钝性损伤致下胸部肋骨骨折合并腹腔脏器损伤的危险因素分析

摘要

目的 分析钝性损伤致下胸部肋骨骨折合并腹腔脏器损伤的危险因素和早期预测因子.方法 回顾性分析2015年1月—2017年12月厦门大学附属东南医院收治的183例钝性损伤致下胸部肋骨(8~12肋)骨折患者,其中经CT影像学或剖腹探查诊断合并腹腔脏器损伤34例(腹腔脏器损伤组),无腹腔脏器损伤149例(无腹腔脏器损伤组),收集患者人口学特征(性别、年龄)、致伤原因(交通事故、高处坠落、意外跌倒、暴力击打)、肋骨骨折部位(单侧、双侧)和数目、入院时生命体征(收缩压、心率)、腹部体征、实验室指标(红细胞压积),通过单因素和多因素Logiistic回归分析合并腹腔脏器损伤的相关因素.结果 本组183例钝性损伤致下胸部肋骨骨折患者中左侧肋骨骨折91例,右侧肋骨骨折79例,双侧肋骨骨折13例.本组合并腹腔脏器损伤比例为18.6%(34/183),共计发生57处脏器损伤,其中脾脏损伤27例、肝脏损伤18例、肾脏损伤6例、肾上腺损伤3例、胰腺损伤2例、十二指肠损伤1例.单因素分析发现,性别和肋骨骨折数目与合并腹腔脏器损伤无关联,而年龄(X2=6.349,P=0.012)、是否机动车事故(X2=7.133,P=0.008)、肋骨骨折部位(X2=11.506,P =0.001)、入院时收缩压(X2=18.531,P <0.001)、心率(X2=5.932,P =0.015)、腹部体征(X2=6.416,P=0.011)和红细胞压积(X2=6.685,P=0.010)与合并腹腔脏器损伤存在关联.多因素Logistic回归分析发现,机动车事故(OR=5.64,95%CI:2.57~11.61,P=0.008)、双侧肋骨骨折(OR=4.25,95%CI:1.63~12.87,P=0.025)、入院时红细胞压积<40%(OR=2.16,95%CI:1.98~5.29, P=0.017)是同时合并腹腔脏器损伤的独立危险因素.结论 对于钝性损伤致下胸部肋骨骨折,尤其是机动车事故、双侧肋骨骨折、存在明显失血指征者,要高度警惕合并腹腔脏器损伤的可能.%Objective To analyze the risk factors and early predictors of intraperitoneal injury in patients with thoracic lower rib fracture caused by blunt injury.Methods A series of 183 patients with lower rib(8-12 rib) fracture caused by blunt injury in Southeast Hospital Affiliated to Xiamen University from Jan.2015 to Dec.2017 were enrolled and analyzed retrospectively.The patients were divided into abdominal visceral injury group(n=34) and non abdominal visceral injury group(n=149)diagnosed either by CT imaging or on urgent laparotomy.The de-mographic characteristics(gender,age),mechanism of injury(traffic accident,falling,falling accidents,violence), site of rib fracture(unilateral or bilateral),number of fractured ribs,vital signs on patients arrival(systolic blood pressure,heart rate),abdominal signs,hematocrit(Hct)were collected.The related factors of abdominal viscera in-jury were analyzed by single factor and multiple factor Logistic regression analysis.Results There were 91 case of left rib fracture,79 cases of right rib fracture and 13 cases of bilateral rib fracture.The proportion of the combined abdominal cavity organ damage was 18.6%(34/183),a total of 57 visceral injuries,including 27 case of spleen in-jury,18 cases of liver injury,6 cases of renal injury,3 cases of adrenal injury,2 cases of pancreatic injury,1 case of duodenal injury.Single factor analysis showed that gender and number of fractured ribs were not associated with ab -dominal organ injuries,however,age(X2=6.349,P=0.012),motor vehicle accident(X2=7.133,P=0.008),site of rib fracture(X2=11.506,P=0.001),systolic blood pressure at admission(X2=18.531, P<0.001),heart rate (X2=5.932,P=0.015),abdominal signs(X2=6.416,P=0.011)and hematocrit(X2=6.685,P=0.010)were associated with abdominal organ injuries.Multivariate Logistic regression analysis showed that motor vehicle acci-dents(OR=5.64,95%CI:2.57-11.61,P=0.008),bilateral rib fractures(OR=4.25,95%CI:1.63-12.87,P=0.025),admission hematocrit <40%(OR=2.16,95%CI:1.98-5.29,P=0.017)were independent risk factors of abdominal visceral injury.Conclusion For patients with lower rib fractures caused by blunt injury,especially who had motor vehicle accidents,bilateral rib fractures and significant bleeding indications should be highly vigilant a-gainst the possibility of abdominal visceral injury.