Đang tải... (xem toàn văn)
Chan doan VTPM de, nhtfng chu quan thi co the bo sot nhtfng ton thtfdng nang. Thtfdng ton cd theo dtfdng di ciia vat nhon, khong lan rong... Ixiai nay ton thtfdng rat phtfc [r]
(1)PHAN 6
CHAN THI/dNG
1 VET THtfONG PHAN MEM
1 DAI C l/O N G
1.1 Vet thvfc/ng p h an m em (VTPM) la mot cap ctfu thtfdng gap d moi tuyen ngoai khoa No bao gom ca nhtfng vet thtfdng nho, nhtf vet thtfdng da dau ddn thuan, den nhtfng vet thtfdng ldn, dap nat phan mem rong, ton thtfdng ca mach mau va than kinh
Chan doan VTPM de, nhtfng chu quan thi co the bo sot nhtfng ton thtfdng nang Xii tri VTPM theo nguyen tkc: cat loc - rach rong - d e h d
1.2 Phan loai vet thtfdng phan m em
1.2.1. Phan loai vet thiidng phan mem theo thdi gian Friedrich
- Vet thtfdng phan mem den sdm trtfdc - gid, la thdi gian co stf hien dien cua vi khuan nhtfng neu the trang benh nhan tot, vet thtfdng nho va cap ctfu kip thdi thi kha nang nhiem khuan thap
- Vet thtfdng phan mem den muon sau — 12 gid, la thdi gian vi khuan da phat trien ttf to chtfc chet, hoai tii bat dau xam lan, tan cong to chtfc song, chung gay nen dau hieu nhiem trung tren lam sang, theo the trang benh nhan va mtfc ton thtfdng
- Vet thtfdng phan mem den muon, nhiem khuan: sau 24 gid, neu vet thtfdng rong, dap nat phan mem nhieu thi co the gay nhiem trung mau
1.2.2. Phan loai vet thiidng p h a n mem theo dac diem ton thiidng
- Cac vet chdt da nho, nong Thtfdng ton n&m d thtfdng bi, tren 16p te bao day Vet thtfdng ttf lanh
Riia sach phan chi vdi xa phong va ntf6c am, bang vo khuan bao ve vet thtfdng - Cac vet thtfdng rach da ddn thuan, c a n - cd khong bi ton thtfdng
Neu den sdm trtfdc gid, sau cat loc co the dinh da thtfa Den muon, cat loc, de hd Khau da lan
- Cac vet thtfdng sau, vao qua can den ldp cd Co hai nhom:
(2)+ Thtfdng ton phan mem nang tai nan giao thong, dan ban v v Ixiai ton thtfdng rat phtfc tap Dap nat cd nang kem theo ton thtfdng ca mach mau, than kinh Ty le cat cut chi cao
1.2.3 B o n g lo c d a : la toan bo cau true ldp da bi bong khoi ldp can cd tren dien rong qua 1/2 chu vi chi, tham chi' lot het nhtf lot da dau, hoac nhtf lot da chi dtfdi kieu “ lot bit — tat”
Phan da bong loc se bi hoai ttf vi khong co mach nuoi Khi xtf tri: can phai xtf tri nhii va da mong, nghia la lang het to chtfc trung va bi, rach o quan cd vat da loc Nuoi vat da luc la nhd tham thau {xem hinh 6.1 vd hinh 6.2).
Long
Dau mut than kinh Ldp vay SLfng
Bieu bi
Tuyen mo hoi
' Chan bi va bi
M ach bach huyet
Day than kinh va mach mau
Tuyen ba nhon qq nang long
Nang long
Hinh 6.1 Cau true cua da
Hinh 6.2 Loc da cang chan
1.3 C a c v e t th tfd n g p h a n m e m dtfofc k h a u k in : hau het vet thtfdng phan mem sau cat loc, nen de hd da Co ndi co the khau da thi dau ngav
- Vet thtfdng dau mat - Vet thudng ban tay
Tuy nhien, vdi cac vet thudng bi can (ngtfdi, sue vat), cac vet thtfdng may nong nghiep, luon luon de hd ke ca hai ndi nav
(3)2 NGUYEN TAG XU TRI VET THl/dNG PHAN MEM
- Cac vet thtfdng phan mem phai dtfdc xtf tri cang sdm cang tot, tot nhat la gid dau
- Loai bo toi da cac to chtfc hoai ttf, mau tu, di vat, ngoc ngach cua vet thtfdng - Khong lam ton thtfdng them cac to chtfc lanh (do cac chat sat khuan vao vet thtfdng, cat loc qua mtfc, dot dien nhieu v.v ), ctfng nhtf khong dtfa them qua nhieu di vat vao vet thtfdng (cac loai chi khau, buoc, clip v.v )
- Phuc hoi hinh the, cd nang, tham my thuoc vao dieu kien cho phep, khong nen toi Uu hoa ttf dau
3 X V TRI VET THl/dNG PHAN MEM DEN S6M
3.1 Cap ctfu ban dau vet thtfdng phan m em
- Bang vo khuan vet thtfdng phan mem sau sat trung rong xung quanh vet thtfdng
- Bat dong tam thdi bang nep doi vdi nhtfng vet thtfdng ldn
- Theo doi va de phong soc vdi vet thtfdng p h in mem ldn, d&p nat nhieu - Dtfng thuoc khang sinh toan than, giam dau, tiem phong uon van 3.2 Xtf tri vet thtfdng p han m em
