最全攻略:股骨近端骨折的診斷和治療 AAOS精編教程

↑↑↑點我收聽本期內容

本期唯醫FM將為您陸續放送美國骨科醫師協會（AAOS）精編教程性書籍《AAOS Essentials of Musculoskeletal Care 5th》。

中國醫師協會骨科醫師分會（CAOS）已獲授權出版中文版書籍，並已組織國內多個著名醫院的醫生完成了全文翻譯，紙質版即將刊印，電子英文原版也會陸續在唯醫網發布。本期為大家放送教程節選內容：股骨近端骨折的診斷和治療。

長按二維碼查看完整譯文

髖關節骨折又稱股骨近端骨折，常見於合併骨質疏鬆的老年人，主要包括兩種骨折：股骨頸骨折和轉子間骨折。這兩種骨折的發病率相當，好發人群一致，但手術治療方法卻不相同。股骨頸骨折是一種髖關節囊內骨折，顧名思義，其發生在股骨近端髖關節囊之內（圖1）。

Hip fractures (proximal femur fractures)are a common injury in elderly individuals with osteoporosis. These fracture sgenerally involve either the femoral neck or the intertrochanteric region. Both types occur with approximately the same frequency and affect a similar patient population; however, surgical treatment of the two injuries differs. Femoral neck fractures also are known as intracapsular hip fractures and thus by definition occur in the region of the proximal femur that is within the hip capsule itself(Figure 1).

圖1  前後位片示股骨頸骨折並移位（箭頭）

Figure 1 AP radiograph demonstrates a displaced femoral neck fracture (arrow)

髖關節囊內骨折常會破壞股骨頭的血運，因此，骨不連和缺血性骨壞死是這類骨折常見的併發症。轉子間骨折是關節囊外骨折，其發生在股骨近端股骨頸基底部與小轉子遠端之間的區域內（圖2）。與股骨頸骨折相比，治療轉子間骨折需要更加堅強的內固定。由於轉子間骨折一般不會破壞股骨頭的血運，所以骨不連和骨壞死的發生率低於股骨頸骨折，但是，內固定失敗的問題在轉子間骨折遠較股骨頸骨折常見。

Intracapsular hip fractures often lead to a disruption of the blood supply to the femoral head; thus, nonunion andosteonecrosis are common complications of this injury. Intertrochanteric hip fractures are extracapsular, occurring in the region of the proximal femur between the base of the femoral neck and the distal aspect of the lesser trochanter (Figure 2), and they require more robust fixation than do femoral neck fractures. They are associated with lower rates of osteonecrosis or nonunion, as the blood supply to the femoral head is not typically disrupted; however, implant failure is a much more common problem with these injuries

圖2  前後位片示轉子間骨折（箭頭）

Figure 2 AP radiograph demonstrates an intertrochanteric fracture of the hip (arrow)

高齡是股骨近端骨折最重要的危險因素。在50歲以後，年齡每增加10歲，髖關節骨折的發生率就會加倍。髖關節骨折的發生還有很多其他原因：老年人本體感覺功能減退，缺乏自我保護的反應，這使得他們摔倒的可能性大大增加。而且，由於老年人行走緩慢，摔倒時容易向側面而不是前面倒下，大腿外側和髖關節區域常會首先著地，故容易發生此部位的骨折。另外，頭暈、中風、暈厥、周圍神經病變以及某些藥物的應用也會影響老年人的平衡感，使老年人更容易發生髖關節骨折。

Advanced age is the most important risk factor for a proximal femur fracture. The frequency of hip fractures generally doubles with each decade beyond age 50 years. There are several reasons for this. Decreased proprioceptive function and loss of protective responses increase the likelihood that elderly individuals will fall. Also, because elderly individuals walk slowly, when they fall they tend to fall to the side as opposed to forward, so the lateral thigh and hip region often strikes the ground first. Dizziness, stroke, syncope, peripheral neuropathies, and medications are other factors that can compromise balance and predisposeelderly patients to hip fractures.

