脊柱和骨盆骨折2-中山大學(xué)-外科學(xué)

脊柱和骨盆骨折2-中山大學(xué)-外科學(xué)第一頁，共77頁。FractureofSpine&Pelvis課時數(shù)2內(nèi)容簡介脊柱骨折脊髓損傷骨盆骨折第二頁，共77頁。問題？？？如何診斷脊柱脊髓損傷？骨盆骨折的治療原則？第三頁，共77頁。FractureofSpine&PelvisOrthopedicsDep.JinWang第四頁，共77頁。TipsofThisTalkReallydifficultandcomplexPlentyofnewwordsEvenhardforresidentsSeatbackHavefunAskquestionsFollowingthebrainstormingForgetthetest第五頁，共77頁。Spinalfractures脊柱骨折SpinalCordInjury脊髓損傷第六頁，共77頁。TheInjuryofthespineFracturesanddislocationsofthespineareseriousinjuriesthatmostcommonlyoccurinyoungpeopleNearly43%ofpatientswithspinalcordinjuriessustainmultipleinjuries第七頁，共77頁。TraumaCenter&SpineCenter第八頁，共77頁。AnatomyofVertebralColumnComposedofalternatingbonyvertebraeandfibrocartilaginousdiscsthatareconnectedbystrongligamentsandsupportedbymusculaturethatextendsfromtheskulltothepelvisandprovidesaxialsupporttothebodyAtypicalvertebraiscomposedofananteriorbodyandaposteriorarchmadeupoftwopediclesandtwolaminaethatareunitedposteriorlytoformthespinousprocess第九頁，共77頁。ThethreecolumnsofthespineTheanteriorcolumn(A)consistsoftheanteriorlongitudinalligament,anteriorpartofthevertebralbody,andtheanteriorportionoftheannulusfibrosisThemiddlecolumn(B)consistsoftheposteriorlongitudinalligament,posteriorpartofthevertebralbody,andposteriorportionoftheannulusTheposteriorcolumn(C)consistsofthebonyandligamentousposteriorelements第十頁，共77頁。EvaluationofSpinalInjury

HISTORY

MechanismofinjuryCommoncauses:motorvehicleaccidents,falls,divingaccidents,andgunshotwoundsPHYSICALEXAMINATION

NEUROLOGICALEVALUATION

第十一頁，共77頁。NEUROLOGICALEVALUATIONSensory,motor,andreflexfunction,isimportantindeterminingprognosisandtreatment第十二頁，共77頁。NeurologicexaminationrecommendedbytheAmericanSpinalInjuryAssociation(ASIA)第十三頁，共77頁。SensoryExaminationDermatomelandmarks---thenippleline(T4),xiphoidprocess(T7),umbilicus(T10),andinguinalregion(T12,L1),aswellastheperineumandperianalregion(S2,S3,andS4)Evidenceofsacralsensorysparingcanestablishthediagnosisofanincompletespinalcordinjury第十四頁，共77頁。MotorExaminationTheextremitiesandtrunkSacralmotorsparing---voluntaryrectalsphincter/toeflexorcontractionsIfvoluntarycontractionofthesacrallyinnervatedmusclesispresent,thentheprognosisforrecoveryofmotorfunctionisgood.第十五頁，共77頁。第十六頁，共77頁。screeningexaminationofthelowerextremitiesassessesthemotorfunctionofthelumbarandfirstsacralnerveroots:hipadductorsL1-L2;kneeextensionL3-L4;kneeflexionL5-S1;greattoeextensionL5;andgreattoeflexionS1第十七頁，共77頁。ReflexesexaminationPhysicalreflexesPathologyreflexes第十八頁，共77頁。RoentgenographicExamination

Theinitial---alateralviewofthecervicalspine&anteroposteriorviewsofthechestandpelvisEasymissed:theodontoidprocessorthecervicothoracicjunctionCervicPTS---Anteroposterior,lateral,right/leftobliqueprojections第十九頁，共77頁。Standardradiographsofthecervicalspine

第二十頁，共77頁。Flexion-extensionviews第二十一頁，共77頁。OtherImagingexaminationComputedTomography(CT)MagneticResonanceImaging(MRI)Injuriestoosseous,ligamentous,andneurologicalstructures---beevaluatedaccuratelyCT---helpfulinevaluatingthedegreeofcompromiseofthespinalcanal第二十二頁，共77頁。Imagesfromascreeningcomputedtomography(CT).第二十三頁，共77頁。EmergencyRoomManagement