3.2.1 Vo cd m : tot nhat la gay me noi quan hoac gav te vtfng vdi cac chi Vet thtfdng ldn khong dtfdc gav te tai cho vi co the gay soc cho benh nhan
3.2.2 Ga ro: ddi vdi vet thtfdng phan mem d cac chi, nen dung ga ro, tot nhat la ga ro hdi vdi ap ltfc hdi la 250mmHg Ga ro d goc chi
3.2.3 Ve sin h x u n g q u a n h vet th iid ng bang xa phong sat khuan va ntfdc am Ddi vdi cac vet thtfdng qua ban co the danh rtfa bang ntfdc muoi sinh ly Sat khuan vet thtfdng theo htfdng ttf ngoai, che phu vtfng xung qtfanh vet thtfdng bang khan md vo khuan
3.2.4 C dt lo c m ep v e t th iid n g
- Dung dao mo cat da quanh vet thtfdng, cach mep vet thtfdng - 3mm
- Da dau mat, ban tay la ndi giau mach mau nuoi dtfdng, chong dd nhiem khuan tot nen chi can cat loc tiet kiem de sau dd vtfa de khau, dd bi co keo anh htfdng den tham my
(4)3.2.5 Cdt loc vd day vet thuong
* To chiic dtfdi da co the cat loc rong rai vi kho lam sach, ldp md chong dd nhiem khuan kem, hoai tu nhanh can trd to chiic hat lam day va lien vet thtfdng
* Ldp can cd: lay het di vat, cat bo to chtfc dap nat, hoai tii, ngam mau cho den to chtfc lanh va day vet thtfdng, ltfu y khong lam ton thtfdng cac bo mach than kinh
- Thay dung cu, thay gang, sat khuan, che ph u lai vet thtfdng, chuyen sang thi sach.
3.2.6 M d rong m ieng vet thUctng, pha huy cac ngoc ngach, riia vet thtfdng bang ntfdc muoi 0,9% hoac ntfdc oxy gia - 2%
3.2.7 D d n la u dtfdc dat ttf day vet thtfdng ngdai, d in ltfu ndi thap nhat (dung ong hoac lam cao su)
4 XU1 TRI VET THl/dNG PHAN MEM DEN MUON
* Cac vet thtfdng phan mem den muon co stfng ne, vang xung quanh vet thtfdng, viem tay nhtfng chtfa co mu thi dtfdc xtf tri theo ky thuat nhtf tren, d£n ltfu rong rai, de hd, nhtfng tranh ton thtfdng to chtfc lanh gay chay mau tran lan, pha vd hang rao bao ve de nhiem trung lan rong
* Vet thtfdng den muon co mu, nhtfng o mu da thong ngoai, it to chtfc hoai tii va di vat thi thay bang hang co dap gac dtfdc tham tfdt bang cac dung dich tfu trtfdng nhtf huyet man 10%, den sach thi xii tri tiep (cat loc vet thtfdng thi hai)
* Vdi cac vet thtfdng co cac o mu kho thong, nhieu to chtfc hoai ttf va di vat thi xii tri toi thieu: cat bo to chtfc hoai ttf, lay di vat, rach dan ltfu that tot, thay bang hoac nho giot riia hang
5 KHAU VET THl/CfNG
5.1 Khau kin vet thtfdng ky dau: co rat nhieu dieu kien can xem xet de quyet dinh
- Co the khau ky dau doi vdi vet thtfdng den sdm trtfdc gid, co the keo dai moc thdi gian den 12 gid neu vet thtfdng da dtfdc sd ctfu tot va co dtf phdng khang sinh Cac vet thtfdng sau 12 gid thi de hd khdng khau kin thi dau.
- Moi trtfdng tai nan khong phai la moi trtfdng o nhiem nang
- Vet thtfdng nong nghiep, sue vat can, hoa v.v dtf den sdm ctfng nen rat than quyet dinh khau ky dau Tot nhat nen la de hd
- Tinh trang da phai du che phu vet thtfdng, khau khong bi cang mep da Nhtfng vat da hinh sao, bong loc rong, vat da loc co cudng quay xudng dtfdi hay mtfi vat da hep, da vtfng cd ldp md day v.v deu la nhtfng vat da khong thuan tien cho khau ky dau
- Sau cat loc khong dam bao da loai bd het di vat, ngoc ngach, nghi ngd co nhiem khuan yem khi, hoai thtf v.v , thi khong dtfdc khau da thi dau
(5)5.2 Khau ky dau muon sau cat loc de hd da hean toan, che phu vet thtfdng, thay bang bang gac co tha'm cac dung dich Uu trtfdng, sau - khdng thay dau hieu nhiem trtfng thi co the khau kin lai hoac khau dinh da keo mep vet thtfdng lai gan, tao dieu kien thuan ldi hdn chd khau da thi hai
5.3 Khau da thi hai thtfdng sau - vet thtfdng da co to chtfc hat moc tot, khong ton tai cac ngoc ngach chtfa dich, mu, to chtfc hoai ttf thi co the cat loc tdi day vet thtfdng, lay het to chtfc xd, cam mau tot hoac dat dan ltfu ttf day vet thtfdng va khau kin
6 KY THUAT KHAU
* Khau phai lay den day vet thtfdng, tranh de lai khdang Vet thtfdng sau khau ttfng ldp ttf nong den sau
* Mep da khong dtfdc cang, neu cang c6 the boc tach, rach doi chieu hay chuyen vat (xem hinh 6.3 vd hinh 6.4).
