课件：脊柱和骨盆骨折中山大学外科学.ppt

Fracture of Spine & Pelvis,课时数 2 内容简介 脊柱骨折 脊髓损伤 骨盆骨折,问题？,如何诊断脊柱脊髓损伤？ 骨盆骨折的治疗原则？,Fracture of Spine & Pelvis,Orthopedics Dep. Jin Wang,Tips of This Talk,Really difficult and complex Plenty of new words Even hard for residents Seat back Have fun Ask questions Following the brain storming Forget the test,Spinal fractures脊柱骨折,Spinal Cord Injury脊髓损伤,The Injury of the spine,Fractures and dislocations of the spine are serious injuries that most commonly occur in young people Nearly 43% of patients with spinal cord injuries sustain multiple injuries,Trauma Center & Spine Center,Anatomy of Vertebral Column,Composed of alternating bony vertebrae and fibrocartilaginous 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 form the spinous process,The three columns of the spine,The anterior column (A) consists of the anterior longitudinal ligament, anterior part of the vertebral body, and the anterior portion of the annulus fibrosis The middle column (B) consists of the posterior longitudinal ligament, posterior part of the vertebral body, and posterior portion of the annulus The posterior column (C) consists of the bony and ligamentous posterior elements,Evaluation of Spinal Injury,HISTORY Mechanism of injury Common causes: motor vehicle accidents, falls, diving accidents, and gunshot wounds PHYSICAL EXAMINATION NEUROLOGICAL EVALUATION,NEUROLOGICAL EVALUATION,Sensory, 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 inguinal 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 injury,Motor Examination,The extremities and trunk Sacral motor sparing- voluntary rectal sphincter / toe flexor contractions If voluntary 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; great toe extension L5; and great toe flexion S1,Reflexes examination,Physical reflexes Pathology reflexes,Roentgenographic Examination,The initial-a lateral view of the cervical spine & anteroposterior views of the chest and pelvis Easy missed: the odontoid process or the cervicothoracic junction Cervic PTS-Anteroposterior, lateral, right / left oblique projections,Standard radiographs of the cervical spine,Flexion-extension views,Other Imaging examination,Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Injuries to osseous, ligamentous, and neurological structures-be evaluated accurately CT- helpful in evaluating 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 specialists Hypotension, hypothermia, and bradycardia-3 changes in vital signs - suggest 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 roentgenographic evidence of vertebral injury,The axial CT of the atlas(C1) revealed an anterior arch fracture,CLASSIFICATION,The mechanistic classification Vertical Compression (VC) Distractive Flexion (DF) Compression Extension (CE) Distractive Extension (DE) Lateral Flexion (LF) Compressive Flexion (CF),TIPS,Instability Stretch Test,Goals of Treatment,To realign the spine To prevent loss of function of undamaged neurological tissue To improve neurological recovery To obtain and maintain spinal stability To obtain early functional recovery,Guideline,Spinal alignment can be obtained by skeletal traction through spring-loaded Gardner-Wells tongs or a halo ring Open reduction and stabilization if spinal realignment cannot be obtained by traction,Nonoperative Treatment,Many cervical spine injuries can be treated without surgery Immobilization in a rigid cervical orthosis for 8 to 12 weeks may be sufficient (Halo Vest Immobilization),Operative Treatment,Unstable injuries of the cervical spine, with or without neurological deficit, generally require operative treatment Open reduction and internal fixation are indicated to obtain stability and allow early functional rehabilitation,Principles of operation,The injury must be clearly defined before surgery by plain roentgenograms, high-resolution CT scanning with sagittal and coronal reconstruction, or MRI Laminectomy has a limited role Compression of the cervical cord or roots by retropulsed bone fragments or disc material usually is anterior; therefore anterior decompression and fusion, with or without internal fixation, are indicated For posterior ligamentous or bony instability, posterior stabilization with internal fixation and bone grafting are indicated,Injuries to Upper Cervical Spine (Occiput to C2),Rotary Subluxation of C1 on C2 Dens Fracture,Rotary Subluxation of C1 on C2.,Uncommon in adults By motor vehicle accidents Torticollis and restricted neck motion- often not recognized at initial evaluation An 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 side CT A halo ring or operational-a halo vest 8 to 12 weeks,Odontoid fractures齿状突骨折,Type I injury demonstrates an avulsion fracture of the tip of the odontoid Type II fractures are located at the waist of the odontoid Type III fractures extend caudally into the cancellous bone of the body of the axis,Dens Fracture- odontoid fractures,Type I - uncommon, and even if nonunion occurs after inadequate immobilization, no instability results Type II -the most common, 36% nonunion rate for both displaced and nondisplaced fractures Type III -a large cancellous base and heal without surgery in 90% of patients,Type II odontoid fracture. A solid C12 fusion was demonstrated,Internal Fixation of Upper Cervical Spine,Hot & Spice Recent advances in internal fixation have allowed its use in the cervical spine,2019/8/5,40,可编辑,Traumatic Spondylolisthesis of the Axis (Hangman Fractures),Incurred during the hanging of criminals Motor vehicle accidents with hyperextension of the head The 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 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 fracture,C: Satisfactory closed reduction could be achieved in a halo using an extended head position. D: A partial loss of reduction 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 fracture,Lower Cervical Spine (C3-7),The primary goals of treatment Realign the spine Prevent loss of function of uninjured neurological tissue Improve neurological recovery Obtain and maintain spinal stability Obtain early functional recovery,Compression flexion injuries,Flexion compression injury,Thoracic and Lumbosacral Fractures,The treatment of unstable fractures and fracture-dislocations of the thoracic and lumbar spine-controversial Nonoperative treatment Open reduction and rigid internal fixation with posterior instrumentation laminectomy alone is contraindicated in fracture-dislocations because it fails to relieve the anterior compression and increases spinal instability,This flexion-distraction injury (seat belt fracture) was the result of an automobile accident,The Spinal Cord Injury脊髓损伤,4,500 years ago- was described as “a disease one cannot treat” . Paralysis remains incurable Improved care has allowed patients with a spinal cord injury better function, improved quality of life, and prolonged survival Experience and research continue,Spinal Cord Injury,Overall, 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 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 weeks A positive bulbocavernosus reflex or return of the anal wink reflex- indicates the end of spinal shock If no motor or sensory function below the level 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 Syndromes,Definition An incomplete spinal cord injury is one in which some motor or sensory function is spared distal to the cord injury A complete spinal cord injury is manifested by total motor and sensory loss distal to the injury When 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,Resulting from incomplete traumatic lesions The 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.,Spinal Cord Syndromes,Central cord syndrome - a quadriparesis involving the upper extremities to a greater degree than the lower Brown-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 Posterior cord syndrome A mixed syndrome Conus medullaris syndrome Cauda equina syndrome,Pelvic 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 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 approach,Clinical Findings,History-Injury mechanism The physical examination: Palpation-bony landmarks Compression - stability Rectovaginal examination - a bony spike , contaminating - 30-50%, closed fractures- 8-15% Associated injuries-lower urinary tract injuries, distal vascular status, neurologic examination,Clinical Findings,A plain anteroposterior pelvic radiograph -inlet and outlet views Judets oblique views -acetabulum Ct scanning - further delineate Vascular and urologic imaging may also be required,Treatment,Associated injuries -take precedence over treatment of the pelvic fracture Hemorrhage General resuscitation principles-adequate tissue perfusion Hypovolemia may not be corrected by fluid and blood replacement alone Pelvic external fixator is a useful tool to manage volume depletion Internal fixation - later stage,Associated Injuries,Hemorrhage- the small to medium-sized arteries and vein, Occasionally big vessels Thrombosis-a high incidence of thrombosis of the pelvic veins, 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 sequelae Urogenital injuries,Location of Fractures,The pelvic ring The acetabulum,Injuries to The Pelvic Ring,3% for all fractures. wide spectrum: avulsion fracture to life-threatening severely unstable pelvic ring disruption Treatment-stable or unstable Injuries involving the pelvic ring in two or more sites create an unstable segment. The integrity of the posterior sacroiliac ligamentous complex-determine instability. Intact-rotationally unstable; disrupted, both rotationally and vertically unstable,Classification,A dynamic classification system - the mechanism of injury and residual instability Type A: involve the pelvic ring in only one place and are stable Type B: two or more sites, rotationally unstable Type C: both rotationally and vertically unstable,Type A Fractures,Type A1: Avulsion - muscle origins Type A2: the iliac wing-Isolated fractures of the iliac wing without intra-articular extension TypeA3: Obturator fractures-the pubic 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 Fracture,Involve the pelvic ring in two or more sites- create a segment that is rotationally unstable but vertically stable Type B1: open-book fractures occur from anteroposterior compression Type 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 B,Symptomatic treatment Reduction-lateral compression Manipulation under general anesthesia Reduction can be maintainted A hip spica But more often external or internal fixation is currently favored,Type C,Both rotationally and vertically unstable Result from a vertical shear mechanism, like a fall from a height,Treatment of Type C,Reduction- longitudinal skeletal traction through the distal femur or the proximal tibia, 8-12 weeks External fixation alone is insufficient to maintain reduction in highly unstable fractures, but it may help control bleeding and eases nursing care Open reduction and internal fixation is often required The surgical technique is demanding, and there is a significant risk of complications.,Complications,Chronic low back pain and posterior sacroiliac pain-long-term complain, 50% Nearly 5% of type C injuries-a leg length discrepancy of more than 2-5cm Residual gait abnormalities-12-32% Nonunion rate -around 3% Neurologic deficit-6-10% Urologic- 5-20%,Fracture