正文：骨(gu)(gu)(gu)折后，局部血(xue)腫(zhong)(zhong)(zhong)(zhong)是臨床(chuang)常見癥狀和(he)體征，是骨(gu)(gu)(gu)折過(guo)程(cheng)中(zhong)的(de)(de)重(zhong)要病理(li)(li)表現之一(yi)。從血(xue)腫(zhong)(zhong)(zhong)(zhong)形成開始到(dao)血(xue)腫(zhong)(zhong)(zhong)(zhong)凝固。血(xue)腫(zhong)(zhong)(zhong)(zhong)機(ji)(ji)化與吸收代(dai)替貫穿于(yu)骨(gu)(gu)(gu)折愈(yu)合的(de)(de)全過(guo)程(cheng)。學者及專著在論述(shu)骨(gu)(gu)(gu)折愈(yu)合的(de)(de)機(ji)(ji)理(li)(li)時(shi)，都(dou)提(ti)到(dao)血(xue)腫(zhong)(zhong)(zhong)(zhong)機(ji)(ji)化或從血(xue)腫(zhong)(zhong)(zhong)(zhong)、血(xue)腫(zhong)(zhong)(zhong)(zhong)凝固及血(xue)腫(zhong)(zhong)(zhong)(zhong)機(ji)(ji)化開始論述(shu)。由此可見血(xue)腫(zhong)(zhong)(zhong)(zhong)是參(can)人骨(gu)(gu)(gu)癡形成的(de)(de)重(zhong)要因素之一(yi)。血(xue)腫(zhong)(zhong)(zhong)(zhong)機(ji)(ji)化是骨(gu)(gu)(gu)折愈(yu)合過(guo)程(cheng)中(zhong)的(de)(de)重(zhong)要一(yi)環。雖然血(xue)腫(zhong)(zhong)(zhong)(zhong)機(ji)(ji)化這一(yi)理(li)(li)論在論述(shu)骨(gu)(gu)(gu)折愈(yu)合機(ji)(ji)理(li)(li)時(shi)都(dou)提(ti)到(dao)，但是在臨床(chuang)治(zhi)療(liao)骨(gu)(gu)(gu)折中(zhong)確很少重(zhong)視、探(tan)討這一(yi)理(li)(li)論并應(ying)用(yong)于(yu)臨床(chuang)，因此，充分認(ren)識血(xue)腫(zhong)(zhong)(zhong)(zhong)對骨(gu)(gu)(gu)痂形成的(de)(de)影響有極其重(zhong)要的(de)(de)意義(yi)。筆(bi)者從探(tan)析血(xue)腫(zhong)(zhong)(zhong)(zhong)機(ji)(ji)化理(li)(li)論和(he)臨床(chuang)觀(guan)察(cha)人手，論述(shu)血(xue)腫(zhong)(zhong)(zhong)(zhong)對骨(gu)(gu)(gu)痂形成的(de)(de)意義(yi)，從而加深對血(xue)腫(zhong)(zhong)(zhong)(zhong)的(de)(de)認(ren)識，以提(ti)高臨床(chuang)治(zhi)療(liao)效(xiao)果(guo)。

一、骨折(zhe)后局(ju)部病理(li)生(sheng)理(li)變化

骨(gu)(gu)(gu)折(zhe)后骨(gu)(gu)(gu)本身和其周(zhou)圍的(de)(de)(de)(de)軟組(zu)織均遭(zao)受到(dao)不同(tong)(tong)程度的(de)(de)(de)(de)破壞(huai)，骨(gu)(gu)(gu)及(ji)骨(gu)(gu)(gu)髓腔和周(zhou)圍的(de)(de)(de)(de)軟組(zu)織因(yin)遭(zao)受到(dao)破壞(huai)而(er)發生(sheng)不同(tong)(tong)程度的(de)(de)(de)(de)出血(xue)，骨(gu)(gu)(gu)斷端附近(jin)的(de)(de)(de)(de)骨(gu)(gu)(gu)細胞(bao)因(yin)受傷(shang)和缺血(xue)而(er)壞(huai)死，血(xue)腫充(chong)滿(man)了各組(zu)織的(de)(de)(de)(de)間隙。血(xue)腫于(yu)(yu)傷(shang)后4～5小(xiao)時(shi)開始(shi)凝固，鄰近(jin)斷端的(de)(de)(de)(de)骨(gu)(gu)(gu)外(wai)膜(mo)于(yu)(yu)骨(gu)(gu)(gu)折(zhe)后24小(xiao)時(shi)內即出現組(zu)織學變化，深層的(de)(de)(de)(de)細胞(bao)增(zeng)(zeng)(zeng)多，胞(bao)漿增(zeng)(zeng)(zeng)加，胞(bao)核(he)增(zeng)(zeng)(zeng)大(da)，越近(jin)骨(gu)(gu)(gu)折(zhe)端的(de)(de)(de)(de)骨(gu)(gu)(gu)外(wai)膜(mo)反應越明顯。一周(zhou)后在增(zeng)(zeng)(zeng)厚(hou)的(de)(de)(de)(de)骨(gu)(gu)(gu)外(wai)膜(mo)中(zhong)，即出現與(yu)骨(gu)(gu)(gu)干平行并緊密相連(lian)的(de)(de)(de)(de)片狀骨(gu)(gu)(gu)樣組(zu)織。

