外科学教学课件：FRACTURES OF SPINE AND PELVIC

1、FRACTURES OF SPINE AND PELVIC,fracture of the spine,间接暴力最多见 垂直分力压缩 水平分力脱位，易引起脊髓损伤 最易受损的节段：T10-L2（胸腰段）,Disc and Ligaments,Anatomy,Three-column concept The anterior column contains the anterior longitudinal ligament, the anterior 2/3 of the vertebral body, and the anterior portion of the annulus fibro

2、sus. The middle column consists of the posterior longitudinal ligament, the posterior 1/3 of the vertebral body, and the posterior aspect of the annulus fibrosus. The posterior column includes the neural arch, the ligamentum flavum, the facet capsules, and the interspinous ligaments,Biomechanical th

3、eory(Denis) Anterior column Middle column Posterior column,Vertebra,The cervical spinal column is extremely vulnerable to injury Meyer identified C2 and C5 as the two most common areas of cervical spine injury. Injuries of the cervical spine produce neurological damage in approximately 40% of patien

4、ts,High-Violence (young patient) Low-Violence (old patient) “Gunshot”-violence(fighting),Fracture Mechanism,Classifications,Fractures of thoracolumbar spine,cause isolated failure of the anterior column and result from forward flexion. rarely associated with neurological deficit,1)Wedge compression

5、fractures:,Compress-flexion Anterior part of V.body compressed No canal involvement Neurologically intact,Compression Fracture,the anterior and middle columns fail because of a compressive load, with no loss of integrity of the posterior elements,2)Stable burst fractures:,Axial compression Middle co

6、lumn compressed Canal involvement Neurological deficit,Burst Fracture,the anterior and middle columns fail in compression, and the posterior column is disrupted. The posterior column can fail in compression, lateral flexion, or rotation. There is a tendency for posttraumatic kyphosis and progressive

7、 neural symptoms because of instability,3)Unstable burst fractures:,are horizontal avulsion injuries of the vertebral bodies caused by flexion about an axis anterior to the anterior longitudinal ligament. The entire vertebra is pulled apart by a strong tensile force,4)Chance fractures:,Chance Injury

8、,Injury involves 3-columns Usually little comminution Center of rotation: ALL PLC disrupted or posterior neural arch fractured transversely,the flexion axis is posterior to the anterior longitudinal ligament. The anterior column fails in compression while the middle and posterior columns fail in ten

9、sion. This injury is unstable because the ligamentum flavum, interspinous ligaments, and supraspinous ligaments usually are disrupted,5)Flexion distraction injuries:,are characterized by malalignment of the neural canal, which has been totally disrupted. Usually all three columns have failed in shea

10、r. At the affected level, one part of the spinal canal has been displaced in the transverse plane,6)Translational injuries:,关节突交锁,Fracture-dislocation,Classifications,Fractures of cervical spine,1.Flexion injury,the result of compression of anterior column and distraction of posterior column anterio

11、r subluxation: caused by rupture of the ligament of posterior column ( complete or incomplete), bilateral facet dislocations: extreme flexionrupture of ligament of middle and posterior column (may with approximately 50% anterior subluxation of the vertebral body. In a more severe case, may have full

12、 vertebral body width displacement anteriorly or a grossly unstable motion segment, giving the appearance of a floating vertebra ) simple wedge compression: commonly seen in clinic, and happened more frequently in osteoporosis patient,2. Vertical compression injury,(1) Jefferson fracture: fracture o

13、f anterior and posterior arch of atlas,A, Drawing indicating axial view of stable Jefferson fracture (transverse ligament intact). B, Drawing indicating axial view of unstable Jefferson fracture (transverse ligament ruptured),(2) Burst fracture: commonly seen in C5 and C6 The centrum is fragmented,

14、and the displacement is peripheral in multiple directions. The centrum fails, with significant impaction and fragmentation. The posterior aspect of the vertebral body is fractured and may be displaced into the spinal canal.,3. Extension injury,(1) Distractive extension 过伸性脱位 either failure of the an

15、terior ligamentous complex or a transverse fracture of the centrum evidence of failure of the posterior ligamentous complex, with displacement of the upper vertebral body posteriorly into the spinal canal, in addition to the changes seen in the previous injuries,急刹车或撞车 脊髓中央管周围损伤 特征性体征：额面部有外伤痕迹,(2) H

16、angmans fracture: vertical fracture of the vertebral arch of dens 枢椎椎弓骨折 缢死者骨折,Anderson and DAlonzo classified odontoid fractures into three types Type I is oblique fracture through upper part of odontoid process Type II is fracture at junction of odontoid process and body of second cervical vertebr

17、a Type III is fracture through upper body of vertebra,4. Fracture of unknown mechanisms -Dens fracture,Three types of odontoid process fractures,临床表现、检查和诊断,严重外伤史， 局部疼痛，翻身困难，腹胀 注意全身情况，棘突压痛，脊髓损伤 线检查及CT、 MRI,急救搬运 身体平直不扭转 保护颈部,治疗 胸腰椎骨折的治疗 单纯性压缩性骨折 椎体压缩不到15者、或年老体弱者：保持脊柱过伸 （仰卧硬板床，局部垫枕，背肌锻炼量力而行） 椎体压缩超过15者、

