脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)課件

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1、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)Fracture of Spine & Pelvis 課時(shí)數(shù) 2 內(nèi)容簡(jiǎn)介 脊柱骨折 脊髓損傷 骨盆骨折脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)問(wèn)題？ 如何診斷脊柱脊髓損傷？ 骨盆骨折的治療原則？脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Fracture of Spine & PelvisOrthopedics Dep.Jin Wang脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Tips of This Talk Really difficult and complex Plenty of new words Even hard for reside

2、nts Seat back Have fun Ask questions Following the brain storming Forget the test脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Spinal fractures脊柱骨折Spinal Cord Injury脊髓損傷脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)The Injury of the spine Fractures and dislocations of the spine are serious injuries that most commonly occur in young people Nearly 43% of pat

3、ients with spinal cord injuries sustain multiple injuries 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Trauma Center & Spine Center脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Anatomy of Vertebral ColumnAnatomy of Vertebral Column Composed of alternating bony vertebrae and fibrocartilaginous discs that are connected by strong ligaments and supported by m

4、usculature 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 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)The three columns of th

5、e spine The anterior column (A)(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)(B) consists of the posterior longitudinal ligament, posterior part of the vertebral body, and posterior porti

6、on of the annulus The posterior column (C)(C) consists of the bony and ligamentous posterior elements脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Evaluation of Spinal Evaluation of Spinal InjuryInjury HISTORYHISTORY Mechanism of injury Common causes: motor vehicle accidents, falls, diving accidents, and gunshot wounds PHYSICAL

7、 EXAMINATIONPHYSICAL EXAMINATION NEUROLOGICAL EVALUATIONNEUROLOGICAL EVALUATION 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)NEUROLOGICAL NEUROLOGICAL EVALUATIONEVALUATION Sensory, motor, and reflex function, is important in determining prognosis and treatment 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Neurologic examination recommended by the American

8、 Spinal Injury Association (ASIA) 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)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 sensorysacral sensory sparing can est

9、ablish the diagnosis of an incomplete spinal cord injury脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)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 m

10、otor function is good. 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)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脊柱和骨盆骨折2 中山大學(xué)

11、 外科學(xué)Reflexes examination Physical reflexes Pathology reflexes脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Roentgenographic Roentgenographic ExaminationExamination 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 Ce

12、rvic PTS-Anteroposterior, lateral, right / left oblique projections脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Standard radiographs of the cervical spine 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Flexion-extension views 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Other Imaging examination Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Injuries to osseous, ligamentou

13、s, and neurological structures-be evaluated accurately CT- helpful in evaluating the degree of compromise of the spinal canal 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Images from a screening computed tomography (CT). 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Emergency Room Emergency Room ManagementManagement The initial examination-general surgery

14、, 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 脊柱和骨盆骨折2 中山大學(xué) 外科

15、學(xué)Cervical Spine InjuriesCervical 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 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)The axial CT of the atlas(C1) revealed an anterior ar

16、ch fracture脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)CLASSIFICATIONCLASSIFICATION The mechanistic classification Vertical Compression (VC)Vertical Compression (VC) Distractive Flexion (DF)Distractive Flexion (DF) Compression Extension (CE)Compression Extension (CE) Distractive Extension (DE)Distractive Extension (DE) Latera

17、l Flexion (LF)Lateral Flexion (LF) Compressive Flexion (CF)Compressive Flexion (CF) 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)TIPS InstabilityInstability Stretch TestStretch Test脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Goals of TreatmentTreatment To realign the spine To prevent loss of function of undamaged neurological tissue To improve neurologi

18、cal recovery To obtain and maintain spinal stability To obtain early functional recovery 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)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

19、 by traction脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Nonoperative TreatmentNonoperative 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 ImmobilizationHalo Vest Immobilization)脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Operative Treatment

20、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 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Principles of operation The injur

21、y 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 anteri

22、or 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脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Injuries to Upper Cervical Injuries to Upper Cervical Spine (Occiput to C2)Spine

23、 (Occiput to C2) Rotary Subluxation of C1 on C2Rotary Subluxation of C1 on C2 Dens FractureDens Fracture 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Rotary Subluxation of Rotary Subluxation of C1 on C2.C1 on C2. Uncommon in adults By motor vehicle accidents Torticollis and restricted neck motion- often not recognized at initi

24、al 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脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Odontoid fractures齒狀突骨折 Type I injury demonstrates an av

25、ulsion 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脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Dens Fracture-Dens Fracture- odontoid fractures Type I - uncommon, and even if nonunion occurs aft

26、er 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脊柱和骨盆骨折2 中山大學(xué) 外科學(xué) Type II odontoid fracture. A solid C12 fusion was demonstrated

27、脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Internal Fixation of Internal Fixation of Upper Cervical SpineUpper Cervical Spine Hot & Spice Recent advances in internal fixation have allowed its use in the cervical spine脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Traumatic Traumatic Spondylolisthesis of the Spondylolisthesis of the Axis (Hangman Fracture

28、s)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) 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)A lateral radiograph shows the C-2

