REPORT CV. AN INVESTIGATION ON THE REGENERATION O NERVES WITH REGARD TO SURGICAL TREATMENT OF CERTAIN PARALYSES
REPORT CV. AN INVESTIGATION ON THE REGENERATION O NERVES WITH REGARD TO SURGICAL TREATMENT OF CERTAIN PARALYSES
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DOI：
10.1136/bmj.1.2476.1414-a
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发表时间：
1907-04
影响因子：
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通讯作者：
B. Kilvington
中科院分区：
文献类型：
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作者：
B. Kilvington
结合最近对这一问题的讨论，我是否可以简要地陈述一下在医院对这类损伤的一些常见类型，采用保守和手术措施治疗的大量经验的结果？在全身麻醉的情况下，习惯性地在尽可能早的时候进行复位。在股骨中，轴骨折为横向骨折、短斜骨折或扭转（螺旋）骨折。结果，通过伸展等，骨折越接近横向越接近完美；在后者中，位移很少被标记出来，因此结果在其中一些是完美的。在第二类中，我对通过伸展来减少（更不用说保持）纵向位移的困难和常常不可能感到惊讶；然而，在经历了开放手术和延伸手术的极端困难之后，我并不感到惊讶，在许多情况下，明显很少缩短；因此，一个有用的，虽然不是完美的，肢体的不同程度的缩短通常产生。这些骨折大部分发生在儿童身上。对于骶骨骨折，我自己和其他人的经验使我得出结论，除了手术措施外，绝不能将碎片放置或保持在接近良好的位置。在这里，坚持保守方法通常导致缩短约1英寸。只要我能观察到这些病人（几个月以上），就会发现他们有不同程度的外翻、畸形、疼痛，其中经常涉及到穷人寻求一份不那么积极的职业的必要性。在一个或两个病例中，病人可能在三或四个月后能够拄着拐杖或拐杖蹒跚而行，这些令人痛苦的特征在医院实践中并不罕见，在医务室可能经常出现。相比之下，根据经验，我们只能满怀信心地期望，在十周内，通过有效的措施，功能将完全恢复，不会缩短；我只会提到一个近3英寸的螺旋骨折病例。手术后，七周后，他就能在楼上跑步了，没有跛行。对于波特骨折的保守治疗，不必多说，因为令人遗憾的僵硬、畸形和无法恢复活动生活，至少会导致几个月，如果不是永久性的，在许多情况下，大多数外科医生都认为手术是治疗这些损伤的首选方法。腿骨骨折，；如果是横向的，有时可以通过操作减少横向位移；螺旋骨折很少出现这种情况，尤其是明显的短缩。综上所述，手术治疗股骨骨折的康复时间约为手术治疗股骨骨折的一半，而胫骨和腓骨骨折的康复时间约为保守治疗功能低下患者的三分之二；虽然疼痛，疼痛和僵硬是后一类病例恢复期的显著特征，但在手术病例的整个治疗过程中却明显缺席。在肱骨骨折中，我只需要提到旋转、角度和纵向移位、延迟愈合以及由于干扰臂丛和肌肉螺旋神经功能而导致的瘫痪，这些有时是由于保守治疗（不一定是由于忽视治疗）造成的，并比较它们不完全或延迟的功能恢复和痛苦的恢复期，持续数月或数年。一次性手术后，术后8周内功能完全恢复。由于上述一些失败而必须进行的二次手术，向我清楚地表明，除了进一步延缓恢复期外，所涉及的困难大大增加。预防这些失败总是比治疗好得多。最后，分离下骨骺。至于肱骨，foitofiexton在少数情况下确实成功了，而且还不是最糟糕的；但是，有了这个。除少数例外情况外，唯一值得我们自豪的结果是，通过后切口将下碎片扳入位置，没有暴力，通过完全屈曲保持相对位置。通过这种方法，较少的重新出血和肿胀引起，随后的关节运动，采取所有情况，是无限的好。总之，仅在脓毒症中总结手术风险。我从来没有见过手术干预骨折导致的痉挛，至于在骨头中留下钢板、螺钉、金属丝等的缺点，我也没有遇到过任何需要后续麻烦的例子。随后。移除它们。这样的操作，如有必要，。无论如何，这都是最简单的程序，
IN connexion with recent discussions on this subject, may I be permitted to state briefly the results of a considerable hoopital experience of some of the commoner varieties of this class of Injury, treated both by conservative and operative measures? Attempts at reduction have habitually been made under general anaesthesia at tbe earliest moment possible. In the femur, fractures of the shaft have been transverse, short oblique, or torsion (spiral) fractures.. The, reslt, by extension, etc., has been nearer perfection the more the fracture approached the transverse; In the latter the displacement is seldom marked, and the result consequently perfect in some of them. In the second class I have been astontshed at the difficulty and frequent impoesiblblty of reducing (and more so of maintaining reduction of) the longitudinal displacement by extension; this did not sonrpriseme, bowever, after experiencing the extreme difficultteo of doing so by open operation combined with extensiQn in many cases with apparently little shortening; as a consequencea useful, though not perfect, limb with a varying amount of shortening has usually resulted. The large majority of these fractures have been in cl¢lldren. With splral fractures my own experiences and those of others h%ve led me to the conclusion that never, by other than operative measures, can the fragments be placed or maintained in even approximately good position. Persistence in conservative methods has here usually led to shortening of aboout 1 In., often more, eversion, deformity, ap4 pain in varying degrees for as long as I have been able to watch the patients (over geveral months), involving frequently In the poor the necessity for seeking a less aetive occupation. In one or two cases the patient has perhaps been able to hobble with a stick or crutch at the end of three or four months, and these distressing tallures are not an uncommon sight in hospital practice, and possibly frequent In infirmaries. We have only to contrast a confident expectation, warranted by experience, of a perfect restoration of function with no shortening at all In ten weeks at the outside by operative measures; I will only mention a case of a spiral fracture with nearly 3 In. shortening after extension, who, after operation, was running upstairs under seven weeks later with no limp. Little need be said about conservative treatment In Pott's fracture, for the deplorable stiffnees, deformity, and inability to resvime active life, which result at least for several months, If not permanently, In so many cases, have led most surgeons to consider operation the method of choice in these Injuries. In fractures of the bones of the leg,;if transverse, lateral displacement can sometimes be reduced by manipulation; rarely is thls so with spiral fractures, especially if shortentng be at all marked. To summarize, convalescence In cases operated on has taken about half the time in fractures of the femur, and In fractures of tibia aud fibula about two thirds the time necessary for an inferior functional result in those treated conservatively; while aching, pain, and stiffness marked features in the convalescence of the latter class of case, is conspicuously absent throughout the whole treatment in cases operated on. Among fractures of the humerus I need only mention the rotatory, angular, and longitudinal displacements, delayed union, and paralysis due to interference with the functions of the brachial plexus and musculo-spiral nerve, which sometimes have resulted from conservative treatment (not necessarily from neglect of treatmwent), and compare ttieir imperfect or delayed functional recovery and painful convalescence, extending into months or years, with the moral certainty of complete functional recovery in siU to eight weeks when operated on at once. Secondary operations, necessitated by some of the above fatlures, have demonstrated clearly to me the greatly increased difficulties Involved in addition to a farther retarded period of convalescence. The prevention of these failures is always vastly preferable to the cure. Finally, in separation of the lower epiphysis. of the humerus, foitoiie fiexton has certainly sucoeeded in a few cases, and those not the wrorst; but, with .thes.e fewr exceptions, the only results wbich could justify our taking a pride In the patients have been attained by levering the lower fragment into position, without violenee, through a posterior incision, apposition being maintained by full flexion. By this method less renewed haemorrhage and swelllng is -caused, and the subsequent joint movements, taking all cases, is infinitely better. In conclusion, the risks of operation are summed up im sepsis only. I have never seen supppation result from operative interference in fractures, while as to the disadvantages of leaving plates, screws, wires, etc., In the bone,, I have come across no single instance In which any subsequent trouble has atsany time necessitated. the subsequent.removal of them. Such an operation, if necessary,. would, in any case, be the simplest procedure,