18、或青壮年：两桌法过伸复位 ,石膏背心,爆破型骨折的治疗 无骨块压迫者双踝悬吊法复位 有骨块突入伴神经症状手术治疗（解除压迫，植骨，内固定） Chance骨折，屈曲牵拉型损伤，脊柱骨折脱位： 切开复位植骨,颈椎骨折的治疗 颈椎半脱位 早期石膏颈围固定3个月（预防迟发性并发症） 晚期颈椎不稳与畸形：手术,稳定型颈椎骨折 压缩或移位较轻者：颌枕吊带牵引头颈胸石膏固定3个月 明显压缩或脱位：颅骨牵引头颈胸石膏固定3个月 四肢瘫痪及牵引失败：手术内固定 伴关节突交锁者，须考虑切开复位,单侧小关节脱位 快速牵引8小时，失败时手术 爆裂型骨折有神经症状者 病情稳定后早期手术，有风险,过伸型损伤 无移位者，牵

19、引后换石膏 有移位及脊髓受压者，稳定后手术,齿状突骨折 没移位型骨折、型、型骨折，牵引后改石膏 型骨折移位超过4mm手术,Lateral view of cervical spine after internal fixation of C4-5 dislocation with lateral mass plates and screws,Type I fractures are uncommon, and even if nonunion occurs after inadequate immobilization, no instability results Type II fract

20、ures are the most common Type III fractures have a large cancellous base and heal without surgery in 90% of patients,Treatment of dens fracture:,Anterior fixation of dens fracture with cannulated screws,Surgical Approach,Posterior approach Relies on intact ALL If burst component present, optimal tre

21、atment with pedicle screws (maintain anterior column length, dont over compress- increase retropulsion ),Spinal Cord Injury,脊髓损伤,截瘫：脊柱骨折，移位的椎体或突入椎管的骨片，压迫脊髓或马尾，受伤平面以下，双侧对称性感觉、运动、反射、括约肌功能丧失，完全性截瘫或不完全性截瘫。 四肢瘫 ：颈段脊髓损伤后，除双下肢外，双上肢也有神经功能障碍 。,病理 脊髓震荡 ：脊髓遭受强烈震荡后，暂时性功能抑制，立即发生完全性迟缓性瘫痪，常在数小时或数分钟内完全恢复 脊髓挫伤与出血：脊髓

22、实质性破坏，愈后差别较大 脊髓断裂：无恢复希望，不完全断裂称挫裂伤 脊髓受压：骨折脱位的移位、小骨折片、突出的椎间盘、黄韧带、硬膜外血肿等压迫脊髓，软瘫，及时解除压迫可部分或全部恢复 马尾神经损伤：第2腰椎以下骨折脱位,临床表现 1. 脊髓损伤： 脊髓休克期间迟缓性瘫痪 24周后痉挛性瘫痪 截瘫和四肢瘫早期均为弛缓瘫，2-4周后变为痉挛瘫 2. 脊髓圆锥损伤 ： 第1腰椎骨折，括约肌功能障碍， 双下肢可正常,3. 马尾神经损伤 ： 第2腰椎以下骨折， 迟缓性瘫痪，病理征阴性 4. 截瘫指数： 运动、感觉、括约肌功能 0：正常，1：部分异常，2：完全丧失,Complication 1. resp

23、iratory failure/ pneumonic infection 颈髓损伤的严重并发症 胸式呼吸（肋间肌） 腹式呼吸（膈肌） 膈神经：C345 截瘫1周左右 发热，应考虑呼吸道感染。,2. urinary system infection/calculus 3. bedsore,4. Misalignment of body temperature 多见于颈髓损伤后 自主（植物）神经功能紊乱 高热，40度 药物降温（不妥） 病危征兆，死亡率高,治疗原则 1. 合适的固定：颌枕吊带牵引，颅骨牵引,2. 减轻脊髓水肿和继发性损害 地塞米松：静脉1周，后改口服2周。 甘露醇： 250ML，日

24、2次，用1周。 甲泼尼龙：伤后8小时内快速给药。 高压氧： 伤后4-6时内应用 。,3. 手术治疗 目的： 解除压迫，恢复脊柱稳定， 脊髓功能恢复困难 手术指征 关节突交锁， 骨片突入椎管压迫脊髓 截瘫平面不断上升， 复位不满意 ，仍有不稳定因素,PELVIC FRACTURES,motor-vehicle accident industrial trauma sporting events fall from great height,Fractures of Pelvis,Category Common characteristic Differentiating characterist

25、ic LC 1 Anterior transverse Sacral compression fracture (pubic rami) on side of impact LC 2 Anterior transverse Crescent (iliac wing) fracture fracture (pubic rami) LC 3 Anterior transverse Contralateral open book fracture (pubic rami) (APC) injury,Lateral compression (LC) injuries,APC 1 Symphyseal

26、diastasis Slight widening of pubic symphysis and/or Sl joint; stretched but intact anterior and posterior ligaments APC 2 Symphyseal diastasis Widened Sl joint, or anterior vertical disrupted anterior ligaments; fracture intact posterior ligaments APC 3 Symphyseal diastasis Complete hemipelvis separ

27、ation but no or anterior vertical vertical displacement; complete sacroiliac fracture joint disruption; complete anterior and posterior ligament disruption,Anteroposterior compression (APC),VS Symphyseal diastasis or Vertical displacement anteriorly anterior vertical fracture and posteriorly, usually through Sl joint, occasionally through iliac wing and/or sacrum,Vertical shear (VS) injuries,CM Anterior and/or posterior, Combination of other injury vertical and/or transverse patterns; LC/VS or