股骨头骨折的诊治进展  

Progress in diagnosis and care of fractures of the femoral head

作　　者：高悠水[1] 孙玉强[1] 张长青[1] 

机构地区：[1]上海交通大学附属第六人民医院骨科,200233

出　　处：《中华骨科杂志》2016年第6期361-369,共9页Chinese Journal of Orthopaedics

摘　　要：股骨头骨折多见于青壮年，损伤机制多为车辆撞击形成的仪表盘损伤，可伴或不伴髋关节脱位。股骨头骨折除髋关节疼痛和功能障碍外，典型的体征还包括髋关节屈曲、内收、内旋及下肢短缩，将CT扫描以及MR检查作为股骨头骨折的诊断措施已逐渐被广泛接受。Pipkin分型和Brumback分型是股骨头骨折最常采用的分型方法，这两种方法对制定手术方法、判断预后均有一定价值。越来越多的临床研究证实，在青壮年股骨头骨折中，保守治疗一般只适用于无移位或移位〈 2 mm的类型，且要求髋关节稳定性良好，髋关节间隙内无软骨游离体、盂唇卡压，头臼匹配关系良好，而手术是绝大多数病例的必然选择。对于股骨头骨折伴后脱位闭合复位失败、股骨头合并股骨颈骨折、复位后头臼不匹配、坐骨神经损伤进行性加重等，需要急诊切开复位。手术入路是近年来股骨头骨折研究的热点之一，在对照Kocher-Langenbeck（K-L）入路和Smith-Peterson（S-P）入路时发现，S-P入路的手术时间和出血量较少，视野也较好，但其异位骨化的发生率高于K-L入路。以大转子截骨、关节囊切开行髋关节前脱位的Ganz入路是近年来治疗股骨头骨折的新方法，它可显露股骨头的全貌，也不会损伤旋股内侧动脉，不会造成医源性股骨头坏死。股骨头骨折仍以各种类型的螺钉作为主要的固定方式。骨关节炎和股骨头坏死是最常见的并发症，这不仅与初始的损伤暴力和机制有关，也与复位质量及手术技术等医源性因素密切相关。人工髋关节置换术对于极度粉碎或老年患者的股骨头骨折也是一种良好的治疗选择。Fractures of the femoral head （FFH） are mainly seen in young adults, and the majority mechanism is due to dashboard injury in crushing vehicles. FFH can be present with or without posterior dislocation of the hip joint. Except for periarticular pain and hip dysfunction, the typical signs include flexion, adduction and internal rotation of the hip and shortening of involved limb. CT and MRI get their popularity as diagnostic methods for FFH. An emergency open reduction should be indicated in the scenario of failed closed reduction in FFH with posterior dislocation, of FFH with femoral neck fractures, of unmatched head and acetabulum following closed reduction and of deteriorating sciatic nerve damage. Pipkin as well as Brumback classification is still the most popularly used methods, which have great significance for establishment of surgical strategy and prediction of prognosis. More and more clinical evidences show conservative care of FFH should only be indicated for non-displaced fractures or displacement less than 2 mm. These cases must meet the following criteria simultaneously, including stable hip joint, concentric head and acetabulum, no free fractured fragments in the joint space and no labrum entrapment. Operative care is naturally the treatment of choice. Surgical approaches for FFH are hot topics in recent years. In previous control studies to compare Kocher-Langenbeck （K-L） and Smith-Peterson （S-P） approach, it is revealed less operative time, less blood loss and better operative field you can get in S-P approach, however, the incidence of ectopic ossification is higher. Ganz approach, which is characterized by osteotomy of great trochanter, hip capsulotomy and surgical dislocation of the hip, is a novel pattern for operative care of FFH. Ganz approach can show the entire femoral head, while can not damage medial femoral circumflex artery （MFCA） and induce iatrogenic osteonecrosis of the femoral head （ONFH）. Various screws are the main implants for the fixation of fractured femora

关 键 词：股骨头骨折 Pipkin分型 人工髋关节置换术 闭合复位失败 手术入路 股骨头坏死 医源性因素 损伤机制 

分 类 号：R687.3[医药卫生—骨科学]