Hinh 6.3 Cat loc den to chtfc lanh
va day vet thi/dng, khau khong de lai khoang Hinh 6.4 Khau vat da goc nhon
tAi LIEU THAM KHAO
1 Benh hoc Ngoai tap NXB Y hoc, 2006
2 Atlas of clinical anatom y - D&R Development, Inc 1997-1998
3 Atlas of Orthopaedic Surgical Explosures Thieme New York & Stuttgart 2000 Trauma M anual, 2nd Edition Lippincott W illiams & W ilkins 2002
5 Skeletal Traum a Elsevier Science (USA) 2003
6 Rockwood & G reen's Fractures in Adults, 6th Edition Lippincott W illiam s & W ilkins 2006
7 Cam pbell’s O perative Orthopaedics (Eleventh edition) - Edited by S.Terry Canale & Jam es H Beaty 2007
(6)2 GAY XUONG TRE EM
1 DAI Cl/ONG
Tre em khong phai la ngtfdi ldn thu nho nen gay xtfdng d tre em co nhieu diem khac han vdi gay xtfdng cua ngtfdi ldn
1.1 Dac diem gay xtfdng of tre em
- M ang xtfdng tre em rat day de sinh xtfdng, xtfdng mem, de uon cong nen hay bi gay ’’canh ttfdi ” La loai gay vtfng, it di lech, dieu tri chu yeu la bao ton (xem hinh 6.5).
- Dau xtfdng dai, co cac dia sun tiep hdp, de tre phat trien chieu cao vi vay r&t hay bi gay bong dia sun Gay ndi can nan that tot de tranh bi roi loan phat trien ve sau (xem hinh 6.6).
Hinh 6.5 Gay canh ttfdi xtfdng Hinh 6.6 Gay bong sun tiep
cang tay dau tren xtfdng chay
1.2 Di lech dau xtfdng gay
Tre em co kha nang bu trtf tot cac loai di lech
- Di lech sang ben, xudng tre em co the ttf dieu chinh dtfdc, it dd lai di chtfng vdi cac trtfdng hdp ngan dtfdi - 2cm va gap goc dtfdi 10°
- Di lech xoay (xoay xoay ngoai) btf trtf kem, anh htfdng den cac khdp lan can, lam mat khdp bi venh
Xtfdng cd khdp chom cau (khdp hang, khdp vai) bu trii dtfdc it Xtfdng cd khdp rong roc (khdp gdi, khdp cd chan) bu trtf rat kem
(7)1.3 Thu’cfng ton sun phat trien
Tre em hay bi gay bong sun phat trien, ndi yeu nhat cua xUdng
1.3.1 Phan gay bong sun phat trien d tre em, theo Salter-Harris (xem hinh 6.7)
Do 1: gay bong ngang tren ldp sun phat trien
Do 2: kem theo m ot m au xUdng tam giac cua h an h xUdng.
Do 3: dUdng gay di vad khdp, qua dia sun phat trien, co bi roi loan phat trien it Do 4: dudng gay cheo tii dau xUdng, den hanh xUdng qua sun phat trien, sun bi roi loan phat trien nang va dien khdp bi khap khenh
Do 5: vung sun bi gay lun, thudng chan doan hoi ciiu thay chi dai, chi ngkn,
khong chan doan sdm dUdc.
Do Do Do Do Do 5
Hinh 6.7 Phan gay bong sun phat trien d tre em, theo Salter-Harris
1.3.2 Roi loan p h a t trien dau xiidng sun tiep hpp bi ton thiidng
Muon thay sdm thudng ton, dung cong hUdng tii, chup vao tuan thii den tuan 17 sau gay xUdng, la mot cau xUdng bac qua sun phat trien Xquang thong thudng cung thay dUdc, song muon hdn (xem hinh 6.8).
Hinh 6.8 Cau xtfdng d sun phat trien tren IRM
Gay kieu va dia sun phat trien khong bi ton thudng, can nan xUdng that tot ve giai phau
(8)Vf du: gay loi cau ngoai xUdng canh tay d tre chua di hoc, da so la gay kieu 4, manh gay loi cau gay qua rong roc va xoay 180°, vdi mat gay nhin ngoai hau het phai mo dat lai va co dinh ben
Khi co gay d vung sun phat trien, phai bao trtidc cho cha me diia tre ve cac roi loan phat trien sau
1.3.3 X u tri c a n b a c c a u q u a s u n p h a t tr ie n Tuy tuoi benh nhan va gap goc
- Doi vdi tre ldn: thUdng due xUdng stia true - Doi vdi tre be:
+ Neu gap goc dudi 20 chi can due bo cau xUdng
-I- Neu gap goc tren 20 do: due bo cau xUdng va due xUdng stia true
2 MOT SO GAY Xl/ONG HAY GAP TRE EM• • 2.1 Gay tren loi cau xifofng canh tay
Gap trung binh d tre tuoi, diem yeu cua xUdng
Dau dudi xUdng canh tay be rong, phia trUdc co ho vet, phia sau co hd khuyu Cac diem cot hoa (diem tao xUdng de tre ldn len) gom mot diem chi'nh tao nen than xUdng canh tay va bo’n diem phu tao nen dau dudi cua canh tay Cac diem phu cot hoa het tre tren 16 tuoi Day la nhting diem yeu gay loai gay tren loi cau (TLC) bien nhat d tre em (xem hinh 6.9 vd hinh 6.10).