29、 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: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 hangman

30、s fracture脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)C:C: Satisfactory closed reduction could be achieved in a halo using an extended head position. D: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 he

31、r nonoperative management.Nonoperative treatment of type IIa hangmans fracture脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Lower Cervical Spine (C3-7)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 ma

32、intain spinal stability Obtain early functional recovery 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué) Compression flexion injuries脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Flexion compression injury脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Thoracic and Lumbosacral FracturesThoracic and Lumbosacral Fractures The treatment of unstable fractures and fracture-dislocations of the

33、 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 脊柱和骨盆骨折2 中山大學(xué)

34、外科學(xué) This flexion-distraction injury (seat belt fracture) was the result of an automobile accident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)The Spinal Cord Injury脊髓損傷 4,500 years ago- was described as “a disease one cannot treat” . Paralysis remains incurable Improved care has allowed patients with a spinal

35、cord injury better function, improved quality of life, and prolonged survival Experience and research continue脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)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

36、age and sex without spinal cord injury Regional trauma centers and increased training of paramedics and emergency medical technicians- survival increased 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)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

37、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 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Spinal Cord

38、 SyndromesSpinal 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

39、and no sacral sensation or motor function has returned, the paralysis will be permanent and complete in most patients. 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Spinal Cord SyndromesSpinal Cord Syndromes Resulting from incomplete traumatic lesions The greater the sparing of motor and sensory functions distal to the injury,

40、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. 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Spinal Cord SyndromesSpinal Cord SyndromesCentral cord syndrome - a quadriparesis involving the

41、 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 Posterior cord syndrome A mixed syndrome Conus medullaris syndromeCauda eq

42、uina syndrome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)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 se

43、verity 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脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Clinical Findings History-Injury mechanism The physical examination: Palpa

44、tion-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脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Clinical Findings A plain anteroposterior pelvic radi

45、ograph -inlet and outlet views Judets oblique views -acetabulum Ct scanning - further delineate Vascular and urologic imaging may also be required脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Treatment Associated injuries -take precedence over treatment of the pelvic fracture Hemorrhage General resuscitation principles-adequate

46、 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脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Associated InjuriesHemorrhage- the small to medium-sized arteries and vein, Occasionally big ves

47、sels 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-neura

48、praxia type- favorable outcome, 10% permanent neurologic sequelaeUrogenital injuries脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Location of FracturesThe pelvic ringThe acetabulum 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Injuries to The Pelvic Ring 3% for all fractures. wide spectrum: avulsion fracture to life-threatening severely unstable pelvic rin

49、g 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脊柱和骨盆骨折

50、2 中山大學(xué) 外科學(xué)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 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Type A Frac

51、tures 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 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Treatment of Type A Conservative treatment- usually sufficient Symptomati

52、c, with bed rest and analgesia, early ambulation, and weight bearing as tolerated. 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)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 T

53、ype 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) 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Treatment of Type B B Symptomatic treatment Reduction-lateral compression Manipulation under general

54、anesthesia Reduction can be maintainted A hip spica But more often external or internal fixation is currently favored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)Type C Both rotationally and vertically unstable Result from a vertical shear mechanism, like a fall from a height 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Treatment of Type

55、 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

56、redThe surgical technique is demanding, and there is a significant risk of complications. 脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)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

57、-32% Nonunion rate -around 3% Neurologic deficit-6-10% Urologic- 5-20%脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Fractures of the acetabulum Direct trauma on the trochanteric region Indirect axial loading through the lower limb The position of the limb at the time of impact (rotation, flexion, abduction, or adduction)-determ

58、ine the pattern of injury Comminution is common脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Classification Letournel -based on which column is involved The anterior column -the anterior iliac crest, the anterior half of the acetabulum, and the pubic ramus The posterior column-the sciatic buttress and the sciatic notch, the pos

59、terior half of the acetabulum, and the ischial tuberosity Two oblique views , Ct scanning Ten different types Five simple patterns (one fracture line) Five complex patterns (the association of two or more simple patterns)脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Treatment The goal -a spherical congruency between the femoral

60、 head and weight-bearing acetabular dome, and to maintain it until bones are healed longitudinal skeletal traction through a distal femoral or proximal tibial pin pulling axially, 6-8 weeks before full weight bearing Any residual displacement after traction is an indication for open reduction and in

61、ternal fixation A clear correlation between anatomic reduction and prognosis脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)Complications Post-traumatic degenerative joint disease Heterotopic ossification Femoral head osteonecrosis Deep vein thrombosis When the reduction is stable and fixation is solid, the patient can be mobiliz

62、ed after a few days with non-weight-bearing ambulation, and weight bearing may begin as early as 6 weeks Routinely use postoperative prophylactic anticoagulation and heterotopic bone formation prophylaxis with irradiation or indomethacin, or both脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)重點(diǎn)和難點(diǎn) 重點(diǎn) 脊柱骨折診斷 骨盆骨折的治療原則 難點(diǎn) 脊髓損傷脊柱和骨盆骨折2 中山大學(xué) 外科學(xué)