chuyên đề xương

8/3/2019 chuyn xng

1/81

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi.

Gy u d i x ng cnh tay .

Gy u di xng cnh tay c nhiu dng, hay gp nh sau:

1. Gy li cu ngoi:

Thng thy tr em cha i hc, khi ng chng tay, lc y

theo xng quay thc ln li cu lm li cu ngoi ri ra. y

co ko lm li cu xoay 180, din gy quay ra ngoi, y

l loi gy phi m ph bin nht d tui mu gio.

2. Gy trn li cu :

y l loi gy ph bin tr em, ng gy ngoi khp ch x-

ng b yu, ton l gy dui do ng chng tay, thng iu

tr khng m.3. Gy lin li cu ch T, ch Y:

y l gy ni khp di lch nhiu ngi ln, thn xng gy

c u nhn thc xung di, lm ba ri 2 khi li cu v

rng rc ra xa nhau.

Gy trn li cu x ng cnh tay .

I. i cng : Dch t: L mt dng gy u di xng cnh tay, ph

bin nht tr em, ch yu t 5 15 tui, nam chim

70%.

a s gy dui sau ng chng tay. Bn gy thng l bn

tri.

Xng gy trn khp khuu~3cm, ng gy ngoi khp.

u di lun di lch ra sau. u trn chc ra trc ti npkhuu, c th chc vo ng mch cnh tay v thn

kinh gia.

Hanoi Medical University:LTL1

8/3/2019 chuyn xng

2/81


Xng gy thng t bin chng (bin chng do gy x-

ng) nhng i khi lm hng ng mch cnh tay v

c th gy hi chng Volkmann.

Thng iu tr bo tn, rt t m v d lin, tin lngc nng tt song hay gy 2 di chng (bin chng ca

iu tr): tri xng cn tr gp khuu v cng tay

vo vo trong xu.

II. Gii phu bnh v phn loi:

1. ng gy v di lch:

a) Ni gy

L 1 vng xng yu v mng do c h mm khuu vh mm vt. y l loi gy ngoi khp cho d trong

khp khuu c th trn dch, ln mu.

b) Gy dui:

ng gy cho t trc di ti sau trn. u trn nhn di

lch ra trc, hay chc thng phn mm pha trc, e

do b mch thn kinh. u di di lch ra sau. Cc c

gp v sp ko u gy di xoay v gp gc vo

trong.

c) Gy gp :

ng gy cho t sau di n trc trn. u di di lch

ra trc v xoay trong. u trn nhn di lch ra sau c

th m thng gn c tam u v lm thng da.

Thng khng lm tn thng mch mu, thn kinh.

2. Th ng tn mch mu, thn kinh :

a) Mch mu :

Mt s trng hp ng mch cnh tay b thng tn

song phn nhiu l b chn gp ch t khi b rch hay

t.


8/3/2019 chuyn xng

3/81


Nguy c chnh l thiu mu: Sng n cng di cn, x-

ng di lch chn p lm cn tr lu thng mch mu

nn t chc c tay b vng hoc trng bch, ri b

thoi ho v hoi t. Cui cng c cng tay b x homnh. Cc ngn tay b co rt. l co cng do thiu

mu nui (Hi chng Volkmann).

b) Thn kinh :

Thn kinh gia v tr (?) c th b lit nh trong

khong 5% tng s. Thng lit thn kinh c hi phc

hon ton.

3. Phn loi :

a) Theo c ch v di lch gp dui :

Gy dui: chim 95%. Do chn thng gin tip: bnh

nhn ng chng gan tay ra trc, khi khuu dui.

Gy gp (hay gp ngi ln hn): Do chn thng trc

tip, v d: bnh nhn ng ra sau, chng ln khuu

tay gp nhn.

b) Theo mc di lch cc u gy, trn Xquang:

Gy 1 : Ch gy 1 lp v xng, khng lch: him

Gy 2 : Gy c 2 v xng vi u di b y ra sau:

t gp

Gy 3 : u di lch ra sau, ln trn, vo trong (gy

dui). C th di lch hon ton nhng v xng cn tip

xc nhau: ph bin.

Gy 4 : Di lch nh 3 nhng 2 u gy ri xa

nhau.

III. Chn on :

Sau ng chng tay, bn tri hay b hn bn phi 2 4

ln.


8/3/2019 chuyn xng

4/81


Triu chng

Tay lnh ly tay au, khuu gp nh chng 30.

Nu nh nhng, gp hn vn c.

Vng trn khuu sm b sng to, xut hin phng nc do tr gy ri lon dinh dng, cc ngn tay sng, tm

lnh.

S vng khuu thy pha trc c u xng nhn thuc

u trn tri ra ti np khuu. Pha sau gn c tam

u mm bnh thng, khng cng nh trt khp

khuu. Cc mm xng (mm khuu, mm trn li cu,

v mm trn rng rc) vn cn i to tam gic cn.

Cn khm mch : c khi mch b chn, b rch vi mch

ngoi vi yu. i khi thy khoang trc cng tay cng

cng.

Khm thn kinh : Dy thn kinh gia v thn kinh

quay

Xquang: Phim thng cn ch u di lch vo trong

v vo nghing kt hp vi phim nghing chia 4

.

IV. iu tr:

1. Nn b bt:

a. Ch nh:

Hu ht ch cn nn b v thng gy lin ht. D

sng n t, cn nn cp cu, li mun l khng

ng.

K thut:

V cm : Tr nh cho nhn n ung 6h gy m. Tr

ln hn c th gy t m ri nch. Sau lp ai

ko ngc nch.


8/3/2019 chuyn xng

5/81


Th 1 : Ngi nn 2 ko c bn tay thng khuu

ng mch i km c gii thot.

Th 2 : a cng tay ra ngoi chng 20, kt hp nn

u di ra ngoi. Th 3 : va duy tr sc ko, va gp dn khuu, lc

ny ngi nn 2 chuyn ch ln u ( ko), ngi

nn chnh m cc ngn v u di xng cnh tay v

dng 2 ngn y u di ra trc. Nu y c th

nh nhng gp khuu khng cn tr xng.

Th 4 : Nn gp khuu 120 v xoay sp cng tay

gy c vng. Sau lt m trc np khuu vlm bt cnh cng bn tay rch dc.

Xong chp kim tra ngay. Nu khng t , gy m

thm v nn li ngay. Nu t th treo gc tay cao

cho sng n. bt tu tui, chng 5-6 tun. Sau

phc hi t nhin khng cn tp.

Nu vng khuu n nhiu th khng nn c cp cu

m treo gc tay 3-4 hm ri mi nn.

b. Theo di trong thi gian bt :

Khi ngn tay hi co, th ng dui au chi, phi

ngh ti hi chng Volkmann ni rng bt v gc

tay cao.

2. Ko qua mm khuu:

a) Ch nh :

Sng n to qu, khng th nn chnh c.

Nn c song khng vng, khi gp khuu 110

th chn mch mu.

C du hiu thiu mu nui Volkmann (u chi lnh,

ngn tay hi co, mch yu th ng,dui u ngn

au but).


8/3/2019 chuyn xng

6/81


Phi ko ln tri, cng tay nn sp, tp gp khuu

d v c trng lc, ko khng b cng tay vo

vo trong.

3. M t li:a) Ch nh:

Gy di lch din khp, nn khng t phi m.

Nn m sm, c nh vng v tp sm th tt, nu l-

ng l v th iu tr ni, nn khng t, thi gian

tt nht cho m s mt i, kh t li, thm ch b

co rt phn mm, vim c ct ho. Tr nhng trng

hp khng m sm c : b sy st da nhiu, b th-

ng tn phn mm, b vt thng h, b thm nhiu

thng tn khc, ton trng km.

b) C 2 cch m :

Nn kn di mn hunh quang tng sng, ghim 2 inh

Kirschner qua da, cho v song song qua gy. c

Muller lm t 1939.

M c nh bn trong, tr b c nh vi cc inh

cho, inh Kirchner hay Steinann nh, no p. Tr ln,

ngi ln c nh vi 2 np vt 2 bn ct xng.

V. Di chng :

1. Can lch :

Lch ngang tr em, kh nng t thch nghi vi di lch

ngang rt kh. D di lch nhiu song khng vo

nghing, kh nng t sa cha rt tt.

Lch nhiu, can cn non : nn m ph can t li, c

nh vi ghim inh Kirchner.

Lch nhiu, can chc : khng nn ph can t li

2. Chi xng


8/3/2019 chuyn xng

7/81


T u trn lm lm cho khng gp c khuu ht

tm. Gy sm th ph can t li. Gy mun th ch

gy lin vng th m sm gm b xng chi

tng gp khuu.3. Cng tay vo vo trong :

Di chng ny kh ph bin (~ 30%). Bnh thng theo

sinh l th cng tay v cnh tay l 0 hoc cng tay

vo ngoi trung bnh 11 v nhiu nht 26. Sau gy

nu cng tay vo trong th xu. So vi tay lnh chnh

10 th mc, nu chnh 30 th m c xng

sa li trc. Sau ghim inh Kirchner c nh hayb bt gi trc tt, khuu thng vi tr em; c

nh vng chc vi np vt, tp c ng sm vi tr

ln, ngi ln. Chng 10% s cas vo trong l l do ri

lon pht trin nhan xng li cu trong tiu, v vy

c xng sa trc vi ln cho ti khi trng thnh.

4. Co rt gn Volkmann :

c m t nm 1991. C gp ngn b thiu mu nui,

x ho, co rt.

Cn sm, b nh: np bt chnh dui dn.

Co qup nng: chuyn khoa m tc ri h thp

nguyn u c gp ngn, m ko di gn, m lm

ngn xng.

Gy lin li cu x ng cnh tay

I. i c ng :

L mt dng gy u di xng cnh tay, thng ngi

ln.


8/3/2019 chuyn xng

8/81


y l 1 loi gy kh, v tr gy l ni c h mm

khuu v h mm vt lm xng mng v yu, gy

ni khp, gn thn kinh quay v thn kinh tr.

Chn on lm sng kh v khp khuu sng n ln vsm.

Thng c ch nh iu tr phu thut.

II. Th ng tn gii phu bnh l:

1. Th hay gp l gy ch V, T:

Loi gy ch T: gy ngang trn li cu v gy dc tch

ri li cu v rng rc.

Loi gy ch V: hai ng gy cho nhau, u gy trnnhn thc xung lm ba rng li cu v rng rc.

2. Phn loi : Riseborough nu 4 kiu:

Gy khng di lch.

Gy li cu, rng rc khng xoay.

Li cu, rng rc ri xa nhau v xoay.

Gy vn nhiu mnh din khp.

III. Chn on : Chn on lm sng kh v khp khuu chng sng

n v c mu t ln. C th s thy cc li cu b ba.

Do , ring vng khuu khi sng n nhiu, ngi ta

trng ch vo Xquang chn on.

Nu mnh gy b hoc bnh nhn t tui qu, kh

chn on, c khi phi chp khp khuu 2 bn so

snh.IV. iu tr:

1. Nguyn tc:


8/3/2019 chuyn xng

9/81


i vi ngi tr, phi c nh li gii phu tp sm.

Vi ngi gi, cho tp sm quan trng hn l phc hi

gii phu.

D l cch iu tr g m bt ng lu u s bcng khp.

2. iu tr khng m:

a. Bt ng bt:

- Ch nh:

Gy khng di lch .

- K thut

Bt ng: ko p li cu v rng rc, t khuuvung, bt cnh cng bn tay rch dc, gc tay cao

cho sng. Khi sng, p thm 2 bn khuu, cho b

trn. Sau 2 3 tun, bt treo tay vo khn qung c

tp.

b. Ko lin tc :

- Ch nh :

C chng ch nh m: sng n nhiu qu, da b

ng dp nhiu, ton trng km.

Ch m.

Gy vn nhiu mnh.

Gy h bn.

- K thut:

Xuyn inh vo mm khuu, ko t thng ln tri kt

hp nn p cc mnh gy. Thi gian ko lin tc 6

tun. B t ko, tp c ng khp khuu.

c. K thut treo c tay vo c :

- Ch nh:


8/3/2019 chuyn xng

10/81


Cho ngi gi, cn ngoi tr sm, khng cn bnh nhn

cng tc nhiu.

- K thut:

Cho gp khuu, c tay buc treo vo c, cng gpkhuu cng tt. Khuu t do. Tp ngay bn ngn

tay, sau 7 ngy tp ung a vai. Sau gy 2 tun, tp

dui dn khuu, khi tp mnh gy t nn vo. Sau 6

tun xng lin, b khn treo c, tp thm 3 4 thng.

3. iu tr m :

M nn c nh bn trong, c 2 cch:

a. M nh:

Ct g li cu v rng rc, lp li quan h din khp.

Sau m b bt hay ko lin tc 6 tun. Cch ny t

lm.

b. M ln:

- Ch nh:

Bnh nhn tr, cht lng xng tt, mnh v to

kt hp xng

- K thut

Tch ri ch bm tn gn c tam u (mm khuu),

lt ln trn, bo v thn kinh tr, t li cc u gy,

c nh chc li cu vi rng rc bng 1 vt xng

xp nm ngang, i khi thm 1 inh Kirchner song

song nm ngang cho khi xoay. Hai bn ct xng, c

nh vi 2 np vt hnh ch A, c nh. Nh c nh

vng chc, sau m tp c sm.