白人女性髖關節骨折的發生數量比非洲裔、美洲裔或墨西哥裔女性高2到3倍，提示此病的發生有人種差異。其他的危險因素還包括：長期坐位的生活習慣、吸菸、飲酒、應用精神藥物、老年痴呆、骨質疏鬆、以及生活在城市等。

White women are two to three times more likely than African American or Hispanic women to sustain a hip fracture. Other risk factors include sedentary lifestyle, smoking, alcoholism, use of psychotropic medication, dementia, osteoporosis, and living in an urban area.

大部分患者會有摔倒後腹股溝區疼痛，患肢不能負重及行走。少部分患者仍可藉助拐杖和助行器行走，但負重會引起腹股溝或臀部疼痛，行走時疼痛會明顯加重。有些患者偶爾還會有股骨髁上區域的牽涉痛。在摔倒後有髖部疼痛的老年患者，在排除骨折前，均應按照髖關節骨折來處理。

Mostpatients report a fall followed by pain in the groin and the inability to bearweight on the extremity or ambulate. A few patients will be able to walk with crutches, a cane, or a walker but have groin or buttock pain on weight bearingthat worsens with ambulation. Occasionally, patients report pain referred to the supracondylar region of the knee. Elderly patients with hip pain after afall should be treated as if they have a hip fracture until proven otherwise.

• 體格檢查

股骨頸或轉子間骨折並有移位的患者，在仰臥時會呈現患肢外展外旋畸形並較健側短縮。股骨頸疲勞骨折或骨折無移位的患者，可能沒有明顯的畸形，但是當檢查者在髖關節伸直的狀態下輕輕旋轉患肢時，會誘發疼痛，而且患者無法完成直腿抬高（保持膝關節伸直，踝部抬離檢查臺面）。

Apatient with a displaced femoral neck or intertrochanteric fracture, when supine, lies with the limb externally rotated and abducted; if the fracture isdisplaced, the leg will also be shortened. A patient with a stress fracture ora nondisplaced fracture of the femoral neck may have no obvious deformity. Attempts by the examiner to gently rotate the limb while the hip is extendedelicit pain, and the patient will be unable to perform a straight leg raise (liftthe heel on the affected side off the examination table while keeping the kneestraight).

• 影像學檢查

患側髖關節的前後位片和仰臥水平投照側位片可以顯示大多數股骨近端骨折。對於可疑股骨近端骨折的患者，應避免攝蛙式側位片，因為此體位會導致患者嚴重的疼痛，並可能使原本無移位的骨折端移位。如果病史和體格檢查均提示骨折，但X線平片未發現骨折，應行MRI檢查進行明確（圖3）。

An AP view of the pelvis and cross-tablelateral views of the involved hip reveal most fractures of the proximal femur.It is important to avoid a frog-lateral radiograph in a patient with asuspected proximal femur fracture because that patient positioning will cause severe pain and may cause displacement of a nondisplaced fracture. An MRIshould be obtained if the history and physical examination are suggestive of afracture but plain radiographs are negative (Figure 3).

圖3  MRI T1加權象顯示無移位的轉子間骨折

Figure 3 T1-weighted MRI demonstrates anondisplaced intertrochanteric hip fracture (arrow).

病理性骨折（原發或繼發腫瘤，良性或惡性）

Pathologicfracture (underlying or associated tumor, benign or malignant)

骨盆骨折（髖關節活動度正常，外旋疼痛）

Pelvicfracture (normal hip joint motion, pain on external rotation)

股骨頸或骨盆應力骨折（除了髖關節活動疼痛其他均正常）

Stressfracture of the femoral neck or pelvis (normal but painful hip motion)

股骨近端骨折通常是健康狀況不佳的標誌，很多併發症會伴隨這種損傷出現，例如：血栓栓塞、肺炎、褥瘡、泌尿系感染等。據報導，老年人股骨近端骨折後1年內死亡率為10%-30%，患者常會喪失雙下肢行走能力和生活自理能力。除此之外，與骨折直接相關的併發症包括骨不連和骨壞死。

Proximal femur fractures are generallymarkers of poor health, and medical complications frequently accompany these　injuries, including thromboembolic events, pneumonia, decubitus ulcers, andurinary tract infections. The 1-year mortality rate following proximal femur fracturesin elderly patients has been reported to be 10% to 30%, and patients often loseboth ambulatory capacity and functional independence. Complications directlyrelated to the fracture include nonunion and osteonecrosis.

