老年股骨转子间骨折是一种常见且严重的骨质疏松性髋部骨折，致死、致残率高。近年来，国际上在老年股骨转子间骨折的诊疗方面有很多的研究和进展，加速康复外科（enhanced recovery after surgery, ERAS）理念的引入进一步提高了治疗效果[1]。但我国目前的诊疗现状并不乐观，缺乏相应的规范和指南。遵循科学性、实用性和先进性的原则，经全国数百位创伤骨科专家讨论通过，制定本指南。本指南仅适用于≥65岁低能量损伤造成的新鲜非病理性股骨转子间骨折患者。
股骨转子间骨折对老年人的影响巨大，一方面骨折后病死率增加，另一方面骨折后活动能力和生活质量下降，不能回到受伤前的生活环境，需要更高的看护级别[2-6]。虽然近年来在手术治疗和康复等方面取得了很大进步，但在很多方面仍有争议，很多问题急需改善。
股骨转子间骨折约占老年髋部骨折的50%，其发生率与老年髋部骨折的增长情况一致。我国是世界上老年人口规模最大的国家，目前进入高速老龄化时期，最终会转向重度老龄化和高龄化[7]。髋部骨折的发生率一方面与人口结构相关，随着年龄的增加而升高，如75～84岁人群在10年内髋部骨折的发生率高达7%[8]。随着我国老年人口绝对数量的增加，老年髋部骨折的人数必将快速增长。髋部骨折的发生率另一方面与不同年龄阶段人口的标化发生率相关，在唐山地区进行的调查发现，65岁以上人口髋部骨折的发生率在2010年较1994年有显著增长，男性增长85%，女性增长306%[9]。老年人年龄标化发生率的增长，是造成我国老年髋部骨折人数增长的另一个因素。
1.临床表现：患者多数会有明确外伤史，通常为低能量创伤，多主诉髋关节疼痛，部分患者主诉膝关节疼痛。移位性骨折疼痛严重，不能活动，并伴有肢体畸形。无移位骨折可能疼痛轻，甚至能够负重，要避免漏诊。2.影像学检查：正、侧位X线是首选检查。CT扫描有助于全面了解骨折形态。对于临床怀疑骨折但X线片示阴性者，推荐首选磁共振成像检查，如果没有条件可以选择核素扫描或复查X线，不推荐把CT扫描作为首选[10]。3.分型：股骨转子间骨折分型方法众多，可以简单地分为顺转子间骨折、反转子间骨折和转子下骨折。2018年AO/OTA分型[11]将股骨转子间骨折分为：①简单的顺转子间骨折（31A1型）：包括单纯大转子骨折或小转子骨折，两部分顺转子间骨折，外侧壁完整的粉碎顺转子间骨折；②外侧壁不完整的粉碎顺转子间骨折（31A2型）；③反转子间骨折（31A3型）。4.早期处理：对老年股骨转子间骨折患者在急诊室应尽早评估，尽快安排收入院治疗[12]。在急诊室建议由骨科医生和内科医生共同评估患者情况，并进行相应的紧急处理[12]。应立即进行疼痛程度评估，并尽早开始镇痛治疗，推荐进行区域阻滞麻醉镇痛[13-15]。术前不建议常规牵引，包括皮牵引和骨牵引[16-18]。
（一） 治疗原则
对于老年股骨转子间骨折，无论选择手术或非手术治疗，都存在相应的风险和并发症。由于非手术治疗病死率、致残率更高，因此对于大多数患者，手术治疗是首选。非手术治疗常常被认为是姑息性治疗，仅适用于身体状况极差，手术风险极大，预期生存时间短的患者。
在选择手术或非手术治疗时，需要依据每个患者的情况进行个体化分析，尤其要考虑内科合并疾病的严重程度，以及医生的治疗经验。对存在严重内科合并疾病的患者，常常需要医生评估手术和非手术治疗各自的风险和获益，并跟患者和家属深入沟通。
（二） 手术时机
老年股骨转子间骨折手术应尽早进行，推荐在入院48 h内手术，这时手术效果更好，包括减轻疼痛、减少并发症、缩短住院时间，而延迟手术会增加病死率[19-23]。因为内科合并疾病而延迟手术的患者病死率最高，而这些患者会由于尽早手术获益最大[10]，因此应尽快调整患者的身体情况。手术应尽量安排在常规工作时间，以便及时得到有经验医生的帮助[12]。