j Nu - 11mm i Nam 1 - 26mm i:
Nur: -8 tuoi Nam: - tuoi NU 8-11 tuoi
Nam: 9-13 tuoi
NCr 7-11 tuoi Nam: 8-13 tuoi
Hinh 6.9 Cac diem cot hoa vung khuyu tay Hinh 6.10 Xquang gay tren loi cau
d tre em xtfdng canh tay
2.2 Gay loi cau ngoai xtfofng canh tay (xem hinh 6.11)
Da s6 trtidng hdp gav loi cau ngoai xUdng canh tay chi di'nh cd d phan dudi (nguyen uy cd tren loi cau) loi cau bi cd keo di lech 180 vdi mat gay xoay ngoai
(9)Day la loai gay cdn mo d tre em (do - ) Loai gay dUdc xem la gav theo
dUdng sun phat trien, co trUdng hdp ve sau tre bi khuyu ngoai
Hinh 6.11 Gay loi cau ngoai xtfdng canh tay
2.3 Gay ch om quay
Anh hUdng rat nhieu tdi cd nang khuyu ve sau (xem hinh 6.12).
Neu gay - 2, dieu tri bao ton, gay - dieu tri bang phau thuat Do (gay bong sun phat trien), chom quay hoai tti, phai thay bang chom kim loai 2.4 Gay than xtfofng d ui tre em
Dudi 12 tuoi chu yeu dieu tri bao ton Neu tre tren 12 tuoi dieu tri phau thuat ket hdp xUdng Ngay nay, gay than xUdng dui d tre nhd (dudi 10 tuoi) nhung di lech xoay, can mo sdm de tranh thoai hoa cac khdp ve sau Ky thuat mo tranh xam pham vao sun phat trien (xem hinh 6.13).
(10)2.5 G ay xufOng hof of tre em
Do siic de khang yeu, gay hd d tre em hay bi nhiem trung nen can theo doi va dieu tri noi tru
Neu gay hd nhiem trung se gay nen viem xUdng sau chan thudng lam phiic tap them qua trinh dieu tri va ton kem sau
tAi l i e u t h a m k h a o
1 Cap ciiu chan thudng NXB Y hoc, 2006
2 Atlas of clinical anatomy - D&R Development, Inc 1997-1998 Trauma M anual, 2nd Edition Lippincott W illiams & W ilkins 2002
4 Rockwood & Green's Fractures in Adults, 6th Edition Lippincott Williams & W ilkins 2006
5 Campbell’s Operative Orthopaedics (Eleventh edition) - Edited by S.Terry Canale & James H Beaty 2007
6 Master Techniques in Orthopaedic Surgery: R econstructive Knee Surgery, 3rd Edition Lippincott W illiams & W ilkins 2008
(11)3 GAY XL/ONG HO
1 DAI C U O N G
1.1 Gay xtfdng hd la loai gay xUOng ma o gav thong vdi moi trudng ben ngoai qua vet thUdng phan m em (xem hinh 6.14).
Neu gay xiidng kin, kem m ot vet thudng ph an m em d cu n g m ot doan chi, phai dieu tri nhu mot gay xUdng hd, neu khong, til n h iem tru n g phan m em se lan vao xUdng.
Hinh 6.14 Hinh anh gay hd hai xi/dng cang chan
1.2 Dich te hoc
Ty le gay xUdng hd diing dau cap ciiu chan thtidng (chiem 40 - 50% tong so gay xUdng).
Gay xudng hd gap o' moi liia tuoi, moi gidi, nhung hay gap nhat la tuoi lao dong (20 - 40 tuoi), nam nhieu hdn nii (3/1)
Chi hay bi gay xiidng hd nhat theo thii tii la cang chan, cang tay, cac ngon tay, ngon chan, dui
