股骨髓内钉置入时臀上神经和臀中肌损伤的危险  

Risk of Superior Gluteal Nerve and Gluteus Medius Muscle Injury During Femoral Nail Insertion

作　　者：潘志军（译）[1] 陈建松（译）[1] 

机构地区：[1]浙江大学医学院附属第二医院骨科 310009

出　　处：《中华骨科杂志》2007年第12期219-223,共5页Chinese Journal of Orthopaedics

摘　　要：背景：外展无力和跛行作为闭合顺行股骨髓内钉固定的并发症已被大家公认，其最可能的原因是臀上神经和臀中肌的医原性损伤。本研究的目的在于通过尸体标本，来评估在下肢不同位置插入髓内钉时对神经和肌肉损伤的危险性。 方法：我们共研究10具13个经福尔马林液保存的成人髋关节标本。将标本置于完全侧卧位，直径9mm的扩髓器经股骨髁间切迹进入，以逆行方式插入并穿透臀中肌。选择髋关节屈曲15°和内收15°（位置1）、厨曲30°和内收30°（位置2）和屈曲60°和内收30°（位置3）三个位置插入扩髓器，测量臀中肌深面扩髓器进口处与臀上神经下支间距离（神经一扩髓器距离）和扩髓器穿透臀中肌时进口和出口的距离（肌肉内距离）。 结果：位置l组平均神经一扩髓器距离为7mm，平均肌肉内距离24mm，其中3个髋有神经直接损伤，2个髋的神经一扩髓器距离为≤5mm；位置2组平均神经一扩髓器距离是21mm，平均肌肉间距离为18mm；位置3组平均神经一扩髓器距离是33mm，平均肌肉间距离为11mm，此组中无一个扩髓器与神经之间的距离〈20mm。结论：闭合顺行置入股骨髓内钉时，臀上神经和臀中肌损伤的危险性随着髋关节屈曲和内收角度的增加而减少。 临床相关性：当患者仰卧于骨折牵引床顺行置入股骨髓内钉时，其髋关节屈曲和内收角度受限，臀上神经和臀中肌被损伤的危险性较高；若患者侧卧于骨折牵引床或以“醉汉位”（sloppy lateral position）侧卧于普通手术床时，髋关节可达到更大程度的屈曲和内收，神经肌肉损伤的危险性较前者小；因此，在置入股骨髓内钉时，增加髋关节屈曲和内收角度有助于降低臀上神经和臀中肌损伤的危险性。。Background： Abduction weakness and limping is a well-recognized complication of closed antegrade insertion of femoral nails, latrogenic injuries to the superior gluteal nerve and the gluteus medius muscle are the most likely contributing factors. The purpose of this study of cadavers was to assess the risk of nerve and muscle injury with various lower-limb positions used during nail insertion. Methods： We studied thirteen hips of ten formalin-fixed adult cadavers. With the cadaver in the full lateral position, a 9-ram reamer was introduced in a retrograde fashion from the intercondylar notch and passed through the gluteus medius muscle. The distance between the point of entry of the reamer into the undersurface of this muscle and the inferior main branch of the superior gluteal nerve （the nerve-reamer distance） and the distance between the entry and exit points of the reamer in the gluteus medius muscle （the intrsrouscle distance） were measured in three different hip positions： 15° of flexion and 15° of edduction （Position 1）, 30° of flexion and 30° of adduction （Position 2）, and 60° of flexion and 30° of edduction （Position 3）. Results： In Position 1, the average nerve-reamer distance was 7 ram and the average intramuscle distance was 24 mm. In three hips the reamer injured the nerve directly, and in two other hips the distance was ≤5 ram. In Position 2, the average nerve-reamer distance was 21 mm and the average intramuscle distance was 18 ram. In Position 3, the average nerve-rearner distance was 33 mm and the average intramuscle distance was 11 mm. None of the reamers in this position came closer than 20 mm to the nerve. Conclusions： The risk of injury to the superior gluteal nerve and the gluteus medius muscle during closed antegrede insertion of a femoral nail is lessened by increasing the amount of hip flexion and adduction. Clinical Relevance： The risk of injury to both the superior gluteal nerve and the gluteus medias muscle is higher with limited degrees of

关 键 词：臀中肌损伤 股骨髓内钉 臀上神经 神经肌肉损伤 髋关节屈曲 尸体标本 髓内钉固定 

分 类 号：R274.320.5[医药卫生—中医骨伤科学] R681.8[医药卫生—中医学]