二、骨折后(hou)局部(bu)血腫病(bing)理生理變化

骨(gu)折(zhe)后，骨(gu)折(zhe)斷端附(fu)近的骨(gu)膜、骨(gu)質、髓腔及鄰(lin)(lin)近軟組織(zhi)中的血(xue)管(guan)破裂(lie)出血(xue)，于斷端及周圍形成血(xue)腫。同(tong)時，斷端及鄰(lin)(lin)近部位由于細(xi)胞(bao)壞死，相鄰(lin)(lin)血(xue)管(guan)擴張、充血(xue)，多(duo)形核白細(xi)胞(bao)、

吞噬細胞及(ji)血(xue)(xue)漿滲出(chu)而水腫(zhong)。繼之血(xue)(xue)腫(zhong)周圍的纖(xian)維組織增生，包(bao)圍并(bing)伸入血(xue)(xue)腫(zhong)中，吸收并(bing)代替血(xue)(xue)腫(zhong)，血(xue)(xue)腫(zhong)開始機化。

三、血腫(zhong)機化與骨痂形成生理

在骨(gu)(gu)(gu)(gu)(gu)折(zhe)后的(de)(de)(de)前兩(liang)周(zhou)(zhou)中，血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)尚(shang)未(wei)機化，血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)內(nei)凝集的(de)(de)(de)紅血(xue)(xue)球和(he)纖(xian)維(wei)蛋(dan)白尚(shang)未(wei)被(bei)吞噬清除，新(xin)生(sheng)的(de)(de)(de)毛細血(xue)(xue)管尚(shang)未(wei)深人(ren)，因此，由骨(gu)(gu)(gu)(gu)(gu)外(wai)(wai)膜產(chan)(chan)生(sheng)的(de)(de)(de)成(cheng)骨(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)(bao)不能進(jin)入或通過(guo)血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)，而只能沿著血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)外(wai)(wai)圍(wei)(wei)(wei)向骨(gu)(gu)(gu)(gu)(gu)折(zhe)線(xian)推進(jin)。在血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)機化前，骨(gu)(gu)(gu)(gu)(gu)折(zhe)線(xian)兩(liang)邊增生(sheng)的(de)(de)(de)成(cheng)骨(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)(bao)只能在它的(de)(de)(de)外(wai)(wai)圍(wei)(wei)(wei)會合，隨著血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)被(bei)增生(sheng)伸人(ren)的(de)(de)(de)纖(xian)維(wei)組(zu)織所(suo)分(fen)(fen)隔和(he)通過(guo)異物巨細胞(bao)(bao)(bao)。吞噬細胞(bao)(bao)(bao)等作用吸收代(dai)替，骨(gu)(gu)(gu)(gu)(gu)折(zhe)斷(duan)端之間及(ji)周(zhou)(zhou)圍(wei)(wei)(wei)，即被(bei)增生(sheng)的(de)(de)(de)纖(xian)維(wei)組(zu)織所(suo)代(dai)替充(chong)填。血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)外(wai)(wai)圍(wei)(wei)(wei)的(de)(de)(de)成(cheng)骨(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)(bao)或成(cheng)軟(ruan)(ruan)骨(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)(bao)亦涌入血(xue)(xue)腫(zhong)(zhong)(zhong)(zhong)內(nei)及(ji)斷(duan)端間隙內(nei)，與(yu)髓腔內(nei)骨(gu)(gu)(gu)(gu)(gu)膜產(chan)(chan)生(sheng)的(de)(de)(de)骨(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)(bao)相會合，形成(cheng)橋梁骨(gu)(gu)(gu)(gu)(gu)痂及(ji)接近骨(gu)(gu)(gu)(gu)(gu)折(zhe)線(xian)部分(fen)(fen)的(de)(de)(de)內(nei)外(wai)(wai)骨(gu)(gu)(gu)(gu)(gu)痂。位于(yu)斷(duan)端周(zhou)(zhou)圍(wei)(wei)(wei)的(de)(de)(de)部分(fen)(fen)纖(xian)維(wei)組(zu)織開始(shi)向軟(ruan)(ruan)骨(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)(bao)分(fen)(fen)化，形成(cheng)幼稚的(de)(de)(de)成(cheng)軟(ruan)(ruan)骨(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)(bao)并產(chan)(chan)軟(ruan)(ruan)骨(gu)(gu)(gu)(gu)(gu)基質(zhi)，通過(guo)軟(ruan)(ruan)骨(gu)(gu)(gu)(gu)(gu)內(nei)骨(gu)(gu)(gu)(gu)(gu)化，形成(cheng)新(xin)生(sheng)骨(gu)(gu)(gu)(gu)(gu)。