1.3 Van de d ieu tri gay xtfdng ho?
Triidc the kv XIX, gay xUdng hd dUa den cat cut chi
Treng chien tranh The gidi: viec phat hien bot bo de bat dong chi, danh dau mot giai doan quan cua cap ciiu chan thtidng
Ngay nay, viec cat cut chi van con, song ty le giam nhieu vi nhting tien bo vUdt
bac cua Nganh \ te noi chung va nganh chan thtidng noi rieng, cac linh \rtic khoa hoc va to chtic cap ctiu:
(12)- Tien bo phau thuat tao hinh - Tien bo trong linh vUc khang sinh
- To chiic tot cac trung tam cap ciiu chan thudng tii cd sd den trung Udng Dao tao cac chuyen khoa va cac phau thuat vien bai ban
- San xuat dUdc cac loai vat lieu tot de co dinh ngoai
Vi vay, viec dieu tri gay xUdng hd chi la van de la lam tranh nhiem trung vet thudng va chong lien xiidng
2 N G U Y E N N H A N , CCf CH E
2.1 G ay xtfofng hd cd che ch an thtfdng trtfc tiep
Gay xUdng hd chan thudng triic tiep ttf ngdai vad chiem ty le 80 - 90%, ton thudng nang d phan mem, xUdng gay phiic tap Day la loai chan thtidng manh, toe nhanh
2.1.1 Thai b in h
Tai nan giao thong diing dau, chiem khoang 50% tong so nguyen nhan gay gay xUdng hd Dac biet co nhting tai nan tham khoe, nhieu benh nhan bi cting mot luc va gay hd nang nhieu xUdng
Tai nan lao dong Doi vdi cong nhan bi tai nan phan ldn cac day chuyen lao dong gay nen Vdi nong dan chu yeu cac may nong nghiep: may gat, may dao dat, lam gach
Tai nan the due the thao v.v 2.1.2 Thdi c h ie n
Tai nan hoa Viet Nam da song hoa binh, song so bom dan cu cua chien tranh rat nhieu va gay nhieu thtidng vong
Gay xUdng hd hoa la mot loai gay xtidng hd rat nang vi ngoai cd che chan thuo'ng triic tiep co song nang liidng (dong nang) cua vien dan co siic pha huy ldn
2.2 G ay xtfdng ho/ cd che ch an thtfdng gian tiep
Gay xUdng hd chan thudng tti trdng Xtidng thtidng gay cheo x o in phan mem ton thtidng nhe
Vi du:
Gay hd tren loi cau xtidng canh tay d tre em dd benh nhan nga chd'ng tay liic tac dong truyen doc true cang tay len vung tren loi cau xiidng canh tay la ndi yeu nhat (do cac diem cot hoa) gay nen gay xtidng va choc dau xtidng ngoai
Gay kin hai xUdng cang chan nhting bat dong khong tot, di lech dau xUdng nhon lam cho mao chay dam ngoai
(13)3 GIAI P H A U B E N H V A SIN H LY B E N H G A Y X U C iN G HCf
3.1 Giai phau benh
3.1.1 Da ton thtfdng nang hay nhe cd che chan thtfdng.
Co the vet thudng rach da nho (gay hd 1), can lUu y nhieu trtidng hdp vet thiidng da nho, n h u n g phia dudi to chtic dap n at nhieu.
Co the bong loc da dien rong, lot da kieu “lot bit-tat” Nhting trtidng hdp nay, da nguy cd hoai tti mat mach nuoi
3.1.2 Cdn, cd
Dung giap, dtit cd, tham chi mat rong can cd, lo xtidng
Ton thtidng cd bao gid cung nang hdn da, nen rat hay bo sot gay xtidng hd nang nham la
TrUdc xtidng dam thung da bang mot vet thtidng nho, thi no da lam dtit nhieu cd, dung giap phan mem ben canh (gay hd trdng choc ra)
3.1.3 Mach, than kinh
Dap nat, dtit mot phan hoac toan bo Nhting trtidng hdp dUdc xep loai gay xtidng hd 3c
3.1.4 Xtfdng
Gay xUdng hd cd che chan thtidng trtic tiep thi xtidng gay phtic tap (nhieu tang, nhieu doan), neu cd che chan thtidng gian tiep thi xUdng gay ddn gian
(gay doi ngang, gay cheo)
Tom lai: tai o gay xtidng hd la mot vung co nhieu to chtic chet(cua cd, cua xtidng, cua da, gan), co nhieu di vat (quan ao, bun dat, manh kim loai), co nhieu mau tu, tao mot vung dac biet thuan ldi chd sti phat trien cua vi khuan 3.2 Sinh ly ben h
3.2.1 Nhiem triing vet thtfdng
Tat ca moi vet thudng deu c6 sti hien dien cua vi khuan, sdng n6 phu thuoc vad the trang benh nhan, mtic ton thtidng va sti can thiep kip thdi cua thay thuoc ma co gay nen nhiem khuan vet thtidng hay khong
Benh nhan gia yeu, stic de khang kem (phu nti sau de) hoac bi benh man tinh (suy gan, suy than) de bi nhiem trung vet thtidng
Neu gay xtidng hd diidc xti tri tot, sdm trtidc gid thi gop phan lam giam ty le nhiem trting vet thudng
(14)3.2.2 Dien bien nhiem trung vet thiidng gay xiidng hd (theo Friedrich)
(jiai doan chtfa nhiem khu&n (giai doan u benh): sau tai nan dtfdi 6h Neu benh nhan den sdm giai doan nay, gay xtfdng hd nhe, the trang benh nhan tot, thay thuoc can thiep kip thdi thi kha n&ng nhiem trung vet thtfdng bi han che
Giai doan tiem tang: sau tai nan - 12 h, neu vet thtfdng khong dtfdc xtf tri, vi khuan se phat trien ttf to chtfc dap nat, to chtfc hoai ttf, roi xam lan vao cac to chiic song, gay nen phan tfng viem