Nu m khng vng, sau m xuyn inh mm

khuu ko t v tp sm.

c. M to hnh khp

khuu:


8/3/2019 chuyn xng

11/81


- Ch nh:

Cho gy h nng, gy vn nhiu mnh.

- K thut

M ly b cc li cu v ri nhau. Bt ng tmthi ri cho c ng khp sm. Nu nghi ngi lng khp,

nn ch nh m th 2.

Ghim inh ri b bt: Xuyn inh qua mm khuu

ko t, hai bn tay p 2 bn cho li cu v rng rc p

vo nhau. Xong ghim inh Kirchner qua da, cho

gy c nh, xuyn cho qua u trn. Xong vi 3

inh ny trong bt. Cch ny khng c ng c sm

khuu v c nguy c nhim khun theo chn inh.

d. Thay khp nhn to:

Thay th u di xng cnh tay vi Vitallium. C th

thay th ton b khp khuu cho vim khp nng sau

chn thng.

Bin chng nhiu, kt qu xa ang theo di, cha kt

lun c.

Sau m treo tay cao, cho c ng ngay, cho c ng

ch ng, khng nn lm c ng th ng.

V. Bin chng:

Thn kinh, mch mu

Khng lin xng: him gp

Hoi t v mch: Rt him.

Cng khuu, mt c ng khuu: y l bin chng

ch yu do:

Chn p c hc: u xng chi cn tr gp khuu, cc

li cu bin dng, din khp hng.


8/3/2019 chuyn xng

12/81


Cc h mm khuu, mm vt b y v can si, t

chc x lp y, gy li cu di lch.

X ho cnh khp sau chn thng, k thut np vt

km. Nhim khun.

Thao tc mnh khi ang lin xng, lm rch cc ch

dnh gy cng khp

Bt ng lu qu.

Gy li cu xng cnh tay.

VI. i c ng : Gy li cu chim khong 20% gy u di xng cnh

tay tr em cha i hc, do ng chng tay.

Mnh gy c c phn trn li cu l ngoi khp v m

ngoi rng rc l ni khp, c nhiu mnh nh.

Khi c bm trn li cu ngoi thng lm cho mnh

gy xoay 180, din gy quay ra ngoi.

iu tr thng phi m.VII. Chn on :

1. Lm sng :

2. Xquang :

Ch n im ct ho u di xng cnh tay:

Li cu: c nhn ct ho sm nht, vo 1 nm tui.

Mm trn rng rc, ct ho 4 6 tui.

Rng rc ct ho 9 10 tui. Mm trn li cu ct ho vo 12 tui, nhn xng nh

song mnh v c sn thng to.

VIII. iu tr :


8/3/2019 chuyn xng

13/81


Nn iu tr cng sm cng tt v khuu chng b s-

ng n. mun qu 48h thng kh iu tr.

Gy t di lch: np bt khuu vung, cng tay sp

2 3 tun, tp. Gy c di lch va: c th nn, p trc tip ln khuu

vng c xng gy y li cu vo v tr ca n.

Bt ng np bt hay ghim 1 kim Kirchner qua da.

Gy lch nhiu, mnh gy xoay 180, m t li c

nh vi vt xng xp c nh hay 2 inh Kirchner. Sau

10 14 ngy th tp. Bt ng lu d b cng khp,

Tr b chy nhy phc hi t nhin

Gy thn xng cng tay

I. i c ng :

Gy thn xng cng tay l gy vng mng lin ct di li c

nh u 2 cm v trn khp c tay 4 cm.

tr em rt hay gp: c 1 2 ca ngi ln th tr em l

10.

Hai xng cng tay c chc nng sp nga 180 l rt quan

trng cho cc ng tc chnh xc trong sinh hot v nhiu

ng tc ngh nghip. Quan trng nht l chc nng sp.

Khng iu tr tht tt th mt nhiu chc nng khc na,

v 2 xng cng tay c nhiu quan h khp: bn trn: quay

cnh tay, tr cnh tay; bn di: quay c tay; gia 2 xng:

quay tr trn, quay tr di.

II. c im gii phu:

Xng quay v xng tr v mng lin ct to nn mt khung

sp nga quay quanh trc l ng thng i qua chm quay

v mm trm tr.


8/3/2019 chuyn xng

14/81


1/4 trn xng quay c cong ra, gi l nga m

nh l li c nh u, l ni bm tn c nh u v c

nga ngn lm nga cng tay v gp khuu.

3/4 di xng quay c cong sp, gia l ch bm tnc sp trn, di c c sp vung, hai c ny lm sp cng

tay.

Mun sp nga tt cn:

- Mng lin ct rng.

- u di xng quay xung thp hn xng tr 6 10mm.

- cong sp tt.

- Ch gy khng xoay: di lch ny khng thy trn

Xquang.

V th khi iu tr kt hp xng cn ch cc yu cu

trn, ngoi ra do 2 xng cng tay c lin quan mt thit vi

nhau, trong qu trnh lin, xng ny c th lm nh hng

ti xng kia, v vy cn nn chnh tt c 2 xng.

V ni gy:

- Gy c 2 xng cng tay: 2/3 tng s.

- Gy ring xng quay: 1/4 tng s.

- Gy ring xng tr: rt t gp.

Ni gy 1/3 gia ph bin nht (55%), 1/3 di (40%) cn 1/3

trn him gp (5%).

V ng gy :

- Gy ngang, hi cho, c rng xng: 77%

- Gy mnh ri, thng l mnh nh: 20%

- Gy xon di, gy 2 hay nhiu ni: 3%.V di lch cc u gy:

- Gy cao 2/3 trn: c nh u v c nga ngn ko

u trn nga ra ngoi, c sp trn v c sp vung ko

u di sp vo trong gy di lch nhiu nn kt qu


8/3/2019 chuyn xng

15/81


chnh hnh km, thng phi m, cng gy cao cng phi

m nhiu. Cn ch ti di lch xoay v kh thy trn

Xquang nhng li gy nh hng nhiu ti c nng cng tay.

- Gy thp 1/3 di: u trn t di lch do c s i khngca 2 nhm c sp v nga.

y l loi gy xu, nhiu bin chng :chn p khoang v di

chng: khp gi, can lch, dnh quay tr, hn ch chc nng

gp khuu.

C nhiu cch m kt hp xng: km nht l ng inh

ni tu vi kim Kuntcher, Rush, thng cn thm bt chng

xoay. Np vt kiu c Lambotte, Lane c nhiu bin chng.

Ch c m vi np p kiu Danis v gn y np vis c 2

xng vi dng c AO/ASIF l c kt qu tt hn c.

Gy xng quay n thun kh nn chnh.

Gy xng tr n thun cng kh nn chnh, c bit c

th li khp gi khi gy thp v u tren b c nh bi

mm khuu v hm xich ma ln, u di th li di ng theo

xng quay.

III. Chn on :

1. Lm sng :

Thng chn on d khi gy 2 xng:

- Cng tay sng n bin dng r.

- t b bin chng thn kinh song khi cng tay pha trc

b cng cng, ngn tay gim c ng, au qu mc, phi

ngh ti hi chng khoang gii thot cn, khi b di

chng Volkmann do thiu mu nui.Gy cnh ti tr em v gy t di lch:

- Triu chng lm sng ngho nn: ti vng gy au chi,

sng n, c bm tm mun.

- Cn da vo Xquang chn on.


8/3/2019 chuyn xng

16/81


2. Xquang:

- Phi ly ht khp khuu v khp c tay trnh b st

thng tn nh trt khp quay tr trn, quay tr di. Phi

chp c phim thng v nghing.- Vi xng tr gy cao, cn trnh b st trt chm xng

quay km theo (gy trt Monteggia).

3. Vi gy ring xng quay thp, cn trnh b st trt mm

trm tr (gy trt Galeazzi).

IV. iu tr :

1. Nguyn tc :

Phc hi tt hnh th gii phu c xng quay v xng

tr.

Tp vn ng sm khp khuu, khp c tay.

2. iu tr khng m:

Gy cnh ti hoc gy t di lch:

- Nn ko nh nhng theo trc chi.

- Bt cnh cng bn tay rch dc, khuu gp 90,

bt 6 8 tun ( tr em) v 10 12 tun (ngi ln).

Gy 1/3 di cng tay t di lch:

- V cm: Tr em: gy t tnh mch; Ngi ln: gy t ti

ch, hoc gy t m ri thn kinh cnh tay.

- Cch nn:

+ Bnh nhn nm nga. Cnh tay dng ngang 90. Khuu

gp vung gc. Nn gy m. t bng vi ko ngc li,

t 1/3 di cnh tay, c nh vo mc tng, chn 1

ming vn rng gia 2 bng vi cho rng, khi p cnhtay.

+ Ngi ko dng 1 bn tay nm ngn ci bnh nhn, ko

theo hng trc cng tay, ko trn xng quay l chnh. Bn

tay kia nm cc ngn 2, 3, 4 ca bnh nhn ko thm


8/3/2019 chuyn xng

17/81


hi lch pha trc. Sc ko trn ngn ci ca bnh nhn

phi mnh hn. Ko lin tc v tng dn trong vng 10

pht cha gp gc v ht di lch gi chng ln nhau

cc u gy.+ Ngi nn bp vo khe lin ct v nn p 1 bn

cha di lch bn cc u gy. Xong t 2 np bt

mt trc v sau cng tay. Trn np bt t 2 que a

tre hay g, di 10 12 cm, to 1cm, tng ng vi mng

lin ct.

*Ch : Gy cao xng quay (tr em) cn cng tay

nga.

Gy thp xng quay cn cng tay sp.

+ Qun thm bt trn ra ngoi (cnh cng bn tay).

Rch dc mt bn. bt 10 12 tun, tp sm trong

thi gian bt.

3. iu tr m:

1) Ch nh:

- Gy cao 2/3 trn.

- Kt qu nn b khng t .Nu phim kim tra thy

nn c 1/3 2/3 thn xng th vn xem l t.

- Gy 2 ni trn 1 xng.

- C triu chng ca phn mm chn vo gia cc u

gy.

- Gy 1 xng quay di lch.

- Gy c bin chng: gy h, chn p khoang.

2) V cm: gy m ni kh qun.3) ng vo:

- i vi xng quay l ng ni chm quay vi mm trm

quay (ng Thomson) hoc ng Henry.

- i vi xng tr l ng mo tr.


8/3/2019 chuyn xng

18/81


4) Cc phng php m chnh:

- inh ni tu:

+ Ch nh:

*s dng tt cho gy xng tr do xng thng v 1/4 trnxng quay do c nhiu nhnh ca thn kinh quay vy

xung quanh.

* bnh nhn ngho cht xng.

*Dng np vt b hng, khng lin.

+ Chng ch nh:

*Tnh trng vim.

*ng tu hp.

*Sn u xng cha kn.

+ u im so vi np vt:

*Khng hay t bc tch mng xng.

*so m nh

*M kn khng ghp xng.

*Can vng, ly inh khng s m li.

+ Cc loi inh ni tu:

*ng inh ni tu vi inh trn nh inh Kirchner, Rush,

thng khng vng, cn b thm thm bt ngoi cho khi

xoay.

*ng inh ni tu vi inh c cnh Laffite, Kuntscher,

vng chc hn, xoay hn.

*ng inh kn c cht di mm hunh quang tng sng

ngy nay hay c dng.

- Np vt:+ Ch nh:

*S dng tt cho gy 3/4 di xng quay do xng khng

thng, ng tu rng, khng u.

*Gy h.


8/3/2019 chuyn xng

19/81


*Cc chng ch nh inh ni tu.

+ C 2 cch t np:

*t ln mng xng, khng tch mng xng ra khi xng.

*t di mng xng.i vi mnh ri to, hoc c nh vi 1 2 vt ngoi np,

hoc t mnh ri di np ri bt vt lun.

Mnh ri qu 1/3 thn xng nn ghp xng t thn ngay.

+ Cc loi np vt:

*Kt hp xng vi np vt kiu c Lambotte. Lane kt qu

xu, b khp gi n 30%.

*Kt hp xng vi np vt kiu Danis v gn y np vis

c p ca ASIF. y l phng php kt hp xng l tng.

Lin tt n 95%, tn trng cc on cong sinh l ca x-

ng gy, v bnh nhn c th tp phc hi chc nng

sm.

V. Gy h xng cng tay: T l gy h 2 xng cng tay

cao, ch sau gy h cng chn, v xng tr nm l ngay

di da.

1. Vi gy h I: Xng chc t trong ra, nn ct lc, khu

kn. Khi vt thng lnh vo ngy 10 21 th m c nh

bn trong.

2. Gy h nng, n mun:

- Gy h III n mun > 8h l nng.

- Tt nht l c nh ngoi. Phng tin c nh ngoi

c 2 u im:

+ C nh vi cc xa gy, gy khng c d vt.+ t v tr gii phu xng tt. Phn ln c b phn iu

chnh khi khe gy h ra th p kht gy.

- Ch nh chnh ca khung c nh ngoi l:

+ Gy h nng, thng tn da v phn mm rng.


8/3/2019 chuyn xng

20/81


+ Gy h thu khp, trt khp, mt phn mm rng.

+ Khp gi, nhim trng.