要达到尽早手术的目标，需要医院管理部门制定相应的流程和路径，并协调相关科室。组建多学科协作治疗组，有助于提高效率和治疗结果[2428]。建议在治疗过程中有老年科专业医生参与[12]。很多研究表明，骨科和老年科共同管理患者的模式优于传统的骨科病房收治会诊模式[25-28]。
（三） 术前准备
老年股骨转子间骨折患者常常合并有多种内科疾病，围手术期病死风险高，建议参考《中国老年患者围术期麻醉管理指导意见(2014)》尽快进行系统、全面的评估[29-31]。着重评估重要脏器系统功能，此外还建议评估患者的认知功能和营养状况。在评估时除了询问病史和体格检查，需要进行必要的辅助检查，比如：血常规、尿常规、生化功能、凝血功能、传染病筛查、胸片、心电图。其他的辅助检查比如心脏超声，是否需要常规进行，何时需要检查，都还存在争议。进行过多没有必要的辅助检查，可能无法降低手术风险，反而会延迟手术时间。
对患者存在的一些状况，要尽快进行调整，以利于手术的实施，这包括：循环容量不足、电解质紊乱、心力衰竭、严重血糖异常、贫血、低氧血症等。但对一些患者长期存在的情况或短期内无法改善的情况，不应为了不切实际的目标而延迟手术。比如肺部感染，在患者髋部骨折卧床的情况下很难治疗，此时不建议为彻底治愈肺部感染而长时间推迟手术[12]。
很多老年患者会因为不同的原因服用抗凝、抗栓药物，在术前准备时要考虑所用药物的类别和原因，兼顾这些药物带来的围手术期出血风险和停用这些药物带来的栓塞风险。如抗栓药物阿司匹林和氯吡格雷，目前有证据支持可以不用推迟手术时机[32-34]。如果停药后心血管系统血栓的风险低，可以停药；如果停药后血栓的风险高、尤其是对近期放置了冠状动脉内支架的患者，应该与心内科医生协商，血栓高危患者不能停药；如果术中出血量多可通过输注血小板拮抗。
（四）手术方案
对老年股骨转子间骨折，复位固定是治疗的首选，关节置换的适应证非常有限，这包括肿瘤导致的病理性骨折、严重骨质疏松（如肾性骨病）、伤前已存在严重髋关节关节炎等[35]。
老年股骨转子间骨折手术的目标是允许患者术后即可坐起活动，且允许患肢完全负重[12]。这就对手术提出了较高的要求，包括骨折复位的标准、内固定的选择和置入位置，而优良复位是达到稳定固定的前提。骨折的复位要求正、侧位均有皮质接触，避免间隙，因为这有助于分担内固定物承受的应力，降低内固定失效的风险。骨折的复位还要注意力线，避免髋内翻畸形和旋转畸形。复位需要在透视下进行，首先尝试闭合复位，如果闭合复位不能达到满意复位时，需要进行经皮撬拨复位或切开复位。
老年股骨转子间骨折常用的内固定物为动力髋螺钉和髓内钉，锁定钢板的疗效尚需证实。对于稳定型骨折，选择动力髋螺钉或髓内钉均可[36-38]；对于不稳定型骨折，优先选择髓内钉固定[37,39-43]；对于反转子间骨折或转子下骨折，优先选择髓内钉固定[44-46]。固定头颈骨折块的拉力螺钉或螺旋刀片，在透视正位应置于股骨头中下1/3，在透视侧位应置于股骨头中1/3[47-48]，并注意尖顶距<25 mm[49]。
（五）麻醉与围手术期处理
老年股骨转子间骨折手术的麻醉，建议由对老年人麻醉有经验的麻醉医生实施或在其指导下进行[12]。椎管内麻醉和全身麻醉是最常采用的麻醉方式[12]，除非存在禁忌，应首先考虑椎管内麻醉[50]。对服用抗凝抗栓药的患者，要进行针对性分析。目前无证据表明单纯服用阿司匹林或氯吡格雷会增加椎管内麻醉时血肿的风险，但对于联合双抗的患者，建议避免采用椎管内麻醉，因为椎管内血肿的风险会升高[51-53]。对使用低分子肝素的患者，可以在停药10～12 h后进行椎管内麻醉[12]。外周神经阻滞更多是一种镇痛手段，可以做为全身麻醉的辅助，也可以作为术后多模式镇痛的一部分[54]。