Theinitialexamination---generalsurgery,anesthesia,respiratory,neurosurgery,andorthopaedicspecialistsHypotension,hypothermia,andbradycardia----3changesinvitalsigns---suggestacervicalorupperthoracicfracturewithspinalcordinjuryabovethelevelofT6High-dosemethylprednisolonewithin8hoursofinjury第二十四頁，共77頁。CervicalSpineInjuries

VulnerabletoinjuryTwoparticularareas:C1toC2andC5toC7,C2andC5----themostcommon40%ofneurologicaldamage10%---noobviousroentgenographicevidenceofvertebralinjury第二十五頁，共77頁。TheaxialCToftheatlas(C1)revealedananteriorarchfracture第二十六頁，共77頁。CLASSIFICATION

ThemechanisticclassificationVerticalCompression(VC)

DistractiveFlexion(DF)

CompressionExtension(CE)

DistractiveExtension(DE)

LateralFlexion(LF)

CompressiveFlexion(CF)

第二十七頁，共77頁。TIPSInstabilityStretchTest第二十八頁，共77頁。GoalsofTreatment

TorealignthespineTopreventlossoffunctionofundamagedneurologicaltissueToimproveneurologicalrecoveryToobtainandmaintainspinalstabilityToobtainearlyfunctionalrecovery第二十九頁，共77頁。GuidelineSpinalalignmentcanbeobtainedbyskeletaltractionthroughspring-loadedGardner-WellstongsorahaloringOpenreductionandstabilizationifspinalrealignmentcannotbeobtainedbytraction第三十頁，共77頁。NonoperativeTreatmentManycervicalspineinjuriescanbetreatedwithoutsurgeryImmobilizationinarigidcervicalorthosisfor8to12weeksmaybesufficient(HaloVestImmobilization)第三十一頁，共77頁。OperativeTreatmentUnstableinjuriesofthecervicalspine,withorwithoutneurologicaldeficit,generallyrequireoperativetreatmentOpenreductionandinternalfixationareindicatedtoobtainstabilityandallowearlyfunctionalrehabilitation第三十二頁，共77頁。PrinciplesofoperationTheinjurymustbeclearlydefinedbeforesurgerybyplainroentgenograms,high-resolutionCTscanningwithsagittalandcoronalreconstruction,orMRILaminectomyhasalimitedroleCompressionofthecervicalcordorrootsbyretropulsedbonefragmentsordiscmaterialusuallyisanterior;thereforeanteriordecompressionandfusion,withorwithoutinternalfixation,areindicatedForposteriorligamentousorbonyinstability,posteriorstabilizationwithinternalfixationandbonegraftingareindicated第三十三頁，共77頁。InjuriestoUpperCervicalSpine(OcciputtoC2)

RotarySubluxationofC1onC2DensFracture

第三十四頁，共77頁。RotarySubluxationofC1onC2.UncommoninadultsBymotorvehicleaccidentsTorticollisandrestrictedneckmotion---oftennotrecognizedatinitialevaluationAnopen-mouthodontoidroentgenogrammayrevealthe"winksign"causedbyoverridingoftheC1-2jointononesideandanormalconfigurationontheothersideCTAhaloringoroperational---ahalovest8to12weeks第三十五頁，共77頁。Odontoidfractures齒狀突骨折TypeIinjurydemonstratesanavulsionfractureofthetipoftheodontoidTypeIIfracturesarelocatedatthewaistoftheodontoidTypeIIIfracturesextendcaudallyintothecancellousboneofthebodyoftheaxis第三十六頁，共77頁。DensFracture---odontoidfracturesTypeI---uncommon,andevenifnonunionoccursafterinadequateimmobilization,noinstabilityresultsTypeII---themostcommon,36%nonunionrateforbothdisplacedandnondisplacedfracturesTypeIII---alargecancellousbaseandhealwithoutsurgeryin90%ofpatients第三十七頁，共77頁。TypeIIodontoidfracture.AsolidC1–2fusionwasdemonstrated第三十八頁，共77頁。InternalFixationofUpperCervicalSpineHot&SpiceRecentadvancesininternalfixationhavealloweditsuseinthecervicalspine第三十九頁，共77頁。TraumaticSpondylolisthesisoftheAxis(HangmanFractures)IncurredduringthehangingofcriminalsMotorvehicleaccidentswithhyperextensionoftheheadTheocciputisforceddownagainsttheposteriorarchoftheatlas,whichinturnisforcedagainstthepediclesofC2(Axis)第四十頁，共77頁。AlateralradiographshowstheC-2vertebralbodyinthis42-year-oldwomanwhowasinacarcrashtobesagittallyrotatedandanteriorlydisplacedrelativetotheC-3body.B:Asexpectedfromtheplainradiographs,theaxialCTimagesconfirmbilateralfracturesthroughthenarrowpartofthepars(smallarrows)TypeIIahangman'sfracture第四十一頁，共77頁。C:Satisfactoryclosedreductioncouldbeachievedinahalousinganextendedheadposition.D:Apartiallossofreductionbutsolidhealingofthefractureoccurredafter4monthsofhaloimmobilization.Thepatienthasremainedcomplaint-freeaftercompletionofhernonoperativemanagement.NonoperativetreatmentoftypeIIahangman'sfracture第四十二頁，共77頁。LowerCervicalSpine(C3-7)TheprimarygoalsoftreatmentRealignthespinePreventlossoffunctionofuninjuredneurologicaltissueImproveneurologicalrecoveryObtainandmaintainspinalstabilityObtainearlyfunctionalrecovery第四十三頁，共77頁。Compressionflexioninjuries第四十四頁，共77頁。Flexioncompressioninjury第四十五頁，共77頁。ThoracicandLumbosacralFractures