四、骨折愈合機理(li)的理(li)論(lun)學說

關(guan)于骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)愈合(he)機(ji)理(li)的(de)(de)(de)(de)(de)(de)(de)理(li)論有(you)(you)(you)很多，對成(cheng)(cheng)(cheng)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)的(de)(de)(de)(de)(de)(de)(de)來(lai)源國內(nei)(nei)(nei)外(wai)有(you)(you)(you)諸家學(xue)(xue)(xue)說。有(you)(you)(you)的(de)(de)(de)(de)(de)(de)(de)學(xue)(xue)(xue)者(zhe)(zhe)(zhe)認(ren)(ren)(ren)為成(cheng)(cheng)(cheng)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)細胞(bao)(bao)是(shi)來(lai)源于有(you)(you)(you)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)形成(cheng)(cheng)(cheng)本(ben)能(neng)的(de)(de)(de)(de)(de)(de)(de)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)祖先細胞(bao)(bao)，見(jian)于骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)的(de)(de)(de)(de)(de)(de)(de)表(biao)面(mian)及(ji)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)髓腔內(nei)(nei)(nei)，隨(sui)著(zhu)這種細胞(bao)(bao)的(de)(de)(de)(de)(de)(de)(de)繁殖，形成(cheng)(cheng)(cheng)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)環圈，從骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)兩端向骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)線進(jin)(jin)發“會師”融合(he)，將斷(duan)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)“焊接”起來(lai)。也有(you)(you)(you)的(de)(de)(de)(de)(de)(de)(de)學(xue)(xue)(xue)者(zhe)(zhe)(zhe)認(ren)(ren)(ren)為血腫(zhong)(zhong)機(ji)化(hua)(hua)(hua)(hua)(hua)，機(ji)化(hua)(hua)(hua)(hua)(hua)后(hou)的(de)(de)(de)(de)(de)(de)(de)血腫(zhong)(zhong)通過(guo)(guo)附(fu)近(jin)的(de)(de)(de)(de)(de)(de)(de)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)膜(mo)(mo)代骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)的(de)(de)(de)(de)(de)(de)(de)誘導，逐漸變(bian)為軟骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)，軟骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)再(zai)鈣(gai)化(hua)(hua)(hua)(hua)(hua)、骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)化(hua)(hua)(hua)(hua)(hua)。還有(you)(you)(you)的(de)(de)(de)(de)(de)(de)(de)學(xue)(xue)(xue)者(zhe)(zhe)(zhe)認(ren)(ren)(ren)為血腫(zhong)(zhong)部位的(de)(de)(de)(de)(de)(de)(de)血運差，骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)附(fu)近(jin)的(de)(de)(de)(de)(de)(de)(de)扭轉。剪力(li)(li)(li)和(he)(he)(he)成(cheng)(cheng)(cheng)角動(dong)(dong)力(li)(li)(li)大，是(shi)促使骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)癡由軟骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)內(nei)(nei)(nei)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)化(hua)(hua)(hua)(hua)(hua)形成(cheng)(cheng)(cheng)的(de)(de)(de)(de)(de)(de)(de)主要原因。Trueta認(ren)(ren)(ren)為修復(fu)來(lai)自血管壁(bi)(bi)的(de)(de)(de)(de)(de)(de)(de)內(nei)(nei)(nei)皮細胞(bao)(bao)。