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  • 97老太遭遇“人生最后一次骨折”,该保守还是手术? 山一大二附院创伤骨科解难题

    泰安东广告招商

    新泰楼德的高奶奶,今年已97岁高龄,平时身体健康,和同样高龄的高爷爷生活在一起,高奶奶日常还要为高爷爷做饭,儿女们不用为照顾二老发愁。“几天前,高奶奶不慎跌倒在地,伤到右髋部,疼痛、无法活动,在当地医院自购膏药贴敷,效果不佳。于7月22日来到我们医院,经X线检查,诊断为右侧股骨粗隆间骨折,我们当即将高奶奶收住院治疗。”山东第一医科大学第二附属医院创伤骨科高扬副主任医师说。 

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    “老年人髋部骨折现在的观点是除了罹患严重的内科疾病,或者意识不清、不能自主活动的病人都应该尽早开始术前准备,尽早手术,尽早恢复到伤前的生活状态。但是面对一个97岁的老人,如何将术中麻醉、心脑血管病等风险和术后有可能出现的心脏衰竭、呼吸衰竭、谵妄等风险降到最低,成了摆在我们面前的治疗难题。”高扬指出,尽管风险非常高,但是如果不手术,高奶奶可能很快就会进入心理和生理上的恶性循环状态。这也是为什么我们说老人脆性骨折是“人生最后一次骨折”的原因。       

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    为了守护97岁老人的生命,让老人最大程度的恢复健康,高扬副主任医师决定只要有一线希望就要为老人手术治疗——手术是唯一也是最好的治疗途径。7月23日上午,高扬邀请医务处、麻醉科、心血管内科、神经内科、呼吸科等科室进行多学科会诊(MDT),就老人术前、术中、术后的风险防控问题进行了深入讨论,制定了严密的手术方案。当日下午高扬就为老人实施了微创小切口髓内针(PFNA)内固定手术,原来需要“开大刀”切开复位的手术,现在在C臂的辅助下只需几个2厘米的小切口就解决了问题。麻醉过程中,病人血压波动在可控范围之内,有惊无险,手术圆满完成。       

    据了解,山一大二附院曾为数位百岁老人实施眼科手术,为97岁高龄的老人实施骨科手术,并不多见。为了保证手术顺利进行,麻醉科主任张文生主任医师亲自为老人麻醉,创伤骨科高扬副主任医师主刀手术。由于手术需要精准操作,快速完成,以尽可能减轻老人的手术应激反应,同时术中需要实时X线透视检查,高扬副主任医师身着20多斤的铅衣,专心致志地手术着。等手术做完,高扬的整个洗手衣已经被汗水浸透。“创伤骨科医护人员对这位高龄患者给予了精心的医治和护理,从住院到手术仅用了72小时,减少了手术和各种卧床并发症风险的发生。术后坐起、术后即刻饮水,疼痛缓解后康复介入等快速康复(ERAS)措施正在同步实施。此外对于超高龄的老人,术后还需要我们积极防治内科并发症、营养支持等治疗,确保让老人早日康复,回归家庭生活。只要老人恢复健康,我们辛苦也是值得的。”高扬说。  

    【相关链接】 

    老年人要高度重视“脆性骨折”,做好预防很关键      

    在日常生活中,老年人因为摔倒引发骨折的事件并不稀奇。许多老人,夜间起夜时,由于头脑不是很清楚、夜间视线不佳等原因,摔倒在地上,造成髋部骨折;有人洗澡时跌倒,肩膀着地,肱骨上端骨折;有的老人外出买菜时被路上凸起的石头等障碍物绊倒,手撑地,手腕部骨折;有人有的老人不小心蹲坐地上甚至打个喷嚏竟造成椎体压缩性骨折……这类骨折,被称之脆性骨折。         

    脆性骨折,是指无外伤或轻微外伤情况下引起的骨折,又称骨质疏松性骨折,最常见于老年人。通常发生在正常外力不会折断的非创伤部位,如椎体、髋部、前臂、腕部等。脆性骨折是骨质疏松症的最严重后果,能使人致死或致残。有资料显示,髋部或骨盆骨折一年内,死于各种并发症者达20%,而存活者中约50%致残,生活质量明显下降。     

