髕骨骨折治療 髕骨骨折康復鍛煉
發病原因
骨(gu)折(zhe)為(wei)直(zhi)接(jie)暴(bao)(bao)力(li)和(he)間接(jie)暴(bao)(bao)力(li)所致。直(zhi)接(jie)暴(bao)(bao)力(li)多(duo)因外力(li)直(zhi)接(jie)打擊在(zai)髕(bin)骨(gu)上(shang)造成髕(bin)骨(gu)骨(gu)折(zhe),如撞(zhuang)傷、踢傷等,骨(gu)折(zhe)多(duo)為(wei)粉(fen)碎(sui)性。間接(jie)暴(bao)(bao)力(li),多(duo)由于股(gu)四(si)頭(tou)肌(ji)猛(meng)烈收縮(suo)、牽拉所致,如突然滑倒時,膝關節半屈曲位,股(gu)四(si)頭(tou)肌(ji)驟然收縮(suo),牽髕(bin)骨(gu)向上(shang),髕(bin)韌帶固定(ding)髕(bin)骨(gu)下(xia)部,而造成髕(bin)骨(gu)骨(gu)折(zhe),多(duo)為(wei)橫行骨(gu)折(zhe)。
治療方法
無移位或移位在0.5cm以內的髕骨骨折:
可采用保守治療。早期冷敷,加壓包扎,減少局部出血。保持膝(xi)關節(jie)伸直位(wei),用石膏(gao)托或下(xia)肢支架固定(ding)4-6周,即可開始(shi)股四頭肌等(deng)長收縮。6周后開始(shi)作膝(xi)關節(jie)主動屈伸活動訓(xun)練。固定(ding)過程中,若關節(jie)內(nei)血腫(zhong)張力大(da),可在嚴格無菌(jun)條件下(xia)抽出積血,加壓包扎。
移位大于0.5c的髕骨骨折:
建議手(shou)術治療。髕骨骨折(zhe)的(de)內(nei)(nei)固(gu)定(ding)(ding)方法(fa)多種,可分(fen)為兩類,一類行內(nei)(nei)固(gu)定(ding)(ding)后仍需一定(ding)(ding)時間的(de)外固(gu)定(ding)(ding);另一類內(nei)(nei)固(gu)定(ding)(ding)比較堅強,不需外固(gu)定(ding)(ding)。
1. 張力帶鋼絲(si)內固(gu)(gu)定(ding)術(shu):①適應證:髕(bin)骨(gu)橫(heng)(heng)行骨(gu)折(zhe);能(neng)復位(wei)的髕(bin)骨(gu)粉碎性骨(gu)折(zhe);②手術(shu)方法:髕(bin)前縱行或(huo)橫(heng)(heng)弧行切口,顯露骨(gu)折(zhe)線,自遠折(zhe)端(duan)骨(gu)折(zhe)面,逆行穿出用(yong)(yong)兩(liang)根直(zhi)徑1.5mm的克氏針(zhen)固(gu)(gu)定(ding)骨(gu)折(zhe)端(duan),手伸入關(guan)節(jie)(jie)腔(qiang)內,觸髕(bin)骨(gu)關(guan)節(jie)(jie)面平整后,用(yong)(yong)鋼絲(si)或(huo)鋼纜作(zuo)“8”字或(huo)環形纏繞克氏針(zhen)固(gu)(gu)定(ding)。③術(shu)后處理:不用(yong)(yong)外固(gu)(gu)定(ding),術(shu)后第二(er)天(tian)練習股四頭肌收縮,多數骨(gu)折(zhe)患者(zhe)在術(shu)后2周能(neng)屈(qu)膝90°并下地行走。
2. 髕骨(gu)上(shang)極或下(xia)級切除,股(gu)(gu)四(si)頭(tou)肌腱(jian)重新附(fu)麗術(shu):①切除較小骨(gu)塊或骨(gu)折(zhe)粉碎(sui)部分(fen),將髕韌(ren)帶附(fu)麗于(yu)髕骨(gu)上(shang)段,或將股(gu)(gu)四(si)頭(tou)肌附(fu)麗于(yu)髕骨(gu)下(xia)段骨(gu)折(zhe);②術(shu)后(hou)處理:用多(duo)量敷料包(bao)扎(zha),長(chang)腿石膏伸直位固定3周(zhou),去石膏后(hou)不負重練習關(guan)節活動(dong)(dong)。6周(zhou)后(hou)扶(fu)拐逐漸負重行走,并加(jia)強關(guan)節活動(dong)(dong)度及(ji)股(gu)(gu)四(si)頭(tou)肌肌力鍛煉。此法(fa)可(ke)保全髕骨(gu)作(zuo)用,愈合快,股(gu)(gu)四(si)頭(tou)功能(neng)得以恢復,無骨(gu)折(zhe)愈合及(ji)關(guan)節面不平滑問(wen)題。
3.髕(bin)骨(gu)全切(qie)(qie)(qie)(qie)除(chu):適用于不能復(fu)位,不能部(bu)(bu)分切(qie)(qie)(qie)(qie)除(chu)的(de)(de)嚴重粉(fen)碎性(xing)骨(gu)折。切(qie)(qie)(qie)(qie)除(chu)粉(fen)碎骨(gu)折塊時,應盡(jin)量保護其骨(gu)膜及股四頭(tou)(tou)肌(ji)腱(jian)(jian)(jian)膜。切(qie)(qie)(qie)(qie)除(chu)后(hou)縫合(he)撕(si)裂的(de)(de)擴張部(bu)(bu)及關節囊,使其恢復(fu)到正(zheng)常(chang)松緊度。然(ran)后(hou),將(jiang)股四頭(tou)(tou)肌(ji)腱(jian)(jian)(jian)下(xia)拉與髕(bin)腱(jian)(jian)(jian)縫合(he)。