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

Gy u di xng 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 xng 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 xng 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 np khuu, c th chc vo ng mch cnh tay v thn kinh gia.

Hanoi Medical University:LTL 1

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Xng gy thng t bin chng (bin chng do gy xng) 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 lng c 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:

a) Ni gy L 1 vng xng yu v mng do c h mm khuu v h 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.

1. ng gy v di lch:

2. Thng 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.

Hanoi Medical University:LTL 2

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Nguy c chnh l thiu mu: Sng n cng di cn, xng 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 ho mnh. 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.

Hanoi Medical University:LTL 3

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

1. Nn b bt:

Hanoi Medical University:LTL 4

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 v lm 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). Hanoi Medical University:LTL 5

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

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

V.

Di chng :
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

1. Can lch :

2. Chi xng

Hanoi Medical University:LTL 6

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 hay b 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 xng cnh tay

I. i cng : L mt dng gy u di xng cnh tay, thng ngi ln.

Hanoi Medical University:LTL 7

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 v sm. Thng c ch nh iu tr phu thut. II. Thng tn gii phu bnh l: 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 trn nhn 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: 1. Th hay gp l gy ch V, T:

Hanoi Medical University:LTL 8

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 b cng 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 khuu vung, 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 : 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: Ch nh :

Hanoi Medical University:LTL 9

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 gp khuu 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. 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: Hanoi Medical University:LTL 10 M ln:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Ch nh: Cho gy h nng, gy vn nhiu mnh. K thut M ly b cc li cu v ri nhau. Bt ng tm thi 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.

Hanoi Medical University:LTL 11

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

Hanoi Medical University:LTL 12

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Nn iu tr cng sm cng tt v khuu chng b sng 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 cng : 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.

Hanoi Medical University:LTL 13

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 tn c 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%. Gy cao 2/3 trn: c nh u v c nga ngn ko

V di lch cc u gy: 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 Hanoi Medical University:LTL 14

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 khng ca 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 : 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 1. Lm sng :

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, Cn da vo Xquang chn on. Hanoi Medical University:LTL 15 sng n, c bm tm mun.

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 Cch nn: ch, hoc gy t m ri thn kinh cnh tay. + 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 cnh tay. + 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 Hanoi Medical University:LTL 16

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 Gy 2 ni trn 1 xng. C triu chng ca phn mm chn vo gia cc u Gy 1 xng quay di lch. Gy c bin chng: gy h, chn p khoang.

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

gy.

2) V cm: gy m ni kh qun. 3) ng vo: i vi xng quay l ng ni chm quay vi mm trm i vi xng tr l ng mo tr. Hanoi Medical University:LTL 17 quay (ng Thomson) hoc ng Henry.

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 4) Cc phng php m chnh: inh ni tu: + Ch nh: *s dng tt cho gy xng tr do xng thng v 1/4 trn xng 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. Hanoi Medical University:LTL 18

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. *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 xng 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. Hanoi Medical University:LTL 19

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 nng hai 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 nt c, tn thng mch muv c cc Triu chng: khoang vng cng tay khu tr li, c bit l khoang trc. + 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). Hanoi Medical University:LTL 20

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + o p lc khoang > 50mmHg. Cn x tr rch cn cp cu gii chn p khoang, Cn gp hi chng khoang sau m do cm mu km, sau 2 tun v da che li. 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 Bnh nhn c bn tay r c c. Thn kinh gia b chn p trong ng c tay, pha trc Biu hin: T, gim vn ng vng thn kinh gia, teo X tr : M rch dc dy chng vng trc cng tay, gii gia. 3. Hi chng ng c tay: l dy chng vng trc c tay, pha sau l can lch xng. dn c m ci, t t ngn 2, 3. 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.

Hanoi Medical University:LTL 21

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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, Lm sng: Gim sp nga cng tay, s thy can lch Xquang: Thy r can lch. X tr: Cn kt hp xng sm v sa trc. Hanoi Medical University:LTL 22 nhim khun. ni g.