3. Chn cch m: Kt hp xng hay c nh ngoi:

- cng tay, c nh ngoi kh lm. i vi gy h nnghai xng, chn mt xng no gy nh nht, v d ch gy

ngang, kt hp xng ngay vi inh ni tu bng inh

Rush, inh 3 cnh Sage.cn xng kia, b nng, ch

phn mm lnh s x tr sau.

- Khi x tr cn ti nhiu ra gy. Ti vi nhiu lt

huyt thanh ra, ct lc k, rt quan trng, cho khng

sinh, nga un vn. Bt ng bt. Trng hp gip nt rng,

mt phn mm: ct lc, h, v da, chuyn vt, khi vt

thng lnh, m sau 2 7 ngy.

- nu din bin xu, nhim khun nng, m ly xng

cht, ti ht. Trng hp b nhim khun nhiu, x ho

phn mm, nht l b hng mch mu, thn kinh th xt

ct ct chi.

VI. Cc bin chng:

1. Hi chng khoang: cng tay khi c mt khi cng cng

mt trc, phi ngh ti hi chng khoang.

- Do dp n t c, tn thng mch muv c cc

khoang vng cng tay khu tr li, c bit l khoang trc.

- Triu chng:

+ au nhc vng cng tay kiu chut rt, bnh nhn ku

au su d di.

+ T, gim c ng u chi, cc ngn tay hi tm lnh.+ Cng tay sng to, n, cng cng c bit l khu trc.

+ S vo rt au, tay lnh, nht.

+ Mch ngoi vi ch mt trong 1/4 s trng hp (mch

chnh vn cn nhng cc mch nh vo cc c mt).


8/3/2019 chuyn xng

21/81


+ o p lc khoang > 50mmHg.

- Cn x tr rch cn cp cu gii chn p khoang,

sau 2 tun v da che li.

- Cn gp hi chng khoang sau m do cm mu km,do ng cn su. Trc khi ng vt thng cn tho garo

v cm mu k. Lp cn su cng tay dy, chc khng

khu. Ch khu lp di da v da.

2. t thn kinh quay :

- Thng gp khi gy 1/3 trn gn c xng quay v 1/3

gia.

- Bnh nhn c bn tay r c c.

3. Hi chng ng c tay:

- Thn kinh gia b chn p trong ng c tay, pha trc

l dy chng vng trc c tay, pha sau l can lch xng.

- Biu hin: T, gim vn ng vng thn kinh gia, teo

dn c m ci, t t ngn 2, 3.

- X tr : M rch dc dy chng vng trc cng tay, gii

thot thn kinh gia.

4. Hi chng Volkmann:

- Nguyn nhn :

+ Do hi chng khoang li.

+ Do tn thng mch nui dng.

+ Do bt cha t nhng cha ti mc hoi t, kh pht hin.

Cc l do trn dn ti : x ho c vng cng tay trc, c

bit l c gp chung nng.

- Biu hin :+ Thiu dinh dng khu cng tay trc.

+ Ri lon dinh dng, da kh, ra m hi tay, au nhiu khi

c ng.


8/3/2019 chuyn xng

22/81


+ Cng bn tay c hnh nh c bit : Cc ngn tay

dui kh, t 1 dui, t 2 3 co qup li, cng tay trc

dt, l r 2 xng.

- X tr:+ Bo tn np v cc bng cao su nn dui cc ngn.

+ Phu thut:

*Lm ngn xng: Ly b cc xng vng c hoc lm

ngn cc xng vng cng tay.

*Lm trng gn: Ngn tay c th dui c.

*Ko di gn: phc tp, kh.

5. Lon dng Sudek:

- C th pht hin c trong qu trnh b bt.

- Lm sng:

+ Giai on nng m: Ngn tay sng n, nng m, v m

hi, t ngn 3 co li th ng.

+ Giai on kh t: Bn tay kh t, lnh gi. lng

rng,xng mt vi, gi l xng thu tinh.

- iu tr:

+ Bt ng thm.

+ Thuc gim au Steroid.

+ Vitamin B.

+ Phong b gc chi.

+ Ct hch giao cm 2, 3 pha sau.

6. Can lch, khng lin:

- Nguyn nhn: do di lch nhiu, nn chnh khng tt,

nhim khun.- Lm sng: Gim sp nga cng tay, s thy can lch

ni g.

- Xquang: Thy r can lch.

- X tr: Cn kt hp xng sm v sa trc.


8/3/2019 chuyn xng

23/81


7. Khp gi:

- Do ko lin tc qu mnh, c nh khng thi gian,

k thut nn m km, do gy 1 xng n c, do bn

thn cu trc xng cng tay rt c, din tip xc lib.

- Biu hin:

+ Khng sp nga c.

+ C c ng bt thng.

+ Xquang: khng thy can xng.

- X tr: thng m kt hp xng v ghp xng t thn

t di mng xng kiu Phemister v nhi thm xng

xp t thn kiu Matti vo khe gy.

8. Nhim khun sau m: him gp, song nng.

- M rng vt m, ti ra, khng sinh.

- Bt ng bt.

- Nu gy c c nh bng kt hp xng th m

tht rng vt thng phn mm song khng c ly b ph-

ng tin c nh. Du c nhim khun, cho b bt, s ln

vn lin xng. Khi xng gy lin ri mi rt kim loi hay ly

b. Tnh trng nhim khun cn li th ti ht. Ti ht th

tt cho vim xng ng mu, y cng kh.

- Khi tnh trng vim nhim ht, vt thng kh c trn

6 thng, m phc hi ly xng cht, kim loi

VII. iu tr cc trng hp c bit :

1. Gy trt Monteggia :

- Nn ht trt chm quay s lm ht di lch chm tr.- Nn xng tr.

- Bt ng.

2. Gy thn xng cng tay tr em:


8/3/2019 chuyn xng

24/81


- Rt hay gp, c n 5 10 ln hn so vi ngi ln. Nh

c mng xng nn 80% trng hp l gy cnh ti, ln, gp

gc, ch khong 2% l c di lch.

- iu tr d dng song ch di chng Volkmann rtnng, l co rt gp cc ngn tay do thiu mu nui.

- Cc di lch gp gc thng c t sa cha nu l 15 -

20. Qu 10 tui cn t cha c 50% gp gc.

- Tr ln, b di lch nhiu, ch nh m l 1- 2% trng

hp.

Gy c xng i

I. i cng:

1. Gy c xng i l nhng gy nm gia chm v khi

mu chuyn xng i. L loi gy ni khp.

2. Xy ra mi la tui, nhng nhiu nht ngi gi sau

chn thng nh (ng trt chn p mu chuyn ln xung

t) v xng b long v c xem l gy bnh l. Thanh

nin v tr tui thng ch gp sau chn thng mnh.

3. C xng i c v tr ni khp v c nui dng ngho

nn. Sau gy mch mu hay b thng tn gy nguy c

khng lin, tiu c v chm.

4. Ch n gin vi ngi tr tui, tri li i vi ngi gi

y l mt loi gy rt nng, ngy cng ph bin do tui

th dn s ngy cng cao, ngi gi > 60 tui m kt hp x-

ng c t l lin xng < 5%, cho nn phi thay chm hoc

thay khp hng ton phn.II. Gii phu, sinh l.

1. Cu to u trn xng i:

1) Cu trc b xng:


8/3/2019 chuyn xng

25/81


- H hnh qut i t b di c to ln chm xng i

theo hnh qut, l h chu lc nn. Cn qut l ni c

cht xng m c.

- H hnh vm nm mu chuyn ln, l h chu lc va.Cc b pha ngoi ca vm i ln chm xng i, an

cho v vung gc vi cc b h qut tm chm.

- V vy u trn xng i c

+ 2 v tr vng: Tm chm v vng cn qut. y l cc

v tr t inh kim loi khi m kt hp xng.

+ im yu xng: v tr nm gia 2 h d b gy.

2. Cht xng: nu xng vng chc nh ngi tr tui th

t b gy. Tri li ngi gi xng b long, nhiu nht l

pha trong h vm nn d gy ch vi chn thng nh v

kt hp xng sau gy thng hng.

3. H mch nui dng c xng i rt km, cng st chm

cng km:

- T ng mch dy chng trn: cp mu t v c ti

liu cho rng trn 8 tui l tc.

- T ng mch thn xng i ln: Cng st chm cng

t nhnh.

- T cc ng mch m i ca ng mch i su: cp

mu nhiu nht, chy vng quanh c nn gy c hay gy

tn thng cc mch ny.

- Sau gy mu chy ra do thng tn mch ng li gy

tng p lc trong bao khp lm chn p mch mu cn li

dn n c xng i cng thiu dng.4. Bao khp bao bc gn ht c xng i: pha trc bao

khp bm vo ng lin mu chuyn song pha sau, na

ngoi c nm ngoi khp. Hot dch trong bao khp ph hu

qu trnh lin xng th pht nn xng rt kh lin.


8/3/2019 chuyn xng

26/81


5. Do tnh cht gii phu v sinh l nh trn nn sau gy c

xng i thy 2 hin tng cho d iu tr hon ho: hoi t

chm v tiu c.

6. Cc gc theo sinh l trc c v trc thn to gc130. Khi gy hu ht l gy khp, gc ny cn di 110 v di

lch nhiu. S t gy dng, gc ny ln hn 150 v ci

nhau , Ngoi ra so vi mt phng lng th chm vnh ra trc

l 10 - 20.Cn bit khi thay chm.

7. C c vai tr quan trng trong di lch:

1) Khi c mng: c xu hng ko u di ln trn, gy

ngn chi.2) Khi c khp y chu: c xu hng ko u xng

khp vo trong.

3) Khi c thp, c bt, c tht lng chu lm xoay chn

ra ngoi: du hiu bn chn .

III. Phn loi cc loi gy :

1. Da vo v tr gy:

1) Gy trong khp:

- Gy di chm.

- Gy c chnh danh hay gy xuyn c.

2) Gy ngoi khp:

- Gy c mu chuyn.

- Gy lin mu chuyn.

2. Theo hng ng gy: phn loi ca Pauwels, xt gc

to bi ng gy v ng ngang chn tri:

1) < 30: Pauwels 1: D lin xng.

2) 30 70: Pauwels 2: Gc cng ln cng kh lin x-

ng.

3) > 70: Pauwels 3: Rt kh lin.

3. Theo di lch da vo Xquang: theo Garden.


8/3/2019 chuyn xng

27/81


1) Garden 1: Gy 1 phn c: gy khng hon ton, gy gi

nhau. Cc b xng pha di c cn nguyn vn.

2) Garden 2: Gy hon ton khng di lch, cc b xng

chu lc nn b gy.3) Garden 3: Gy hon ton, di lch, nhng cn dnh vo

nhau.

4) Garden 4: Gy hon ton, di lch hon ton, chm quay

t do.

4. Theo hng di lch:

1) Gy khp chim 70%.

2) Gy dng chim 30%.

IV. Chn on:

1. Th gy khp (gy ri): 70% trng hp:

1) Thng gp cc b gi, c bit l c cc bnh long

xng do ng nghing.

2) C nhng du hiu khng c trng:

- au hng, mt c nng, m vo gt chn au

hng, khng th dui gi m nhc gt khi ging.

- Chi b gy ngn hn so vi bn lnh, mt c trong bn

au ln cao hn so vi bn lnh. o ng Nlaton Ros:

gp khc do mu chuyn b ko ln trn. Din tch tam

gic Bryand hp li.

- i b khp vo trong, u gi xoay ra ngoi.

- n vo vng khp hng bnh nhn rt au, c im

au chi pha ngoi tam gic Scarpa.

- G vo mu chuyn ln hoc g vo gt chn dn lnth bnh nhn rt au vng khp hng. Ngoi ra c th

c trn dch khp gi mun.

3) 2 du hiu c trng:

- Gy ni khp:


8/3/2019 chuyn xng

28/81


+ Hng khng sng n.

+ Bn chn xoay ra ngoi 60.

- Gy ngoi khp:

+ Hng bm tm, sng n.+ Bn chn st mt ging.

- Ngi gi cn lu pht hin v chn on nhiu bnh

ton thn km theo (tim mch, i ng)

- Ch : khng nn tm du hiu lo xo xng v s gy

au.

- Vi nhng trng hp gy khp in hnh th nhng

du hiu lm sng trn l chn on, khng

nhng th n cn gip cho ta bit c v tr gy c

thi x tr thch hp v tin lng.

2. Th gy dng (gy ci):

- Thng ngh n khi: ngi hay gp n gi mn

kinh long xng Sau 1 c ng p vng mu chuyn ln

xung t, bnh nhn:

- au nhiu vng khp hng: Gy c trng hp bnh

nhn ch hi au nh kiu ng dp phn mm.

- Bnh nhn vn c th i li c hoc nhc chn c.

- Khm trn lm sng khng thy g c bit ngoi

du hiu au vng hng v ch khi chp Xquang mi cho

ta chn on xc nh.

- Din bin: C 3 cch din bin:

+ Bnh nhn ng ch thy hi au, khng bit l xng

gy gi, tip tc i li c vi bc au chi hng do ch gyri ra, khuu xung, gy ci tr thnh gy khp vi y vi

cc triu chng.


8/3/2019 chuyn xng

29/81


+ Bnh nhn vn i li c, vn ng trong trong nhng

ngy tip theo sau trong 1 ng tc xon vn no ,

ch gy ri ra v tr thnh gy khp.

