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河南省洛阳正骨医院（河南省骨科医院） 骨盆髋臼损伤微创诊疗研究组 E-mail：china_pelvis@163.com WeChat：doc_humane200119 Cell phone：13643878285 著作权声明：本图文原创，享有著作权。
手感的训练：从骶髂螺钉垫片被驱入髂骨说起 唯有努力自己，才不辜负光阴  My heartis overflowing with PELVS affairs, and my brain also occupied by thoughts allabout them. If I can’t do them better, I must reinforce my heart and brain muchmore energetically. ——蔡鸿敏 | Miles Stone 2021-12-24 【本期关键词】 手术操作手感、骶髂螺钉、经骶骨侧翼压缩骨折且经髂骨新月形骨折的骶髂关节损伤（脱位）、骨盆骨折、骨质疏松。 曾几何时，我在看到Joel M. Matta发文教训Milton Lee (Chip) Routt Jr. 只凭借透视和空心钉来打骶髂螺钉时，心中多是愤愤不平，对于他所说的“手感很重要”，虽然承认，但也不以为然。随着自己头上的白发、经历的事情越来越多以及脑中的思考越来越纷繁细致，才真正地体会到“领航者”的每一言每一语、每一字每一句的金贵。“不听老人言”，何其稚嫩！
跟严谨和标准的透视监视相比，操作手感的重要性虽不能与之平分秋色，但也绝不是可以不被重视的。凡事都有多面性，越是研究和了解的多，越是能看到唾手可得的书籍资料上所记录的泾渭分明的一面的另些面。单就骨盆髋臼微创的相关透视像而言，如果您认为那就是它们的真面目而信以为真且不求甚解的话，您可能就离吃亏不远了；除了深究它们不轻易为人知的其他方面外，手感也是确保我们能精准置入微创螺钉的诀窍，二者互补，相得益彰。因此，我往期文章里曾不止一次地提到过包括听觉、触觉反馈在内的广义的操作手感。
不懂解剖也没有手感示例1
不懂解剖也没有手感示例2
不懂解剖也没有手感示例3
没有手感到“蛮”示例：久钻不进，就该停下来想想了
操作手感的培养是一个长期的、细致的、用心的过程，重视起来之后，我们无需只争朝夕，慢慢来就是了。这个题目，或许应该是道有用的学问，没有见诸于书籍、文献，或许是因为它多有“只可意会，不可言传”的因素？那么，我们大家就一起来努力试试吧！尽管在这方面没有系统的理论研究，但有一点我要着重强调：骨外科绝非力量的靶场，强大的力量会滤除精细的手感，甚至导致操作失误，而且不经意间显示出操作者的“粗”和“蛮”：一手拧入螺钉，另一手在对侧奋力对抗，他就是不明白螺钉还有“自攻自钻”属性；一手在二窗触诊四边体，另一手钻孔，只知道用力推进动力钻来驱动克氏针尖旋进，没有细细体会针尖在骨皮质内的旋震，不懂得在针尖将将钻透骨皮质的时候的手上的那种“收”和“离”的劲儿，结果把自己的手指钻透并钉在病人骨盆上；一味地、不停地使足前臂、腕和手的力量，拧啊拧，拧得骶髂螺钉穿透骶椎体侧前方骨皮质，进入真骨盆两厘米长，把自己的脸吓绿……其实，通过听觉反馈和触觉感知，我们慢慢地、积极地训练手感，就会越来越自如地施展手上的那种进和收的力道，我们就能判断出螺钉在骨内行进的大致位置，例如我们能清楚地分辨出导针在骨性通道内行进的“路段”，感知到螺钉突破骶髂关节两层骨皮质，经过骶骨侧翼松质骨，进入骶椎体相对密实的松质骨内的过程，我们还能在钻头将将要钻透长管状骨的厚皮质的时候发挥手上的往回收的劲儿，以至于不让钻头落空太过于明显而损伤软组织。 此文所列举病例——一个经骶骨侧翼压缩骨折且经髂骨新月形骨折的骶髂关节损伤——是最近关于疏忽操作手感而导致失误的：骶髂关节拉力螺钉的垫片被驱入髂骨内，从而丢失了固定力。当然，这个病例有他的特殊性——骶髂螺钉入点离骨折端近和术中感知到的骨质疏松等，但这不是失误的根本原因，对操作手感无感才是。来看详细的图片说明吧。
骶髂螺钉导针很顺利就位。螺钉置入操作开始。注意空心钉的“自攻自钻”特性，骨盆所有部位的骨质都无需钻孔和攻丝！ The guidewires were positioned nice and easy. Screw inserting started,without forgetting the self-drilling-and-tapping property of the screw whichnecessitated no more manipulations of drilling and tapping.
透视髂骨入口位像，显示髂骨翼后部的外板，监视螺钉就位。此时，垫片离髂骨外板不足1cm啦。 The iliac inlet view was taken to display the outer iliac table whichprovided the screw with a practical radiographic anatomical landmark to secureits final position, noting that the washer was close to the landmark of thetable at a distance no more than 1 cm.