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 li b. 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 phng 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. VII. Khi tnh trng vim nhim ht, vt thng kh c trn iu tr cc trng hp c bit : Nn ht trt chm quay s lm ht di lch chm tr. Nn xng tr. Bt ng. 6 thng, m phc hi ly xng cht, kim loi 1. Gy trt Monteggia :

2. Gy thn xng cng tay tr em:

Hanoi Medical University:LTL 23

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 rt Cc di lch gp gc thng c t sa cha nu l 15 nng, l co rt gp cc ngn tay do thiu mu nui. 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 xng c t l lin xng < 5%, cho nn phi thay chm hoc thay khp hng ton phn. II. Gii phu, sinh l. 1) Cu trc b xng: 1. Cu to u trn xng i:

Hanoi Medical University:LTL 24

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 T ng mch thn xng i ln: Cng st chm cng T cc ng mch m i ca ng mch i su: cp liu cho rng trn 8 tui l tc. t nhnh. 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. Hanoi Medical University:LTL 25

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 gc 130. 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) Gy trong khp: Gy di chm. Gy c chnh danh hay gy xuyn c. Gy c mu chuyn. Gy lin mu chuyn. 1. Da vo v tr gy:

2) Gy ngoi khp:

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 xng. 3) > 70: Pauwels 3: Rt kh lin. 3. Theo di lch da vo Xquang: theo Garden. Hanoi Medical University:LTL 26

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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) 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 Chi b gy ngn hn so vi bn lnh, mt c trong bn hng, khng th dui gi m nhc gt khi ging. 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 G vo mu chuyn ln hoc g vo gt chn dn ln 1. Th gy khp (gy ri): 70% trng hp:

au chi pha ngoi tam gic Scarpa. th 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: Hanoi Medical University:LTL 27

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 Ch : khng nn tm du hiu lo xo xng v s gy Vi nhng trng hp gy khp in hnh th nhng ton thn km theo (tim mch, i ng) au. 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 Bnh nhn vn c th i li c hoc nhc chn c. Khm trn lm sng khng thy g c bit ngoi nhn ch hi au nh kiu ng dp phn mm.

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 gy ri ra, khuu xung, gy ci tr thnh gy khp vi y vi cc triu chng.

Hanoi Medical University:LTL 28

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 dn dn 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. Hanoi Medical University:LTL 29

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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, hng 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) 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 tc tnh mch, nhim khun tit niu, lot do t ): Qun gy, khng cn iu tr xng m ch cn cu Cho thuc gim au, khng sinh. Hanoi Medical University:LTL 30 bnh nhn thot khi nhng bin chng gy t vong. 1. Nguyn tc :

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 hnh v 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 xng. 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. Hanoi Medical University:LTL 31

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Gy 1 phn ngoi khp: M vt A.O, bt, ko. Gy ni khp: thng c kt qu km. vit nam t l

3) M kt hp xng cho ngi gi: lin xng l 2 5 %, trn th gii ~ 30% , hu ht my thng 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. Hanoi Medical University:LTL 32

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 xng nh i vi kt hp xng. + nhc im: chc phn chm kim loi khng nh chm xng. 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 cn thn 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. Hanoi Medical University:LTL 33

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. C th dng ximng xng c nh tt k c khi b long xng. 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 Nguyn nhn : lin gi l khp gi. + Nui dng km nn 1 phn u gy tiu i. Hanoi Medical University:LTL 34

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + Nn khng tt. + i li sm. Lm sng : au vng hng, i kh, bc ht, c du hiu Xquang : khng thy can xng, chm tiu i t nhiu. Do bt ng lu, thay i din t . Lc u au, hn ch vn ng khp hng sau Xquang : hp khe khp, m u xng, chi xng. Do nui dng km, gy st chm Pauwels 3. Bnh nhn khng i li c Xquang : hnh nh tiu chm. ngn ko. 2) Thoi khp :

dnh khp. 3) 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 i I. 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. Hanoi Medical University:LTL 35

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

Hanoi Medical University:LTL 36

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 xng 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 Vn ng i v cng chn gim hon ton. rc i, tip l au d di. 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 Chi ngn, gp gc, c th cm nhn c ch g ln ca u gi gp v xoay ngoi. Cc triu chng bm tm vng thp v khp gi xut Trn dch khp gi: do c bao hot dch c t u i.

mt ging. u xng gy.

hin mun.