Giai doan nhiem khuan: sau tai nan 12h Ttf nhiem khuan tai cho vet thtfdng, co the lan rong va gay nen nhiem khuan mau Dac biet nguy hiem la nhiem trung yem
3.2.3 Lien vet thiidng, lien xiidng ga y xiidng hd
Lien vet thtfdng rat quan trpng vi n6 se che phu, bao ve xtfdng tot, loai trif dtfdc nhiem khuan Mat khac, lien vet thtfdng sdm tao dieu kien xtf tri xtfdng cho giai doan sau (neu can)
Mot vet thtfdng lien tot khong di vat, khong nhiem khujkn, khong chen ep va thieu mau nuoi dtfdng (vi vay nguyen t&c dieu tri gay xtfdng hd 1^ cat loc, rach rong, de hd)
Lien xtfdng tot vet thtfdng khong nhiem trung, xtfdng bat dong vtfng v& khong bi mat doan xtfdng(mat xtfdng chan thtfdng va mat xtfdng dd phau thu&t vien lay bo)
3.2.4 Soc chan thiidng
Do mat mau, dau, doc to cua to chtfc dap nat Gay xtfdng hd cang nang, d xtfdng ldn, cang de bi soc
Trung binh mot gay xtfdng hd cang chan mat 500ml - 1000ml mau, dui mat 1000ml - 1500ml mau Bat dong chi tot la phtfdng phap phong va chong soc hieu qua
Loai gay Ltfdng m au mat
Gay hd cang chan 0 - 1000ml
Gay hd dui 1000 - 1500ml
Gay hd xtfdng chau 1 0 -2 0 m l
4 P H A N L O A I G A Y X l /d N G H d
4.1 Dtfa vao cd che ch an thtfdng
Chia gay xtfdng hd hai loai:
(15)4.2 Dtfa vao thofi gian (Theo F riedrich)
- Gay xtfdng hd den sdm: la thdi gian tti luc bi tai nan den dtidc dtfa vad vien trtfdc - gid
- Gay xtfdng hd den muon: la thdi gian tti luc bi tai nan den dtidc dtia vao vien sau gid
- Gay xtfdng hd nhiem trung, tai cho day mu thoi 4.3 Dtfa vao ton thtfdng phan m em
Tren the gidi co nhieu cach phan loai gay xtidng hd dtia vao ton thtfdng phdn mem nhti: Oestrern (Dtic, chia gay xtidng hd do), Couchoix (Phap, chia gay xtfdng hd do), A.O (Hiep hoi Chan thtidng chinh hinh Qu6c te, chia gay xtfdng hd do)
Nhtfng hien nay, phan loai theo Gustilo (My) la ddn gian nhat, chi'nh xac va dtidc ting dung nhieu nhat
Phan dc gay xtfdng hd theo Gustilo, gom ba nhu sau:
- Do 1: Gay xtfdng hd ma vet thtidng phan mem nhd dtidi 1cm, gdn, sach Day la loai gay hd nhe, thtfdng cd che chan thtidng gian tiep Ve mat dieu tri: cac chi dinh nhtf gay xtidng ki'n
- D o 2: Vet thtidng phan mem - 10cm, xung quanh vet thtidng gon sach - Do 3: Cd che chan thtidng manh vdi nang ltidng cao Ton thtfdng phan mem nang, xtfdng gay phtic tap, ty le cat cut chi rat cao 15% Do lai chia ra:
- Do 3a: Dap nat phan mem rong, nhting xtidng dtidc che phu mot cach thich hdp
- Do 3b: M at phan mem rpng, 16 xtidng ngdai Sau cat loc vet thtidng, phai chuyen vat da - can, hoac vat cd de che xtidng, neu khdng xtidng se chet
- Do 3c: Ngoai cac ton thtidng nhti dp 3b, kem theo ton thtidng mach va than kinh, nhe thi dung giap, nang thi mat doan Ty le ctiu dtidc chi loai rat thap
5 CHAN D O A N
Chan ddan gay xtfdng hd bao gom chan doan xac dinh, chan doan gay hd theo Gustilo va chan doan cac ton thtidng phoi hdp
5.1 C han d o a n xa c d in h
Dtia vao cac benh canh lam sang, tti nang den nhe, tti gay xtidng hd den sdm den gay xtidng hd den muon
(16)- Sau cat loc vet thudng thay o gay thong v6i vet thudng
- Gay xUdng hd den m uon: chay m u qua vet thudng, co the lo dau xUdng viem.
- X q u a n g : c h u p p h im th a n g , n g h ie n g de xa c d in h mtic ton th u d n g xUdng, sif di lech va d u k ie n d u n g cu co d in h xtidng
- Do dao dong dong mach tren lam sang nghi ngd ton thudng mach 5.2 Chan doan gay xtfdng hcf theo G U S T IL O
C h a n d o a n xa c d in h g a y xUdng hd thtidng la d i , n h u n g c h a n ddan gav hd mdi la q u a n t r o n g (x e m d p h a n p h a n loai ga y xtidng hd) N h ie u vet thu dn g nho ttidng ting 1, de ch u q u a n k h o n g th e o doi, se bo sot m o t d u n g g ia p n a n g can cd b e n trong, d a n d e n cu t chi
TrUdc b e n h n h a n , ngUdi t h a y th u o c phai d a n h gia chi'nh xa c ga y hd vi c&n cti va o m a p h a u t h u a t v ie n c h o n phtidng p h a p m o thi'ch hdp
5.3 C han doan cac ton thtfdng phoi hdp (da ch an thtfdng)
Cac gay xtidng ldn vdi chan thudng manh thudng hay co cac tdn thudng phoi hdp vdi chan thudng so nao, chan thudng ngUc, bung
Cd the nhd cac phudng tien can lam sang trd giup nhu chup cat ldp vi ti'nh, sieu am v.v
6 D IE U T R I
6.1 Cap ctfu ban dau
* Bdng vet thitctng: sat trting, bang ep vet thtidng de cam mau Han che toi da viec md bang nhieu lan tai phdng kham de tranh boi nhiem
* Bat dong vitng o ga y bang cac loai nep, tren va dtidi o gay mot khdp Ltiu y: khdng dtidc keo dau xtidng tut vao, tranh dtia vi khuan vao sau ben
