3. Khớp giả 15% với điều trị bảo tồn
Rockwood, Adult, 2010
4. Gãy 1/3 giữa xương đòn ở người trẻ, di lệch hoàn toàn: KHX sẽ tốt hơn
Gãy 1/3 giữa xương đòn với chồng ngắn và nát sẽ có kết quả kém hơn
Rockwood, Adult, 2010
5. * Grade
of recommendation
• Grade A: Good evidence (high-quality prospective,
randomized clinical trials [RCTs] with consistent
findings) recommending for or against intervention
• Grade B: Fair evidence (lesser-quality RCTs, prospective
comparative studies, case-control series)
recommending for or against intervention
• Grade C: Poor-quality evidence (case series or experts'
opinions) recommending for or against intervention
• Grade I: There is insufficient or conflicting evidence,
not allowing a recommendation for or against
intervention
Rockwood, Adult, 2010
7. Chỉ định tương đối để KHX đòn 1/3 giữa:
chồng ngắn > 2 cm, > 3 mảnh
Bệnh nhân muốn mổ để mau hoạt động lại
Campbell, 2013
8. Trước kia….
• Most clavicular fractures heal uneventfully without serious
consequences with nonoperative treatment.
• Historically, the resulting bony prominences have been
believed to be preferable to an unsightly scar from open
reduction and internal fixation (ORIF).
• Treatment guidelines were based on Neer and Rowe’s two
large series that showed nonunion rates of less than 1% in
conservatively managed fractures compared with nearly 4%
in operatively treated fractures.
• These results established the concept that union rates and
function were excellent with conservative treatment of
clavicular fractures and were better than those after
operative treatment.
Campbell, 2013
9. Gần đây….
• More recent studies have questioned union rates,
functional recovery, and the morbidity of malunions after
conservative treatment.
• A prospective observational study of 868 patients with
clavicular fractures treated nonoperatively found a
nonunion rate of 6.2%.
• Risk factors identified were advanced age, female sex,
100% displacement (lack of cortical contact), and presence
of comminution.
• A meta-analysis including 2144 fractures showed a
nonunion rate of 15% for displaced clavicular fractures
treated nonoperatively, whereas the nonunion rate for
ORIF was only 2% (Table 57-1).
Campbell, 2013
11. Có vẻ là nhóm di lệch không ổn với bảo tồn.
Hội Chỉnh hình Canada vào cuộc…
Thus, there appears to be a subgroup of patients—those
with displaced fractures—who do not do as well as
previously thought.
These concerns led the Canadian Orthopaedic Trauma
Society to initiate a multicenter prospective
randomized trial to compare nonoperative treatment
and plate fixation of displaced clavicular fractures. They
concluded that operative treatment resulted in
improved functional outcomes and lower rates of
malunion and nonunion. Complications occurred in 23
(37%) of 62 patients treated operatively, compared
with 31 (63%) of 49 treated nonoperatively(Table 57-2).
Campbell, 2013
12. So sánh các mặt giữa mổ và không mổ
Campbell, 2013
13. www.jbjs.org: báo mới đây: July 2013.
13% không lành xương khi bảo tồn, liên quan đến hút thuốc
• Risk Factors for Nonunion After Nonoperative Treatment
of Displaced Midshaft Fractures of the Clavicle
• J Bone Joint Surg Am, 2013 Jul 03;95(13):1153-1158.
– Thirteen percent of displaced diaphyseal fractures in
patients who were at least eighteen years of age did
not heal.
– Smoking was the strongest risk factor, and smoking
cessation should be an integral part of treatment.
JBJS, 2013, July
17. Ca 3:
• Hai tháng sau mổ
KHX, kim lồi ra
ngoài da: rút hay
không?
• Cắt ngắn, đẩy vô.
• Lại lồi. Rút?
18. Ca 3: Sau rút kim lộ, ổ gãy bung. Xử trí tiếp?
19. Ca 4: một bệnh nhân, hai thế chụp cách nhau 30 phút.
Bảo tồn hay Mổ?
Bệnh nhân: kiên quyết mổ, sau khi nghe giải thích đầy đủ về sẹo,
nhiễm trùng, mổ lại lấy dụng cụ, trồi đinh, vướng nẹp...
20. Ca 5: Nhiễm trùng sau mổ là ác mộng!
Và giải pháp bất động ngoài chữa nhiễm trùng…
PTV nào dám cho bệnh nhân SắP Mổ xem hình này?
Hình chụp từ báo cáo của Ts Bs Cao Thỉ: Nhân 3 trường hợp phẫu thuật xương đòn nhiễm trùng
Báo cáo tại Hội Nghị Khoa Học 2012, Hội CTCH TPHCM
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