Hanoi Medical University:LTL 37

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 xng 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 Sau ngi mng tr c ng tc c ng bt thKhng c shock. i sng, nn hi chc.

2) Tr s sinh: ng, khng p chn c.

5. Xquang: Sau khi c nh tm thi v chng shock : 1) Xquang xng i: a. Loi phim: Hanoi Medical University:LTL 38

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 phng 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 Phng php: shock. + 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 nhng cho 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.

Hanoi Medical University:LTL 39

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. c. Khm nhanh pht hin cc thng tn nng hn gy thn xng i s no, ngc bng, cc biu hin tn thng 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 3 tun, kim tra thy nn chnh t yu cu th chuyn sang b bt. e. Tr em > 12 tui: thng m: Gy ngang: nn m. Hanoi Medical University:LTL 40

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 nn Gy thp 1/3 di, u di b co ko gp ra sau (c sinh Gy gy thn xng i tr em khi chp kim tra kt b cn u di chi t th dng, hi xoay ra ngoi. i). qu nn b nu trc xng tng i thng, cc u xng 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 B bt d lm cng khp, teo c nhng li d lin xng. Ch nh: hon ton, d nn chnh, bt chu lng chn. h. Phng php xuyn inh ko t: + 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 hng 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: Hanoi Medical University:LTL 41

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

Hanoi Medical University:LTL 42

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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. Ch nh: Gy 1/3 trn v 1/3 di. u im: e. Np vt.

+ C nh nh sc p din gy. + Tp phc hi chc nng sm d gy gn khp v khp gi thng mm. Hanoi Medical University:LTL 43

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + Nm vin ngn, dy sm bin chng. Nhc: + Nguy c nhim khun. + C nh khng vng, qu 6 thng cn au, kim tra khng 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 nhim khun.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. Hanoi Medical University:LTL 44

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 K thut: nng n mun. + 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 da Sau 14 ngy ng kn vt thng.

h.

Hanoi Medical University:LTL 45

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 ngi c di cn ung th. Cn sinh thit khi m. ng inh ni tu, ng tu rng thm xi mng xng.

6. Gy do n: Hanoi Medical University:LTL 46

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. VI. 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. 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 thng 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, Lch gi nhau vi ngn chi 1-1.5 cm c chc nng tt b

tt hn l vo sang bn v ra sau. p bng giy.

Hanoi Medical University:LTL 47

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Di lch xoay pht hin vi khm lm sng, phim Lm sng: Chn i tht chn di chn ngn. Vim iu tr: c xng, kt hp xng (t xng di

Xquang kh xc nh. B xoay nhiu cn m sa li. au khp gi. Xquang) 4. Gy li: Xy ra 3 4 tun u khi can cn non, bnh nhn b 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 cong dp inh

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 Gy li hay thy khi dng inh nh dng inh nh 8 thn vo ch khuyt. 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.

Hanoi Medical University:LTL 48

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 thng 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 thiu mu 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: Hanoi Medical University:LTL 49

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 nt 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: Hanoi Medical University:LTL 50

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 1) n sm, ngay sau khi tai nn: C nng: au chi nhiu vng gy. Mt vn ng hon Ton thn: Gy 2 xng cng chn mt khong 500 ml ton. mu 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 Chn on da ch yu vo Xquang. Hanoi Medical University:LTL 51

nh.

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 kinh b 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. Hanoi Medical University:LTL 52

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 (rch t 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 thng 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. Hanoi Medical University:LTL 53

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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: IV. Volkmann cng chn: Ri lon dinh dng nng, km Di chng: Can lch, khp gi. iu tr: 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 dng. 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. Hanoi Medical University:LTL 54 theo x ho v co rt cc c khu sau lm cng gn dui

1. Nguyn tc:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 6 tun 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 dng. Hn ch: + Nguy c nhim khun cao, sm nht l vim xng.

Hanoi Medical University:LTL 55

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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. Hanoi Medical University:LTL 56

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 Gy h 2, 3: b nh i vi gy kn. + 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. Phng:

3) Ri lon dinh dng (hi chng Sudek) (?). + 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. Hanoi Medical University:LTL 57

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 < 1cm. Khng t iu chnh: di lch xon vn + Ngi ln: chi ngn >2cm, gp gc > 30 th m li ph can, t li on xng gy, kt hp xng nu cn. 6) Trc xng xu: Hanoi Medical University:LTL 58

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. t li v tr gi phu. C nh bn ngoi. Sau: ghp xng xp sau ngoi. Lm dnh chy mc. Chuyn xng mc. Chuyn xng mc c mch nui, vi phu.