* Hoi site: phdng, chong soc bang dich va mau thed mach, huyet ap va so ltidng hong cau cua benh nhan Khdng nen chd cd dau hieu soc roi mdi hoi stic Cin hoi stic HA <100mmHg, mach >100 lan/phtit va gay hd nang (do 3)
* Dung thuoc:
- Thuoc phdng uon van(S.A.T 1500 d.v, Anatoxin) - Khang sinh toan than
- Thuoc giam dau (M orphin O.Olg, Feldene 20 mg) Neu chtia loai trti nhting thtidng ton khac thi khdng dtidc dung
Cd van de can chu y:
- Garo: han che toi da viec dat garo cho benh nhan, neu bat buoc dat thi phai tuan thu theo cac nguyen tac cua dat garo
(17)- Rtia vet thiidng: neu c6 dieu kien gay me d tuyen cap ctiu thi rtia vet thudng vdi xa phdng betadin va vdi nhieu niidc Neu khdng cd dieu kien gay me thi cam khdng dUdc rtia vet thudng vi se cd the gay soc chd benh nhan
6.2 D ie u t r i g a y x t fd n g hd? * Tai phdng chuan bi mo
- Vd cam cho benh nhan Tot nhat la gay me noi quan, hoac gay te vung, khong nen gay te tai chd
- Rtia vet thudng bang nhieu ntidc vdi xa phdng Betadin (khoang 20 - 30 lit), lay het di vat d ndng
- Cao long xung quanh vet thtidng
* Tai ph ong mo xti ly vet thudng theo nguyen tac: cat loc - rach rong — co* dinh xiidng vting va de hd
6.2.1 Xii tri vet thiidng p h a n mem: theo thi * T hiban
Cat mep vet thtidng khdang - 5mm
Lay het di vat, cat bd can cd dap nat d ndng Lam sach dau xtidng ban
Rtia vet thudng bang huyet man sinh ly, exy gia, dung dich betadin * Thi sach. Thay toan bo dung cu
Rach rong vet thudng thed true chi, hinh Z Dau chi gay cang sUng ne cang phai rach rdng, can rach rong hdn da Dtidng rach rdng da thudng bang dtidng kinh ddan chi Chti y tranh vting da tren xtidng (mat triidc xtidng chay) va tranh cat ngang nep gap cua khdp
Cat loc to chtic dap nat phia sau tdi chd cd lanh Phau thuat vien phai biet danh gia dau la cd dap nat, dau la cd lanh, neu cat ldc triet de qua thi chi mat cd nang va neu bd sot thtidng ton thi rat nguy hiem cho benh nhan
Cd lanh la cd cdn chac, chay mau tot, cd co kich thich Xti ly mach, than kinh (neu cd):
+ That nhting m ach mau nhd nuoi cd
+ Ndi hoac ghep m ach (gay xUdng hd dd 3c), phuc hdi sti liiu thdng m ach cang sdm cang tot.
+ Than kinh ndi bao hoac sdi than kinh bang vi phau
(18)6.2.2 Xii tri xitctng
Dau xtfdng dtfdc lam sach, lay bo xtfdng vun Cac m anh xtfdng du to, du nho ma dinh vdi can, cd thi van coi nhtf nuoi dtfdng va khong dtfdc lay bo de tranh mat xtfdng sau
* Ket hap xiCOng ben ngay bang dinh hoac nep vit neu the trang benh nhan tot, gay hd 1, den sdm, p h iu thuat vien chuyen khda co kinh nghiem
6 cac ntfdc tien tien, ngtfdi ta ket hdp xtfdng ben vdi ca gay hd 3a Viet Nam, chong chi dinh vi moi trtfdng tai nan ban, dieu kien trang thiet bi y te chtfa cho phep
Day la mot phtfdng phap tot: xtfdng dtfdc che phu, ty le lien xtfdng kha nhung het stfc than vi de nhiem khuan
* Co dinh ngoai (K.C.D.N) Vdi net lich sit:
Khung co' dinh ngoai dtfdc biet den dau tien bdi M algaine ttf cuoi the ky XVIII Nam 1902 Lam botte dung khung co dinh ngoai de ket hdp xtfdng Trong the chien thtf II, nhieu kieu khung co' dinh ngoai (K.C.D.N) cua nhieu tac gia: Hoffmann, Judet, Vidal, Ilizarop vdi nhieu y ttfdng khac nhau: ket xtfdng gay kin, gay hd, phau thuat tao hinh (keo dai chi, dieu tri khdp gia, ban chan khoeo v.v )
Thap nien 70 - 80 den nay, nhieu loai K.C.D.N mdi, tfu viet hdn ddi dap tfng yeu cau phat trien cua nganh chan thtfdng chinh hinh, nhtf: FESSA, AO, ORTHOFIX
Ngay nay, K C.D.N tfng dung nhieu cap ctfu chan thtfdng, dac biet 1& nhiing gay xtfdng hd nang (dd 3), gay xtfdng hd den muon, nhiem khuan v.v Muc dich chinh la ctfu chi khoi phai cat cut(ma trtfdc day khong co K.C.D.N , vdi thiidng ton kieu nay, benh nhan bi cat cut chi la dieu dtfdng nhien)
Phan loai K C D N
* Khung co dinh ngdai mot khoi: Judet; Cham ley; Fessa; A.O (xem hinh 6.15). Uu diem: xtfdng dtfdc bat dpng rat chac, cham sdc tot vet thtfdng phan mem; dac biet de 3b va 3c, ctfu chi khdi cat cut Khung co cau tao ddn gian, Viet Nam che tao dtfdc, gia re Ky thuat li p khung ddn gian, cac tuyen ngoai khoa deu lam dtfdc, ap dung tot cho cap ctfu hang loat (lam nhanh) v.v
Nhtfdc diem: khong dtfdc lam chd gay hd I, gay xtfdng kin, gav xtfdng gan khdp, khdng the chinh nan dtfdc sau mo Ty le khdp gia cao
* Khung cd dinh ngoai co kh6p ndi (chinh dtfdc khong gian ba chieu): Hofmann; A.O; Orthofix; Fessa (the he - 4) (xem hinh 6.16).
