨折对位对线可。择期再行左股骨粗隆间陈旧骨折手术治疗。

讨论

单独的胫腓骨骨折或者股骨粗隆间骨折依据病史、体征和X片等辅助检查,诊断并不困难,但是胫腓骨骨折合并同侧陈旧股骨粗隆间骨折未见相关文献报道。股骨干骨折合并同侧股骨粗隆间骨折占股骨干骨折的2%~9%,国内学者对此亦有报道,并提供了相关的治疗意见,由于这类损伤多为车祸、高处坠落等高能量损伤,故漏诊率较高。

本例患者年龄大,同时合并多种内科疾病,胫骨远端的骨折治疗宜选择微创方式,缩短手术时间,降低手术风险。德国医生Krettek等1997年首次提出桥接接骨技术和微创治疗理念,该方法是在闭合复位情况下经皮插入钢板固定骨折,不仅出血量小,而且对骨折端干扰小,血运破坏少,骨折愈合率很高,是近年来新兴的一种骨折治疗技术,目前MIPPO技术已经被创伤骨科医生们认可,并得以推广使用。本例患者由外院转入我院,随身携带胫腓骨远端骨折的X光片,左下肢佩戴外固定支具,加之老年患者疼痛耐受较强,主管医生在接诊时受到“先入为主”的影响,查体时左下肢支具掩盖了股骨粗隆间骨折后的下肢短缩外旋体征,既往史采集不够详细,导致陈旧性股骨粗隆间骨折的漏诊。因此,在骨科临床诊疗中必须做到全面细致的病史采集和体格检查,完善辅助检查,明确诊断。同时加强医生的继续教育和专业能力培养,严格落实三级查房的核心制度,减少漏诊的发生。

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