不能直接縫合(he)者,可(ke)用股四頭(tou)(tou)肌(ji)腱(jian)(jian)(jian)翻轉(zhuan)修補縫合(he)。在股四頭(tou)(tou)肌(ji)腱(jian)(jian)(jian)上(shang)做“V”形(xing)切(qie)(qie)(qie)(qie)口,把(ba)切(qie)(qie)(qie)(qie)下(xia)的(de)(de)腱(jian)(jian)(jian)瓣下(xia)翻,修補切(qie)(qie)(qie)(qie)除(chu)髕(bin)骨(gu)后(hou)新形(xing)成的(de)(de)缺損(sun)。也(ye)可(ke)用股外(wai)側肌(ji)及股四頭(tou)(tou)肌(ji)腱(jian)(jian)(jian)的(de)(de)外(wai)側部(bu)(bu)的(de)(de)肌(ji)腱(jian)(jian)(jian)瓣向下(xia)翻轉(zhuan)修補切(qie)(qie)(qie)(qie)除(chu)髕(bin)骨(gu)處(chu)的(de)(de)缺損(sun)。術后(hou)石膏(gao)托固定(ding)4周,練習膝關節伸屈活(huo)動(dong)。
功能鍛煉
1. 踝泵練習:患者活動足踝——用力、緩(huan)慢、盡可能(neng)大范圍地(di)活動足踝,對于促進循環、消(xiao)退腫脹、防止深靜(jing)脈(mo)血(xue)栓具(ju)有(you)重要(yao)的意義。
2. 傷后早期疼痛稍減輕后,即應(ying)開始(shi)練(lian)習(xi)肢(zhi)四頭肌(ji)等長收縮,每小時(shi)不少于100次,以防(fang)肢(zhi)四頭肌(ji)粘連(lian),萎縮,伸(shen)膝無力,為(wei)下地行走(zou)打好基礎。如無禁忌,應(ying)隨時(shi)左(zuo)右(you)推(tui)動(dong)髕骨,防(fang)止髕骨與關節(jie)面(mian)粘連(lian),練(lian)習(xi)踝關節(jie)和足部(bu)關節(jie)活動(dong)。
3. 膝(xi)部(bu)軟組織修復愈合后開始(shi)練習抬(tai)腿。傷口拆線(xian)后,如(ru)局部(bu)不腫脹無積液,可帶著(zhu)石膏托扶雙拐下地,患肢不負(fu)重。
4. 4—6周后(hou)去(qu)除外固(gu)定(ding)(ding)(ding),開始(shi)練習膝(xi)關(guan)節(jie)屈(qu)(qu)伸(shen)(shen)活(huo)動(dong)(dong)(dong)。經過(guo)長時(shi)(shi)(shi)間固(gu)定(ding)(ding)(ding),膝(xi)關(guan)節(jie)都有(you)(you)不(bu)(bu)同程(cheng)度(du)的功能(neng)鍛煉(lian)(lian)礙,因(yin)此應采取多(duo)種形式、多(duo)種方(fang)法的鍛煉(lian)(lian),如主(zhu)動(dong)(dong)(dong)鍛煉(lian)(lian)和(he)被(bei)動(dong)(dong)(dong)鍛煉(lian)(lian)結合(he)(he),床(chuang)上(shang)鍛煉(lian)(lian)和(he)床(chuang)下鍛煉(lian)(lian)結合(he)(he),用(yong)器械鍛煉(lian)(lian)和(he)不(bu)(bu)用(yong)器械鍛煉(lian)(lian)結合(he)(he)等。剛(gang)去(qu)除外固(gu)定(ding)(ding)(ding)時(shi)(shi)(shi),主(zhu)動(dong)(dong)(dong)屈(qu)(qu)膝(xi)較困難,可多(duo)采用(yong)被(bei)動(dong)(dong)(dong)啟動(dong)(dong)(dong)形式,如別人幫助屈(qu)(qu)膝(xi);待有(you)(you)一定(ding)(ding)(ding)活(huo)動(dong)(dong)(dong)度(du)后(hou)改為(wei)主(zhu)動(dong)(dong)(dong)活(huo)動(dong)(dong)(dong)。病人可在臥床(chuang)時(shi)(shi)(shi)主(zhu)動(dong)(dong)(dong)伸(shen)(shen)屈(qu)(qu)膝(xi)關(guan)節(jie), 也可下地扶床(chuang)邊或門框下蹲以(yi)練習膝(xi)關(guan)節(jie)伸(shen)(shen)屈(qu)(qu)功能(neng)。壓(ya)砂(sha)袋法也很簡單,即讓病人坐在床(chuang)邊,將患肢(zhi)伸(shen)(shen)出床(chuang)沿,在踝(huai)部上(shang)壓(ya)3kg左右砂(sha)袋,每(mei)次(ci)15分鐘,每(mei)日2—3次(ci),但應注意被(bei)動(dong)(dong)(dong)活(huo)動(dong)(dong)(dong)力量要緩和(he),以(yi)免造(zao)成新(xin)的損傷,同時(shi)(shi)(shi)鍛煉(lian)(lian)的強(qiang)度(du)應因(yin)人而異,以(yi)不(bu)(bu)引起疲(pi)勞為(wei)宜。
5. 術后(hou)不需石膏(gao)托外固定者(zhe),則可以早期(qi)練習關(guan)節活(huo)動功能。