Abstract
目的
探讨难复性Pipkin Ⅰ、Ⅱ型股骨头骨折的临床特征、影像学表现及临床意义。
方法
筛选2010年1月—2019年12月收治的4例难复性Pipkin Ⅰ、Ⅱ型股骨头骨折患者临床资料。男2例，女2例；年龄24～41岁，平均33.5岁。致伤原因：交通事故伤3例，摔伤1例。Pipkin分型：Ⅰ型2例，Ⅱ型2例。受伤至手术时间1～2 d。临床特征为患肢髋关节呈锁定状态，被动活动度差，髋关节轻度屈曲，患肢明显缩短，呈中立位或仅存在轻度内收、内旋。影像学表现为股骨头向后上方脱位，髋臼后缘的坚硬皮质嵌入股骨头松质骨，二者互相挤压嵌顿。病例1～3分别于伤后3、1、3 h行髋关节闭合复位1～2次后，发生股骨颈骨折，损伤类型转变为PipkinⅢ型，遂行切开复位内固定术；病例4未行闭合复位，直接行切开复位内固定术。
结果
病例1～3分别获随访14、17、12个月，分别于术后9、5、10个月发生股骨头坏死，均行人工全髋关节置换术。病例4获随访24个月，无髋关节疼痛及活动受限；影像学检查示内固定物位置良好，骨折愈合，股骨头未见塌陷变形，未发现股骨头坏死迹象。
结论
临床医生需要提高对难复性Pipkin Ⅰ、Ⅱ型股骨头骨折独特临床特征及影像学表现的认识；建议对此类损伤直接采取切开复位并同期固定股骨头骨折治疗，以减少股骨头坏死的发生。
Keywords: 髋关节脱位, 闭合复位, 股骨头骨折, 股骨颈骨折, 股骨头坏死
Abstract
Objective
To summarize the characteristics and clinical significance of irreducible Pipkin type Ⅰ and Ⅱ femoral head fracture-dislocations.
Methods
The clinical data of 4 patients with irreducible Pipkin type Ⅰ and Ⅱ femoral head fracture-dislocations between January 2010 and December 2019 were collected. There were 2 males and 2 females and the age ranged from 24 to 41 years, with an average age of 33.5 years. The cause of injury included traffic accident in 3 cases and falling in 1 case. Pipkin classification was 2 cases of type Ⅰ and 2 cases of type Ⅱ. The time from injury to operation was 1-2 days. The clinical features were that the hip joint of the affected limb was in a locked position, and the passive range of motion was poor. The affected limb was slightly flexed at the hip joint and shortened, in a state of neutral position or slight adduction and internal rotation. The imaging data suggested that the femoral head dislocated backward and upward, and the hard cortex of the posterior edge of the acetabulum was embedded in the cancellous bone of the femoral head, and the two were compressed and incarcerated. Patients of cases 1-3 underwent closed reduction of hip dislocation 1-2 times at 3, 1, and 3 hours after injury respectively, and femoral neck fracture occurred. The injury types changed to Pipkin type Ⅲ, and open reduction and internal fixation were performed. Patient of case 4 did not undergo closed reduction, but underwent open reduction and internal fixation directly.
Results
Patients of cases 1-3 were followed up 14, 17, and 12 months, respectively. They developed osteonecrosis of the femoral head at 9, 5, and 10 months after operation respectively, and all underwent total hip arthroplasty. Patient of case 4 was followed up 24 months and had no hip pain and limited mobility; the imaging data indicated that the internal fixator position was good and the fracture healed; no collapse or deformation of the femoral head was seen, and no osteonecrosis of the femoral head occurred.
Conclusion
Clinicians need to improve their understanding of the unique clinical features and imaging findings of irreducible Pipkin type Ⅰ and Ⅱ femoral head fracture-dislocations. It is suggested that open reduction and simultaneous fixation of femoral head fracture should be directly used to reduce the incidence of osteonecrosis of the femoral head.
