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1、脊柱和骨盆骨折2中山大学外科学问题？如何诊断脊柱脊髓损伤？骨盆骨折的治疗原则？Fracture of Spine&PelvisOrthopedics Dep.Jin WangTips of This TalkReally difficult and complexPlenty of new wordsEven hard for residentsSeat backHave funAsk questionsFollowing the brain storming Forget the testSpinal fractures脊柱骨折Spinal Cord Injury脊髓损伤The Injury
2、 of the spineFractures and dislocations of the spine are serious injuries that most commonly occur in young peopleNearly 43%of patients with spinal cord injuries sustain multiple injuries Trauma Center&Spine CenterAnatomy of Vertebral ColumnComposed of alternating bony vertebrae and fibrocartilagino
3、us discs that are connected by strong ligaments and supported by musculature that extends from the skull to the pelvis and provides axial support to the body A typical vertebra is composed of an anterior body and a posterior arch made up of two pedicles and two laminae that are united posteriorly to
4、 form the spinous process The three columns of the spineThe anterior column(A)consists of the anterior longitudinal ligament,anterior part of the vertebral body,and the anterior portion of the annulus fibrosisThe middle column(B)consists of the posterior longitudinal ligament,posterior part of the v
5、ertebral body,and posterior portion of the annulusThe posterior column(C)consists of the bony and ligamentous posterior elementsEvaluation of Spinal Injury HISTORY Mechanism of injury Common causes:motor vehicle accidents,falls,diving accidents,and gunshot woundsPHYSICAL EXAMINATION NEUROLOGICAL EVA
6、LUATION NEUROLOGICAL EVALUATIONSensory,motor,and reflex function,is important in determining prognosis and treatment Neurologic examination recommended by the American Spinal Injury Association(ASIA)Sensory Examination Dermatome landmarks-the nipple line(T4),xiphoid process(T7),umbilicus(T10),and in
7、guinal region(T12,L1),as well as the perineum and perianal region(S2,S3,and S4)Evidence of sacral sensory sparing can establish the diagnosis of an incomplete spinal cord injuryMotor Examination The extremities and trunkSacral motor sparing-voluntary rectal sphincter/toe flexor contractionsIf volunt
8、ary contraction of the sacrally innervated muscles is present,then the prognosis for recovery of motor function is good.screening examination of the lower extremities assesses the motor function of the lumbar and first sacral nerve roots:hip adductors L1-L2;knee extension L3-L4;knee flexion L5-S1;gr
9、eat toe extension L5;and great toe flexion S1Reflexes examinationPhysical reflexesPathology reflexesRoentgenographic Examination The initial-a lateral view of the cervical spine&anteroposterior views of the chest and pelvisEasy missed:the odontoid process or the cervicothoracic junctionCervic PTS-An
10、teroposterior,lateral,right/left oblique projectionsStandard radiographs of the cervical spine Flexion-extension views Other Imaging examinationComputed Tomography(CT)Magnetic Resonance Imaging(MRI)Injuries to osseous,ligamentous,and neurological structures-be evaluated accurately CT-helpful in eval
11、uating the degree of compromise of the spinal canal Images from a screening computed tomography(CT).Emergency Room Management The initial examination-general surgery,anesthesia,respiratory,neurosurgery,and orthopaedic specialistsHypotension,hypothermia,and bradycardia-3 changes in vital signs-sugges
12、t a cervical or upper thoracic fracture with spinal cord injury above the level of T6 High-dose methylprednisolone within 8 hours of injury Cervical Spine Injuries Vulnerable to injury Two particular areas:C1 to C2 and C5 to C7,C2 and C5-the most common 40%of neurological damage 10%-no obvious roent
13、genographic evidence of vertebral injury The axial CT of the atlas(C1)revealed an anterior arch fractureCLASSIFICATION The mechanistic classification Vertical Compression(VC)Distractive Flexion(DF)Compression Extension(CE)Distractive Extension(DE)Lateral Flexion(LF)Compressive Flexion(CF)TIPSInstabi
14、lityStretch TestGoals of Treatment To realign the spineTo prevent loss of function of undamaged neurological tissue To improve neurological recoveryTo obtain and maintain spinal stabilityTo obtain early functional recovery GuidelineSpinal alignment can be obtained by skeletal traction through spring
15、-loaded Gardner-Wells tongs or a halo ring Open reduction and stabilization if spinal realignment cannot be obtained by tractionNonoperative TreatmentMany cervical spine injuries can be treated without surgeryImmobilization in a rigid cervical orthosis for 8 to 12 weeks may be sufficient(Halo Vest I
16、mmobilization)Operative TreatmentUnstable injuries of the cervical spine,with or without neurological deficit,generally require operative treatmentOpen reduction and internal fixation are indicated to obtain stability and allow early functional rehabilitation Principles of operationThe injury must b
17、e clearly defined before surgery by plain roentgenograms,high-resolution CT scanning with sagittal and coronal reconstruction,or MRILaminectomy has a limited roleCompression of the cervical cord or roots by retropulsed bone fragments or disc material usually is anterior;therefore anterior decompress