术中注意预防患者低体温，术中体温管理应包括常规体温监测并采用必要的保温、升温措施，如使用暖风机、覆盖保温毯、输血输液加温装置等方式来进行体温管理[55]。术后恶心呕吐（postoperative nausea and vomiting, PONV）会延迟患者术后康复，推荐采用多模式的方式预防PONV，并根据患者具体情况选择不同的预防止吐药物[56]。
术后建议转监护条件好的麻醉恢复室观察，重症患者直接转ICU治疗。对存在低氧血症的患者要进行吸氧和监护。注意水、电解质平衡，建议术后尽早恢复口服补液。建议无症状患者输血指征为血红蛋白<80 g/L[12]，对存在心源性胸痛、充血性心力衰竭、无法解释的心动过速、低血压且在输液治疗后不见好转的患者，可以适当放宽输血指征[57-59]。要注意术后疼痛的评估和处理，推荐采用包括神经阻滞在内的多模式镇痛[60]。建议预防性应用抗生素，以降低感染的风险[61]。
积极合理的康复对避免卧床并发症、恢复患者功能、预防再骨折均非常重要。建议术后24h内开始在康复医生指导下进行床上活动和康复，建议尽早开始下床活动，且允许患肢完全负重[12]。
要注意预防卧床并发症，包括褥疮、肺部感染、泌尿系感染等。自患者就诊时起，包括整个住院和康复过程，都应该进行褥疮风险的评估。对足跟、骶尾部等褥疮的高危部位，可用软垫进行保护。对褥疮的高危患者，建议选用可调节压力的充气床垫[12]。鼓励患者坐起活动，进行呼吸训练，以预防肺部感染。老年患者易发生吞咽困难而导致吸入性肺炎，应加强护理。除非必要，应尽量避免应用导尿管。谵妄在老年股骨转子间骨折患者手术前后很常见，要注意预防、评估和处理。骨折后便秘较为常见，要注意预防和治疗。
静脉血栓栓塞症的预防：老年股骨转子间骨折是静脉血栓的高危人群，建议常规预防[10]。预防措施包括基本预防、物理预防和药物预防[62]。基本预防包括尽早手术、缩短手术时间、减少手术创伤、围手术期适度补液及尽早开始康复锻炼等。物理预防包括足底静脉泵、间歇充气加压装置及梯度弹力袜等。可以选择的预防药物包括普通肝素、低分子肝素、磺达肝素、华法林、阿司匹林等，其中低分子肝素是首选，用药时间为10～14 d，可以延长至术后35 d[63]。
老年股骨转子间骨折患者，将来再发骨折的风险与无骨折者相比明显增加[64-65]，建议进行系统性预防[66]，这包括对骨质疏松的评估和治疗，以及跌倒的评估和预防[67-68]。
骨质疏松评估目的是鉴别继发性骨质疏松，判断骨质疏松的严重程度及骨转化情况。评估方法包括实验室检查和骨密度检查，腰椎与髋部双能X线吸收法是检测骨密度的首选。骨质疏松的药物治疗包括基础用药和抗骨质疏松药物。建议所有老年股骨转子间骨折患者补充钙和维生素D[69-72]。抗骨质疏松药物分为抗骨吸收药物（双磷酸盐、选择性雌激素受体调节剂等）及促骨形成药物（甲状旁腺素）2大类。有证据显示多数抗骨吸收药物并不影响骨折愈合[73-75]。多种药物联用常无显著优势，但对重度骨质疏松者，甲状旁腺素联合抗骨吸收药物的贯续治疗可能有获益[76]。
跌倒的原因很多，包括环境因素、生理因素和神经骨骼肌肉系统因素等。因此跌倒评估需要多学科联合，针对多个因素进行评估，包括：跌倒的过程、肌肉力量和平衡能力、视力状况、认知能力和神经系统状况、小便失禁情况、合并疾病情况、居住环境等[77]。相应的治疗需要个体化进行，如力量和平衡能力训练、视力评估后的治疗、服用药物的调整、居住环境安全性的评估和处理等[77]。
说明：本指南作为学术性指导意见，主要是基于文献的结果和专家的观点，具体实施时需要根据本地区、医院及患者的实际情况而定。
参考文献
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