7) Mt on xng:

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, ct ngn 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. Hanoi Medical University:LTL 59

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 S cu ng. M cng sm cng tt < 6h. Ct lc, rch rng, c nh vng. 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

2) Nguyn tc:

3) S cu:

nn li xng gy. 4) Phng v chng shock: Truyn dch, truyn mu. Hanoi Medical University:LTL 60

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Khng sinh ton thn. S.A.T Gim au Morphin. Ct lc vt thng phn mm. Ra vt thng bng Betadine. X tr xng:

5) iu tr:

+ dnh xng cng nhiu cng tt. + Tt c nhng xng d nh, d ln cn dnh vo mng xng, 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: IX. Khng sinh liu cao ton thn. K cao chi. Bi ph tun hon, in gii 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 xng m iu tr khng m bng ko nn b. Hanoi Medical University:LTL 61

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 t chi, 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 xng 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 rt cao 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. Hanoi Medical University:LTL 62

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

Hanoi Medical University:LTL 63

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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) 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 1. Gii phu bnh:

Hanoi Medical University:LTL 64

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 tng 6 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 thng 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: C ch trc tip: gy h t ngoi vo, vt thng bn C ch gin tip: gy h t trong ra, vt thng sch v 1. Da vo c ch chn thng: v gy phc tp. gy gn. 2. Da vo thi gian: Theo Friedrich: Gy xng h n sm: < 8h. Hanoi Medical University:LTL 65

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 xng 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. V. IIIa: Thng tn rng song xng cn c phn mm IIIb: Xng l, phi chuyn vt da che ph xng. IIIc: km theo thng tn mch mu, thn kinh ln. Nguyn nhn v c ch: che ph.

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 gy chc 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:

Hanoi Medical University:LTL 66

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 thng 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 P lc m tnh (ht bi bn vo lng vt thng). kch thch to nh dao ng trong my nhp ri nh xuyn qua i chng hn (do vy l ra thng to).

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. Hanoi Medical University:LTL 67

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 thng bng), 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 Gy xng m c nc tu xng chy qua vt thng phn Sau khi ct lc vt thng thy gy thng vi vt thGy h n mun: chy m qua vt thng, c th l Xquang thng nghing xc nh mc thng o giao ng mch khi trn lm sng nghi ng thng ngoi. mm. ng. u xng vim. tn xng, s di lch v d kin c nh xng. 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

Hanoi Medical University:LTL 68

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 6. Khm mch mu: nu nghi ng thng tn mch mu, yu cu thm d Doppler, chp ng mch VII. X tr Cp cu ban u tt. X tr gy xng: ct lc, rch rng, c nh xng 1. Nguyn tc:

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 bnh nhn. 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: Hanoi Medical University:LTL 69

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. V cm ni kh qun. Ra vt thng bng nhiu nc vi x phng betadine, Co lng xung quanh vt thng.

ly ht d vt nng. 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: Hanoi Medical University:LTL 70

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

Hanoi Medical University:LTL 71

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. + 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 to cn 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. Xng 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, c b 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 Hanoi Medical University:LTL 72

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. 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 thng li. 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 Hanoi Medical University:LTL 73

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. c mng xng s b cht, nn phi che ph ngay bng phn mm. Cn mng xng nu lun c gi m th xng sng. V d sau gy h nng cng chn, hay dng vt c dp hay c gp su cng chn chuyn sang bn 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, Gc cao chi cho sng n, cho khng sinh. Vic dng h hon ton. khng sinh khng gip g khi ct lc khng ng. Cho khng sinh 36 48h sau m. 3) Sau c nh chi gy bng cc cch sau: a. Kt hp xng bn trong ngay: c ch nh cht ch: + Gy h I v II. + n trc 8h. + C phu thut vin v phng tin thun li. V d gy ngang xng chy c thng tn da t, n sm. Kt hp xng m din gy khng tip xc v gy khng vng khi xu hn l khng kt hp xng.

