外科脊柱骨盆骨折课件

FractureofSpine Pelvis脊柱 骨盆骨折 TipsofThisTalk ReallydifficultandcomplexPlentyofnewwordsEvenhardforresidentsSeatbackHavefunAskquestionsFollowingthebrainstormingForgetthetest Spinalfractures脊柱骨折 TheInjuryofthespine脊柱创伤 FracturesanddislocationsofthespineareseriousinjuriesthatmostcommonlyoccurinyoungpeopleNearly43 ofpatientswithspinalcordinjuriessustainmultipleinjuries AnatomyofVertebralColumn Thethreecolumnsofthespine 脊柱的三柱理论 Theanteriorcolumn A Anteriorlongitudinalligament 前纵韧带Anteriorpartofthevertebralbody 椎体前部Anteriorportionoftheannulusfibrosis 纤维环 Themiddlecolumn B Posteriorlongitudinalligament 后纵韧带PosteriorpartofthevertebralbodyPosteriorportionoftheannulus 纤维环 Theposteriorcolumn C BonyLigamentousposteriorelements CLASSIFICATION Magral ThemechanisticclassificationCompressionVertical 垂直压缩FlexionDistractiveFlexion Chance 屈曲分离型Rotational 旋转型DistractiveExtension 伸直分离型 CLASSIFICATION StablespinalfractureGentletomiddlecompressiveF theposteriorcolumnisintactUnstablespinalfracture2 3columnSplinteredF middlecolumn spinalcanalnarrowWithdislocation CLASSIFICATION CompressionFI 1 3 II 2 3 III 3 3SplinteredFAvulsionFChanceFF Dislocation EvaluationofSpinalInjury 脊柱损伤的诊断 HISTORYMechanismofinjury 受伤的机制Commoncauses motorvehicleaccidents falls divingaccidents andgunshotwoundsPHYSICALEXAMINATIONWatch touch press listen moveNEUROLOGICALEVALUATION 神经系统评估 NEUROLOGICALEVALUATION 神经系统评估 Sensory motor andreflexfunction isimportantindeterminingprognosisandtreatment 感觉 运动 反射 决定预后和治疗 RoentgenographicExamination X线 Theinitial alateralviewofthecervicalspine 颈椎侧位片 anteroposteriorviewsofthechestandpelvis 胸部 骨盆正位片Easymissed theodontoidprocess 齿状突orthecervicothoracicjunction颈胸段CervicPTS Anteroposterior lateral right leftobliqueprojections 斜位 Standardradiographsofthecervicalspine Lateralview Anteroposteriorview Obliqueprojections Odontoidprocess Flexion extensionviews OtherImagingexamination ComputedTomography CT MagneticResonanceImaging MRI Injuriestoosseous ligamentous andneurologicalstructures beevaluatedaccuratelyCT helpfulinevaluatingthedegreeofcompromiseofthespinalcanal 椎管 Computedtomography CT CervicalSpineInjuries Vulnerabletoinjury 容易受伤Twoparticularareas C1toC2andC5toC740 ofneurologicaldamage10 noobviousroentgenographicevidenceofvertebralinjury 椎体无损伤 Guideline Spinalalignmentcanbeobtainedbyskeletaltractionthroughspring loadedGardner WellstongsorahaloringOpenreductionandstabilizationifspinalrealignmentcannotbeobtainedbytraction NonoperativeTreatment ManycervicalspineinjuriescanbetreatedwithoutsurgeryImmobilizationinarigidcervicalorthosisfor8to12weeksmaybesufficient HaloVestImmobilization OperativeTreatment Unstableinjuriesofthecervicalspine withorwithoutneurologicaldeficit generallyrequireoperativetreatmentOpenreductionandinternalfixation InjuriestoUpperCervicalSpine OcciputtoC2 JeffersonF Anterior PosteriorarchF RotarySubluxationofC1onC2DensFractureHangmanF atlas 寰椎 C1 ananteriorarchfractureTreatment Immobilizationinaplaster headtochest orrigidcervicalorthosis12weeks JeffersonF RotarySubluxationofC1onC2 UncommoninadultsBymotorvehicleaccidentsTorticollisandrestrictedneckmotion oftennotrecognizedatinitialevaluationAnopen mouthodontoidroentgenogrammayrevealthe winksign causedbyoverridingoftheC1 2jointononesideandanormalconfigurationontheothersideCTTraction C1 2Fusionoperation Odontoidfractures TypeIinjurydemonstratesanavulsionfractureofthetipoftheodontoidTypeIIfracturesarelocatedatthewaistoftheodontoidTypeIIIfracturesextendcaudallyintothecancellousboneofthebodyoftheaxis