外科学课件：骨盆和髋臼骨折（英文版）

FracturesofthePelvisandAcetabulumFracturesofthePelvisAnatomyThepelvisiscomposedanteriorlyoftheringofthepubicandischialramiconnectedwiththesymphysispubis.Afibrocartilaginousdiscseparatesthetwopubicbodies.Posteriorly,thesacrumandthetwoinnominatebonesarejoinedatthesacroiliacjointbytheinterosseoussacroiliacligaments,theanteriorandposteriorsacroiliacligaments,thesacrotuberousligaments,thesacrospinousligaments,andtheassociatediliolumbarligaments.4.Thisligamentouscomplexprovidesstabilitytotheposteriorsacroiliaccomplex,sincethesacroiliacjointitselfhasnoinherentbonystability.A,MajorposteriorstabilizingstructuresofpelvicringB,Tilecomparesrelationshipofposteriorpelvicligamentousandbonystructurestosuspensionbridge,withsacrumsuspendedbetweentwoposterosuperioriliacspines

ClassificationsCategoryCommoncharacteristicDifferentiatingcharacteristicLC1AnteriortransverseSacralcompressionfracture(pubicrami)onsideofimpactLC2AnteriortransverseCrescent(iliacwing)fracturefracture(pubicrami)

LC3AnteriortransverseContralateralopenbookfracture(pubicrami)(APC)injuryLateralcompression(LC)injuriesYoungandBurgessClassificationAPC1SymphysealdiastasisSlightwideningofpubicsymphysisand/orSljoint;stretchedbutintactanteriorandposteriorligamentsAPC2SymphysealdiastasisWidenedSljoint,oranteriorverticaldisruptedanteriorligaments;fractureintactposteriorligaments

APC3SymphysealdiastasisCompletehemipelvisseparation

butnooranteriorverticalverticaldisplacement;

completesacroiliacfracturejointdisruption;

completeanteriorandposteriorligamentdisruption

Anteroposteriorcompression(APC)VSSymphysealdiastasisorVerticaldisplacementanteriorlyanteriorverticalfractureandposteriorly,usuallythroughSljoint,occasionallythroughiliacwingand/orsacrum

Verticalshear(VS)injuriesCMAnteriorand/orposterior,Combinationofotherinjuryverticaland/ortransversepatterns;LC/VSorLC/APCcomponentsCombinedmechanical(VS)injuriesTileclassificationsystem

involvesthreegroupsbasedontheconceptofpelvicstabilityTypeA:

Stable(posteriorarchintact)

A1:AvulsioninjuryA2:IliacwingoranteriorarchfractureA3:atransversesacrococcygealfractureTypeB:

Partiallystable

(incompletedisruptionofposteriorarch)rotationallyunstable,verticalystableB1:Openbookinjury(externalrotation)B2:Lateralcompressioninjury(internalrotation)B2-1:IpsilateralanteriorandposteriorinjuriesB2-2:Contralateral(buckethandle)injuriesB3:BilateralTypeC:Unstable(completedisruptionofposteriorarch)C1:UnilateralC1-1:IliacfractureC1-2:Sacroiliacfracture-dislocationC1-3:SacralfractureC2:Bilateral,withonesidetypeB,onesidetypeCC3:BilateralDennisclassificationofSacralfractureTypeITypeIITypeIIIClinicalfindings

Ahistoryofhigh-energyinjurycausedbymotorvehicleormotorcyclecollisionsorfallsfromheightsPelvicfracturesareassociatedwithotherinjuriessuchashead,chest,abdominalandretroperitonealvascularinjuriesthatmaybelife-threateningRoentgenographicevaluation

Thestandardroentgenographicprojectionsrequiredforevaluationofpelvicfracturesareananteroposteriorviewofthepelvisandthe40-degreecaudalinletand40-degreecephaladoutletviewsdescribedbyPennalComputedtomographyisanessentialpartoftheevaluationofanysignificantpelvicinjury.B,Forty-degreecephaladoutletviewofpelvisA,Forty-degreecaudadinletviewofpelvis

A,TiletypeB1pelvicinjurywithdiastasisofsymphysisandanteriorwideningofsacroiliacjoint.B,CTscanshowsthatposteriorsacroiliacjointligamentsareintact