+ Bnh nhn vn i li vn ng sau 3 4 tun xng dndn t lin v sau 4 6 tun xng lin vng.

- Gy ci nu bit v chn on ng cch th tin lng

tt hn hn gy ri. V vy khi nghi gy ci c xng i

cn chp v c Xquang tht chnh xc v hng bnh

nhn phng nga ch gy ri ra thnh gy khp.

3. Cn lm sng :

- Xquang thng :

+ Chp 2 phim thng v nghing. Tt nht nn ly c

khung chu nhm pht hin nhng tn thng phi hp.

Khi chp phi ko nh chn v xoay trong bn chn 20

th c xng i mi hin ra. Nu chn xoay ngoi

th thy hnh nh c rt ( khng thy c xng i ).

- CT scaner lt ct 30 50 mm.

- Khi nh gi cn quan tm n cc vn sau :

+ Xc nh chc chn c gy xng hay khng v s di

lch ca n. Vi gy dng lu : thng t di lch, s lin tc

ca ng vin c bt, s lin tc ca ng vin quanh

chm, s lin tc ca cc b xng. Vi gy khp: ng gy

r, di lch hon ton. Trn phim nghin thy phn gy

pha chm di lch ra sau, phn gy pha thn xng di

lch ra trc.

+ c bit ch n cung c bt (l cung vng nht),phi c gng phc hi n trong thi gian iu tr.

+ dc ca ng gy phn loi theo Pauwels tin

lng v iu tr.

+ Ch n mc long xng.


8/3/2019 chuyn xng

30/81


- Vi ngi gi b gy c xng i ta nn chp phim

Xquang phi v in tm nhm nh gi tn thng

phi, tim mch ca bnh nhn gip cho tin lng v iu

tr.4. Tm li: chn on gy c xng i cn phi tr li c:

1) C gy hay khng.

2) Gy khp hay dng.

3) Phn loi

4) Tnh trng ton thn (nht l bnh nhn gi).

5. Chn on phn bit: trt khp hng: du hiu l xo, h-

ng gp, khp, cnh bn chn bnh gc c chn lnh.

V. Bin chng:

1. Vi gy dng:

2. Vi gy khp:

1) Gy ni khp: t l lin xng c m khng qu 30%.

2) Gy ngoi khp: T l lin xng tt hn (c th 95%).

VI. X tr :

1. Nguyn tc :

1) Cu sng bnh nhn l u tin s 1, sau l phc hi

c nng khp hng.

2) Phng v iu tr di chng.

3) iu tr bin chng.

2. iu tr khng m :

1) Bnh nhn l ln, suy tim mt b, i ng nng,

nhi mu c tim. lit hoc qu gi yu : c nguy c t

vong v cc bin chng do nm lu ( vim phi, vim tctnh mch, nhim khun tit niu, lot do t ):

- Qun gy, khng cn iu tr xng m ch cn cu

bnh nhn thot khi nhng bin chng gy t vong.

- Cho thuc gim au, khng sinh.


8/3/2019 chuyn xng

31/81


- cho ngi dy sm, xoa bp, vn dng i li bng nng.

- Tp h hp, tp ho khc m di, nng cao th trng

2) Gy gi nhau, khng di lch (Garden 1,2), th trng tt,

tr, c th mang bt tp i li: Nn trn bn chmh hnhv b bt Whitmann : b bt m ly thn v chi bn gy,

bt t nht 3 thng.

3) gy y c khng c iu kin m, gy gi nhau,

khng di lch (Garden 1, 2):

- Gy t, soi di mn hunh quang tng sng, xuyn 3 4

inh Kirchner theo nhiu hng trong phm vi c xng i,

c nh gy v nh bnh nhn vn ng

khng au, ngi dy v vn ng c sm.

- loi ny nguy c hoi t v khun l 18%, dng inh to,

d toc, d tt inh.

4) Gy 1 phn ngoi khp : xuyn inh qua li cu i ko

lin tc 2 4 tun, sau b bt cho tp sm (ngi tr).

3. iu tr phu thut:

1) Nhn chung i vi nhng trng hp gy khp th phu

thut vn l phng php a li hiu qu tt nht, bnh

nhn i li dc sm, phc hi tt. Nn m cng sm cng

tt, v m cng sm cng b hoi t v khun (m sau

1 tun hoi t v khun 100%, m trc 12h: 25%). M tin

hnh trn bn chnh hnh, nn trc ri mi m kt hp x-

ng. u im: kt hp xng tt, trnh bin chng, vn

ng sm. Nhc: tai bin gy m, nhim khun, chm

lin.2) M kt hp xng cho ngi tr:

- Gy ni khp: M t li, c nh bng 2 vt xp A.O,

sau m lm bt chng xoay c que ngang c bn chn,

lin xng tt sau 10 12 tun.


8/3/2019 chuyn xng

32/81


- Gy 1 phn ngoi khp: M vt A.O, bt, ko.

3) M kt hp xng cho ngi gi:

- Gy ni khp: thng c kt qu km. vit nam t l

lin xng l 2 5 %, trn th gii ~ 30% , hu ht mythng u xut hin bin chng do nm lu. Bin php

tt nht l thay chm kim loi theo mu Austin More nhng

chm ny t tin.

- M kt hp xng:

+ Dng inh Smith Peterson c chui l np vt A.O c th

kt hp xng vi bt chng xoay.

+ Dng vt xp: nu cn t long xng.

+ Tuy nhin nu xt iu kin, kh nng lin km, nh gy

st chm, long xng nhiu, ng gy Pauwels 3 th nn

ch ng thay chm th m u tin nu c iu

kin.

+ C th ghp xng t thn chng lin.

- M thay chm kim loi :

+ Loi chm: Ph bin l chm Austin More, cn chm c

m ca s xng cho xng lp y, c nh. Chm

Thompson t dng hn do phi ct c xng n nn c

v v c ng dc nn d chm su vo khi mu

chuyn.

+ Ch nh:

Hay dng cho ngi gi, cng c khi cho ngi tr do yu cu

lao ng cao.

Gy c xng i khng lin v tiu v khun (chim 50%ch nh).

Ngi gi > 70 tui, kh nng sng thm chng 5 nm. Nu

kh nng sng thm lu hn, nht l ngi lm vic nng

nn kt hp xng.


8/3/2019 chuyn xng

33/81


Khi ton trng bnh nhn km, trnh m li ln 2 ly

kim loi khi kt hp xng.

Gy trn bnh nhn c bnh l: Parkinson, lit cng 1/2

thn, long xng, thn kinh tm thn, paget..Bnh nhn cn vn ng sm, ra vin sm.

Gy di chm di lch.

Gy kiu Pauwels 3

Gy nn khng c, gy c > 3 tun.

M c nh bn trong hng

+ chng ch nh:

c nhim khun t trc.

Bnh nhn tr ang tui hot ng.

c bnh vim: vim khp, vim khp do thp.

+ u im:

Bnh nhn dy c sm, i t c ngay, bin chng

do bt ng lu.

Khng c cc bin chng hoi t v khun, khng lin x-

ng nh i vi kt hp xng.

+ nhc im: chc phn chm kim loi khng nh chm x-

ng. Dng lu chm lm mn khp li vo khung chu.

Ngi cn lao ng nng, au, hng

Ngi tr, trung nin b au khi i, phi m li.

+ Ch khi m:

Xt hm khp cn thn, nu c bnh l r cn thay th

ton b khp hng.

ng m: a s m theo ng vo pha sau, bo v cnthn vng hu mn

Mt s trng hp bnh nhn trc m b co cng gp v

khp hng th m vo hng qua ng m pha trc

b trt li.


8/3/2019 chuyn xng

34/81


C th dng ximng xng c nh tt k c khi b long x-

ng. Song dng xi mng khi hng, m li kh v nu b gy

ui chm th kh lin.

Cho aspirin, thuc chng ng trc m.M xong cho dng i, sau 2 ngy cho dt. Sau 2 tun cho

tp i vi nng nch.

+ Bin chng :

Sm : T vong 10%. Gy xng : 3 4 %(mu chyn ln,

thn xng i ngang v xa ui chm). Trt khp : gy

m, nn li, bt ng dng v dui i. Nhim khun sau

m ( 2%) : rch rng, bm ra khng sinh , mun : b

chm, t vong cao.

Mun : au. Lng. Chm li vo hng khp. C thoi ho

cnh khp.

- ng gy 1 phn ngoi khp :

+ m kt hp xng vi np vt A.O.

+ Xuyn inh qua li cu xng i 8 10 tun, sn sc

phng bin chng.

VII. Bin chng, di chng v cch x tr:

1. Bin chng:

1) Vim phi

2) Vim ng tit niu

3) Lot

4) Suy kit

2. Di chng :

1) Khp gi :- Sau 3 thng cha lin gi l lin chm. Sau 6 thng cha

lin gi l khp gi.

- Nguyn nhn :

+ Nui dng km nn 1 phn u gy tiu i.


8/3/2019 chuyn xng

35/81


+ Nn khng tt.

+ i li sm.

- Lm sng : au vng hng, i kh, bc ht, c du hiu

ngn ko.- Xquang : khng thy can xng, chm tiu i t nhiu.

2) Tho i khp :

- Do bt ng lu, thay i din t .

- Lc u au, hn ch vn ng khp hng sau

dnh khp.

- Xquang : hp khe khp, m u xng, chi xng.

3) Tiu chm :

- Do nui dng km, gy st chm Pauwels 3.

- Bnh nhn khng i li c

- Xquang : hnh nh tiu chm.

4) Can lch : Gp gc, gc chm nn h khp.

3. Thiu nin :

1) Ko nn, b bt Whitman ln ti v

2) Ko t lin tc

3) M kt hp xng vi 2 vt Virchoff.

4. Tr tui : Cng lm 3 cch trn v thng lin xng tt

5. 45 60 tui : Cng gn 60 tui cng xt thay chm.

Thay chm cho ngi tr lao ng nhiu thng hng ( do au

qu).

6. > 60 tui : Thng m thay chm.

Gy thn xng iI. i cng:

1. Danh t gy thn xng i ch nhng gy nm

v tr di mu chuyn ln 2 khot ngn tay v trn khi li

cu xng i 2 khot ngn tay.


8/3/2019 chuyn xng

36/81


2. Gp mi la tui: Tr s sinh do tai bin sn khoa. Mi

la tui tr em u gp. Gp nhiu nht ngi ln,

ngui gi gp do di cn ung th.

3. Mt nhiu mu: 1.5 2 lt, cng vi au d dn ti shockdo vy trong cp cu lu bt ng v hi sc chng shock.

4. Gy i l loi gy m nm trong 10% tng s gy xng

c m. Nn m sm nhng khng vi (do thng mt nhiu

mu nn cn thi gian hi sc v nng cao th trng)

5. tr em thng iu tr khng m. Nhng t 12 tui tr

nn bt u m rng ch nh m.

6. Tui gi cng cn m ngi dy sm, k c gy do

ung th.

7. Cch m trc y l: 1/3 gia inh ni tu hoc inh

cht ngang, 1/3 trn v gia inh cht ngang. Sau 1982 th

lm theo k thut sau: 50% s cas inh ni tu kn v 50%

ng kn inh cht ngang.

II. Gii phu bnh:

1. ng gy:

1) Gy ngang hi cho: loi ng gy rng ca kh nn

chnh nhng nu nn c th t c nguy c di lch th

pht trong bt.

2) Gy cho vt/ cho xon: d di lch th pht khi nn

gi trong trong bt.

3) Gy c cc mnh vn, gy 2 tng, gy c thm ng nt

thn xng th l loi gy khng vng, kh nn chnh

v gi bng bt.2. Phn loi theo Win quist:

1) Kiu 1: Gy ngang hay gy cho c t mnh ri.

2) Kiu 2: Gy ngang km mnh ri to < 50% b ngang.


8/3/2019 chuyn xng

37/81


3) Kiu 3: Gy ngang km mnh ri to 50 100% b

ngang.

4) Kiu 4: Gy nhiu mnh, 2 u gy chnh xa nhau.

III. Chn on:1. ngi ln xng i l 1 xng to chc kho li c c bao

bc xung quanh nn phi 1 lc kh mnh mi c th lm gy

xng i. Gy thn xng i thng gp trong cc trng hp

tai nn lao ng, giao thng. i khi ta cn gp gy thn x-

ng i bnh l do di cn ung th.

2. Mc ch chn on: Lu shock mt mu cn iu tr

thc th nhiu ngy, nhiu tun vn c.

3. Lm sng: thng d

1) C nng:

- Trong tai nn bnh nhn c th cm nhn thy ting

rc i, tip l au d di.

- Vn ng i v cng chn gim hon ton.

2) Ton thn: c biu hin shock chn thng mt mu:

mt nht nht, v m hi, mch nhanh, huyt p h (shock

do au v mt mu).

3) Thc th:

- i bin dng r: sng to nhanh, khp.

- Bn chn, cng chn xoay ngoi, b ngoi da trn

mt ging.

- Chi ngn, gp gc, c th cm nhn c ch g ln ca

u xng gy.

- u gi gp v xoay ngoi.- Cc triu chng bm tm vng thp v khp gi xut

hin mun.

- Trn dch khp gi: do c bao hot dch c t u i.


8/3/2019 chuyn xng

38/81


- Khng nn tm cc du hiu au chi, lo xo xng, c

ng bt thng v s rt au cho bnh nhn lm trm

trng thm shock.