Hanoi Medical University:LTL 74

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Nu c kt hp xng th gy xng h thng khng

khu da, khng khu phn mm. Ch khu khp c khng cng che gy v che dng c kt hp xng cn da v cn su lun h. Lu khi kt hp xng vi np vt sau gy h thn xng hay b chm lin, nn ghp xng xp t thn (mo chu) ngay. M np vt m b nhim khun th tt hn m inh ni tu v vim nhim lan rng theo inh trong ng tu. b. C nh ngoi: Vi cc phng tin nh Hoffmann, Fessa c nh bn ngoi l phng tin tt nht x tr gy xng h nng n mun. + u im: c nh c xng song ti gy khng c d vt (kim loi). t c gii phu tt v nh p gi ng u gy v tr trc khi c nh. + Nhc im: Cc cc cht ngang gi khng cho cc u xng p st nhau (khi c hin tng tiu xng sinh l ti gy). Cc mu khung tt th lm c vic p st u gy vi nhau, hoc chng 2 3 thng sau th ly b khung c nh ngoi v b bt ngn ri cho t, cho i. Nn trnh cc xu hng sai lm nh khi chi b gy h nng, c cu chi, c trnh ct ct, c ni li chi t ri bng vi phu. Trnh th thut ch yu ch c nh ngoi. bnh nhn gi b nng nn ct ct chi cu tnh mng bnh nhn. c. Ko lin tc: Ko lin tc tt ch km c nh ngoi. Nh ko lin tc, chi c bt ng, chng gim sng n, xng gy tr li Hanoi Medical University:LTL 75

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. v tr gii phu kh. thi gian ko di thng 4 6 tun, ch gy tng i vng ri chuyn sang b bt thm. Gy cng chn ko trn khung Braun. Khi ko ch c mt sau chi b che lp, cn 3 mt h theo di vt thng. Nu gy h nng i, gy h cao i, vi cc vt thng rng hng, mng, nu c vt thng pha sau c th ko treo t th 90-90 (hng, gi gp 90) v xoay ngoi nh. Vi im v k thut xuyn inh ko t nh sau: + Dng inh Steinmann xuyn qua trn li cu xng i, inh to ko khng cong. + inh to khng ca t xng xp. + Khi khoan inh, dng tc chm cho nng inh, bng xng. + Khi inh qua khi xng dng dng tip khoan tay cho xon si c. Khoan t trong ra trnh phm vo mch mu. + Chn inh cn trch rch da nh cho khi cng. chi trn ko qua mm khuu vn theo nguyn tc 90-90. Lc b bt cn cho vi inh trong bt. d. B bt: Sau x tr vt thng, b bt lm c nhiu ni. y l cch ph bin nht. Phng php n gin, kt qu song thng v tr gii phu xng gy km. B bt cho n khi lin c Trueta nu t ni chin Ty Ban Nha 1939 v c Brown Urban nu chin tranh Vit nam. Bt thm mu, hi song vt thng tt bt ng. gy ch di, nu bt trn c th t sm sau 24h. Vt thng c theo di vi ca s bt. Lu , ch m ca s thng b ph n v vt thng li d b bt ca vo tht, cn c np bt y v bng gi.i vi cc mnh xHanoi Medical University:LTL 76

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. ng v rng, khi ct lc c th sp xp mnh gy v ghim inh Kirchner c nh, inh Kirchner c chp nhn dng cho gy h, khng s n nh l d vt, sau b bt ngoi. Mnh to, ghim mt inh d xoay, nn ghim 2 inh. Quan trng gi nhng mnh to thu khp. Mnh v nhiu d b ngn chi cn ghim 2 inh trn di gy v ko nn, b bt m vi inh. 4) X tr cc thng tn km theo: a. B bong lc da rng: Khc hn vi chuyn vt da lc m, bong lc da do tai nn, da b ng dp, mch nui da b hng nn thng lc u, da b hoi t y. xem da c c ti mu nui khng, c th tim tnh mch mt ng fluorescein v dng nh sng n Wood soi. C th t garo mt thi gian ngn ri tho garo xem tnh trng ti mu cc mch mu nh. Nhng vt da b lc thng tr da vi cc vt rch nh hnh qun c ri bng p cho thot dch. Vt da d kin khng sng nn lng mng ri t li nh kiu t ming da ghp t thn, Nu di , nn c khng dp nt, li lm th phn da ny c th sng. Cn bng p nh v bt ng. b. Thng tn mch mu: + Nu x tr sm, nn kt hp xng trc cho vng ri x tr mch mu sau. + Nu x tr mun hn, nn phc hi lu thng mch mu trc cu chi ri kt hp xng sau, lc ny phi kt hp xng nh nhng cho khi hng ch khu mch mu.

