复杂情况|外科手术管理和创伤性生长板损伤的决策

2011年,6岁的男性持续创伤性lawnmower injury to his right leg. The initial injury was treated at another hospital in the patient’s home state, where it required numerous operations to clean the wound and remove injured tissue. The patient underwent a free flap and skin grafting in order to achieve coverage of the wound. He did have a bony injury to the femur, but it did not require operative fixation at the time.

六年后，即12岁，患者来到了下肢计划在波士欧宝彩票平台顿儿童医院，他开始建立右腿的敲门kne锁，导致了明显的li行。以前，他已经能够参加体育运动并保持活跃，但是现在li行在身体和心理上都影响了他，因为它变得更加明显。

术前评估

病人的妈妈伸出手Collin May, MD, MPH，下肢计划中的儿科骨科外科医生骨科创伤计划在波士顿儿童会员，询问儿子的潜在管理选择。梅博士确定，鉴于患者的增长潜力，他们可以利用这种潜力来改善腿部的一致性。

First, May had to determine where the deformity was coming from. With the patient presenting a knock-kneed alignment, the deformity might have originated from the femur or the tibia. There was also the potential that there were secondary deformities elsewhere.

May analyzed the joint angles preoperatively on both the femur and tibia proximally and distally to assess where the deformity was located. Due to the patient’s history of trauma to the distal femur — and based on imaging showing the tibia was normally aligned — May determined that the deformity was resulting from the distal femur. The patient appeared to have a functioning distal femoral growth plate, with serial x-rays showing the bone increasing in length, however, it was growing more slowly on the lateral (out) side.

一个直接的程序

因此，患者将接受半副治疗方法，其中将小板和螺钉放置在患者远端股骨远端（内部）上的生长板上。这使得生长板的横向部分继续生长，随着患者的生长而拉直肢体。

该过程本身相对简单。涉及一个小切口，两个螺钉和板。但是在这种情况下，许多复杂性在于外科医生和家庭的决策。决定何时去除板的何时很少是一个直接的过程，并围绕许多因素旋转。

决策的复杂性

假设患者的畸形纠正，可能会与家人讨论他们的选择。通常，一旦校正了肢体的比对（或稍微校正），就可以去除板，但是如果畸形出现，则可能必须更换。一旦肢体直接的另一种选择是通过附生术完全停止该生长板的生长，因此畸形不会复发。然后，随着另一只腿继续增长，这将导致腿长差。腿长差可以通过延长较短的侧面或对另一支腿的股骨远端物理进行骨phy骨来管理。最后，如果畸形未完全纠正剩余的生长量，则可能仍然需要进行截骨手术以完全重新对准肢体。

根据五月的说法，患者家庭没有一个统一的决定。决定与每个操作的风险有关，包括患者的当前高度以及他们预计到期时的高度。可能比平均水平短的患者可能不想通过顿悟或肢体缩短失去肢体长度，因此，尽管风险更大，并且涉及更多恢复，他们可能会选择肢体延长手术。相反，可能在成熟时更高的患者可能更适合通过顿悟剂量失去一定的高度。

The array of options in the decision-making process is generally the most complex aspect of this type of case, and involves lengthy discussion with the patient family regarding which option may give their child a chance at the best outcome.