4) Pht hin cc bin chng ca tn thng mch mu,thn kinh khi gy thp 1/3 di do ng mch i sau khi

qua vng c khp chy st xng ti khoeo. ng mch

rch d Chn on nhng rch ngm s gy tc mch t t

v mun th kh Chn on, ch c theo di cht mi

pht hin c: t b, lnh tm dn. Ngoi ra cn pht hin

thng tn:

- Mch chy sau, chy trc.

- Thn kinh hng khoeo trong: Mt cm gic gan chn.

5) Ngoi ra cn phi khm vng hng, cc du hiu gy x-

ng u trn xng i, trt khp hng, tn thng cc

dy chng khp gikm theo.

6) Tm tn thng phi hp ngc bng s.

4. i vi trng hp khng in hnh :

1) tr em: gy cnh ti:

- Lm sng: im au c nh.

- Gim c nng.

- Khng t c.

- Chn on xc nh nh Xquang

2) Tr s sinh:

- Sau ngi mng tr c ng tc c ng bt th-

ng, khng p chn c.

- Khng c shock.- i sng, nn hi chc.

5. Xquang: Sau khi c nh tm thi v chng shock :

1) Xquang xng i:

a. Loi phim:


8/3/2019 chuyn xng

39/81


- Thng nghing: phi ly c c u trn v u di x-

ng i v c th km gy c hay gy trn li cu xng

i.

- Chp tl bit kch thc ng tu. Ngy nay vi ph-ng tin khoan ng tu v cc loi inh a dng, yu cu

chp tl khong cn cn nh trc.

b. Kt qu: cn nh gi c: v tr gy, ng gy, cc

mnh ph, gy 2 hay 3 on, di lch, cc ng nt dc

thn xng trong gy bnh l, ng tu rng hay hp.

2) Xquang khung chu v khp gi: nhm pht hin cc

tn thng km theo.

3) Xquang tim phi thng: nh gi tnh trng ton thn,

h hp, tim mch chun b m. ngi gi cn lm thm

in tm .

IV. iu tr:

1. Nguyn tc:

1) S cu tt chng shock.

a. C nh tm thi:

- Mc ch: gim au, gim bin chng,d phng

shock.

- Phng php:

+ Np g 3 np: 1 np ngoi n ngang nch, 1 np t

chu hng n bn chn t di, 1 np m trong i

t bn n bn chn, sau buc cht li bng bng

cun.

+ Khi khng c phng tin g th c th ko nh nhngcho 2 chi di bng nhau ri buc chi gy vo chi lnh, di

chuyn bnh nhn bng vn cng.

b. m, n nh tinh thn cho bnh nhn.


8/3/2019 chuyn xng

40/81


c. Khm nhanh pht hin cc thng tn nng hn gy

thn xng i s no, ngc bng, cc biu hin tn th-

ng mch, thn kinh.

d. Tim thuc tr tim mch, h hp.e. Gim au: Morphin (cn loi tr c tn thng ngc

bng s).

f. Truyn dch, mu

2) C nh tt, thi gian, tp sm.

2. iu tr thc th:

1) iu tr bo tn: thng ch nh t 0 15 tui do c

mm, d nn, kh nng t iu chnh ln, m d gy

tn thng sn tip hp.

a. Gy sn khoa tr s sinh: ch cn c nh thng trc

bng ba carton cho thng trc 10 12 ngy c can

v ht au, tr li vn ng c bnh thng, ln ln khng

li du vt gy xng.

b. tr cn b: < 1 3 tui: b bt ch, b lun c i bn

lnh, 2 i hi gp v dng cho d chm sc v sinh.

c. Tr 3 6 tui: Dn bng dnh ko 2 chn ln tri, cho

h mng khi ging 1 2 cm.

d. Tr 6 -12 tui:

- Gy m, nn ko chnh tt, sau b bt chu lng

chn 4 12 tun tu tng tui (cng nh tui

thi gian bt ng cng ngn).

- i vi gy phc tp, gy d di lch th pht: xuyn inh

ko lin tc hoc dnh bng dnh ko lin tc trong 3tun, kim tra thy nn chnh t yu cu th

chuyn sang b bt.

e. Tr em > 12 tui: thng m:

- Gy ngang: nn m.


8/3/2019 chuyn xng

41/81


- Gy cho xon: c th nn bt. B bt tr em t gy

cng khp.

f. V k thut b bt :

- Gy cao1/3 trn, u trn dng v xoay ngoi: khi nnb cn u di chi t th dng, hi xoay ra ngoi.

- Gy thp 1/3 di, u di b co ko gp ra sau (c sinh

i).

- Gy gy thn xng i tr em khi chp kim tra kt

qu nn b nu trc xng tng i thng, cc u x-

ng gi nhau < 2cm xem l c, c th s b tr.

g. V b bt ngi ln: b 20 nm nay.

- Khi nn b bt cn gy m ton thn t gin c

hon ton, d nn chnh, bt chu lng chn.

- B bt d lm cng khp, teo c nhng li d lin xng.

h. Phng php xuyn inh ko t:

- Ch nh:

+ Tr em.

+ Ngi ln: chun b m.

- S dng inh Kirchner xuyn li c trc xng chy, nu

tn thng dy chng khp th ko di i nhm: mm

c, sng n... c li cho m. Ko trn rng rc.

- C nhng nhc im: nhim khun chn inh, nh h-

ng c rng trong, rng ngoi, sau lin xng cng gi

nhiu hn.

2) M kt hp xng: Bao gm inh ni tu kn, inh ni

tu h, inh c cht ngang v np vt.a. Ch nh:

- Ngi ln.

- a s gy tr em > 12 tui.

b. inh ni tu h:


8/3/2019 chuyn xng

42/81


- Ch nh:

+ Gy xng i 1/3 gia.

+ Gy ngi gi dy trnh nm lu d dn n bin

chng do nm lu. ng tu rng th nhi thm xi mng x-ng.

+ Gy bnh l do di cn ung th xng: ung th v, phi, tin

lit tuyn, tuyn gip.

- Chng ch nh:

+ Gy 1/3 trn v di.

+ Gy nhiu mnh kiu 3, 4.

+ Gy h 3 n mun. (dng c nh ngoi).

+ Da v phn mm quanh gy b thng tn.

+ iu kin gy m km.

+ C bin dng i cong ra trc.

- Hay dng inh Kuntcher.

- u :

+ Phng tin m r tin, khng cn trang thit b m

ring, my tng sng.

+ Nn xng v gii phu d hn ng kn.

+ Nhn trc tip cc u xng thy r ch nt xng, v

mnh khng di lch m Xquang khng thy.

+ Lp ng xng din gy, b xoay, vng hn.

+ gy 2 tng c on gia c th c nh khng cho

xon vn lc khoan ng tu.

+ Trng hp gy khng lin, ly b c t chc xng,

ghp c xng.- Nhc:

+ li so da.

+ Mt mu.


8/3/2019 chuyn xng

43/81


+ Ly b mt mu t v cc t chc khc gy cn cho

lin xng.

+ Nhim khun.

+ Gim t l lin xng.c. inh ni tu kn: ng inh ni tu di mn tng sng vi

inh thng.

- Ch nh:

- Chng ch nh.

- S dng inh to 12 13mm.

- u:

+ Gi c s ti mu nui nguyn vn ca mng xng.

+ T l nhim khun thp.

+ t gy so c t u i.

+ Gi c cc vn xng quanh gy nn kch thch lin

xng.

- Nhc: cn c iu kin v phu thut vin v trang

thit b.

d. inh c cht ngang: ng kn vi inh cht ngang.

- u im ln nht ca inh cht ngang l i vi gy

nhiu mnh tng gia. Ch nh cho c gy thp

hn, ch ni thn xng v hnh xng, k c gy lin li

cu. Nh inh to chu lc t n 300% so vi xng nn

t c sm.

- Nhc : i hi c y phng tin, k thut vin.

e. Np vt.

- Ch nh: Gy 1/3 trn v 1/3 di.- u im:

+ C nh nh sc p din gy.

+ Tp phc hi chc nng sm d gy gn khp v khp gi

thng mm.


8/3/2019 chuyn xng

44/81


+ Nm vin ngn, dy sm bin chng.

- Nhc:

+ Nguy c nhim khun.

+ C nh khng vng, qu 6 thng cn au, kim trakhng lin (5 10%).

+ C nh qu vng chc nn can yu phi np qu

18 thng mi c c ly b.

+ Gy np ti cc cc l vt do t qu sm.

- Phng php:

+ Mi u xng c t nht 4 vt.

+ Ch khuyt xng nn ly xng xp mo chu ghp

ngay.

+ Ht ng dn lu to.

+ Khng sinh trc m.

3) Sau m cn hng dn tp phc hi chc nng tht tt

cho bnh nhn. Nu t nng sm: Cong, gy inh, gy

np.

V. Cc th lm sng:

1. Gy h xng i:

1) M kt hp xng ngay:

- Ch nh:

+ Gy h 1, 2.

+ M trc 8h.

+ C phng tin v phu thut vin tt.

- Ch :

+ Nu quanh gy c dp nt nhiu rt d nhimkhun.Cc thng tn su c th h nh nhng rt km,

khng nn kt hp xng: do vt n, sng n, ni bn

qu.

+ Khi m ra vt thng k trc khi ct lc.


8/3/2019 chuyn xng

45/81


+ ng rch do m th ng, ch c vt thng h nn

h.

2) C nh ngoi:

- Nhc:+ Khng to c sc p u gy: kh lin.

+ Nhim khun chn inh.

+ Gim c ng gi.

- Tuy vy y l phng php tt nht i vi gy h

nng n mun.

- K thut:

+ Vt thng c h.

+ t cc u xng vo ng v tr.

+ gy khng c d vt.

- C nhiu mu, mu tt c th to c sc p u gy,

mu khng to c sc p u gy cn ly b cho t

to iu kin chng lin xng.

3) Ko lin tc:

- Sau ct lc, rch rng c xuyn inh ko t.

- gy c theo di, chm sc, sng n gim, v tr xng

vo kh. Sau 7 10 ngy c th ng kn da. Sau xt

m nu cn.

4) Ct lc rch rng h: Sau ct lc rng vt thng

v gy c xi ra vi lng nc ln p lc cao sau

h bt ng bt. Theo kin ca mt hi chnh hnh ln:

- Mi gy h u h.

- Sau 7 ngy nu cn th kt hp xng, song li dah.

- Sau 14 ngy ng kn vt thng.


8/3/2019 chuyn xng

46/81


h vt thng lu trong bnh vin, vt thng cn c

bo v tht k. Nu khng c th ng vt thng sau 7

ngy.

2. Tn thng thn kinh, mch mu:1) Thn kinh: t gp.

2) Mch mu: thng tn ng mch i < 2%.

- X tr:

+ Trng hp cn kt hp xng: Nu n sm th kt hp

xng trc sau x tr mch mu, nu n mun th x

tr mch mu trc ri kt hp xng sau.

+ Trng hp gy khng cn kt hp xng: khu mch

mu trc v ko lin tc mo chy.

3. Gy thn xng i km theo gy c xng i cng bn:

- 2 5%.

- Chn on mun do chp phim ht, st.

- X tr :

+ M gy c xng i trc vi 2 3 vt xp 6,5 mm hoc

vt trt p gy DHS.

+ Thn xng i m sau vi np vt.

4. Gy thn xng i km theo gy lin li cu xng i:

- M vo khp kim tra din khp.

- Cc vt xp bt lch tm ch cho inh ni tu.

- inh ni tu ng di n cch sn khp 1 cm.

- Nu gy thnh nhiu mnh, ng gy ng ngang: m

vi np vt.

5. Gy bnh l sau lc nh: ngi gi long xng hoc ngic di cn ung th.

- Cn sinh thit khi m.

- ng inh ni tu, ng tu rng thm xi mng xng.

6. Gy do n:


8/3/2019 chuyn xng

47/81


- Tc thp: iu tr nh gy kn, khng cn ct lc.

- Tc cao: ct lc, rch rng nh i vi gy h 3.

Sau c nh ngoi hay ko lin tc.

VI. Bin chng, di chng:1. Nhim khun sau m :

a. Nhim khun sau m kt hp xng vi np vt nguy

him hn sau m ng inh Kuntcher do vi khun theo

inh lan rng v h tu u gy di khng thot dch.

b. Trng hp inh to chc: inh yn, m rng vt th-

ng ly ht xng cht cho khng sinh.

c. inh hng, inh c nh: Rt inh h rng vt thng

d. Nu xng cht to qu, ly inh h c nh ngoi.

2. Chm lin, khng lin :

- Sau 6 thng cha lin l chm lin.

- Hay thy gy thp thn xng i ng tu rng

inh ni tu khng chc.

- Xquang hoc CT:

+ Can ph i u xng b ra kiu chn voi.

+ c 1 khe sng un ln gia cc u xng.

+ Hnh nh xng b x so cc u gy.

- X tr: Nu inh ni tu khng c nh khng vng,

thay inh to hn, ghp xng t thn, b bt thm. Nu

np b hng, gy, m li thay np v ghp xng t thn.

3. Can lch :

- Thng gp sau iu tr chnh hnh vi ko v b bt.