DensFracture odontoidfractures TypeI uncommon andevenifnonunionoccursafterinadequateimmobilization noinstabilityresultsneckorthosisfor6 8weeksTypeII themostcommon 36 nonunionrateforbothdisplacedandnondisplacedfracturesTraction plasterorHalo orOPTypeIII alargecancellousbaseandhealwithoutsurgeryin90 ofpatientsOrthosisorplasterfor12weeks TypeIIodontoidfracture AsolidC1 2fusionwasdemonstrated InternalFixationofUpperCervicalSpine Hot SpiceRecentadvancesininternalfixationhavealloweditsuseinthecervicalspine HangmanFractures TraumaticSpondylolisthesis 滑脱oftheAxis IncurredduringthehangingofcriminalsMotorvehicleaccidentswithhyperextensionoftheheadvertebralbodymovingforward Archmovingbackward AlateralradiographshowstheC 2vertebralbodyinthis42 year oldwomanwhowasinacarcrashtobesagittallyrotatedandanteriorlydisplacedrelativetotheC 3body Hangman sfracture Satisfactoryclosedreductioncouldbeachievedinahalousinganextendedheadposition Nonoperativetreatmentofhangman sfractureTraction plasterororthosis LowerCervicalSpine C3 7 TheprimarygoalsoftreatmentRealignthespinePreventlossoffunctionofuninjuredneurologicaltissueImproveneurologicalrecoveryObtainandmaintainspinalstabilityObtainearlyfunctionalrecovery CompressionflexioninjuriesCommonC4 5ORC5 6 Flexioncompressioninjury C3 7Treatment Non opPlasterororthosis HaloRingOpDecompressionFrontorbackFusion ThoracicandLumbosacralFractures Thetreatmentofunstablefracturesandfracture dislocationsofthethoracicandlumbarspine controversialNonoperativetreatmentOpenreductionandrigidinternalfixationwithposteriorinstrumentationlaminectomyaloneiscontraindicatedinfracture dislocationsbecauseitfailstorelievetheanteriorcompressionandincreasesspinalinstability Thisflexion distractioninjury seatbeltfracture wastheresultofanautomobileaccident SpinalCordInjury脊髓损伤 TheSpinalCordInjurySuperman 4 500yearsago wasdescribedas adiseaseonecannottreat ParalysisremainsincurableImprovedcarehasallowedpatientswithaspinalcordinjurybetterfunction improvedqualityoflife andprolongedsurvivalExperienceandresearchcontinue SpinalCordInjury Overall 85 ofpatientswithaspinalcordinjurywhosurvivethefirst24hoursarestillalive10yearslatercomparedwith98 ofpatientsofsimilarageandsexwithoutspinalcordinjuryRegionaltraumacentersandincreasedtrainingofparamedicsandemergencymedicaltechnicians survivalincreased Spinalshock lastsfor1 6weeksApositivebulbocavernosusreflex 球海绵体反射orreturnoftheanalwinkreflex 肛门反射 indicatestheendofspinalshockIfnomotororsensoryfunctionbelowthelevelofinjurycanbedocumentedwhenspinalshockends acompletespinalcordinjuryispresentandtheprognosisispoorforrecoveryofdistalmotororsensoryfunction SpinalCordSyndromes Anincompletespinalcordinjury DefinitionAnincompletespinalcordinjuryisoneinwhichsomemotororsensoryfunctionisspareddistaltothecordinjuryWhenthebulbocavernosusreflex 球海绵体反射ispositiveandnosacralsensationormotorfunctionhasreturned theparalysiswillbepermanentandcompleteinmostpatients SpinalCordSyndromes ResultingfromincompletetraumaticlesionsThegreaterthesparingofmotorandsensoryfunctionsdistaltotheinjury thegreatertheexpectedrecovery Themorerapidtherecovery thegreatertheamountofrecovery Whennewrecoveryceasesandaplateauisreached nofurtherrecoverycanbeexpected SpinalCordSyndromes AnteriorcordsyndromePosteriorcordsyndromeCentralcordsyndrome中央脊髓综合症Brown S quardsyndrome半切综合症 Anteriorcordsyndrome PartialparalysisofupperextremityInlowerextremity lossofmotorfunctions butmaintainde