大部分股骨近端骨折需要手術治療，因為非手術治療的風險（主要是長期臥床，可能導致血栓栓塞、肺炎、褥瘡、機體功能失調等）通常高於手術治療，除非患者的身體健康狀況非常差，或者患者本來就無法行走，再或者患者因痴呆在移動時不會引起明顯的疼痛。

Mostproximal femur fractures are treated surgically because the risks ofnonsurgical treatment (primarily related to the extended period of bed restrequired, with the associated risk of thromboembolic events, pneumonia,decubitus ulcers, and general deconditioning) generally outweigh the risks ofsurgical treatment of all except the most medically unstable patients andpatients who are nonambulatory and/or who have dementia with minimal pain associatedwith transfers.

確診為股骨近端骨折的患者需要由矯形外科醫師、內科醫師和麻醉醫師共同進行術前評估，爭取儘快手術。患者需要進行徹底的檢查，以確定是否合併其他疾病，這些合併疾病最好在術前給予妥善治療，儘可能減少術中發病甚至死亡的風險。

Patients in whom a proximal femur fracturehas been diagnosed should be evaluated by an orthopaedic surgeon, an internist,and an anesthesiologist in a timely manner to expedite surgical treatment. Patients should undergo a thoroughevaluation to determine if medical comorbidities are present that can beoptimized preoperatively to decrease the risk of perioperative morbidity and mortality.

對血栓栓塞的預防（物理方法、藥物方法或者二者結合）應該在傷後立即開始，因為這類骨折的患者發生血栓栓塞事件的風險非常高。很多研究顯示，若從患者受傷到實施手術幹預的時間延遲超過48小時，患者的死亡率可能升高。因此，除非有其他方法可以確實減少患者術中風險，否則手術應該在傷後48小時內實施。皮牽引在過去經常用於減輕患者術前的痛苦，但最近的前瞻性隨機對照研究顯示，皮牽引的效果尚不及在膝下墊枕。

Thromboembolic prophylaxis (mechanical,pharmacologic, or both in combination) should be instituted immediately becausethese patients are at extraordinarily high risk for thromboembolic events.Numerous studies have suggested that a delay of more than 48 hours from thetime of injury to surgical intervention is associated with increased mortality.Therefore, surgical intervention should not be delayed longer than 48 hoursunless some other intervention will substantially decrease the patient』 sperioperative risk from surgical treatment. Although skin traction has been commonly used in the past to relieve preoperative discomfort, recent prospective randomized studies have shown that it is less effective than a pillow placed beneath the patient’s knee.

手術方式的選擇主要取決於骨折的位置（股骨頸骨折還是轉子間骨折）、移位程度以及患者的活動水平。轉子間骨折的治療可以採用加壓螺釘及側方鋼板（圖4A），也可以採用髓內釘（圖4B）。無移位或外翻移位的股骨頸骨折可以採用經皮多枚（通常是3枚）加壓螺釘固定（圖4C）。老年人移位明顯的骨折則最常採用關節置換（圖4D）（對於術前活動量很小或無法活動的患者採用半髖關節置換，對於術前能夠正常行走的患者採用全髖關節置換），這是因為如果進行骨折固定，發生骨不連或股骨頭壞死的比率接近50%。小於60歲的股骨頸骨折患者常伴有高能量損傷，及時良好的復位及固定可以帶給患者更好的治療結果，因此，這類損傷應作為外科急症處理。對股骨頸骨折和轉子間骨折的患者進行骨密度測定是病情評估的重要部分，如果骨密度減低，應給予相應的治療。

