宋迪煜 張樹明 喬林 王奎友
. 病例報(bào)告 Case report .
股骨粗隆間骨折手術(shù)并發(fā)股深動(dòng)脈動(dòng)靜脈瘺一例報(bào)告
宋迪煜 張樹明 喬林 王奎友
股骨;骨折;血管系統(tǒng)損傷;手術(shù)后并發(fā)癥;病例報(bào)告
股骨粗隆間骨折并發(fā)的醫(yī)源性血管損傷是一種非常少見的并發(fā)癥,其發(fā)生率約為 0.21%[1]。最早由 Dameron[2]于 1964 年報(bào)道 1 例,此后相繼有部分病例報(bào)道,其損傷形式主要表現(xiàn)為假性動(dòng)脈瘤或血腫[3]。筆者經(jīng)治 1 例股骨粗隆間骨折防旋股骨近端髓內(nèi)釘 ( proximal femoral nail antirotation,PFNA ) 固定術(shù)后第 8 天并發(fā)股深動(dòng)脈動(dòng)靜脈瘺,經(jīng)積極診斷、治療,獲得滿意效果。此病例的特別之處在于其血管損傷類型為動(dòng)靜脈瘺,目前還未見有此類病例報(bào)道。
1. 一般資料:患者,女,77 歲,主因“摔傷致左髖部疼痛伴活動(dòng)受限 8 小時(shí)”入院,既往有甲狀腺功能減退癥病史 10 余年,糖尿病病史 8 年,高血壓病病史 5 年,傷前生活能自理。根據(jù) X 線結(jié)果,明確診斷為左股骨粗隆間骨折 ( 31-A2.1 )。入院時(shí)查體可以發(fā)現(xiàn):雙下肢無明顯腫脹,雙側(cè)足背動(dòng)脈搏動(dòng)正常,足趾毛細(xì)血管充盈實(shí)驗(yàn)正常。血常規(guī)提示血紅蛋白 133 g / L。入院后完善術(shù)前準(zhǔn)備,常規(guī)給予低分子肝素鈣預(yù)防血栓治療至術(shù)前 1 天。
2. 治療方法:入院后第 8 天行手術(shù)治療,手術(shù)常規(guī)在牽引床上進(jìn)行,患肢適當(dāng)牽引,并輕度內(nèi)收內(nèi)旋,骨折復(fù)位順利,對(duì)線對(duì)位滿意。按常規(guī)行 PFNA 內(nèi)固定手術(shù),術(shù)中插入導(dǎo)針順利,并未穿透骨折端進(jìn)入周圍軟組織,遠(yuǎn)端2 枚鎖釘固定。術(shù)中輸紅細(xì)胞 400 ml、血漿 200 ml。術(shù)后常規(guī)給予預(yù)防感染、預(yù)防血栓、控制血糖及血壓等治療,術(shù)后第 1 天復(fù)查血常規(guī)提示:血紅蛋白 109 g / L,紅細(xì)胞比積 33.6%。
術(shù)后第 8 天,患者出現(xiàn)患肢大腿內(nèi)側(cè)明顯疼痛、腫脹、青紫,患肢足背動(dòng)脈仍搏動(dòng)正常,末梢血運(yùn)正常,體溫正常,行下肢 B 超提示:未見明顯異常,暫給予止痛、消腫等對(duì)癥治療,效果欠佳,此后患側(cè)大腿疼痛、腫脹逐漸加重,以夜間明顯。術(shù)后第 10 天,復(fù)查血常規(guī)提示:血紅蛋白 70 g / L,紅細(xì)胞比積降至 22.2%,給予輸血 800 ml;術(shù)后第 12 天,再次復(fù)查血常規(guī):血紅蛋白 69 g / L,紅細(xì)胞比積降至 21.5%。以上情況提示存在持續(xù)性失血,患肢血管損傷可能性大。急診行左下肢血管造影術(shù),術(shù)中發(fā)現(xiàn)股深動(dòng)脈第一穿支的 4 級(jí)分支于小轉(zhuǎn)子下方血管漏血,存在動(dòng)靜脈瘺 ( 圖 1,2 ),給予第一穿支動(dòng)脈彈簧圈栓塞,栓塞后見造影劑滲出停止 ( 圖 3 ),栓塞效果好。栓塞術(shù)后給予輸紅細(xì)胞 800 ml,復(fù)查血常規(guī)提示:血紅蛋白 88 g / L,紅細(xì)胞比積 27.7%。術(shù)后患側(cè)大腿疼痛明顯減輕,腫脹逐漸消退,順利出院。隨訪 6 個(gè)月,患者患肢已無疼痛,腫脹消退,患肢功能恢復(fù)良好。
股骨粗隆間骨折手術(shù)并發(fā)損傷的血管主要包括股總動(dòng)脈、股淺動(dòng)脈、股深動(dòng)脈及其分支。Bartonicek[4]認(rèn)為,相比較而言,股深動(dòng)脈更容易受到損害。Chan 等[5]認(rèn)為,內(nèi)旋下肢可使股深動(dòng)脈更加貼近股骨皮質(zhì),而過度鉆孔容易損傷股深動(dòng)脈及第一、二穿支,其位置相當(dāng)于 DHS的第 3、4 板孔。血管損傷可有不同的受傷機(jī)制,鋒利的骨折塊、突出皮質(zhì)的螺釘尖、遠(yuǎn)端鎖釘可刺傷或擠壓損傷血管[3];電鉆過度鉆孔或不恰當(dāng)放置的牽開器也可損傷血管[6];此外,當(dāng)突出的螺釘長(zhǎng)時(shí)間的刺激或腐蝕血管時(shí)也能造成血管損傷[7]。目前文獻(xiàn)報(bào)道的動(dòng)脈損傷類型包括假性動(dòng)脈瘤[6,8]、動(dòng)脈撕裂[9]、動(dòng)脈堵塞[10]、小分支血管斷裂[3]等,其中最主要損傷類型是假性動(dòng)脈瘤[11]。
圖 1 股深動(dòng)脈第一穿支造影劑顯示異常 ()圖 2 血管損傷部位在第一穿支 (),靜脈提前顯影 () 說明存在動(dòng)靜脈瘺圖 3 成功用彈簧圈栓塞股深動(dòng)脈第一穿支 ()Fig.1 Contrast agent of the frst perforating artery of the profunda femoris artery was abnormal ()Fig.2 The site of injured artery located in the first perforating artery (), and the contrast agent developed ahead of time in the vein (), which implied the presence of arteriovenous fstulaFig.3 Successful coil embolisation of the frst perforating artery ()