他在最后(hou)總結經驗時指(zhi)出：“關(guan)于骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)愈合(he)的(de)(de)(de)(de)(de)(de)(de)機(ji)理(li)還不(bu)十分明白(bai)，但(dan)有(you)(you)(you)一點(dian)(dian)可以(yi)肯定即骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)質是(shi)有(you)(you)(you)鈣(gai)鹽沉著(zhu)的(de)(de)(de)(de)(de)(de)(de)部分硬化(hua)(hua)(hua)(hua)(hua)的(de)(de)(de)(de)(de)(de)(de)‘有(you)(you)(you)機(ji)軟組織(zhi)’，它的(de)(de)(de)(de)(de)(de)(de)組織(zhi)者(zhe)(zhe)(zhe)是(shi)有(you)(you)(you)成(cheng)(cheng)(cheng)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)機(ji)能(neng)的(de)(de)(de)(de)(de)(de)(de)血管。”Leniche和(he)(he)(he)Policand認(ren)(ren)(ren)為骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)修復(fu)不(bu)僅是(shi)來(lai)自特殊(shu)細胞(bao)(bao)，而(er)(er)是(shi)原來(lai)不(bu)活動(dong)(dong)的(de)(de)(de)(de)(de)(de)(de)成(cheng)(cheng)(cheng)纖維(wei)細胞(bao)(bao)，在適當的(de)(de)(de)(de)(de)(de)(de)環境下產生(sheng)(sheng)(sheng)成(cheng)(cheng)(cheng)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)能(neng)力(li)(li)(li)，認(ren)(ren)(ren)為修復(fu)不(bu)僅來(lai)自骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)本(ben)身(shen)，而(er)(er)是(shi)周圍的(de)(de)(de)(de)(de)(de)(de)軟組織(zhi)起關(guan)鍵作用。中醫理(li)論認(ren)(ren)(ren)為活血化(hua)(hua)(hua)(hua)(hua)瘀(yu)(yu)，去(qu)瘀(yu)(yu)生(sheng)(sheng)(sheng)新。血不(bu)活則瘀(yu)(yu)不(bu)去(qu)，瘀(yu)(yu)不(bu)去(qu)則骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)不(bu)能(neng)接也。筆者(zhe)(zhe)(zhe)認(ren)(ren)(ren)為以(yi)上的(de)(de)(de)(de)(de)(de)(de)學(xue)(xue)(xue)說都在血腫(zhong)(zhong)機(ji)化(hua)(hua)(hua)(hua)(hua)過(guo)(guo)程(cheng)(cheng)中實現。血腫(zhong)(zhong)機(ji)化(hua)(hua)(hua)(hua)(hua)過(guo)(guo)程(cheng)(cheng)中包括(kuo)了(le)(le)這些論點(dian)(dian)：骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)后(hou)，局部的(de)(de)(de)(de)(de)(de)(de)血腫(zhong)(zhong)就是(shi)使原來(lai)不(bu)活動(dong)(dong)的(de)(de)(de)(de)(de)(de)(de)成(cheng)(cheng)(cheng)纖維(wei)細胞(bao)(bao)產生(sheng)(sheng)(sheng)成(cheng)(cheng)(cheng)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)能(neng)力(li)(li)(li)的(de)(de)(de)(de)(de)(de)(de)適當環境，是(shi)血腫(zhong)(zhong)刺激(ji)并(bing)激(ji)活了(le)(le)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)斷(duan)端附(fu)近(jin)的(de)(de)(de)(de)(de)(de)(de)內(nei)(nei)(nei)外(wai)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)膜(mo)(mo)及(ji)周圍的(de)(de)(de)(de)(de)(de)(de)軟組織(zhi)，引發了(le)(le)骨(gu)(gu)(gu)(gu)(gu)(gu)(gu)(gu)內(nei)(nei)(nei)外(wai)膜(mo)(mo)增(zeng)生(sheng)(sheng)(sheng)、變(bian)厚，纖維(wei)組織(zhi)的(de)(de)(de)(de)(de)(de)(de)增(zeng)生(sheng)(sheng)(sheng)、毛細血管的(de)(de)(de)(de)(de)(de)(de)增(zeng)生(sheng)(sheng)(sheng)和(he)(he)(he)附(fu)近(jin)血管壁(bi)(bi)的(de)(de)(de)(de)(de)(de)(de)生(sheng)(sheng)(sheng)化(hua)(hua)(hua)(hua)(hua)反應。這些變(bian)化(hua)(hua)(hua)(hua)(hua)是(shi)隨(sui)血腫(zhong)(zhong)的(de)(de)(de)(de)(de)(de)(de)進(jin)(jin)一步機(ji)化(hua)(hua)(hua)(hua)(hua)而(er)(er)發生(sheng)(sheng)(sheng)和(he)(he)(he)發展的(de)(de)(de)(de)(de)(de)(de)。