18、ion and fusion,with or without internal fixation,are indicated For posterior ligamentous or bony instability,posterior stabilization with internal fixation and bone grafting are indicatedInjuries to Upper Cervical Spine(Occiput to C2)Rotary Subluxation of C1 on C2Dens Fracture Rotary Subluxation of
19、C1 on C2.Uncommon in adults By motor vehicle accidentsTorticollis and restricted neck motion-often not recognized at initial evaluationAn open-mouth odontoid roentgenogram may reveal the wink sign caused by overriding of the C1-2 joint on one side and a normal configuration on the other sideCT A hal
20、o ring or operational-a halo vest 8 to 12 weeksOdontoid fractures齿状突骨折Type I injury demonstrates an avulsion fracture of the tip of the odontoidType II fractures are located at the waist of the odontoidType III fractures extend caudally into the cancellous bone of the body of the axisDens Fracture-o
21、dontoid fractures Type I-uncommon,and even if nonunion occurs after inadequate immobilization,no instability resultsType II-the most common,36%nonunion rate for both displaced and nondisplaced fracturesType III-a large cancellous base and heal without surgery in 90%of patientsType II odontoid fractu
22、re.A solid C12 fusion was demonstratedInternal Fixation of Upper Cervical SpineHot&SpiceRecent advances in internal fixation have allowed its use in the cervical spineTraumatic Spondylolisthesis of the Axis(Hangman Fractures)Incurred during the hanging of criminalsMotor vehicle accidents with hypere
23、xtension of the headThe occiput is forced down against the posterior arch of the atlas,which in turn is forced against the pedicles of C2(Axis)A lateral radiograph shows the C-2 vertebral body in this 42-year-old woman who was in a car crash to be sagittally rotated and anteriorly displaced relative
24、 to the C-3 body.B:As expected from the plain radiographs,the axial CT images confirm bilateral fractures through the narrow part of the pars(small arrows)Type IIa hangmans fractureC:Satisfactory closed reduction could be achieved in a halo using an extended head position.D:A partial loss of reducti
25、on but solid healing of the fracture occurred after 4 months of halo immobilization.The patient has remained complaint-free after completion of her nonoperative management.Nonoperative treatment of type IIa hangmans fractureLower Cervical Spine(C3-7)The primary goals of treatment Realign the spinePr
26、event loss of function of uninjured neurological tissueImprove neurological recoveryObtain and maintain spinal stabilityObtain early functional recovery Compression flexion injuriesFlexion compression injuryThoracic and Lumbosacral Fractures The treatment of unstable fractures and fracture-dislocati
27、ons of the thoracic and lumbar spine-controversial Nonoperative treatmentOpen reduction and rigid internal fixation with posterior instrumentationlaminectomy alone is contraindicated in fracture-dislocations because it fails to relieve the anterior compression and increases spinal instability This f
28、lexion-distraction injury(seat belt fracture)was the result of an automobile accidentThe Spinal Cord Injury脊髓损伤4,500 years ago-was described as“a disease one cannot treat”.Paralysis remains incurableImproved care has allowed patients with a spinal cord injury better function,improved quality of life
29、,and prolonged survivalExperience and research continueSpinal Cord InjuryOverall,85%of patients with a spinal cord injury who survive the first 24 hours are still alive 10 years later compared with 98%of patients of similar age and sex without spinal cord injury Regional trauma centers and increased
30、 training of paramedics and emergency medical technicians-survival increased Spinal shock脊髓休克Rarely lasts longer than 24 hours,it may last for days or weeksA positive bulbocavernosus reflex or return of the anal wink reflex-indicates the end of spinal shockIf no motor or sensory function below the l
31、evel of injury can be documented when spinal shock ends,a complete spinal cord injury is present and the prognosis is poor for recovery of distal motor or sensory function Spinal Cord SyndromesDefinitionAn incomplete spinal cord injury is one in which some motor or sensory function is spared distal
32、to the cord injuryA complete spinal cord injury is manifested by total motor and sensory loss distal to the injuryWhen the bulbocavernosus reflex is positive and no sacral sensation or motor function has returned,the paralysis will be permanent and complete in most patients.Spinal Cord Syndromes Res
33、ulting from incomplete traumatic lesionsThe greater the sparing of motor and sensory functions distal to the injury,the greater the expected recovery;The more rapid the recovery,the greater the amount of recovery;When new recovery ceases and a plateau is reached,no further recovery can be expected.S