- Lch gp gc ra trc c b tr tt nht nh hng v gi,tt hn l vo sang bn v ra sau.

- Lch gi nhau vi ngn chi 1-1.5 cm c chc nng tt b

p bng giy.


8/3/2019 chuyn xng

48/81


- Di lch xoay pht hin vi khm lm sng, phim

Xquang kh xc nh. B xoay nhiu cn m sa li.

- Lm sng: Chn i tht chn di chn ngn. Vim

au khp gi.- iu tr: c xng, kt hp xng (t xng di

Xquang)

4. Gy li:

- Xy ra 3 4 tun u khi can cn non, bnh nhn b

ng cong dp inh

- Do cng khp gi,ng tc tp qu th bo.

- Thng sau gy qu 4 thng kh gy li.

- Cn lu sau m kt hp xng i vi np vt, s bt

ng qu tt ca np vt to nn mt s lin xng k

u, trn phim Xquang khng thy can xng, do vy

gy c lin song yu v chu lc c hc, khng c ly b

sm np. Sau m np vt phi qu 18 thng mi c ly

b, gy lin can hi to si, v d sau ng inh ni tu,

do gy c bt ng khng hon ton, to si li vng v

c hc hn.

- Nu gy b khuyt v xng cng nn ghp xng t

thn vo ch khuyt.

- Gy li hay thy khi dng inh nh dng inh nh 8

9mm. Khi mi gy cn un thng li v rt ra ngay, khng

ch lin xng, s khng rt c na. Nn dng inh to 12

14 mch mu kh b cong gy.

5. Cng gi: L mt di chng nng. Do:- iu tr:

+ Xuyn inh li cu gy vim khp.

+ Tp gi chm qu.


8/3/2019 chuyn xng

49/81


+ Khi tp khng di ng xng bnh ch, khng tp co c

t u i.

+ Do ng rch trc trong, trc ngoi lm dnh c t u

i vo can xng, vo da.- Loi gy:

+ Gy nhiu mnh, can xng to si dnh vo c t u.

+ Gy thp u gy chc vo c gy thng tn ti cng

hot dch ca c t u.

- Ngoi ra cn cng do dnh trong v quanh khp.

6. Tc mch do m: m vo mao mch gy nhi mu phi.

Gy thn xng cng chn

I. i cng :

1. Gy 2 xng cng chn l nhng ng gy t di khe khp

gi 5cm ti trn khe khp c chn 5cm.

2. Gy xng cng chn hay gp v hay b gy h.

3. Gy cao 2 xng cng chn d b hi chng khoang, cn

x tr cp cu. Cn gy thp hay b ri lon dinh dng, kh

iu tr.

4. Gy thn xng cng chn s ln c iu tr khng

m song do yu cu nn chnh cao nn bnh nhn tr th-

ng m nhiu.

5. Gy nu lch nhiu thng phi m.

6. D di lch th pht khi ht sng n, nht l vi gy cho

xon.

7. Sau khi b bt hay b ri lon dinh dng, gy thp thiumu nui hay b chm lin, khp gi.

8. M vi inh ni tu c cht ngang, np vt c p kt

qu kh.

II. Nguyn nhn v gii phu bnh:


8/3/2019 chuyn xng

50/81


1. Nguyn nhn trc tip:

1) Lc tc ng trc tip vo xng (cy , gch ,

b nh vo chn). Lc tc ng vo u th gy ti

.2) Thng gy xng chy v xng mc ngang nhau. ng

gy ngang, di lch nhiu nn thng nn kh nhng nu

nn c th t di lch th pht, phn nhiu ch cn

iu tr ngoi tr.

3) Hay b gy vn nhiu mnh hn c ch gin tip.

4) Hay gp gy h. y l loi gy h t ngoi vo, rch

rng v bn, tn thng thng nng hn.

2. Gy gin tip :

1) Nhng chn thng gin tip do b b gp, b xon

vn chn nh b sa chn xung h.

2) Thng gy im yu ca xng chy (ch ni 1/3 gia

v 1/3 di) v xng mc gy cao v tr c xng mc. V

vy cn chp Xquang k cng trnh b st, v tn thng

xng mc pha cao d lm tn thng thn kinh hng

khoeo ngoi.

3) ng gy cho xon theo hng i ca ng gy xng

chy, nn vo th d nhng rt hay di lch th pht trong

bt, thng cn nm vin ko t chng 3 tun.

4) t gy vn n t hn c ch trc tip.

5) t khi gy h hn c ch trc tip, nu c th l h t

trong ra, nn gn sch, tin lng tt hn

III. Chn on :1. Mc ch: Chn on c gy 2 xng cng chn thng

khng kh, song ch yu l phi pht hin c cc bin

chng.

2. Trng hp in hnh gy hon ton c di lch:


8/3/2019 chuyn xng

51/81


1) n sm, ngay sau khi tai nn:

- C nng: au chi nhiu vng gy. Mt vn ng hon

ton.

- Ton thn: Gy 2 xng cng chn mt khong 500 mlmu nn thng t khi shock do gim tun hon nhng c

th b shock do s cu bt ng khng tt gy dau.

- Thc th:

+ Cng chn sng n, bm tm.

+ Bin dng gp gc m ra ngoi v ra sau.

+ Bn chn xoay ra ngoi.

+ Ngn chi.

+ u xng gy ni g di da c nguy c chc thng da.

+ S nh dc b trc xng chy thy mt s lin tc xng,

ch gy au chi.

+ Khng nn tm cc triu chng: c ng bt thng, lo

xo xng v d lm cho tnh trng nng thm.

2) n mun sau vi gi.

- Lon dng:

+ Cng chn sng n to, mt bng, bm tm rng nn

khng r bin dng in hnh.

+ Nt phng nhanh chng lot chy nc . X tr: gc chn

cao trn khung Braun vi ngy, nn sau.

3. Trng hp khng in hnh:

- l nhng trng hp gy khng c di lch hoc di lch

rt t (gy cnh ti tr em, rn xng, chn xng) cn

ch khi:- Bnh nhn au, khng t chn tip t c.

- Vut dc b trc xng chy tm im au chi c

nh.

- Chn on da ch yu vo Xquang.


8/3/2019 chuyn xng

52/81


4. Bin chng:

1) Gy h:

- C 3 :

+ 1: Gy h rch da < 1cm. tn thng phn mm ht.+ 2: Gy h rch da 1 10cm, tn thng phn mm

nhiu hn.

+ 3: Gy h nng rch da > 10cm, c 3 mc :

3A: Thng tn phn mm nng, xng l nhng da vn

che kn xng khi phu thut.

3B: Thng tn phn mm nng, phi chuyn vt da,

c mi che ph.

3C: Nh 3B nhng c thm thng tn mch mu, thn

kinh.

2) Hi chng khoang:

- i vi cc gy 1/3 trn cng chn do c tn thng cc

mch mu, phn mm nhiu cng chn, mu dch chy

ra b cc vch gian c gi li gy chn p nh 1 garo bn

trong, p lc tng ln gy cn tr nui dng ngn chi. V

tr gy bt k cng c th gy hi chng khoang nhng t

l t hn.

- Lm sng:

+ Rt au cng chn, cm gic t di, kin b t cng

chn tr xung, c co rt cng cn au t b tng dn.

+ Cng chn cng to, da trng nht do tun hon mao

mch b cn tr, s vo au, bp chn cng cng.

+ Thm ch c th mt c ng u chi do thn kinhb chn p, khng co c gan bn chn.

+ Bt mch mu chn v mch chy sau rt yu hoc

mt.

+ Bm tm sm, da lnh.


8/3/2019 chuyn xng

53/81


- o p lc khoang:

< 30 mmHg: cn mc bnh thng, ph n.

30 50 mmHg: mc cnh gic, nn rch cn.

>50 mmHg: c hi chng khoang: rch cn cp cu (rcht khoeo n c chn ca khoang).

- Siu m Doppler chn on chc chn.

3) Tn thng mch mu: nhng trng hp c bp chn

cng, phi lu cc trng hp tn thng mch mu, c th

t ri ng mch.

4) Tn thng thn kinh hng khoeo ngoi:

- Thng gp trong gy gin tip, gy cao xng mc, gy

lit c mc bn di v ngn.

5) Tn thng khp: Trn mu trn dch khp gi, c

chn.

6) Thm khm ton din tm tn thng phi hp:

- Ngc bng s.

- Gy mt c trong v gy thp xng mc (Dupuytren).

- Trt khp c chn v gy cho 1/3 trn xng mc

5. Cn lm sng: Xquang:

1) Gip cho chn on xc nh nhng trng hp gy

khng in hnh.

2) Ch gy trc tip thng khng b st tn thng cn

gy gin tip, ng gy cho xon v th lu cc tn th-

ng xng mc cao. Nn yu cu chp Xquang c xng

mc trnh b st. Cc du hiu Xquang s khc nhau gia

gy trc tip v gin tip.6. Trn lm sng nhiu khi cn pht hin cc bin chng

ca gy xng cng chn:Ri lon dinh dng sm :

+ Lc u thng cc nt phng chn.

+ Sau au nhc vng cng chn.


8/3/2019 chuyn xng

54/81


+ Da tm, lnh, sng ho, ri lon bi tit m hi, cm gic

lc nng, lc lnh, c teo.

+ i li nhiu th ph n, ngh th ht.

+ Mun hn: Gim c ng, khp b hn ch, long xng.1) Bin chng mun:

- Volkmann cng chn: Ri lon dinh dng nng, km

theo x ho v co rt cc c khu sau lm cng gn dui

- Di chng: Can lch, khp gi.

IV. iu tr:

1. Nguyn tc:

1) S cu: Bt ng tt, trnh gy h th pht v shock.

2) Nu c gy h, cn bng bo v gy cho tt, trnh bi

nhim.

3) iu tr sm, ng ch nh, khi sng n t,cha lon d-

ng.

4) Phc hi gii phu xng chy l chnh.

5) Chng ri lon dinh dng.

2. iu tr gy kn 2 xng cng chn:

1) Gy khng hoc t di lch: i vi ngi ln b bt i

cng bn chn rch dc, gi gp 10, bt 6 8 tun.

i vi tr em, gy cnh ti th ko l ch yu, nn l ph,

bt 3 4 tun.

2) Gy c di lch:

a. iu tr bo tn: Vic bo tn hnh th gii phu ca

cng chn km hn, b bt lu c nguy c hng khp

gi, lon dng.- Gy ngang vng do gy trc tip.

+ Ko nn tt trn khung Bohler. Ch n gy t trong

ra, gi cho xng chy c cong ch O sinh l, n gy

t di ln, gi cho gy khng sa thp hnh ch V.


8/3/2019 chuyn xng

55/81


+ Sau khi ko nn c th bt i cng bn chn rch

dc, gc chn cao 3 ngy. i vi gy cao c th b bt gp

gi 30 cho chng c sinh i.

+ Vi nhng trng hp gy xa khp gi th sau khong 6tun th b bt i bt m gi kiu chn gi cho

ngi, tp vn ng khp gi. Sau 10 12 tun th b bt.

+ Sau khi b bt tnh trng ri lon dinh dng nng ln (?)

v th cho bnh nhn ngm nc m, bng chun t trn

xung di khong 7 ngy. Kt hp vt l tr liu v tp vn

ng.

- Vi gy cho xon:

+ Xuyn kim qua xng gt ko t v nn lin tc trn

khung Bohler trong khong 3 tun.

+ Sau bt i cng bn chn trn khng rch dc

khong 6 tun. Sau chuyn bt m gi tp khp

gi, tp sm khi cn mang bt.

+ Sau 12 tun b bt.

+ Chng ri lon dinh dng nh trn.

+ Vi tr em khng xuyn inh ko t m ko thng cng

chn ln tri.

b. iu tr phu thut:

- u:

+ Phc hi tt v gii phu, t phc hi tt chc nng.

+ Kt hp xng tt gip cho gii phng c 2 khp ln

cn, nn vn ng c sm, trnh teo c, cng khp lon d-

ng.- Hn ch:

+ Nguy c nhim khun cao, sm nht l vim xng.


8/3/2019 chuyn xng

56/81


+ Chm lin xng: do ph vo gy, mt cc mu cc v

t bo to ct, d vt l (dng c khi kt hp xng) do dinh

dng cng chn km.

+ Tai bin ca gy m cng c th c.+ Tn km.

+ Ph thuc vo iu kin trang thit b, phu thut

vin, khng phi u cng m c.

- Ch nh:

+ iu tr bo tn tht bi.

+ Gy kn 2 tng c on gia di.

+ Gy cho xon nn kng vo.

- Phng php:

+ inh Kuntcher ni tu phi hp vi bt chng xoay tt

nht l inh cht ngang chng xoay, nht l gy vn 1/3

gia.

+ Np vt A.O.

+ C nh ngoi vi: Nht l i vi gy h, nhim khun.

3. iu tr bin chng:

1) Gy h:

- Theo phn loi Gustilo, khi b gy h, nguy c nhim

khun rt ln, iu tr lu v tn km, cn can lch,

chm lin d iu tr hn nn ct lc, h l an ton

nht mc d c th bi nhim nhng cn tt hn kn.

- Kt hp xng: Ch nh:

+ Gy h 1,2.

+ n trc 8h.+ C y ngi v phng tin.

- C nh ngoi bng cc khung c nh: hay dng

khung Fessa, Hoffman.