五、臨床觀察與分析

在(zai)(zai)臨床中筆者隨機(ji)閱片(pian)(pian)多(duo)年，對不(bu)(bu)(bu)(bu)同(tong)類(lei)型的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)和(he)(he)不(bu)(bu)(bu)(bu)同(tong)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)治(zhi)療(liao)方法進(jin)行(xing)觀察，通過分類(lei)對比(bi)(bi)(bi)(bi)(bi)和(he)(he)分析(xi)，發現在(zai)(zai)影響(xiang)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)愈合的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)客觀因素相(xiang)(xiang)似(si)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)情況下，治(zhi)療(liao)方法不(bu)(bu)(bu)(bu)同(tong)和(he)(he)局(ju)部(bu)(bu)有(you)(you)(you)無血(xue)(xue)(xue)(xue)(xue)腫對骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)形(xing)成(cheng)(cheng)(cheng)(cheng)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)早(zao)(zao)晚(wan)差(cha)異(yi)很大：正(zheng)(zheng)確(que)可(ke)(ke)靠的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)外固(gu)(gu)(gu)定(ding)(ding)比(bi)(bi)(bi)(bi)(bi)正(zheng)(zheng)確(que)可(ke)(ke)靠的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)內(nei)(nei)(nei)固(gu)(gu)(gu)定(ding)(ding)骨(gu)(gu)(gu)(gu)(gu)(gu)癡形(xing)成(cheng)(cheng)(cheng)(cheng)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)早(zao)(zao)，外固(gu)(gu)(gu)定(ding)(ding)一(yi)般(ban)在(zai)(zai)10～30天(tian)內(nei)(nei)(nei)，攝片(pian)(pian)可(ke)(ke)見(jian)骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)形(xing)成(cheng)(cheng)(cheng)(cheng)；而內(nei)(nei)(nei)固(gu)(gu)(gu)定(ding)(ding)則在(zai)(zai)40——90天(tian)內(nei)(nei)(nei)攝片(pian)(pian)可(ke)(ke)見(jian)骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)。正(zheng)(zheng)確(que)可(ke)(ke)靠的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)髓內(nei)(nei)(nei)針(zhen)固(gu)(gu)(gu)定(ding)(ding)比(bi)(bi)(bi)(bi)(bi)正(zheng)(zheng)確(que)可(ke)(ke)靠的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)鋼(gang)(gang)板(ban)內(nei)(nei)(nei)固(gu)(gu)(gu)定(ding)(ding)骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)形(xing)成(cheng)(cheng)(cheng)(cheng)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)早(zao)(zao)。同(tong)樣(yang)(yang)正(zheng)(zheng)確(que)可(ke)(ke)靠的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)內(nei)(nei)(nei)固(gu)(gu)(gu)定(ding)(ding)，對位(wei)(wei)(wei)(wei)對線欠佳的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)比(bi)(bi)(bi)(bi)(bi)對位(wei)(wei)(wei)(wei)對線良好的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)早(zao)(zao)，小的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)骨(gu)(gu)(gu)(gu)(gu)(gu)缺如比(bi)(bi)(bi)(bi)(bi)對位(wei)(wei)(wei)(wei)嚴密(mi)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)早(zao)(zao)。橫行(xing)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)比(bi)(bi)(bi)(bi)(bi)斜(xie)行(xing)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)早(zao)(zao)。小夾板(ban)固(gu)(gu)(gu)定(ding)(ding)比(bi)(bi)(bi)(bi)(bi)石(shi)膏(gao)固(gu)(gu)(gu)定(ding)(ding)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)早(zao)(zao)。在(zai)(zai)切開復(fu)位(wei)(wei)(wei)(wei)內(nei)(nei)(nei)固(gu)(gu)(gu)定(ding)(ding)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)手術中，亦觀察到骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)后(hou)7～10天(tian)手術時(shi)局(ju)部(bu)(bu)有(you)(you)(you)血(xue)(xue)(xue)(xue)(xue)腫的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)術中可(ke)(ke)見(jian)到血(xue)(xue)(xue)(xue)(xue)腫己不(bu)(bu)(bu)(bu)同(tong)程度的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)機(ji)化(hua)(hua)，骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)斷(duan)端(duan)間隙(xi)(xi)及其周(zhou)圍(wei)有(you)(you)(you)骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)，它緊(jin)貼于(yu)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)斷(duan)端(duan)間隙(xi)(xi)表面(mian)，用手指不(bu)(bu)(bu)(bu)易剝離；而局(ju)部(bu)(bu)無血(xue)(xue)(xue)(xue)(xue)腫或血(xue)(xue)(xue)(xue)(xue)腫很小者則見(jian)不(bu)(bu)(bu)(bu)到骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)。