Keywords: Dislocation of hip joint, closed reduction, femoral head fracture, femoral neck fracture, osteonecrosis of the femoral head
髋关节脱位大多由高能量损伤引起，其中82%～94%患者为髋关节后脱位[1-3]。Pipkin骨折是指髋关节后脱位伴股骨头骨折，按股骨头骨折形态分为Ⅰ型和Ⅱ型[4-6]。早期识别、及时复位对于成功治疗Pipkin Ⅰ、Ⅱ型股骨头骨折非常重要[4，7]。通常首选急诊于麻醉状态下行髋关节脱位手法复位，但临床上亦存在部分Pipkin Ⅰ、Ⅱ型股骨头骨折无法闭合复位或强行复位后出现股骨颈骨折的情况，定义为难复性Pipkin Ⅰ、Ⅱ型股骨头骨折[8-10]。难复性Pipkin Ⅰ、Ⅱ型股骨头骨折一旦转变为Ⅲ型骨折，危害巨大。
目前针对难复性Pipkin Ⅰ、Ⅱ型股骨头骨折的临床特征及影像学表现鲜有报道[1，11-14]。如何尽早识别难复性股骨头骨折，采取何种复位方式，如何降低医源性损害的发生等均有待进一步解决。现回顾分析2010年1月—2019年12月我院收治的4例难复性Pipkin Ⅰ、Ⅱ型股骨头骨折患者临床资料，旨在提高临床医生对难复性股骨头骨折的认识，正确处置以避免医源性损伤的发生。报告如下。
1. 临床资料
1.1. 一般资料
本组男2例，女2例；年龄24～41岁，平均33.5岁。左侧3例，右侧1例。致伤原因：交通事故伤3例，摔伤1例。Pipkin分型：Ⅰ型2例，Ⅱ型2例。难复性Pipkin Ⅰ、Ⅱ型股骨头骨折临床表现：患肢髋关节呈锁定状态而非弹性固定，被动活动度差，髋关节轻度屈曲，患肢明显缩短，呈中立位或仅存在轻度内收、内旋（图1）。合并下唇贯通伤、牙齿脱落1例，蛛网膜下腔出血、头面部多发挫裂伤及第5掌骨远端骨折1例。受伤至手术时间1～2 d。患者临床资料见表1。
图 1.
Clinical manifestations of right irreducible Pipkin type Ⅰ femoral head fracture-dislocation
右侧难复性Pipkin Ⅰ型股骨头骨折临床表现
a. 正位；b. 侧位
a. Front view; b. Lateral view
表 1.
Clinical data of patients
患者临床资料
| 序号
No. |
年龄
（岁） Age (years) |
性别
Gender |
致伤原因
Cause of injury |
闭合复位次数
Times of closed reduction |
受伤至手术
时间（d） Interval between injury and operation (days) |
Pipkin分型
Pipkin classification |
合并伤
Combined injury |
闭合复位后出现
股骨颈骨折 Femoral neck fracture after closed reduction |
手术入路
Surgical approach |
股骨头坏死
Osteonecrosis of the femoral head |
| 1 | 39 | 女 | 交通事故伤 | 2 | 1 | Ⅱ | 下唇贯通伤、牙齿脱位 | + | Kocher-Langenbeck | + |
| 2 | 24 | 男 | 摔伤 | 1 | 1 | Ⅰ | − | + | Ganz | + |
| 3 | 41 | 女 | 交通事故伤 | 2 | 2 | Ⅱ | 蛛网膜下腔出血、头面部多发挫裂伤、第5掌骨远端骨折 | + | Kocher-Langenbeck | + |
| 4 | 30 | 男 | 交通事故伤 | − | 1 | Ⅰ | − | − | Ganz | − |
1.2. 治疗方法
1.2.1. 影像学表现及闭合复位技术