+ u: Xng thng trc, gy khng c d vt.


8/3/2019 chuyn xng

57/81


+ Nhc: Khng c lc p nn chm lin xng.

- Xuyn inh xng gt ko lin tc trn khung sau b

bt vi inh trong bt (p dng cho gy nhiu mnh khng

vng).- Gy h 1: C th st khun quanh vt thng, nn

b nh i vi gy kn.

- Gy h 2, 3:

+ Ct lc vt thng.

+ Nu sng n nhiu so vi bn chi lnh tng ng: Rch

rng, hon ton phn mm.

+ Bt ng.

+ Sau 7 ngy kt hp xng, tip tc h.

2) Hi chng khoang:

- M cp cu khi p lc khoang > 30 mmHg.

- Rch rng cn ly mu t.

- Kim tra tm thng tn mch mu x tr.

- Khng khu c, khng b bt trn, da h.

- Sau 1 tun c th ng che da li, v da.

3) Ri lon dinh dng (hi chng Sudek) (?).

- Phng:

+ Tp sm trnh ng tc th ng.

+ Khi b bt: ngm nc m, bng chun, tp vt l tr liu.

- iu tr: vt l tr liu, phong b novocaine, ct hch

giao cm.

4) Khp gi:

- Sau 4 thng cha lin.- Nguyn nhn:

+ Thngng do gy thp 1/3 di, nui km.

+ Mt on xng.

+ Phn mm chn vo gy.


8/3/2019 chuyn xng

58/81


+ C nh khng tt.

- Biu hin:

+ Khng i li c.

+ Bc ht.+ C ng bt thng.

+ Xquang: khng lin xng.

- X tr: m ghp xng:

+ Phng php Matti: nhi t chc xng xp vo khe h.

+ Phng php Phemister: Ghp xng vo gy di mng

xng.

+ Phng php Judet: bc v xng.

- Khp gi nhim khun: nng, trc ht phi lo lin xng,

sau .

5) Can lch: lch > 5 cc gc .

- gy lin thnh can chc nhng lch trc.

- Nguyn nhn:

+ Thng do gy phc tp, b khng tt, di lch th pht.

+ Can lch gc m ra ngoi v vo trong.

- Nu khng x tr th h kp c chn, gi, hng.

- Dng ri th t im gia cung i. Nu qu ri ri

vo bn chn: cn thch nghi c, ri ra ngoi, vo trong:

h khp ln cn.

- Can lch gp gc m ra sau, trc: h khp chy sn.

- gy cha lin: sa bt nn thm.

- X tr:

+ Tr em: t iu chnh c nu gp gc < 10, ngn chi 2cm, gp gc > 30 th m li ph

can, t li on xng gy, kt hp xng nu cn.

6) Trc xng xu:


8/3/2019 chuyn xng

59/81


- t li v tr gi phu.

- C nh bn ngoi.

- Sau: ghp xng xp sau ngoi.

7) Mt on xng:- Lm dnh chy mc.

- Chuyn xng mc.

- Chuyn xng mc c mch nui, vi phu.

8) Lon dng Sudeck:

Hay gp bnh nhn: bt lu qu, khng chu t tp

i, gy nhiu, dp nt phn mm rng, dn n ri lon

thn kinh giao cm. Sng n, au, nhiu nt phng, da

i mu tm, dy. Xquang: mt vi rng cng chn.

9) Mt da : rch theo qun c, nh li bng hi p.

Nu khng: chuyn vt da.

V. Gy ring xng chy

1. Gy u trn xng chy: hi chng bp chn cng +

tn thng khp gi.

2. Gy thn xng chy.

3. Gy u di xng chy.

1) Gy 1/3 di: ri lon dinh dng.

2) Bong sn u di xng chy km gy xng chy, mc

cao.

3) Gy 2 mt c, gy Dupuytren.

4. Gy ngang khng di lch: bt 8 10 tun.

5. Gy di lch: nn kh, khng t: chuyn m

6. Theo di lin xng: 3 thng khng lin: c gy, ctngn xng mc ri b bt.

VI. Gy ring xng mc:

1. Bng chun p nh cho au, cho i.

2. i au: bt rch dc.


8/3/2019 chuyn xng

60/81


VII. Cc phng php c nng cho gy 2 xng cng chn:

1. u: sm gii phang khp gi.

2. Nhc: gy km vng, di lch.

3. Cc phng php:1) Bt m gi: 3 tun u nn b ln i 1/3 trn, sau 3

tun lm bt m gi Sarmiento tp gp gi.

2) Bt Delbet: Gii phng khp gi v c chn.

3) Ko, b np g mm gii phng 2 khp gi cc cong

sinh l.

VIII. Chn on, nguyn tc iu tr gy xng h:

1. Chn on:

1) Chn on xc nh:

2) Chn on gy theo Gustilo:

3) Chn on a chn thng phi hp.

2. iu tr:

1) Mc ch:

- Lin vt thng phn mm tt.

- Lin xng sm

2) Nguyn tc:

- S cu ng.

- M cng sm cng tt < 6h.

- Ct lc, rch rng, c nh vng.

3) S cu:

- St khun vt thng t trong ra ngoi.

- p gc v khun.

- Bng p gy.- Bt ng xng gy bng cc np thng quy, khng

nn li xng gy.

4) Phng v chng shock:

- Truyn dch, truyn mu.


8/3/2019 chuyn xng

61/81


- Khng sinh ton thn.

- S.A.T

- Gim au Morphin.

5) iu tr:- Ct lc vt thng phn mm.

- Ra vt thng bng Betadine.

- X tr xng:

+ dnh xng cng nhiu cng tt.

+ Tt c nhng xng d nh, d ln cn dnh vo mng x-

ng, c phi li xng ti ch.

+ Ly b nhng xng nh ri. Nhng xng ln ri ra : lm

sch t li trnh mt on xng nng v sau.

6) iu tr v theo di sau m:

- Khng sinh liu cao ton thn.

- K cao chi.

- Bi ph tun hon, in gii

IX. Gy mm chy :

1. Mm chy hayb ln xp do li cu ngoi i p xung

khi gi b lc tc ng t ngoi vo v chn cong ch X.

2. Hay gp cc thng tn phi hp sau :

1) V ln mm chy ngoi.

2) Rch sn chm ngoi.

3) Rch dy chng bn trong gi.

3. Mm chy c khi b v c 2 bn sau ng cao.

4. Khi mm chy gy di lch th thng ch nh m.

Lch bao nhiu th m th cha thng nht (c th l 3mm,nhng a s l chn lch 5mm, nht l 10mm. Cch m

l t li mm chy v kt hp xng vi np vt ch T.

5. V nhiu mnh c 2 mm chy: khng th m kt hp x-

ng m iu tr khng m bng ko nn b.


8/3/2019 chuyn xng

62/81


X. Hi chng chn p khoang:

Khi lc va mnh vo 1/3 trn cng chn, hay gp hi chng

chn p khoang. Khoang khng gin n nm di cn ni c

ca c dp. Khi sng n th chn p mch mu dn ti hoi tchi, cn cp cu rch cn gii thot khoang.

Hi chng chn p khoang nh sau:

1. C chn thng nng lm gy xng 1/3 trn cng chn.

2. Bp chn sng n v cng cng.

3. ngoi vi mch yu v mt dn.

4. u chi tm lnh.

5. Th ng dui ngn rt au. Bp vo khoang au chi.

6. o p lc khoang bng ct thu ngn.

- Bnh thng: 7 8 mmHg.

- Hi chng chn p khoang:

+ Nn rch cn khi p lc o c > 30mmHg

+ >50mmHg: cn rch cn cp cu v d hoi t chi.

7. Mt s t trng hp c km tn thng ng mch, tnh

mch vng khoeo, cn phi khu ni. Nu tht th hoi t

90 100%.

8. C nhiu ni rch cn nhng thng rch dc sau trong x-

ng chy t khoeo ti trn c chn, rch ti cn su (cn

ni c).

XI. Gy thn xng cng chn :

1. Gy thn xng cng chn rt hay gp. Xng ny cn

iu tr khng m.

2. Nhng nu l bnh nhn tr tui, yu cu nn chnh rtcao cho khi hng khp c chn v khp gi, nn m nu:

1) c 1 gp gc > 5 (1 trong 4 gp gc: ra trc, ra sau, vo

trong, ra ngoi).

2) Di lch xoay > 10, nht l b xoay trong.


8/3/2019 chuyn xng

63/81


3) Ngn chi 10 12mm.

3. Ngi trn 60 tui thng khng m v iu tr c nng

sm cho mm gi. Cch nn b:

1) Gy m ton thn (nhn n 6h) v nn b trn bnchnh hnh hoc khung Bohler hnh ch nht.

2) Ch n gy t bn trong ra cho xng chy ch C,

trnh ch X. y gy t di ln trnh gy sa xung.

3) B bt i cng bn chn rch dc. Sau 7 ngy qun

trn. Sau 6 tun b bt m gi tp mm khp gi v

bt tt c 3 thng.

4) Nn b 1 th thng lm cho gy ngang do gy trc tip

cn gy cho xon do gy gin tip (sa chn xung h)

Gy xng h

I. i cng:

1. Gy xng h l gy xng c rch da v phn mm lm

gy thng vi mi trng bn ngoi. Nu gy xng kn km

theo mt vt thng phn mm cng mt on chi th coi

nh mt gy xng h.

2. Nguy c chnh khi b gy xng h l nhim khun. Nu

i vi gy xng kn, tnh trng xng l quan trng th khi

b gy xng h, tnh trng xng tr nn t quan trng. Quan

trng nht l thng tn da v phn mm quanh xng gy.

Khi c s lng ln phn mm mt sc sng, tnh trng vim

nhim tr nn nng, d gy vim xng.

3. Gy xng h nng m b vim xng th iu tr kh,lu di v rt tn km, c khi cn nguy him cho tnh mng

bnh nhn.


8/3/2019 chuyn xng

64/81


4. Nu thng tn phn mm t, c th xem nh gy xng

kn, tri li, b qu nng, thng tn mch mu thn kinh,

d phi ct ct chi.

II. Lch s:1. Hipocrate: h vt thng.

2. Galen: vim m l vn quan trng nht trong qu

trnh phc hi.

3. Desault (th k 18): Rch rng v su ly t chc cht

v dn lu.

4. Larey (hc tr Desault): ct lc cng sm cng tt.

5. Mathysen nu vic b bt iu tr.

III. Gii phu bnh v sinh l bnh:

1. Gii phu bnh:

1) Da: C th vt thng rch da nh nh gy h I, song

pha di t chc di da dp nt nhiu. C th bong lc da

din rng, lt da, hoi t do mt mch nui c nguy c

nhim khun ln.

2) Cn, c: ng dp, t c, thm ch mt rng cn

c, l xng. Tn thng c bao gi cng nng hn da,

nn c th b st gy xng h nng do Chn on l

I.

3) Mch, thn kinh: dp nt, t mt phn hay ton b.

4) Xng: Gy xng h do c ch chn thng trc tip th

xng gy phc tp, nu do c ch gin tip th gy n

gin.

2. Sinh l bnh:1) Nhim khun vt thng: Mi vt thng gy xng h

u c s hin din ca vi khun, song c gy tnh

trng nhim khun hay khng cn ph thuc vo mc


8/3/2019 chuyn xng

65/81


nhim bn ca vt thng, th trng bnh nhn, loi vi

khun v c bit l thi gian can thip sm hay mun.

2) Din bin nhim khun ca vt thng trong gy xng

h: giai on cha nhim khun < 6h, giai on tim tng6 12h gy nn phn ng vim, giai on nhim khun >

12h. T nhim khun ti ch vt thng, c th lan rng

gy nhim khun huyt, c bit nguy him l nhim

khun ym kh.

3) Lin vt thng, lin xng trong gy xng h:

- Lin vt thng rt quan trng v n s che ph, bo v

xng tt, loi tr c nhim khun. Mt khc lin vt th-

ng sm cn to iu kin x l xng cho giai on sau

nu cn. Mt vt thng lin tt khi khng cn d vt,

khng cn chn p v thiu mu nui dng. V vy nguyn

tc iu tr gy xng h l: ct lc, rch rng, h.

- Lin xng tt khi vt thng khng nhim khun, bt

ng vng v khng mt on xng do chn thng hay

phu thut vin ly b.

4) Shock chn thng do mt mu, au, c t ca t

chc dp nt. Gy xng h cng nng, xng ln cng d

b shock. Bt ng chi tt l phng php phng shock

hiu qu.

IV. Phn loi:

1. Da vo c ch chn thng:

- C ch trc tip: gy h t ngoi vo, vt thng bn

v gy phc tp.- C ch gin tip: gy h t trong ra, vt thng sch v

gy gn.

2. Da vo thi gian: Theo Friedrich:

- Gy xng h n sm: < 8h.


8/3/2019 chuyn xng

66/81


- Gy xng h n mun: > 8h. Gy xng h nhim

khun, ti ch y m thi.

3. Da vo thng tn phn mm: theo Gustilo.

1) I:- Vt thng rch da di 1cm, thng do u xng nhn

chc t trong ra ngoi, vt thng do nng lng thp, thng

tn c t.

- Phi hi k ch khng phi gy xng h I l nh v

c vt thng rch da di 1cm song nng, khng th xem

thng nh b nhim bn nng, b gy do nng lng ln, bn

trong b gip nt nhiu.