出(chu)現骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)有(you)(you)(you)無或早(zao)(zao)晚(wan)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)這種差(cha)異(yi)，主要是因為(wei)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)局(ju)部(bu)(bu)內(nei)(nei)(nei)環(huan)境(jing)(jing)存(cun)在(zai)(zai)著差(cha)異(yi)即有(you)(you)(you)無血(xue)(xue)(xue)(xue)(xue)腫這個適當(dang)環(huan)境(jing)(jing)。外固(gu)(gu)(gu)定(ding)(ding)，血(xue)(xue)(xue)(xue)(xue)腫存(cun)在(zai)(zai)，骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)局(ju)部(bu)(bu)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)適當(dang)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)內(nei)(nei)(nei)環(huan)境(jing)(jing)未受(shou)到干(gan)擾和(he)(he)破(po)(po)壞，因此(ci)骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)就形(xing)成(cheng)(cheng)(cheng)(cheng)早(zao)(zao)；而切開復(fu)位(wei)(wei)(wei)(wei)內(nei)(nei)(nei)固(gu)(gu)(gu)定(ding)(ding)，血(xue)(xue)(xue)(xue)(xue)腫被徹底(di)清除，骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)斷(duan)端(duan)及其周(zhou)圍(wei)軟組織(zhi)缺少血(xue)(xue)(xue)(xue)(xue)腫這個適當(dang)環(huan)境(jing)(jing)和(he)(he)血(xue)(xue)(xue)(xue)(xue)腫機(ji)化(hua)(hua)這一(yi)重(zhong)要過程，因此(ci)骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)就形(xing)成(cheng)(cheng)(cheng)(cheng)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)晚(wan)。髓內(nei)(nei)(nei)針(zhen)固(gu)(gu)(gu)定(ding)(ding)與鋼(gang)(gang)板(ban)固(gu)(gu)(gu)定(ding)(ding)相(xiang)(xiang)比(bi)(bi)(bi)(bi)(bi)，髓內(nei)(nei)(nei)針(zhen)固(gu)(gu)(gu)定(ding)(ding)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)斷(duan)端(duan)間隙(xi)(xi)不(bu)(bu)(bu)(bu)及鋼(gang)(gang)板(ban)固(gu)(gu)(gu)定(ding)(ding)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)嚴密(mi)，固(gu)(gu)(gu)定(ding)(ding)后(hou)髓腔及骨(gu)(gu)(gu)(gu)(gu)(gu)質(zhi)滲血(xue)(xue)(xue)(xue)(xue)較鋼(gang)(gang)板(ban)固(gu)(gu)(gu)定(ding)(ding)相(xiang)(xiang)對要多(duo)，仍能形(xing)成(cheng)(cheng)(cheng)(cheng)陰(yin)性(xing)血(xue)(xue)(xue)(xue)(xue)腫，相(xiang)(xiang)對改善了內(nei)(nei)(nei)環(huan)境(jing)(jing)。粉碎(sui)性(xing)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)及小的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)骨(gu)(gu)(gu)(gu)(gu)(gu)缺如亦同(tong)樣(yang)(yang)較橫行(xing)或斜(xie)行(xing)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)術后(hou)滲血(xue)(xue)(xue)(xue)(xue)較多(duo)，亦能形(xing)成(cheng)(cheng)(cheng)(cheng)一(yi)定(ding)(ding)血(xue)(xue)(xue)(xue)(xue)腫，為(wei)骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)形(xing)成(cheng)(cheng)(cheng)(cheng)創造了適當(dang)的(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)(de)內(nei)(nei)(nei)環(huan)境(jing)(jing)。橫行(xing)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)術后(hou)相(xiang)(xiang)對比(bi)(bi)(bi)(bi)(bi)斜(xie)行(xing)骨(gu)(gu)(gu)(gu)(gu)(gu)折(zhe)(zhe)(zhe)術后(hou)斷(duan)端(duan)間隙(xi)(xi)大，滲血(xue)(xue)(xue)(xue)(xue)多(duo)。而小夾板(ban)固(gu)(gu)(gu)定(ding)(ding)與石(shi)膏(gao)固(gu)(gu)(gu)定(ding)(ding)相(xiang)(xiang)比(bi)(bi)(bi)(bi)(bi)，雖然內(nei)(nei)(nei)環(huan)境(jing)(jing)一(yi)樣(yang)(yang)未受(shou)到破(po)(po)壞和(he)(he)干(gan)擾，但石(shi)膏(gao)性(xing)寒涼不(bu)(bu)(bu)(bu)利(li)于(yu)活(huo)血(xue)(xue)(xue)(xue)(xue)化(hua)(hua)瘀、促進(jin)血(xue)(xue)(xue)(xue)(xue)腫早(zao)(zao)期機(ji)化(hua)(hua)，所以骨(gu)(gu)(gu)(gu)(gu)(gu)痂(jia)(jia)(jia)形(xing)成(cheng)(cheng)(cheng)(cheng)有(you)(you)(you)差(cha)異(yi)。

