In situ replantation of partial bone fragments for depressed skull fractures in children

doi:10.3969/j.issn.2095-4344.2014.16.025

Abstract

Abstract:

BACKGROUND: For depressed skull fractures in children, retaining their skull and narrowing surgical incision meet the concept of minimally invasive surgery as important as ensuring the surgical safety and therapeutic effects, which is also the requirement of children’s parents.

OBJECTIVE: To explore the curative effects of in suit replantation of free bone fragments based on a small incision in children with depressed skull fractures.

METHODS: Fifteen patients with depressed skull fractures, aged 3-16 years, were selected and subject to CT examination and manual examination of the scalp at fractured site under general anesthesia for labeling fracture range. Then, one or two bone fragments corresponding to the fracture site and size were selected. A small incision with a length equal to the outer edge of bone fragments removed. Postoperative follow-up was employed for observation of clinical effects.

RESULTS AND CONCLUSION: An incision, 5-7 cm in length, were made, and one bone fragment was removed from six cases, and two bone fractures were removed from nine cases. Intraoperatively, there were six cases of epidural hematoma, three cases of subdural hematoma, six cases of brain contusion and bleeding. For fracture fixation, one skull lock was used in eight cases, two skull locks in six cases, and three bone plates in one cases. Postoperative CT showed 12 cases of good fracture reduction displayed basic symmetry with the contralateral skull; 3 cases showed partially depressed bone fragments that were less than 0.5 cm; 6 cases had a little skull defects with a diameter < 1.0 cm; 6 cases had mild epidural hematoma or effusion which was eliminated after conservative treatment. Eleven of 15 cases were followed for 2 month to 3 years, and showed no changes in skull shape on CT films compared with those at discharge and presented with good stability. In addition, there were one case of mild limb paralysis, one case of mild language barriers, and one case of mild seizures, but all these cased were well controlled by drugs. These findings indicate that in situ replantation of partially free bone fragments is suitable for depressed skull fractures in children.

中国组织工程研究杂志出版内容重点：生物材料；骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性；组织工程

全文链接：

Key words: biocompatible materials, skull fractures, child, perioperative period

CLC Number:

R318

Lai Jie-yu, Chen Zhong-zhi, Wang Ren-chun, Jia Cheng-wu, Chu Guang-xin, Jing Fang-kun. In situ replantation of partial bone fragments for depressed skull fractures in children[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(16): 2613-2618.

