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]
Trang 1PHAN 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 6 - 8 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 6 — 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, tuy theo the trang benh nhan va mtfc do 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 6 gid, sau khi cat loc co the dinh da thtfa Den muon, cat loc, de hd Khau da lan 2
- Cac vet thtfdng sau, vao qua can den ldp cd Co hai nhom:
+ Thtfdng ton cd nhe do cac vat sac nhon nhtf dao, kiem chem v.v Thtfdng ton
cd theo dtfdng di ciia vat nhon, khong lan rong
Trang 2+ Thtfdng ton phan mem nang do tai nan giao thong, do dan ban v v Ixiai nay 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 nay 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 ha bi, rach o quan cd vat
da loc Nuoi vat da luc nay 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 ha 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 khi cat loc, nen de hd da Co 2 ndi co the khau da thi dau ngav
- Vet thtfdng dau mat
- Vet thudng ban tay
Tuy nhien, vdi cac vet thudng do bi can (ngtfdi, sue vat), cac vet thtfdng do may
nong nghiep, luon luon de hd ke ca hai ndi nav
37 1
Trang 32 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 trong 6 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 tuy thuoc vao dieu kien cho phep, khong nen toi Uu hoa ngay ttf dau
3.1 Cap ctfu ban dau vet thtfdng phan m em
- Bang vo khuan vet thtfdng phan mem sau khi 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 khi 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 trong ra 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 2 - 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
- Da bi rach thanh hinh sao hoac thanh vat bong loc, can ltfu y cac goc nhon rat de bi hoai ttf cac vat da bong loc co cuong quay xudng dtfdi, loc ngam tren dien rong co mau tu phia dtfdi se khong thuan ldi cho nuoi dtfdng Neu thay co nguy cd hoai ttf, phai cat lang da thanh ldp da mong, rach mat sang cho thoat dich, bang bat dong
Trang 43.2.5 Cdt loc thanh 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 1 - 2%
3.2.7 D d n la u dtfdc dat ttf day vet thtfdng ra 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 do 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 ra ngoai, it to chtfc hoai tii va di vat thi thay bang hang ngay co dap gac dtfdc tham tfdt bang cac dung dich tfu trtfdng nhtf huyet thanh man 10%, den khi 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 ngay
5 KHAU VET THl/CfNG
5.1 Khau kin vet thtfdng ngay ky dau: co rat nhieu dieu kien can xem xet de quyet dinh
- Co the khau ngay ky dau doi vdi vet thtfdng den sdm trtfdc 6 gid, co the keo dai moc thdi gian nay 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 ngay thi dau.
- Moi trtfdng tai nan khong phai la moi trtfdng o nhiem nang.
- Vet thtfdng nong nghiep, sue vat can, hoa khi v.v dtf den sdm ctfng nen rat than trong khi quyet dinh khau ngay ky dau Tot nhat nen la de hd
- Tinh trang da phai du che phu vet thtfdng, khi 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 khi 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
376
Trang 55.2 Khau ky dau muon sau khi cat loc de hd da hean toan, che phu vet thtfdng, thay bang bang gac co tha'm cac dung dich Uu trtfdng, sau 4 - 5 ngay 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 8 - 1 5 ngay khi vet thtfdng da co to chtfc hat moc tot, khong con 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 trong 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 trong Hinh 6.4 Khau vat da goc nhon
tAi LIEU THAM KHAO
1 Benh hoc Ngoai tap 2 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
4 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
8 Skeletal Traum a 4th ed W B Saunders Company Edited by Browner 2008
Trang 62 GAY XUONG 6 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 nay Gay ndi nay can nan that tot de tranh bi roi loan
phat trien ve sau (xem hinh 6.6).
Hinh 6.5 Gay canh ttfdi 2 xtfdng Hinh 6.6 Gay bong sun tiep
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 1 - 2cm va gap goc dtfdi 10°
- Di lech xoay (xoay trong 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
Cd the chap nhan xoay ngoai den 10 , xoay trong khdng chap nhan
Trang 71.3 Thu’cfng ton sun phat trien
Tre em hay bi gay bong sun phat trien, ndi yeu nhat cua xUdng
1.3.1 Phan do 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 khi thay chi dai, chi ngkn,
khong chan doan sdm dUdc.
Do 1 Do 2 Do 3 Do 4 Do 5
Hinh 6.7 Phan do gay bong sun phat trien d tre em, theo Salter-Harris
1.3.2 Roi loan p h a t trien dau xiidng do sun tiep hpp bi ton thiidng
Muon thay sdm thudng ton, dung cong hUdng tii, chup vao tuan thii 3 den tuan 17 sau gay xUdng, do 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 1 va 2 dia sun phat trien khong bi ton thudng, can nan xUdng that tot ve giai phau
Gay kieu 3 va 4, nhat la 4, gay pham dia sun phat trien, yeu cau nan chinh ve giai phau la cao, nan phai hoan hao cho nen thudng phai mo nan, co dinh vflng de han che di chiing
Trang 8Vf 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 ra ngoai hau het phai mo dat lai va co dinh ben trong
Khi co gay d vung sun phat trien, phai bao trtidc cho cha me diia tre ve cac roi loan phat trien sau nay
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 tuy do gap goc
- Doi vdi tre ldn: thUdng due xUdng stia true
- Doi vdi tre be:
+ Neu gap goc dudi 20 do chi can due bo cau xUdng
-I- Neu gap goc tren 20 do: due bo cau xUdng va due xUdng stia true
2.1 Gay tren loi cau xifofng canh tay
Gap trung binh d tre 8 tuoi, do 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 nay cot hoa het khi tre tren 16 tuoi Day la nhting diem yeu gay ra loai gay
tren loi cau (TLC) pho bien nhat d tre em (xem hinh 6.9 vd hinh 6.10).
j Nu 1 - 11mm i
Nam 1 - 26mm i:
Nur: 5 -8 tuoi Nam: 7 - 9 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
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 con di'nh cd d phan dudi (nguyen uy cd tren loi cau) con loi cau bi cd keo di lech 180 do vdi mat gay xoay ra ngoai
380
Trang 9Day la loai gay cdn mo d tre em (do 3 - 4 ) Loai gay nay dUdc xem la gav theo
dUdng sun phat trien, co trUdng hdp ve sau tre bi veo khuyu ra 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 do 1 - 2, dieu tri bao ton, gay do 3 - 4 dieu tri bang phau thuat
Do 4 (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).
Trang 102.5 G ay xufOng hof of tre em
Do siic de khang yeu, gay hd do 1 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 nay
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
3 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
382