六、血腫(zhong)、血腫(zhong)機化對骨(gu)痂形成(cheng)的意義

從骨(gu)(gu)折(zhe)后局部病理生(sheng)理變(bian)(bian)化(hua)，血(xue)(xue)腫(zhong)(zhong)(zhong)病理生(sheng)理變(bian)(bian)化(hua)、血(xue)(xue)腫(zhong)(zhong)(zhong)機(ji)(ji)(ji)化(hua)與(yu)(yu)(yu)骨(gu)(gu)痂(jia)形(xing)成(cheng)(cheng)過程、骨(gu)(gu)折(zhe)愈合機(ji)(ji)(ji)理的(de)(de)(de)理論及(ji)(ji)臨床資料(liao)(liao)分類(lei)對(dui)比分析(xi)可知(zhi)，血(xue)(xue)腫(zhong)(zhong)(zhong)在(zai)24小時內(nei)就能(neng)(neng)刺(ci)激骨(gu)(gu)膜(mo)增生(sheng)肥厚(hou)、成(cheng)(cheng)骨(gu)(gu)細胞(bao)(bao)增生(sheng)，并(bing)刺(ci)激其周(zhou)(zhou)圍的(de)(de)(de)纖維組織增主及(ji)(ji)毛細血(xue)(xue)管(guan)的(de)(de)(de)增生(sheng)，使原來不活動的(de)(de)(de)成(cheng)(cheng)纖維細胞(bao)(bao)產生(sheng)成(cheng)(cheng)骨(gu)(gu)能(neng)(neng)力，這些(xie)生(sheng)理生(sheng)化(hua)反應是(shi)依賴血(xue)(xue)腫(zhong)(zhong)(zhong)這個(ge)適(shi)當(dang)的(de)(de)(de)環(huan)境，在(zai)這個(ge)適(shi)當(dang)的(de)(de)(de)環(huan)境中(zhong)(zhong)被(bei)激活的(de)(de)(de)，并(bing)隨著血(xue)(xue)腫(zhong)(zhong)(zhong)機(ji)(ji)(ji)化(hua)而發展(zhan)的(de)(de)(de)。綜上(shang)所述，血(xue)(xue)腫(zhong)(zhong)(zhong)對(dui)骨(gu)(gu)痂(jia)形(xing)成(cheng)(cheng)可歸納為以下幾個(ge)意義：骨(gu)(gu)折(zhe)斷(duan)端(duan)及(ji)(ji)其周(zhou)(zhou)圍的(de)(de)(de)軟(ruan)組織是(shi)在(zai)血(xue)(xue)腫(zhong)(zhong)(zhong)這個(ge)適(shi)當(dang)的(de)(de)(de)環(huan)境中(zhong)(zhong)被(bei)激活，使它們具有產生(sheng)成(cheng)(cheng)骨(gu)(gu)細胞(bao)(bao)的(de)(de)(de)能(neng)(neng)力；血(xue)(xue)腫(zhong)(zhong)(zhong)是(shi)骨(gu)(gu)痂(jia)形(xing)成(cheng)(cheng)基礎和前提(ti)，骨(gu)(gu)痂(jia)是(shi)通過血(xue)