Takeuchi, Naohide, Masumoto, Kazuyuki, Nojiri, Junichi, Akiho, Shunsuke, Hotokezaka, Shunsuke, Sasaki, Kosuke, Kawaguchi, Kenichi, Tsukamoto, Nobuaki, Momii, Kenta, Fujita, Naohiro, and Mae, Takao
A 73-year-old female was hit by a car, and transferred to our hospital. On examination, her consciousness was alert, but her vital signs were unstable. There are three 10-cm open wounds on her right buttock. X-rays showed an unstable pelvic ring fracture, a right femoral shaft, a right proximal tibia and a right tibial plafond fractures. One hour after the injury, transarterial embolization (TAE) followed by external fixation (EF), and retroperitoneal pelvic packing (RPP) was performed. Two days and five days after the injury, thorough debridement of the open wounds was performed. The skin defect on the right buttock and the lower abdomen had enlarged to 40 x 35 cm, therefore, negative pressure wound therapy was applied. On the same day, right femur was fixed using a retrograde intramedullary nailing. 12 days after the injury, the proximal tibial fracture was fixed using a plate, and the tibial plafond fracture was fixed using screws and external fixators. 28 days after the injury, the split-thickness skin graft was performed on the right buttock and the lower abdomen. Seven months after the injury, the open wounds were completely healed without infection. She was able to walk smoothly with a T-cane. For the management of open pelvic ring fractures, it is essential to perform TAE, EF and RPP as soon as possible. Providing aggressive management, including thorough debridement, is mandatory to prevent severe infection and sepsis. We achieved a good clinical outcome by using a combination of TAE, EF, RPP and staged surgery, including thorough debridement., 我々は，骨盤輪開放骨折を伴った多発骨折の一例を経験したので報告する．症例：73歳女性．歩行中に乗用車にはねられ受傷した．初診時，意識清明であったが，ショック状態を認めた(血圧：51/31mmHg，脈拍：63回/分)．骨盤と右下肢に腫脹・変形と，右殿部に約10cmの開放創を3ヶ所認めた．単純X線撮影・CTにて，不安定型骨盤輪開放骨折(AO分類：61-B2.2，Gustilo分類：gradeⅢA)，右大腿骨骨幹部骨折(AO分類：32-A2.3)，右脛骨近位端骨折(AO分類：41-B3.2)，右脛骨天蓋開放骨折(AO分類：43-C2.3)と診断した．搬送1時間後に経カテーテル的動脈塞栓術(TAE)を施行し，続いて骨盤創外固定術と後腹膜ガーゼパッキングを施行した．血圧は113/59 mmHgと改善した．さらに，右大腿骨・脛骨骨折に対して創外固定術を行った．受傷2日目に右殿部開放創のデブリドメント・局所陰圧吸引処置を開始した．受傷5日目に開放創の皮膚壊死を認めたため，デブリドメントを追加した．皮膚欠損は40 x 35cmとなった．同日大腿骨骨幹部骨折に対して逆行性髄内釘固定術を施行した．受傷12日目に，右脛骨近位端骨折に対してplate固定術を，右脛骨天蓋開放骨折に対してscrew固定と創外固定術を施行した．受傷28日目に，右殿部・下腹部の開放創に対して分層植皮術を施行した．受傷7ヶ月後，開放創は感染を合併せず治癒し，杖歩行可能となった．骨盤輪開放骨折は大量出血や感染・敗血症を合併することが多く，死亡率の高い外傷の一つである．大量出血に対しては，TAE・創外固定術・後腹膜ガーゼパッキングを可及的早期に行うことが必須である．また，開放創の積極的なデブリドメントが感染・敗血症の予防として重要である．本症例では，TAE・創外固定術・後腹膜ガーゼパッキングと段階的な手術により良好な治療結果を得ることができた．