    老年人发生骨折后,尤其是髋部骨折,由于不能活动,血流淤滞,再加上骨折创伤对血管内皮的损伤,患者往往会出现血栓,下肢深静脉血栓脱落漂移到肺部动脉,会发生肺栓塞,从而危及患者的生命。因此脆性骨折尤其是髋部骨折并发各种并发症的几率高,严重威胁着老人的生命,被称为老人人生的最后一次骨折。        

    随着社会人口的老龄化,骨质疏松症已经成为危害老年人健康的全球性公共健康问题,业界和公众都应该提高对骨质疏松症及脆性骨折的认识,重视预防和治疗工作。  

    及早识别骨质疏松,脆性骨折的高危人群     

    骨质疏松症的患病率随着年龄的增长而增加,我国50岁以上绝经期妇女的患病率约为20%,男性为8%~10%。骨量减少的人群更多。此外,体型比较瘦的人,或伴有糖尿病、甲亢、胃肠道疾病,或父母有过脆性骨折史,长期使用激素(糖皮质激素)的人,都是骨质疏松症的高危人群。      

    如何自己识别骨质疏松症呢?要根据身体的表现。驼背、行走不便、容易跌倒、脆性骨折,都是骨质疏松症的典型表现。最常见的临床症状是不同程度、不同部位的骨骼及关节疼痛,多无关节红肿(变形),常伴有腰腿乏力、双下肢抽筋,弯腰、翻身、下蹲、行走等活动困难或受限制。对于中老年人,要及早进行检查,及早进行抗骨质疏松治疗。     

    如何从生活方式上防治骨质疏松症?一是注意加强营养,均衡膳食,多吃富含蛋白质、钙、维生素C、维生素D、矿物质的食品,如虾、蛤、深绿色蔬菜、燕麦、豆制品等;二是多晒太阳,规律运动,可选择散步、慢跑、太极拳、做保健操等项目,通过增加日照与户外运动,调节全身代谢状态,改善骨骼血液循环状况,提高性激素水平,促进钙吸收,缓解骨质疏松,减少骨量丢失保存骨量;三是戒烟、限酒,避免过量饮用咖啡、碳酸饮料,尽量避免或少用影响骨代谢的药物等。

    老年人要把防跌倒放在首位     

    跌倒是导致老年人骨折的直接原因。预防跌倒,是预防老年人脆性骨折的首要措施。具体如下:久坐后站起时,应缓慢站起并扶稳扶手,避免体位改变引起体位性低血压而跌倒;有心脑血管疾病的老年人,应按时服药,密切监测,定期随诊,肢体活动不灵者外出时要有家人陪伴,根据身体情况拄拐杖或坐轮椅;室内地板应保持干燥,用大片防滑地毯替代小面积的垫子,灯具足够明亮;室内要有通畅的行走空间,电线靠边、桌椅居中放置,墙边过道都加扶手;卫生间过道宜设置感应开关,晚间不用开灯就有充分照明;卫生间内马桶和淋浴区周围全设置扶手,必要时去掉门槛;洗澡时要准备好小凳子,坐着穿裤和鞋,防止跌倒;雨雪天尽量少出门,避免滑倒;不要攀登梯子或爬高活动,不宜在陡坡上行走,以防跌倒。      老年人脆性骨折的治疗除非有严重的内科疾病不能耐受麻醉和手术的病人,都应该尽可能的接受手术治疗。在国际上已经有学者提出“Hip Stroke”的概念,认为髋部骨折应和心脑血管卒中疾病一样属于急症处理的范畴。尽快术前检查、尽快进入手术治疗、尽快恢复至伤前水平是考验一个医院老年髋部骨折治疗水平的标准。为此,山一大二附院创伤骨科在老年髋部骨折治疗方面不断总结经验,优化术前检查项目和流程、术中以迅速、微创、解剖复位、稳定固定为目标,在老年髋部骨折的治疗方面积累了丰富经验。

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