(xue)腫(zhong)(zhong)(zhong)機(ji)(ji)(ji)化(hua)形(xing)成(cheng)(cheng)的(de)(de)(de)；血(xue)(xue)腫(zhong)(zhong)(zhong)是(shi)骨(gu)(gu)折(zhe)斷(duan)端(duan)間隙充填材料(liao)(liao)，是(shi)成(cheng)(cheng)骨(gu)(gu)細胞(bao)(bao)向骨(gu)(gu)折(zhe)線爬(pa)行的(de)(de)(de)橋(qiao)梁；血(xue)(xue)腫(zhong)(zhong)(zhong)機(ji)(ji)(ji)化(hua)是(shi)骨(gu)(gu)折(zhe)愈合的(de)(de)(de)重要(yao)過程，是(shi)軟(ruan)骨(gu)(gu)細胞(bao)(bao)分化(hua)的(de)(de)(de)前提(ti)和新生(sheng)骨(gu)(gu)的(de)(de)(de)基礎。總之(zhi)血(xue)(xue)腫(zhong)(zhong)(zhong)與(yu)(yu)(yu)血(xue)(xue)腫(zhong)(zhong)(zhong)機(ji)(ji)(ji)化(hua)的(de)(de)(de)過程，既概(gai)括了諸家學(xue)者關于骨(gu)(gu)折(zhe)愈合機(ji)(ji)(ji)理的(de)(de)(de)學(xue)說并(bing)與(yu)(yu)(yu)這些(xie)理論相(xiang)(xiang)吻合，亦與(yu)(yu)(yu)中(zhong)(zhong)醫治療骨(gu)(gu)折(zhe)的(de)(de)(de)傳統說法相(xiang)(xiang)符合。

結語：血腫、血腫機(ji)化(hua)(hua)的意義(yi)不(bu)僅在(zai)理論(lun)上要確認，而且(qie)在(zai)臨床治療(liao)中(zhong)更應注意應用。在(zai)現代的骨(gu)折(zhe)治療(liao)中(zhong)，仍(reng)應借(jie)鑒(jian)和(he)發揚中(zhong)國(guo)中(zhong)醫(yi)傳統接骨(gu)及用藥(yao)的經驗，達到因(yin)勢利(li)導，順(shun)乎自然，盡可能避免或少誤用切開復位手(shou)術(shu)，使骨(gu)折(zhe)后(hou)局(ju)部的適當的內環境不(bu)受(shou)干擾和(he)破壞，因(yin)勢利(li)導對血腫吸收和(he)機(ji)化(hua)(hua)的有(you)利(li)因(yin)素，克服(fu)不(bu)利(li)因(yin)素，保證骨(gu)折(zhe)的早期愈合。

附；典型病例

患者徐某，男，43歲(sui)，農民(min)。因車禍傷，右股導干骨折并雙(shuang)下肢廣泛(fan)(fan)皮損(sun)，因皮膚廣泛(fan)(fan)損(sun)傷，當也醫院(yuan)未作骨處理。l月后因綠膿(nong)桿菌感染轉我院(yuan)治療。于60天攝片(pian)示：右股骨干兩端分離約5cm，中間有一大骨片(pian)連接己呈畸(ji)形愈(yu)合，曾試(shi)用手法加壓復(fu)位失敗。

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