34、pinal Cord SyndromesCentral cord syndrome-a quadriparesis involving the upper extremities to a greater degree than the lowerBrown-Squard syndrome-half of the spinal cord-motor weakness on the side of the lesion and the contralateral loss of pain and temperature sensation Anterior cord syndrome Poste
35、rior cord syndrome A mixed syndrome Conus medullaris syndromeCauda equina syndromePelvic Fracture 骨盆骨折 Both pelvic bones articulate with the sacrum through the sacroiliac joints and the symphysis pubis Upper body weight is transmitted across the hip joint to lower limbs via the sciatic buttress and
36、the acetabulum The mechanism and severity of trauma will determine the pattern of injury Osteoarticular structures and adjacent soft tissues will be involved in varying degrees and combinations Treatment may require a multidisciplinary approachClinical FindingsHistory-Injury mechanism The physical e
37、xamination:Palpation-bony landmarksCompression-stabilityRectovaginal examination-a bony spike,contaminating-30-50%,closed fractures-8-15%Associated injuries-lower urinary tract injuries,distal vascular status,neurologic examinationClinical FindingsA plain anteroposterior pelvic radiograph-inlet and
38、outlet viewsJudets oblique views-acetabulum Ct scanning-further delineate Vascular and urologic imaging may also be requiredTreatmentAssociated injuries-take precedence over treatment of the pelvic fractureHemorrhage General resuscitation principles-adequate tissue perfusionHypovolemia may not be co
39、rrected by fluid and blood replacement alone Pelvic external fixator is a useful tool to manage volume depletion Internal fixation-later stageAssociated InjuriesHemorrhage-the small to medium-sized arteries and vein,Occasionally big vessels Thrombosis-a high incidence of thrombosis of the pelvic vei
40、ns,use prophylactic anticoagulation once the acute hemorrhagic phase has passed(24-48 hours)Neurologic injury-common,the roots,or the peripheral nerve itself(sciatic,femoral,obturator,pudendal,or superior gluteal).Most of-neurapraxia type-favorable outcome,10%permanent neurologic sequelaeUrogenital
41、injuriesLocation of FracturesThe pelvic ringThe acetabulum Injuries to The Pelvic Ring3%for all fractures.wide spectrum:avulsion fracture to life-threatening severely unstable pelvic ring disruptionTreatment-stable or unstableInjuries involving the pelvic ring in two or more sites create an unstable
42、 segment.The integrity of the posterior sacroiliac ligamentous complex-determine instability.Intact-rotationally unstable;disrupted,both rotationally and vertically unstableClassificationA dynamic classification system-the mechanism of injury and residual instabilityType A:involve the pelvic ring in
43、 only one place and are stableType B:two or more sites,rotationally unstable Type C:both rotationally and vertically unstable Type A FracturesType A1:Avulsion-muscle origins Type A2:the iliac wing-Isolated fractures of the iliac wing without intra-articular extension TypeA3:Obturator fractures-the p
44、ubic or ischial rami-minimally displaced Treatment of Type A Conservative treatment-usually sufficient Symptomatic,with bed rest and analgesia,early ambulation,and weight bearing as tolerated.Type B FractureInvolve the pelvic ring in two or more sites-create a segment that is rotationally unstable b
45、ut vertically stableType B1:open-book fractures occur from anteroposterior compressionType B2 and B3:lateral compression fractures.A lateral force-inward displacement of hemipelvis through the sacroiliac complex and ipsilateral(B2)or,contralateral pubic rami(B3)Treatment of Type BSymptomatic treatme
46、nt Reduction-lateral compression Manipulation under general anesthesiaReduction can be maintaintedA hip spicaBut more often external or internal fixation is currently favoredType CBoth rotationally and vertically unstableResult from a vertical shear mechanism,like a fall from a height Treatment of T
47、ype CReduction-longitudinal skeletal traction through the distal femur or the proximal tibia,8-12 weeksExternal fixation alone is insufficient to maintain reduction in highly unstable fractures,but it may help control bleeding and eases nursing careOpen reduction and internal fixation is often requi
48、redThe surgical technique is demanding,and there is a significant risk of complications.ComplicationsChronic low back pain and posterior sacroiliac pain-long-term complain,50%Nearly 5%of type C injuries-a leg length discrepancy of more than 2-5cmResidual gait abnormalities-12-32%Nonunion rate-around
49、 3%Neurologic deficit-6-10%Urologic-5-20%Fractures of the acetabulumDirect trauma on the trochanteric region Indirect axial loading through the lower limbThe position of the limb at the time of impact(rotation,flexion,abduction,or adduction)-determine the pattern of injuryComminution is commonClassi
50、ficationLetournel-based on which column is involvedThe anterior column-the anterior iliac crest,the anterior half of the acetabulum,and the pubic ramusThe posterior column-the sciatic buttress and the sciatic notch,the posterior half of the acetabulum,and the ischial tuberosityTwo oblique views,Ct s