患者伤后行正侧位X线片和CT三维重建检查。病例1～3具有相似的影像学表现：正侧位X线片示部分股骨头保留在髋臼中，脱位的股骨头、颈相对于髋臼位于后上；股骨头、颈与髋臼后缘紧密地嵌合和锁定。CT三维重建示髋臼后缘坚硬的皮质骨形似“楔子”状，紧密嵌顿于股骨头松质骨内。病例1～3分别于伤后3、1、3 h进行闭合复位。患者于全身麻醉下取仰卧位，采用Bigelow法行髋关节闭合复位1～2次，复位不成功且C臂X线机透视证实发生股骨颈骨折，损伤类型转变为PipkinⅢ型。遂放弃闭合复位，行切开复位内固定术。
通过病例1～3临床特征及影像学检查经验的积累，总结难复性Pipkin Ⅰ、Ⅱ型股骨头骨折特征，病例4正侧位X线片和CT三维重建检查发现上述影像学特征后，未尝试闭合复位，直接行切开复位内固定术。
1.2.2. 切开复位内固定术
手术采用Kocher-Langenbeck入路（2例）或Ganz入路（2例）。术中见脱位的股骨头通过后上盂唇与髋臼之间撕裂的间隙脱位于髋臼后上方，形似纽扣及纽孔的关系，撕裂且极度紧张的后上盂唇和关节囊限制了脱位股骨头的活动。股骨头前下方关节面存在缺损，同时缺损区可见部分骨质压缩，股骨头紧密嵌压于髋臼后壁内。首先解除关节囊及盂唇的交锁，直视下复位股骨头骨折，螺钉固定。维持下肢牵引，复位股骨头于髋臼内。3例出现股骨颈骨折的患者，以股骨头与股骨颈外侧皮质为参照复位骨折断端，复位满意后于大转子下方垂直骨折线平行拧入空心螺钉固定。以1～2枚3.5 mm锚钉修复后方撕裂的盂唇。采用Ganz入路的患者再复位大转子骨块，垂直截骨线拧入螺钉固定。
1.3. 术后处理及疗效观察指标
术后常规给予抗凝、镇痛及对症支持治疗，指导患者进行功能康复锻炼。术后1个月及之后每3个月定期复查髋关节正侧位X线片，观察骨折愈合情况及是否发生股骨头坏死。
2. 结果
病例1～3分别获随访14、17、12个月，分别于术后9、5、10个月发生股骨头坏死，均行人工全髋关节置换术。病例4获随访24个月，无髋关节疼痛及活动受限；影像学检查示内固定物位置良好，骨折愈合，股骨头未见塌陷变形，未发现股骨头坏死迹象。见图2、3。
图 2.
Case 2
病例2
a. 术前骨盆正位X线片；b、c. 术前冠状位、矢状位CT；d、e. 闭合复位后冠状位、矢状位CT；f、g. 切开复位内固定术后1个月右髋关节正侧位X线片示内固定物位置良好，股骨头形态良好；h、i. 术后5个月右髋关节正侧位X线片示发生股骨头坏死（箭头）；j. 人工全髋关节置换术后3 d正位X线片
a. Anteroposterior X-ray film of the pelvis before operation; b, c. Coronal and sagittal CT before operation; d, e. Coronal and sagittal CT after closed reduction; f, g. Anteroposterior and lateral X-ray films of the right hip joint at 1 month after operation showed good position of internal fixator and good shape of femoral head; h, i. Anteroposterior and lateral X-ray films of the right hip joint at 5 months after operation showed that osteonecrosis of the femoral head (arrow) occurred; j. Anteroposterior X-ray film of the right hip joint at 3 days after total hip arthroplasty
图 3.