本例血管損傷表現(xiàn)為股深動(dòng)脈第一穿支動(dòng)靜脈瘺,位于粗隆間骨折部位與遠(yuǎn)端第一個(gè)鎖釘之間;考慮到術(shù)中骨折復(fù)位順利,亦未發(fā)現(xiàn)導(dǎo)針穿出骨折部位,因此被骨折塊、或螺釘、或電鉆、或?qū)п槗p傷血管的可能性不大。Ryzewicz[3]曾報(bào)道 1 例股骨粗隆間骨折手術(shù)并發(fā)股深動(dòng)脈分支損傷的病例,其損傷部位位于內(nèi)固定遠(yuǎn)端,其考慮可能是牽拉損傷血管。本例患者為老年女性,血管彈性、質(zhì)量下降,損傷血管緊貼股骨,因此也不能排除牽拉所致血管損傷可能。
有文獻(xiàn)報(bào)道,血管損傷所致動(dòng)靜脈瘺的發(fā)生率約2%~4%[12]。在髖部骨折手術(shù)相關(guān)的文獻(xiàn)中還未有此類損傷形式的記載。創(chuàng)傷性動(dòng)靜脈瘺最常見的臨床表現(xiàn)是肢體出血、血腫、腫脹,觸診有震顫,聽診有血管雜音,甚至出現(xiàn)心衰癥狀[13]。本例主要表現(xiàn)為肢體劇烈疼痛、腫脹、血色素進(jìn)行性下降,未發(fā)現(xiàn)局部震顫性包塊、血管雜音,肢體末梢血運(yùn)也是正常的,其原因可能是損傷部位深,且是 4 級(jí)分支小血管損傷。
血管損傷的最后確診依賴于影像學(xué)檢查,常用的無創(chuàng)性成像檢查有超聲多普勒、CT 血管成像。目前血管造影仍是金標(biāo)準(zhǔn),它不僅能夠明確動(dòng)脈損傷性質(zhì),而且能同時(shí)進(jìn)行治療[6]。動(dòng)脈損傷的治療應(yīng)根據(jù)損傷的解剖學(xué)部位及損傷大小決定,不重要的分支或可犧牲的血管可采用微創(chuàng)方法栓塞,而重要的血管需進(jìn)行重建術(shù)[3]。已有的文獻(xiàn)報(bào)道中多采用經(jīng)皮經(jīng)導(dǎo)管彈簧圈栓塞,其療效確切,被認(rèn)為是最有效的方法[6,8]。
綜上所述,股骨粗隆間骨折手術(shù)并發(fā)動(dòng)脈損傷雖然少見,但也應(yīng)該引起足夠的重視。股骨粗隆間骨折牽引復(fù)位時(shí)不宜反復(fù)使用暴力,尤其是存在小粗隆移位的病例;手術(shù)操作需仔細(xì),避免過度牽拉,鉆頭穿透內(nèi)側(cè)皮質(zhì)后應(yīng)避免過度往里鉆,以免損傷內(nèi)側(cè)軟組織,螺釘長(zhǎng)度要適宜等等。如術(shù)后如出現(xiàn)不明原因的患側(cè)大腿疼痛、腫脹、血色素進(jìn)行性下降等,應(yīng)警惕動(dòng)脈損傷的發(fā)生;一旦懷疑存在動(dòng)脈損傷,盡可能行動(dòng)脈造影;當(dāng)明確診斷為次要血管損傷時(shí),經(jīng)導(dǎo)管動(dòng)脈彈簧圈栓塞是一個(gè)有效的治療方法。
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( 本文編輯:王永剛 )
Arteriovenous fistula of profunda femoris artery following fixation of intertrochanteric hip fracture: 1 case report
SONG Di-yu, ZHANG Shu-ming, QIAO Lin, WANG Kui-you. Department of Orthopedics, the second Artillery General Hospital PLA, Beijing, 100088, PRC
Vascular injury is a rare complication following the fxation of intertrochanteric femoral fracture. A case of profunda femoris artery injury after intertrochanteric hip fracture fixation with PFNA will be reported. Arterial injury's manifestation is arteriovenous fstula, which has not been reported before. This patient presented with excessive thigh swelling, substantial pain and progressive drop of haemoglobin 8 days postoperatively. Diagnosis was confrmed by angiographic study and it was successfully treated by coil embolization.
Femur; Fractures, bone; Vascular system injuries; Postoperative complications; Case reports
10.3969/j.issn.2095-252X.2015.12.019
R683, R619
100088 北京,第二炮兵總醫(yī)院骨科
2015-05-06 )