The form of surgical treatment selected isdetermined primarily by fracture location (femoral neck versusintertrochanteric), displacement, and patient activity level. Intertrochanteric　fractures are treated with either a screw and side plate (Figure 4, A) or an intramedullarynail (Figure 4, B). Nondisplaced or valgus impacted femoral neck fractures aretreated by percutaneous fixation with multiple (typically three) screws (Figure4, C). Displaced fractures in elderly patients are typically treatedwith prosthetic replacement (arthroplasty) (Figure 4, D) (eitherhemiarthroplasty for minimal ambulators or nonambulators or total hiparthroplasty for patients who are able to ambulate before surgery) because therisks of nonunion and osteonecrosis approach 50% if fracture fixation is performed.Femoral neck fractures in patients younger than 60 years are typicallyassociated with high-energy trauma and constitute a surgical emergency becauseanatomic surgical fixation in a timely manner is required for optimal outcomes.Bone mineral density measurement should be part of the evaluation of patientswho present with fractures of the femoral neck or intertrochanteric area of thefemur. If low bone mineral density is found, appropriate treatment should be　instituted.

圖4  術後前後位片。A，加壓螺釘及一側鋼板固定轉子間骨折；B，髓內釘固定轉子間骨折；C，3枚空心加壓螺釘固定無移位的股骨頸骨折；D，骨水泥型全髖關節置換治療移位的股骨頸骨折

Figure 4 Postoperative AP radiographs. A, Intertrochanteric hip fracture treated with a screw and side plate. B, Intertrochanteric hip fracture treated with an intramedullary nail. C, Nondisplaced femoral neck fracture treated with three cannulated screws. D, Displaced femoral neck fracture treated with cemented arthroplasty of the hip.

對股骨頸骨折患者進行內固定可能會發生股骨頭缺血壞死或骨不連。不論是行全髖關節置換還是半髖關節置換，假體脫位都有可能發生。而轉子間骨折手術治療最常見的併發症是創傷性關節炎和/或內固定失敗合併骨不連（圖5）。對於所有股骨近端骨折的患者都應該評估其骨質疏鬆的情況並進行適當的治療，因為這類患者可能有對側髖關節骨折以及橈骨遠端骨折和腰椎壓縮骨折等脆性骨折的風險。

Femoralneck fractures treated with internal fixation are associated with osteonecrosisof the femoral head and fracture nonunion. In hips treated with eitherhemiarthroplasty or total hip arthroplasty, prosthetic dislocation can occur.The most common complications of surgical treatment of an intertrochanteric　fracture are post　traumatic arthritis and/or failure of fi xation with nonunion(Figure 5). All patients with proximal femur fractures should undergo　evaluation for osteoporosis and treatment as appropriate because they are at　substantial risk for fracture of the contralateral hip and other fragility fractures,such as distal radius and vertebral compression fractures.

圖5  前後位片顯示轉子間骨折治療後內固定失敗

由於存在骨不連和股骨頭壞死的風險，小於60歲患者的股骨頸骨折應作為外科急症處理。儘快解剖復位並手術固定可以減少併發症的風險。如果患者的病史和體格檢查均提示骨折，但X線平片未發現骨折，應行MRI檢查明確診斷並除外股骨近端骨折。由於非手術治療有很高的併發症發生率，所以對於所有股骨近端骨折均應考慮手術治療。

A femoral neck fracture in a patient younger than 60 years constitutes a surgical emergency because the risk of osteonecrosis and fracture nonunion is substantial. Prompt surgical fixationand an anatomic reduction decrease the risk of these complications. In a　patient with a history and physical examination suggestive of a fracture butwith negative plain radiographs, an MRI should be obtained to definatively　diagnose or rule out a proximal femur fracture. All proximal femur fractures　should be considered for surgical treatment given the high risk of complications associated with nonsurgical treatment.

翻　譯：解　琛 　主治醫師　濟南軍區總醫院

一　校：易誠青　 主任醫師　上海市第一人民醫院

終　審：馬建兵　 主任醫師　西安紅會醫院

「唯醫FM」是由唯醫網推出一檔語音播報類欄目，旨在為廣大醫師提供可隨時收聽且實用的臨床骨科知識，實現學術資源隨身相伴。 無論您是慢跑健身，還是上下班乘車，都可以打開手機，戴上耳機，解放雙眼，隨時隨地，輕鬆學習！

輕鬆3步隨時收聽唯醫FM

以上是唯醫FM的全部內容，歡迎點擊閱讀原文查看本部分完整文獻譯文內容，如果您有任何想聽的內容，歡迎您在下方留言。