Case 4
病例4
a. 术前骨盆正位X线片；b、c. 术前冠状位、矢状位CT；d、e. 术后3 d左髋关节正侧位X线片；f、g. 术后24个月左髋关节正侧位X线片示内固定物位置良好，骨折愈合，未发生股骨头坏死
a. Anteroposterior X-ray film of the pelvis before operation; b, c. Coronal and sagittal CT before operation; d, e. Anteroposterior and lateral X-ray films of the left hip joint at 3 days after operation; f, g. Anteroposterior and lateral X-ray films of the left hip joint at 24 months after operation showed that the internal fixator position was good and the fracture healed, and no osteonecrosis of the femoral head occurred
3. 讨论
髋关节脱位伴股骨头骨折是创伤骨科的急症，应立即复位，大多通过手法复位可获得成功，少数闭合复位不成功，此时如强行闭合复位可能导致股骨颈骨折，使治疗复杂化，对患者造成进一步损害[10，12，15]。我们将这种髋关节脱位伴股骨头骨折定义为难复性股骨头骨折。Sy等[16]报道了4例髋关节脱位合并股骨头骨折患者，这些患者在闭合复位时均出现股骨颈骨折。我们对该类损伤认识不足，本组早期收治的3例患者（病例1～3）亦是如此，即使术前进行了CT平扫及三维重建检查，亦不能完全排除隐匿性骨折可能，采取手法闭合复位过程中造成了股骨颈骨折。由于PipkinⅢ型损伤的复杂性，与相对简单的Pipkin Ⅰ、Ⅱ型损伤相比，发展为股骨头坏死的概率极高[11，13，17]。本组病例1～3尽管及时采取内固定治疗，但仍全部发生股骨头坏死，需行人工全髋关节置换术。有研究提出，髋关节脱位同时合并股骨头及股骨颈骨折时，由于股骨头坏死的高发率，一期不应行切开复位内固定术，而应直接行人工全髋关节置换术[11]。鉴于此类骨折多为高能量外伤所致，患者多为青壮年，一旦出现股骨头坏死需行人工全髋关节置换术，将对其经济及身心造成巨大打击。因此，我们应提高对难复性Pipkin Ⅰ、Ⅱ型股骨头骨折临床特征及影像学表现的认识，尽早识别，避免股骨颈骨折的发生。
本研究中，4例难复性Pipkin Ⅰ、Ⅱ型股骨头骨折患者在术中均证实由于髋臼后壁保持完整，股骨头通过撕裂的关节囊、盂唇与髋臼之间的间隙脱出关节；撕裂的关节囊及盂唇在狭窄的股骨颈区域套住了脱位的股骨头，完整的髋臼后上缘骨壁嵌顿在股骨头骨折处的松质骨内。这种“纽孔”和“嵌顿”效应将脱位的股骨头牢牢固定于髋臼后缘，这一发现也解释了发生难复性Pipkin Ⅰ、Ⅱ型股骨头骨折时，患侧髋关节呈锁定状态、轻度屈曲且被动活动度差。也正是由于“纽孔”和“嵌顿”效应的存在，这种特殊类型骨折复位困难，反复尝试手法闭合复位可能导致股骨颈骨折。
我们建议针对此类难复性Pipkin Ⅰ、Ⅱ型股骨头骨折，不应尝试闭合复位，而应直接行手术切开复位。本研究中，我们根据以上经验，在病例4入院检查后即考虑其存在难复性风险，遂直接采用Ganz入路成功复位髋关节脱位并固定股骨头骨折，未造成股骨颈骨折。该例患者随访24个月未发现股骨头坏死迹象。这种入路为复位骨折脱位提供了良好视野，保证了股骨头骨折的解剖复位，并且可在股骨大转子处取部分松质骨植于股骨头缺损处，同期用锚钉修复撕裂的髋臼盂唇[18]。
综上述，尽管难复性Pipkin Ⅰ、Ⅱ型股骨头骨折发生率较低，但一旦转变为PipkinⅢ型损伤，危害极大。临床医生应提高对这种损伤独特临床特点及影像学表现的认识。对此类损伤我们建议不行闭合复位，以避免股骨颈骨折的发生，直接采取切开复位内固定治疗。本研究局限性在于为单中心研究且样本量小，随访时间较短；此外，本研究中“纽孔”和“嵌顿”效应缺乏典型的MRI图像支持，后续我们需进一步研究完善。
利益冲突 所有作者声明，在课题研究和文章撰写方面不存在利益冲突
伦理声明 研究方案经中国人民解放军北部战区总医院伦理委员会批准［研伦审第（2018）82号］；患者均签署知情同意书
作者贡献声明 王浩然、韩天宇参与研究设计与实施、起草文章；纪振钢、周志斌、宋夏楠参与研究设计、图片筛选与分析，对文章的知识性内容作批评性审阅
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