Complications

Thepotentialcomplicationsofhigh-energypelvicfracturesincludeinjuriestothemajorvesselsandnervesofthepelvisandthemajorviscera,suchastheintestines,thebladder,andtheurethra.Reportedmortalityfromseverepelvicfracturesrangesfrom10%toashighas50%inopenpelvicfractures1)

retroperitonealvascularinjuries2)

majorvisceralinjuries:liver,kidney,orspleenandintestines3)

bladderandurethrainjuries4)

rectalinjuries5)nerveinjuries:lumbosacralplexusandsciaticnerveThemaincomplicationsofthepelvicfracture创伤早期救治—ABCDEF救治方案

（McMurtry1980）

A—airway保持呼吸通畅B—bleeding早期死亡原因，控制出血C—centeralnervoussystemPaCO2

D—digest消化系损伤的处理

E—excretion泌尿生殖系损伤的处理

F—fracture骨折的处理DiagnosisHistory,clinicalfeatures,laboratorydataPelviscompressiontestandseparationtestTreatment

1)

Priorityshouldbegiventothetreatmentofairway,breathing,andcirculationproblems2)Formildlydisplacedlateralcompressioninjuries,bedrestusuallyissufficient3)Operativereductionandinternalfixationofpelvicfracturestraditionallyhavebeendelayedforafewdaystoallowevaluationandtreatmentoflife-threateninginjuries,preoperativeplanning,andassemblyofnecessaryequipment

StablefracturesconservativetherapyUnstablefracturesoperationPosteriorscrewfixationofsacralfracturesandsacroiliacdislocations.Patientpositioning.Anteroposterior,caudad,andcephaladimageintensifierprojectionsshowdrillbitandscrewposition.Transiliacrodfixationofsacralfractures.A,LargeSteinmannpin(8to10mm)isdrilledfromouteraspectofoneiliumthroughoppositeilium.B,Secondrodisinsertedapproximately1.5cmdistalandparalleltothefirst.Iliosacralscrewfixationforsacroiliacorsacralfracture

TransiliacrodsforfixationofsacralfractureExternalfixatortoimmobilizethepelvicfractureAnteriorplatingofsacroiliacjoint

AcetabularFractureAnatomy90°betweeniliumplaneandobturatorplane

Bothare45°tothecoronaryplaneXraycheck:

obturatorobliqueviewIliacobliqueviewCTcheckisnecessary

Elementalfrxpatterns:

-posteriorwall:

-posteriorcolumnfrx:

-transversefrx:

-anteriorcolumnfrx

-anteriorwallfrx:

Associatedfrxpatterns:

-Tshapedfrx:

-posteriorwall+posteriorcolumnfrx:

-transverse+posteriorwallfrx:

-anteriorcolumnorwall+posteriorhemitransverse;

-posteriorcolumn+anteriorcolumnfrxClassificationoftheacetabulumFrxmedialroofarc

-APview

-verticlelineisdrawnfromroofofacetabulumtogeometriccenterofthefemoralhead;

-secondlineisdrawnfromfracturetothegeometriccenter;

-anglesubtendedbytheselinesformsthemedialroofarc;

-thismeasurementappliestotransverseacetabularfracturesandiflessthan45deg,frxisunstableandrequiresORIFRoofArcAngle(Mattaangle)Transversefrxanteriorroofarc

-obturatorobliqueview

-thismeasurementappliestotransverseacetabularfracturesandiflessthan25deg,frxisunstableandrequiresORIFposteriorroofarc

-iliumobliqueview

-thismeasurementappliestotransverseacetabularfracturesandiflessthan70deg,frxisunstableandrequiresORIF

（1）Hipflexion90°Forcetransfertotheheadandacetabulum,alongwiththeaxisoffemoralstem-—Posteriordislocation,posteriorwallfrx,transversefrxplusposteriorwallfrxMechanismofinjury（2）Hipextensionposition

Forcetransfertotheheadandacetabulum,alongwiththeaxisoffemoralstem-—Posteriorupperfrx,transversefrx（3）Forcetransfertotheheadandacetabulum,alongwiththeaxisoffemoralneck-—Posteriorcolumnfrx,transversefrx,anteriorwallfrx,anteriorcolumnfrx,Tfrx,doublecolumnfrxTreatmentConservativethearpyOperativethearpyDisplacementis2mmorlessRoofarcangle(Mattaangle)isover＞45°inAPviewPosteriorwallfrxfragment＜40%theearlier,thebetterAnatomicreductionandinternalfixation

perfectreduction＜1mmresidualdisplacementimperfect1－3mmpoor＞3mmPostOperativeManageme