【作者】 徐亮；

【导师】 邹季；

【作者基本信息】 湖北中医学院 ， 中医骨伤学， 2003， 硕士

【摘要】 [目的] 探讨老年性股骨粗隆间骨折，应用动力髋部螺钉(Dynamic Hip Screw，DHS)手术治疗与非手术治疗的疗效对比。 [资料与方法] 1 一般资料 对我院1999．10-2002．06收治的老年性股骨粗隆间骨折患者，随机抽取28例，均为行走跌伤。其中DHS手术治疗组14例，男7例，女7例，年龄61-78岁，平均69.5岁，根据胥少汀等分型，Ⅰ型2例，Ⅱ型2例，Ⅲ型5例，Ⅳ型3例，逆粗隆型2例。非手术治疗组14例，男6例，女8例，年龄63-80岁，平均71.5岁，Ⅰ型4例，Ⅱ型4例，Ⅲ型2例，Ⅳ型3例，逆粗隆型1例。 2 治疗方法 2．1 DHS手术治疗 本组病例入院后先行胫骨结节牵引3-5天，使肌肉松弛，骨折部位基本对位，同时做好各项术前准备，积极治疗并发症。手术操作要点：手术在C臂机监视下进行，采用连续硬膜外麻醉，侧卧位，患肢大粗隆外侧切口，使骨折端复位，粗螺钉进针点在大粗隆下2-2.5cm水平，股骨外侧中轴线上。C臂机定位：粗螺钉侧位于股骨颈的中轴线上，针尖深度至股骨头软骨下方约1.0-1.5cm处。在大粗隆1cm处平行于粗螺纹钉，经股骨颈向股骨头钉入1枚拉力螺钉，螺纹部须超过骨折线。无须拧紧粗螺钠钉尾部加压螺丝。术后加强护理，鼓励病人进行膝、踝关节功能锻炼，积极防治并发症。术后8周可扶拐不负重下地，对严重粉碎型骨折则必须卧床10-12周后复查X片，视骨痂生长情况决定是否扶拐下地。 2．2 非手术治疗 本组病例全部采用胫骨结节牵引治疗。取髋关节外展约30°位，患肢置于布朗氏架上，行胫骨结节牵引，牵引重量为体重的1／7。牵引期间，定期床边摄片，及时调整牵引，必要时手法复位。牵引中注意防止外旋和内翻畸形，时间6-8周。对个别严重移位粉碎性骨折可适当延长至8-12周。去除牵引后继续在床上活动3-4周。牵引期间鼓励和协助患者进行功能锻炼，练习膝、踝关节功能，积极防治坠积性肺炎、泌尿系感染、褥疮及心血管疾病等并发症。 2．3 疗效评定 按骨折愈合情况，结合董纪元等髋关节疗效标准评分。优：骨折完全愈合，髋部无疼痛，髋关节活动范围恢复到术前状况。良：骨折愈合后，髋部偶有疼痛，活动范围基本正常，患者对治疗比较满意。可：骨折愈合，有轻度髋内翻，髋关节活动受限，有时疼痛。差：骨折畸形愈合或未愈合，髋部疼痛，不能下床活动。 [结果] 1 所有病例均获得6个月-2年半随访，平均随访1年半。DHS手术组与非手术治疗组的平均年龄、临床愈合时间无显著性差异(P＞0.05)。而在住院时间方面，DHS手术组明显优于非手术治疗组，有显著性差异(P＜0.01)。 2 DHS手术组有效率为92.8％，非手术治疗组有效率为78.6％，DHS手术组有效率明显高于非手术治疗组(P＜0.01)，两组疗效有显著性差异。临床医学专业硕士学位论文〔结论〕 老年性股骨粗隆间骨折应尽量争取手术.DHS具有加压与滑动双重功能，可以作为优先考虑的内固定方法.DHs主钉上方另加1枚拉力螺钉，可加大防旋作用.DHs加压螺钉的位置应是在正位平行于股骨颈的长轴，侧位位于股骨颈的中轴线上.仍不能放弃非手术治疗，要辩证地结合病人身体、经济等因素考虑，制定最佳治疗方案.更多还原

【Abstract】 Most intertrochanteric fracture occur in eldly inviduals. The incidence of fracture of the intertrochanteric fracture is increasing, not unexpectedly.since the general life expectancy of the population has increased significantly during the past few decades.Operative treatment can decrease complication and motality rate and the patients can recover early. DHS has the function of compression and sliding and is relatively an ideal implant for treatment of intertrochanteric fracture at present.ObjectiveTo study the effects of dynamic hip screw(DHS) and non-operative treatment for treatment of senile femoral intertrochanteric fracture.Materials and MethodsTwenty eight cases with femoral intertrochanteric fracture from 1999.10-2002.6in our hospital were divided into two groups randomly according to differenttreatment. Forteen patients were treated surgically with DHS. Forteen patients weretreated conservatively with non-operative treatment.Result1 All the patients were followed up from six months to two and half years. Average age,clinical healing time of fracture were no obvious difference ( P > 0. 05 ) between grouo DHS and group non-operative treatment.Admitted time of grouo DHS were shortened significantly (P<0.01) ,compared with group non-operative treatment.2 The effective rates of group DHS and group non-operative treatment were 92.8% and 78.6% respectively. The effective rates of group DHS was significantly higher than that of group non-operative treatment (P<0.01) .ConclusionThe senile patients with femoral intertrochanteric fracture should be operated . DHS has function of compression and sliding. DHS is relatively an ideal implant for treatment of femoral intertrochanteric fracture at present. The lag screw above the DHS lag screw is effective for controlling the rotation of the fracture. The tail of DHS lag screw should be loose. In the antero-posterior X-ray film,the position of the lag screw should be paralled to the long axis of the neck of the femur .In the lateral X-ray film, the position of the lag screw should be on the medial axis of the femoral neck. The non-operative treatment is nessary in some cases.更多还原