Thetreatmentofunstablefracturesandfracture-dislocationsofthethoracicandlumbarspine----controversialNonoperativetreatmentOpenreductionandrigidinternalfixationwithposteriorinstrumentationlaminectomyaloneiscontraindicatedinfracture-dislocationsbecauseitfailstorelievetheanteriorcompressionandincreasesspinalinstability第四十六頁，共77頁。Thisflexion-distractioninjury(seatbeltfracture)wastheresultofanautomobileaccident第四十七頁，共77頁。第四十八頁，共77頁。TheSpinalCordInjury脊髓損傷4,500yearsago---wasdescribedas“adiseaseonecannottreat”.ParalysisremainsincurableImprovedcarehasallowedpatientswithaspinalcordinjurybetterfunction,improvedqualityoflife,andprolongedsurvivalExperienceandresearchcontinue第四十九頁，共77頁。SpinalCordInjuryOverall,85%ofpatientswithaspinalcordinjurywhosurvivethefirst24hoursarestillalive10yearslatercomparedwith98%ofpatientsofsimilarageandsexwithoutspinalcordinjuryRegionaltraumacentersandincreasedtrainingofparamedicsandemergencymedicaltechnicians----survivalincreased第五十頁，共77頁。Spinalshock脊髓休克Rarelylastslongerthan24hours,itmaylastfordaysorweeksApositivebulbocavernosusreflexorreturnoftheanalwinkreflex---indicatestheendofspinalshockIfnomotororsensoryfunctionbelowthelevelofinjurycanbedocumentedwhenspinalshockends,acompletespinalcordinjuryispresentandtheprognosisispoorforrecoveryofdistalmotororsensoryfunction第五十一頁，共77頁。SpinalCordSyndromesDefinitionAnincompletespinalcordinjuryisoneinwhichsomemotororsensoryfunctionisspareddistaltothecordinjuryAcompletespinalcordinjuryismanifestedbytotalmotorandsensorylossdistaltotheinjuryWhenthebulbocavernosusreflexispositiveandnosacralsensationormotorfunctionhasreturned,theparalysiswillbepermanentandcompleteinmostpatients.第五十二頁，共77頁。SpinalCordSyndromes

ResultingfromincompletetraumaticlesionsThegreaterthesparingofmotorandsensoryfunctionsdistaltotheinjury,thegreatertheexpectedrecovery;Themorerapidtherecovery,thegreatertheamountofrecovery;Whennewrecoveryceasesandaplateauisreached,nofurtherrecoverycanbeexpected.第五十三頁，共77頁。SpinalCordSyndromesCentralcordsyndrome---aquadriparesisinvolvingtheupperextremitiestoagreaterdegreethanthelowerBrown-Séquardsyndrome---halfofthespinalcord---motorweaknessonthesideofthelesionandthecontralaterallossofpainandtemperaturesensationAnteriorcordsyndrome

