髓内钉在四肢长管状骨骨折治疗中的应用:扩髓与不扩髓  

Application of intramedullary nailing in the treatment of long tubular bone fractures of the extremities:reaming and non-reaming

作　　者：刘泽民[1] 吕欣[1] Liu Zemin;Lv Xin(Department of Orthopedics,Second Hospital of Shanxi Medical University,Taiyuan 030001,Shanxi Province,China)

机构地区：[1]山西医科大学第二医院骨科,山西省太原市030001

出　　处：《中国组织工程研究》2022年第3期461-467,共7页Chinese Journal of Tissue Engineering Research

摘　　要：背景:髓内钉具有中心固定、弹性固定和避免应力遮挡等优点,常被用于四肢长管状骨骨折的治疗。髓内钉置入前扩髓与非扩髓的选择各有优缺点,目前尚未形成一致意见。目的:总结目前扩髓与不扩髓研究的争议点,以及髓内钉扩髓与不扩髓在四肢长管状骨骨折治疗中的应用现状及发展方向。方法:检索1900年1月至2021年3月PubMed、Web of Science、中国知网及万方数据库,中文检索词为:"扩髓髓内钉、不扩髓髓内钉、股骨、胫骨、肱骨",英文检索词为:"Intramedullary reaming nail,non-reaming nail,femur,tibia,humerus",并辅以手工检索以查全文献。经纳入排除标准筛查,最终纳入57篇文献进行综述。结果与结论:(1)在四肢长管状骨骨折治疗中,扩髓与不扩髓髓内钉固定各有优缺点,扩髓手术时间较长,肺脑栓塞风险高,但患者愈合快、术后锁钉断裂危险性小,而不扩髓手术时间相对较短,方便快捷。(2)扩髓引起的髓内压升高及肺脑栓塞常见于股骨干骨折,高转速及缓慢推进扩髓,可降低髓内压升高幅度,进一步降低肺脑栓塞风险。(3)扩髓将骨干离心血流转化为向心血流,同时局部释放促进骨折愈合的生长因子,使骨折部位成骨作用增强。(4)与非扩髓相比,适度扩髓可置入较大直径髓内钉,提高顶骨接触面积,使整体生物力学稳定性提高。(5)扩髓会导致髓内血运的破坏,但髓外血运将代偿性增生,以此弥补髓内血运的缺失。(6)肱骨远端骨折为避免医源性骨折的发生,选择扩髓髓内钉固定;老年股骨转子间骨折因其髓腔直径大,同时骨强度降低,选择非扩髓髓内钉固定疗效更好;而股骨干骨折由于周围软组织丰富,可提供良好血运,一般选择扩髓髓内钉固定;开放性胫骨骨折出于成本效用分析及避免感染风险的考虑,选择非扩髓髓内钉固定疗效更好;闭合性胫骨骨折扩髓后具有骨折愈合快、优良率高、患�BACKGROUND:With the advantages of central fixation,elastic fixation and avoiding stress shielding,intramedullary nail is often used in the treatment of long tubular bone fractures of extremities.The choice of reaming and non-reaming before intramedullary nail implantation has its own advantages and disadvantages,and there is no consensus at present.OBJECTIVE:To summarize the controversial points of reaming and non-reaming,as well as the application status and development direction of intramedullary nail reaming and non-reaming in the treatment of long tubular bone fractures of extremities.METHODS:PubMed,Web of science,CNKI and Wanfang database were searched from January 1900 to March 2021 with the key words of"intramedullary reaming nail,non-reaming nail,femur,tibia,humerus"in Chinese and English,and the full text was searched by manual search.After inclusion and exclusion criteria screening,57 articles were included in the final review.RESULTS AND CONCLUSION:(1)In the treatment of long tubular bone fractures,reamed and non-reamed intramedullary nail fixations have their own advantages and disadvantages.Reaming operation time is longer,and the risk of pulmonary cerebral embolism is high,but the patients heal quickly and the risk of postoperative locking nail fracture is small,while the time of non-reaming operation is relatively short.(2)The increase of intramedullary pressure and pulmonary cerebral embolism caused by reaming are common in femoral shaft fractures,high speed and slow reaming can reduce the increase of intramedullary pressure and further reduce the risk of pulmonary cerebral embolism.(3)Reaming converts the centrifugal blood flow of the shaft into centripetal blood flow.Simultaneously,the local release of growth factors that promote fracture healing can enhance the osteogenesis of the fracture site.(4)Compared with non-reaming,moderate reaming can be placed into a larger diameter intramedullary nail to increase the contact area of the parietal bone and improve the overall biomechanical stability.(5

关 键 词：扩髓髓内钉 非扩髓髓内钉 肱骨骨折 股骨骨折 胫骨骨折 脂肪栓塞 骨折愈合 生物力学 

分 类 号：R459.9[医药卫生—治疗学] R319[医药卫生—临床医学]