忘记什么啦？对啊，就是“要结合操作手感”啊！另外，还有理性思维啊！唉！垫片被搞到髂骨翼松质骨里啦，再来就要进骶髂关节啦！ Forgot what? Right, the sensation of manipulation with which the insertionwas done in combination. What was more, never forgot the rational thinking.Gosh! What happened? The washer was driven into the ilium. With a little bitmore force, it would be lost in the sacroiliac joint! 看见这，是不是有点慌啦？不管它，就这样？反正还有骶2骶髂螺钉嘛！不行，难看，关键是，没有了固定力！对这种韧带完全失用的骨折类型，螺钉固定力是成功的关键。还是翻修吧！ Confronting the situation, the surgeon could not help himself beingworried. Let it go. It was it. Anyhow, we still had S2 screw. No way! It wasnot a thing of good-or-bad look, but a business of fixation strength. As tosuch a fracture type where the ligaments were all in disfunction, a key tosuccess was just the fixation strength of the iliosacral screws. So, let therevision begin!
我来！退出一段螺钉看看。垫圈怎么可能顺着螺钉的光杆移动一丝一毫呢？ Let me take charge. Backing out a length of the screw, we took a look atwhat would happen. Noting! How could the washer move any tiny stride over asmooth round shaft of the screw?
既然有了一点加压所致骨折端的改变，那还是先置入骶2位置螺钉吧。回过头儿来再搞它。 Now that noting some shift of the fragment driven by the lag screw and thewasher, I decided to insert the S2 screw first. When it was done, I then tookcare of the washer wholeheartedly.
骶2就位啦。来吧，多退一段骶1骶髂螺钉，用细克氏针折个钩子，钩钩试试？ OK, it was done. Come on, let us retreat the lag screw a little more.Bending a K-wire 1.5 mm in diameter into a hook, I tried to catch the washerfor some times.  蹭着它会动，说明它比较松散，还好，继续努力吧！ It was moving when touched by the hook, giving us the fact that it wasloosely settled there. OK, not bad. I kept trying some more. 唉，就是不行！这就好像是“大海捞针”或者“隔靴搔痒”，既难办，又不解决问题。 Finally, it didn’t work! Acting like looking for a needle in the ocean orscratching an itch outside of the boot, it was not only difficult but alsouseless. 他说，直接退钉，用螺纹把它带出来。我问，有用吗，难道忘记它是怎么上到螺钉上的啦？ The situation maker said that we could back out the screw and let thethreats take the washer out. I replied that it couldn’t be applicable if wedidn’t forget how the washer was put over the shaft. 手不停地忙活着，脑子在飞速地翻腾着…… With my hands being busy of trying, my brain was racking in findingsolutions.
好吧！既然钩不到它，何不穿住它，那时，再退钉，螺纹和克氏针就能撑死它，然后再把它薅出来。嗯，螺纹的用处在这里，他说的话虽不那么解决问题，但还是提醒了我，正所谓“三人行，必有我师焉”！ Alright! Now that it couldn’t be hooked, why not went through it! Puttingthe K-wire through the washer and then retreating the screw, the threats wouldbite the washer firmly followed by pulling out them in whole.
诶？等等。薅出来，干嘛？不如留着它们，包括导针，也好作为参照，我再搞一根螺钉进去不好吗？ Were you sure? Why took them out? Why not kept them there as a referencefor placing another screw?
就这么干！嗯，有参考，搞着确实省时省力。很快，骶1新导针就妥啦。 Good! Let’s do it. With the reference being there, we inserted the guidewireof the third iliosacral screw efficiently.
那就拧钉子吧？对，再来个位置螺钉。还是髂骨入口位像。 It then was the time to put the screw in position. Yes, it was a better chooseto insert a position screw. Sure, let the iliac inlet view be on the screen.
还好，还好！新螺钉尾端跟垫圈虽然近乎儿，但似乎并不打架，那就直接拧到位，那么钉屁股就可以顶住垫圈，省得它再掉进去，也算是重建了髂骨外板。 Not bad! Although being approximate to the washer, the screw was not interferingwith it and was inserted in position. Due to their proximity to each other, thebottom of the screw could, acting as a reconstructed outer iliac table, preventthe washer being sunken into the bone once again.
把那个问题螺钉拧进去吧。注意啊，注意什么？嗨，又忘啦？手感嘛！俩手指搓着拧，细细体会，那种阻力突然增加的劲儿！ Ok, let’s move the screw in. Pay attention! To what? Hey, didn’t you be soforgetful. To the sensation of the screw being driven in. Now that the bone wasosteoporotic, two fingers could generate enough force by gentle turning of thescrew driver. During the inserting process, we made sure of feeling the sensationchange of the counterforce passed through the screw and back to the fingers.
嗯，不错不错！这次漂亮啦，也算是认真体会手感是怎么回事啦！ All right, well done! This time the sensation of manipulation was somewhat clear.
好吧！完成任务，下台！ Ok, it done. Let’s the coffee be ready. 此病例的术前后影像资料如下：
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来自： 豆子htpuvvjjvj > 《骨盆髋臼》