Uu diem: khac phuc dtfdc cac nhtfdc diem cua cac loai khung tren Ty le lien xtfdng ky dau cao
(19)Nhtfdc diem: nhap khau hoan toan nen rat dat Doi hoi phau thuat vien co kinh nghiem
Cac bien chting cua khung cd dinh ngoai:
Cac bien chiing nang: ton thtidng mach mau va than kinh Co the gay nen hoi chting chen ep khoang Teo cd, cting khdp va khdp gia
Cac bien chting hay gap, khac phuc dtidc: nhiem khuan chan dinh Gay lai xUdng sau thao khung Can lech xtidng
Hinh 6.15 Khung co djnh ngoai mot khoi
Hinh 6.16 Khung cd khdp noi
* Keo lien tuc ap dung cho chi diidi Gay diii: dting dinh Steim ann hoac Kirschner xuyen qua loi cau dtii de keo lien tuc tren khung Braun Gay c&ng chan keo qua xtidng gdt
Trong ltfdng ked: 1/8 - 1/6 ltfdng cd the
ifu diem : cham soc va theo doi dtidc vet thudng Khi keo lien tuc thi chi chi bi che khuat mot mat dtidi, nam tren khung Braun, lai mat cua chi: mat tren, va mat ngoai tien cho theo doi va cham soc Keo lien tuc lam cho cd dd cang, thuan ldi cho ket hdp xtidng ve sau
Nhtfdc diem : nhieu trtidng hdp phai phau thuat ket hdp xtidng thi
* Bd bot: sau xti tri vet thtidng, lam sach xtidng, dat xtidng ve thang true, phu cd che xiidng keo thang chi va bo bot rach doc, bat dong hai khdp lan can
ifu diem : ap dung dtidc rong rai cho moi tuyen, ddn gian re tien
Nhtfdc diem : kho cham soc vet thtidng, khong bat dong dude xtidng gay.Vi vay kho ctiu dtidc chi gay hd nang
(20)6.2.3 Phuc hoi phan mem
Dat ong dan ltfu, khau cd che xtfdng
Nen de hd da vdi nhtfng gay xtfdng hd 3, o gay o nhiem nang
Trong nhtfng trtfdng hdp gay xtfdng hd 3b (mat phan mem nang, lo xtfdng nhieu): neu p h iu thuat vien chuyen khoa Chan thtfdng - Chinh hinh, co kinh nghiem thi can chuyen vat d a - can, hoac vat cd v.v de che xtfdng ngay, neu khong thi sau c i t loc xong, d ip gac md che xtfdng va chuyen benh nhan den tuyen cao hdn de xtf tri tiep (gac md co the che xtfdng song dtfdc - ngay)
Cam khau da, can vdi nhtfng gay xtfdng hd den muon
6.2.4 Dieu tri sau mo
Khang sinh lieu cao toan than Thtfdng phoi hdp loai khang sinh vtfa co tac dung diet vi khuan Gram dtfdng va Gram am
Dung thuoc chong phu ne cho benh nhan: achym otrypsin Gac chan tren khung Braun hoac treo tay cao sau mo
Theo doi dien bien vet thtfdng hang ngay, phong tranh nhiem khuan Nhtfng nhan gay hd nang, neu can thi sau 48 - 72 gid sau, co the c l t loc lai
7 B IE N CHLfNG
7.1 B ien chtfng n gay
- Soc chan thtfdng mat mau, dau vi vay phai bang va bat dong tot - Ton thtfdng m ach va than kinh gay gay hd 3c
- Tac mach md xtfdng rat hiem gap 7.2 B ien chufng sofm
- Nhiem khuan vet thtfdng, dac biet nguy hiem la nhiem khuan yem khi.Vi vay, xtf tri vet thtfdng phai rach rong, khdng dtfdc khau kin da
- Roi loan dinh dtfdng kieu W olkmann hoac Sudeck Sau mo can de chi ttf the cao 7.3 Di chtfng
- Viem xtfdng sau chan thtfdng Day la mot di chtfng nang ne, dieu tri kho khan, phtfc tap
- Cham lien xtfdng, khdp gia: trdng gay xtfdng hd thi cham lien, khdp gia chiem ty le cad vi mat di stf lien xtfdng sinh ly P h iu thuat ghep xtfdng la b it buoc
- Can lech xtfdng, neu chi n g in qua 2cm, gap goc tren 10 thi phai mo' lai de pha can, stfa true chi
- Teo cd, ciing khdp vi phai bat dpng lau