2) II: vt thng rch da 1 10cm, thng tn bn trong

mc trung bnh, do nng lng ln.

3) III: vt thng rch da trn 10cm, c gip nt nhiu,

nhiu phn t chc b mt sc sng. Cn xem l gy x-

ng h III khi gy xng do vt n c tc cao, gy c

nhiu mnh di lch, gy mt on thn xng, gy ng

rung, bn nhiu, b nghin nt do xe c.

- IIIa: Thng tn rng song xng cn c phn mm

che ph.

- IIIb: Xng l, phi chuyn vt da che ph xng.

- IIIc: km theo thng tn mch mu, thn kinh ln.

V. Nguyn nhn v c ch:

1. Gy xng h do xe c: hay gp xe c va phi ngi i b,

xng chy d b gy h nht, c khi va vo pha sau bp

chn, c ng dp nhiu, thm ch b t ngang u gychc ra pha trc lm rch da, thnh gy h. Loi va vo pha

sau nng v phn mm b dp nt rng.

2. Gy xng h do ho kh:


8/3/2019 chuyn xng

67/81


1) ng nng K = 1/2mv 2 nn khi lng vin n t quan

trng hn tc ca n. Khi vin n hay mnh kim kh

i qua c th, iu khc hn nhau l i qua cht hi

hay i qua cht lng.2) i qua cht hi, v d n xuyn qua phi gp khng

kh c sc cn thp hn, ng nng gii thot t, ph hu

t chc t, ch b hng t chc trn ng n i nn th-

ng tn thng nh, l vo v l ra xp x nhau. Ch

nng khi trn ng i vin n phm phi ph qun hay

mch mu ln.

3) i qua cht lng nh c c nhiu nc, thm ch qua xng

th nc khng nn li c nh khng kh, sc cn rt ln, tc

vin n b cn li t ngt, ng nng gii thot ra

ln theo cng thc: K = 1/2 m(v1 v2) 2 (v1, v2 l tc

trc v sau i qua c th ca vin n.

4) V vy t chc xng b ph hu nhiu do hin tng l

hng tm thi. hin tng ny quan st r trn thc nghim.

Vi tc cao (v d > 8000m/s) vin n vo c th to

ra trong thi gian rt ngn (mt phn nh ca giy) mt

l hng rt ln trong chi th. L hng c c im

chnh nh sau:

- kch thc rt ln, v nh qu bng r, khi mnh n

xuyn qua i chng hn (do vy l ra thng to).

- P lc m tnh (ht bi bn vo lng vt thng).

- kch thch to nh dao ng trong my nhp ri nh

dn.5) Trong phm vi l hng, xng b v nt, mch mu thn

kinh b t ri. Nm gn cnh l hng, thn kinh vn c

th b lit, c b gip na sng na cht. Khi m ch

thy mt ng ph hu b\nh song thng tn rng.


8/3/2019 chuyn xng

68/81


6) Do vy thy r phi rch rng h vt thng.

VI. Lm sng:

1. Khm cc du hiu sinh tn do cc thng tn a chn

thng (chn thng ngc, chn thng s no, chn thngbng), v tnh trng shock. Nu cn cho bnh nhn chp

tim phi thng, siu m bng, C T s no ...

2. Chn on xc nh:

- Gy h nng, mt phn mm ln, u xng gy thi ra

ngoi.

- Gy xng m c nc tu xng chy qua vt thng phn

mm.

- Sau khi ct lc vt thng thy gy thng vi vt th-

ng.

- Gy h n mun: chy m qua vt thng, c th l

u xng vim.

- Xquang thng nghing xc nh mc thng

tn xng, s di lch v d kin c nh xng.

- o giao ng mch khi trn lm sng nghi ng thng

tn mch.

3. Chn on gy xng h theo Gustilo: ch cn cn

c thm vo c ch v hon cnh chn thng khng b

st cc ng dp c nng bn trong d thng tn da ch

I.

4. bnh nhn b va nng vo u, lu hay c thng

tn ct sng c, nht l gy cc t sng c cao, trnh b

st khi bnh nhn hn m.5. Khm cc thng tn xng khc km theo: gy h xng

i hay km theo: trt khp hng, gy c xng i, xng

bnh ch, thng tn cc dy chng khp gi


8/3/2019 chuyn xng

69/81


6. Khm mch mu: nu nghi ng thng tn mch mu, yu

cu thm d Doppler, chp ng mch

VII. X tr

1. Nguyn tc:- Cp cu ban u tt.

- X tr gy xng: ct lc, rch rng, c nh xng

vng v h.

2. Cp cu ban u:

1) Bng s cu: st trng, bng p vt thng cm

mu, gim bt bi nhim ti gy h. Trnh m bng nhiu

ln ti phng khm.

2) Bt ng vng gy trn cc loi np trn v di gy

mt khp. Khng c ko u xng tt vo trnh a

vi khun vo su bn trong.

3) Hi sc: Cn hi sc ngay khi huyt p < 100mmHg,

mch > 100l/ph v gy h III. Dng dch, mu tu theo

mch, huyt p v hng cu bnh nhn.

3) Dng thuc:

- Phng un vn SAT.

- Khng sinh ton thn.

- Gim au: morphin 0,01g, felden 20mg. Nu cha loi

tr cc thng tn bng, ngc, s no th khng c dng.

4) Ch :

- Hn ch ti a vic garo cho bnh nhn.

- Ra vt thng: Nu khng c iu kin gy m th

khng c ra vt thng v c th gy shock cho bnhnhn. Nu c iu kin gy m th ra vt thng ngay

vi x phng betadine, nhiu nc.

3. X tr gy xng h:

1) Chun b m:


8/3/2019 chuyn xng

70/81


- V cm ni kh qun.

- Ra vt thng bng nhiu nc vi x phng betadine,

ly ht d vt nng.

- Co lng xung quanh vt thng.2) X tr phn mm:

a. Th bn:Danh t dbridement c dng ban u

m t vic rch tho m cho mt vt thng b nhim

khun. y l:

- Ct mp vt thng khong 2 5mm.

- Ly b t chc hoi t mt sc sng trong vt thng,

ly b d vt, nht l cc d vt hu c ngn nga vi

khun ym kh

- Lm sch u xng bn

- Ra vt thng bng nc mui sinh l, oxy gi, betadine

v nhiu nc.

b. Th sch: thay ton b dng c:

- Ch c cc vt thng nh, nng, vt thng rch da

n thun th c th ht b hnh qu trm ri khu li.

Cn li, cn rch rng, rch dc, m rng vt thng.

- Rch rng vt thng theo trc chi, hnh Z. u chi gy

cng sng n cng phi rch rng, cn rng hn da. ng

rch da thng bng ng knh on chi, t chc di da

bn th ct lc thm, song khng bc tch nhiu, gip

cho da c sng. Cn dy th rch thm ng ch thp.

Chun b garo.

- Ct lc t chc dp nt pha trong su ti ch c lnh.C do cha nhiu nc nn b thng tn sng p (shock

wave), v d do n c tc bay cao, c nng lng ln.

M rng vt thng c theo th c vi u ngn tay. Cn

nh gi c trc khi ct:


8/3/2019 chuyn xng

71/81


+ V mu sc: trnh nhn nhm mt lp mng mu en

dnh trn b mt c, c khi ly b lp ny, c vn

bnh thng, mu c t c gi tr nht chn on.

+ V chc: c cng chc cng sng.+ V co c: nu cc th c chm phi, ct phi c

rung git, co c l cn sng. co c c gi tr song

khng phi mi c khng co l c cht.

+ Nh m rng vt thng theo th c, vt thng c

ming rng. Brav nu phng chm nu nghi ng cht

c, ly n i, nht l khi c hng mch mu ln. Nn kim

tra li vt thng sau 1 2 ngy (second look) nht l i

vi vt thng dp nt ln. Khi ct lc thm nu cn.

- X tr mch, thn kinh:

+ Mu r t in, mu phun nh nn buc hay khu

buc. Garo gc chi khi cn.

+ B t ng mch, tnh mch nn phc hi lu thng c

hai, i khi ch c ng mch. Khi cn phc hi mch

mu ln trong gy h IIIc, theo phng php c, cn kt hp

xng bn trong trc. Hin nay k thut khu phc hi

mch mu rt tt, ming ni chu c sc ko n 18kg,

cho nn c th khu phc hi mch mu trc, cn chi gy

t np, b bt hay ko lin tc u c.

+ Sau khu mch mu nn rch rng cc cn gii thot cc

khoang c. cng tay, rch m 2 khoang chnh pha tr-

c v sau (xa nhau 180). cng chn, hay rch rng cn

c khp. C th rch cn bng nhng ng rch da nh,lun ko ct ngm di da.

- X tr mnh xng gy:


8/3/2019 chuyn xng

72/81


+ i vi xng gy, t chc c khng tt vi nhim

khun, vi xng th khng km. Bit c c sng

khng kh, vi xng li cng kh.

+ Ni chung, cc mnh xng nh, ri cn ly b. Mnh tocn dnh phn mm nn lm sch t li. i vi mnh to

tch ri, t li s nh ming xng ghp. Nn t li hay

ly b. t li cho khuyt xng song ngi b nhim

khun, thc ra t li mnh xng khng c vn g vi

nhim khun cp tnh. N c li cho vic lin xng v nu

cn th ly b sau. Ly b th vt thng tt hn song

hay b chm lin, khng lin. Nu ngi m t kinh

nghim nn ly b, chu khp gi, v c mt ci kh hn

khp gi l khp gi nhim khun.

+ Xng l trn, v d xng chy th s che ph bng gc

tm du, m s lm cho xng sng c 2 tun, khng nn

chuyn vt che xng trong cp cu, d b hng c vt. X-

ng c mng xng nu gi m khng ng ngi.

- D vt, nht l d vt hu c nn ly b.

- Ti ra vt thng: Gustilo thy ti ra di 10 lt nc, b

nhim khun nhiu so vi ti ra trn 10 lt. Peter Bowis

lm vic cho WHO, nn ti hng chc lt nc, dng nc thin

nhin sch ( chu Phi). Nh ti, vt mu c ra sch, d

ly b d vt, t chc phn mm sng d phn bit, d

ly b, ti lm gim nhim khun.

- Sau khi m ct lc, rch rng, t mt vt thng lng

bng bt ming bin thnh mt vt thng rng ming, cb mt t chc sng, thot dch tt, c kh nng chng

vi nhim bn v vi khun cn li.

- ng kn da: ng kn, ch khu kn da, lm c cho

mt s t trng hp vi ch nh cht ch v n c nhiu


8/3/2019 chuyn xng

73/81


nguy him. T nm 1944 Brenn nu : Mi khu khng

cn thit cu sng thng binh song git cht

h. Ci li ca n l ngn nga bi nhim ca bnh vin,

song ci hi ca n th nhiu. Do vy thng chn cch h. Nhng iu kin ng kn l:

* ly b ht t chc hoi t, d vt, iu ny kh xc

nh.

*Tun hon chi bnh thng, khng d chn on.

*Thn kinh chi khng b thng tn.

*iu kin ton thn tt, khng d xc nh.

*Vt thng c th khu kn, khng cng.

*Khu khng li khong cht.

*Bnh nhn khng c thng tn ni khc.

Khng 7 iu kin trn hay cn nghi ng iu g,

nn h vt thng.

+ Che ph da: da cn che ph nhng t chc khng th

l ra kh tri nh:

*Xng l trn khng c mng xng.

*Gn b l, b mt bao gn.

*Mt s dy chng, thn kinh, mch mu b l.

+ Rch i chiu khu da khi cng v c th dn lu

tt hn. Cn rch di khu vt thng khng cng,

thng di bng vt thng. Khi rch i chiu phi tnh

cho cung da gia vt thng v vt rch cn rng

vt da c nui, trnh hoi t sau ny. Nu vt thng qu

rng ch nn chuyn vt xoay ln cn che vt thngli. Ch nn rch i chiu ni c nhiu c nh i, phn

cao ca cng chn, c tay.

+ Chuyn vt c che gi m cho mng xng: khi b

mt da v t chc di da rng, xng b l. Xng l khng


8/3/2019 chuyn xng

74/81


c mng xng s b cht, nn phi che ph ngay bng

phn mm. Cn mng xng nu lun c gi m th x-

ng sng. V d sau gy h nng cng chn, hay dng

vt c dp hay c gp su cng chn chuyn sangbn che xng, sau v da mng che c.

+ Qua giai on cp tnh, xng b l nh khng c mng

xng che ph c th cu nh khoan qua v xng nhiu l

nh to t chc ht t ng tu ri v da sau. Cch ny

rt tt, nht l i vi tr em. Thng thng v bng chuyn

vt da c cung mch ni vi phu hay chuyn vt ln cn

thng lm sau 7 ngy, khi khu vt thng th 2.

+ Bng sinh vt: khi b l khp, l gn c th che vi

ming da ng loi hay khc loi. iu ny gip cho gn

sng v t chc ht mc. Sau v t thn hay chyn

vt, ghp vt.

- h vt thng: i vi vt thng phn mm ln,

h hon ton.

- Gc cao chi cho sng n, cho khng sinh. Vic dng

khng sinh khng gip g khi ct lc khng ng. Cho

khng sin

Documents

chuyên đề xương