Hanoi Medical University:LTL 77

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. c. Khi c nhiu thng tn: Thng cn s phi hp gia phu thut vin chnh hnh, phu thut vin chung v gy m. VIII. X tr mt s thng tch khc: Ngi tr tui b gy h bn tay, bn chn, ni gy c 1. Gy h bn tay, bn chn: cp mu nui tt nn nhim khun khng phi l vn ln. C th kt hp xng ngay nh i vi gy kn. Thng dng inh Kirchner v t phi bc tch phn Kt hp xng cho php c ng sm, rt quan trng mm. Vi np vt b dnh nhiu hn. trong phc hi chc nng bn tay, bn chn. 2. Gy trt c chn: Gy h I nn kt hp xng ngay, khng c tai bin Gy h III n sm nn kt hp xng ti thiu, cn iu rt quan trng l tp c ng khp c chn sm. ln so vi gy kn. cho x l phn mm. n mun nn li. Nu ko qua gt vn va ko va tp c ng c. 3. Gy h thn xng chy: Gy h I, II: cho bt ng vi bt c gt i, Gy h III nn c nh ngoi, v d khung kt qu tt. Hoffmann. Ch phng tin c nh ngoi 4 6 tun ri chuyn sang b bt. Gy h xng chy c kt hp xng bn trong ch Ngn chi cng chn khng nn qu 1cm v cc c chng 5%. cng chn thch nghi km.

Hanoi Medical University:LTL 78

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. Kt hp cng chn th np vt tt hn inh ni tu

v khi m np vt, tnh trng mt mu nui xng l t v nu b nhim khun th d x tr hn so vi nhim khun c inh ni tu. Np hay t ngoi xng chy, b thng tn nng nn np mt sau xng chy. np mt trong, di da, bin chng nhiu. 4. Gy h cc xng di chi trn: gy chi trn c che ph phn mm tt, thng do chi trn, c nh bn trong hay dng hn hn c nng lng yu, bin chng t. nh ngoi v nhim khun t hn v cc inh ca khung c nh cn tr vic tp luyn bn tay. Gy h I nn kt hp xng ngay. Gy h II, III cnh tay nn lm np bt. Nu gy xng km c thng tn mch mu, thn kinh

nn kt hp xng np vt th ngi vim ng tu v trnh c thng tn ai vai khi m inh ni tu. Gy h ni khp xng cnh tay nn kt hp xng ngay. a s gy h 2 xng cnh tay nn kt hp xng ngay, Mi gy h thn xng c nh bn trong nn ghp

dng np vt th hn dng inh ni tu. xng xp t thn. 5. Gy h xng i trn bnh nhn a chn thng: Nn ct lc vt thng, rch rng vt thng v ko nn b bt, c th b bt vi inh u trn xng chy vo bt. Sau m c th sm dng xe ln nn phi s tt hn. Nu phi nm th cho ko lin tc, sau 7 ngy mi kt hp xng v ng vt thng.

Hanoi Medical University:LTL 79

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. gy h xng i, c nh ngoi km hn cc ni

khc. 6. i vi ngi gi: Ngi gi nm lu s vim phi, nn kt hp xng ri Nu b nhiu thng tn nng chi trn nn ct ct cho dy sm th hn. cu tnh mng Hi chng chn p khoang Khi lc va mnh vo 1/3 trn cng chn, hay gp bp chn cang cng v 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 t chi, 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 >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%.

c > 30mmHg.

Hanoi Medical University:LTL 80

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi. C nhiu ni rch cn nhng thng rch dc sau trong xng chy t khoeo ti trn c chn, rch ti cn su ( cn ni c).

Hanoi Medical University:LTL 81