Figures/Tables 2

2.1 参与者数量分析按意向性分析处理，15例患儿均进入结果分析。 2.2 治疗效果切口长度5-7 cm，约为标记皮瓣开颅切口长度的1/3左右。取出1个骨片6例，取出2个骨片9例。术中探查：硬膜有活动性出血13例，硬脑膜破裂8例，裂口长2-20 mm不等，裂口下局部脑挫裂伤伴皮层动脉或静脉出血6例。清除硬膜外血肿6例，硬膜下血肿3例，扩大硬膜切口处理脑挫裂伤及出血6例；使用1个颅骨锁固定8例，2个颅骨锁6例；使用3个连骨板固定1例。术后CT：12例骨折复位良好，与对侧颅骨基本对称，3例部分骨片仍略有凹陷，但均小于0.5 cm；6例遗留少许颅骨缺损，直径< 1.0 cm；6例伴少量硬膜外血肿或积液，保守治疗后吸收。随访：术后11例随访2个月-3年，格拉斯哥昏迷评分GCS评分均达15分，CT检查骨折区颅骨形状与出院时无变化，稳定性良好。1例遗留肢体轻度偏瘫，1例遗留轻度语言障碍，1例出现轻度癫痫发作，药物控制良好，其余未留明显后遗症(表1)。 2.3 典型病例病例1：8岁男性患儿自高处坠跌致伤头部头痛、呕吐6 h入院，伤后有一过性意识不清。入院时神志恍惚，格拉斯哥昏迷评分GCS为9分。CT见右额颞区颅骨凹陷粉碎性骨折，最长径约7 cm，骨折凹陷深度约2.5 cm，颅骨碎片部分重叠，右侧裂区局部脑挫裂伤。患者父母要求尽量缩小手术切口，征得家属同意后急诊行小切口部分骨片原位回植修复。选取骨折区后部一较大骨片拟术中游离取出,全麻后作右侧额颞部皮瓣切口标记时，置小切口于该骨片后缘，长度约7 cm。牵开头皮切口后取下后上部小碎骨片，于其后部骨折线稍作咬除后骨片松动满意。在轻柔取出骨片时见硬膜下有静脉血及脑脊液涌出，立即予棉片压迫止血，撬拔复位其余骨折片以增加术野，引入显微镜，扩大硬膜裂口达到满意显露。探查见外侧裂静脉有一较小裂口，局部脑挫裂伤。试以微弱功率双极电凝止血成功，静脉保留通畅，局部脑挫裂伤灶予以清理、止血，凝胶海棉垫敷。用免缝合人工硬膜修补硬脑膜裂口，硬膜外置引流管，修整取出之骨片原位回植，颅骨锁一枚固定于正常骨缘。分层缝合皮肤，包扎时松紧适度，避免术区强力压迫。术后4 h复查CT见骨折复位及颅内处置均满意。出院时未留后遗症，格拉斯哥昏迷GCS评分15分，2周时CT见颅骨形态保持良好，随访半年患儿已正常上学(图2)。病例2：5岁女性患儿因砖墙倒塌致伤头部头痛2 d入院，伤后有一过性意识不清及呕吐等。入院时神志恍惚，格拉斯哥昏迷GCS评分9分。CT见左额颞区颅骨凹陷粉碎性骨折，最长径约8 cm，骨折凹陷深度约1.5 cm，颅骨碎片部分重叠。患者父母要求尽量缩小手术切口，征得家属同意后行小切口部分骨片原位回植修复。选取骨折区下方居中的一游离度较大、术野能兼顾全部骨折区的骨片拟作术中取出，左侧额颞部皮瓣切口标记时置小切口于该骨片后缘，长度约5 cm。牵开头皮切口，取下骨片，通过其骨缺损区插入骨撬撬拔复位其余骨折时，见前下方硬膜外有动脉性出血，出血部位露不清，为增加暴露及便于操作，咬除碎骨片间受力点后再取出一骨片，显露脑膜中动脉出血点并双极电凝及骨蜡止血。硬膜外置引流管，修整取出2个骨片原位回植，颅骨锁一枚将其固定于上部稳定度可靠的骨折片下缘。分层缝合皮肤，包扎时松紧适度，避免术区强力压迫。治疗后1周复查CT见部分骨折仍略有凹陷，但均小于0.5 cm，硬膜下少许积液。出院时硬膜下积液已吸收，语言略迟钝。电话随访1年，格拉斯哥昏迷GCS评分15分，语言正常(图3)。病例3：15岁女性患者因车祸致伤头面部头痛、恶心6 h入院，伤后有一过性意识不清。入院时神志恍惚，格拉斯哥昏迷GCS评分9分。CT见右额部颅骨凹陷粉碎性骨折，最长径约4.5 cm，骨折凹陷深度约0.5 cm，合并骨折区少量硬膜外血肿。先予保守治疗，患者头痛症状加重，复查CT见血肿增加达30 mL，于伤后4 d予手术治疗。选取骨折区后方发际内小弧形切口，长度约5 cm，取出下部一骨片，通过其骨缺损区清除硬膜外血肿，复位其余骨折。骨片原位回植，连骨板3枚将其固定于正常骨缘。分层缝合皮肤，包扎。术后复查CT见骨折复位及颅内处置均满意。出院时仍有头痛症状。治疗后8个月CT见颅骨形态保持良好，格拉斯哥昏迷GCS评分15分，随访1年已正常上学，未留后遗症(图4)。"

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