Posteriorcordsyndrome

Amixedsyndrome

ConusmedullarissyndromeCaudaequinasyndrome第五十四頁，共77頁。第五十五頁，共77頁。PelvicFracture骨盆骨折BothpelvicbonesarticulatewiththesacrumthroughthesacroiliacjointsandthesymphysispubisUpperbodyweightistransmittedacrossthehipjointtolowerlimbsviathesciaticbuttressandtheacetabulumThemechanismandseverityoftraumawilldeterminethepatternofinjuryOsteoarticularstructuresandadjacentsofttissueswillbeinvolvedinvaryingdegreesandcombinationsTreatmentmayrequireamultidisciplinaryapproach第五十六頁，共77頁。ClinicalFindingsHistory---InjurymechanismThephysicalexamination:Palpation---bonylandmarksCompression---stabilityRectovaginalexamination---abonyspike,contaminating---30-50%,closedfractures---8-15%Associatedinjuries---lowerurinarytractinjuries,distalvascularstatus,neurologicexamination第五十七頁，共77頁。ClinicalFindingsAplainanteroposteriorpelvicradiograph---inletandoutletviewsJudet’sobliqueviews---acetabulumCtscanning---furtherdelineateVascularandurologicimagingmayalsoberequired第五十八頁，共77頁。Treatment

Associatedinjuries---takeprecedenceovertreatmentofthepelvicfractureHemorrhageGeneralresuscitationprinciples---adequatetissueperfusionHypovolemiamaynotbecorrectedbyfluidandbloodreplacementalonePelvicexternalfixatorisausefultooltomanagevolumedepletionInternalfixation---laterstage第五十九頁，共77頁。AssociatedInjuriesHemorrhage---thesmalltomedium-sizedarteriesandvein,OccasionallybigvesselsThrombosis---ahighincidenceofthrombosisofthepelvicveins,useprophylacticanticoagulationoncetheacutehemorrhagicphasehaspassed(24-48hours)Neurologicinjury---common,theroots,ortheperipheralnerveitself(sciatic,femoral,obturator,pudendal,orsuperiorgluteal).Mostof---neurapraxiatype---favorableoutcome,10%permanentneurologicsequelaeUrogenitalinjuries第六十頁，共77頁。LocationofFracturesThepelvicringTheacetabulum第六十一頁，共77頁。InjuriestoThePelvicRing3%forallfractures.widespectrum:avulsionfracturetolife-threateningseverelyunstablepelvicringdisruptionTreatment---stableorunstableInjuriesinvolvingthepelvicringintwoormoresitescreateanunstablesegment.Theintegrityoftheposteriorsacroiliacligamentouscomplex----determineinstability.Intact---rotationallyunstable;disrupted,bothrotationallyandverticallyunstable第六十二頁，共77頁。ClassificationAdynamicclassificationsystem---themechanismofinjuryandresidualinstabilityTypeA:involvethepelvicringinonlyoneplaceandarestableTypeB:twoormoresites,rotationallyunstableTypeC:bothrotationallyandverticallyunstable第六十三頁，共77頁。TypeAFracturesTypeA1:Avulsion---muscleoriginsTypeA2:theiliacwing---Isolatedfracturesoftheiliacwingwithoutintra-articularextensionTypeA3:Obturatorfractures---thepubicorischialrami---minimallydisplaced第六十四頁，共77頁。TreatmentofTypeAConservativetreatment---usuallysufficientSymptomatic,withbedrestandanalgesia,earlyambulation,andweightbearingastolerated.第六十五頁，共77頁。TypeBFractureInvolvethepelvicringintwoormoresites---createasegmentthatisrotationallyunstablebutverticallystableTypeB1:open-bookfracturesoccurfromanteroposteriorcompressionTypeB2andB3:lateralcompressionfractures.Alateralforce---inwarddisplacementofhemipelvisthroughthesacroiliaccomplexandipsilateral(B2)or,contralateralpubicrami(B3)第六十六頁，共77頁。TreatmentofTypeBSymptomatictreatmentReduction---lateralcompressionManipulationundergeneralanesthesiaReductioncanbemaintaintedAhipspicaButmoreoftenexternalorinternalfixationiscurrentlyfavored第六十七頁，共77頁。第六十八頁，共77頁。TypeCBothrotationallyandverticallyunstableResultfromaverticalshearmechanism,likeafallfromaheight第六十九頁，共77頁。TreatmentofTypeCReduction---longitudinalskeletaltractionthroughthedistalfemurortheproximaltibia,8-12weeksExternalfixationaloneisinsufficienttomaintainreductioninhighlyunstablefractures,butitmayhelpcontrolbleedingandeasesnursingcareOpenreductionandinternalfixationisoftenrequiredThesurgicaltechniqueisdemanding,andthereisasignificantriskofcomplications.第七十頁，共77頁。ComplicationsChroniclowbackpainandposteriorsacroiliacpain---long-termcomplain,50%Nearly5%oftypeCinjuries---aleglengthdiscrepancyofmorethan2-5cmResidualgaitabnormalities----12-32%Nonunionrate---around3%Neurologicdeficit---6-1