脊柱和骨盆骨折2中山大學外科學ppt課件

1、第一頁，共七十七頁。1Fracture of Spine & Pelvis 課時數(shù) 2 內容簡介 脊柱骨折 脊髓損傷 骨盆骨折第二頁，共七十七頁。2問題？ 如何診斷脊柱脊髓損傷？ 骨盆骨折的治療原則？第三頁，共七十七頁。3Fracture of Spine & PelvisOrthopedics Dep.Jin Wang第四頁，共七十七頁。4Tips of This Talk Really difficult and complex Plenty of new words Even hard for residents Seat back Have fun Ask questi

2、ons Following the brain storming Forget the test第五頁，共七十七頁。5Spinal fractures脊柱骨折Spinal Cord Injury脊髓損傷第六頁，共七十七頁。6The 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 multi

3、ple injuries 第七頁，共七十七頁。7Trauma Center & Spine Center第八頁，共七十七頁。8Anatomy of Vertebral ColumnAnatomy 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

4、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 第九頁，共七十七頁。9The three columns of the spineThe anterior column (A)(A) consists of the anterior

5、longitudinal ligament, anterior part of the vertebral body, and the anterior portion of the annulus fibrosisThe middle column (B)(B) consists of the posterior longitudinal ligament, posterior part of the vertebral body, and posterior portion of the annulusThe posterior column (C)(C) consists of the

6、bony and ligamentous posterior elements第十頁，共七十七頁。10Evaluation of Spinal Evaluation of Spinal InjuryInjury HISTORYHISTORY Mechanism of injury Common causes: motor vehicle accidents, falls, diving accidents, and gunshot wounds PHYSICAL EXAMINATIONPHYSICAL EXAMINATION NEUROLOGICAL EVALUATIONNEUROLOGICA

7、L EVALUATION 第十一頁，共七十七頁。11NEUROLOGICAL NEUROLOGICAL EVALUATIONEVALUATION Sensory, motor, and reflex function, is important in determining prognosis and treatment 第十二頁，共七十七頁。12Neurologic examination recommended by the American Spinal Injury Association (ASIA) 第十三頁，共七十七頁。13Sensory Examination Dermatom

8、e 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 establish the diagnosis of an incomplete spinal cord injury第十四頁，共七十七頁。14Motor Exam

9、ination 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. 第十五頁，共七十七頁。15第十六頁，共七十七頁。16screening examination of the lower

10、 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第十七頁，共七十七頁。17Reflexes examination Physical reflexes Pathology reflexes第十八頁，共七十七頁。18Roentgenographic Roen

11、tgenographic 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 Cervic PTS-Anteroposterior, lateral, right / left oblique projections第十九頁，共七十七頁。19Standard radiog

12、raphs of the cervical spine 第二十頁，共七十七頁。20Flexion-extension views 第二十一頁，共七十七頁。21Other 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

13、of the spinal canal 第二十二頁，共七十七頁。22Images from a screening computed tomography (CT). 第二十三頁，共七十七頁。23Emergency Room Emergency Room ManagementManagement The initial examination-general surgery, anesthesia, respiratory, neurosurgery, and orthopaedic specialists Hypotension, hypothermia, and bradycardia-3

14、 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 第二十四頁，共七十七頁。24Cervical Spine InjuriesCervical Spine Injuries Vulnerable to injury Two particular areas: C1 to C2 and C5 to C7, C

15、2 and C5 -the most common 40% of neurological damage 10% -no obvious roentgenographic evidence of vertebral injury 第二十五頁，共七十七頁。25The axial CT of the atlas(C1) revealed an anterior arch fracture第二十六頁，共七十七頁。26CLASSIFICATIONCLASSIFICATION The mechanistic classification Vertical Compression (VC)Vertical

16、 Compression (VC) Distractive Flexion (DF)Distractive Flexion (DF) Compression Extension (CE)Compression Extension (CE) Distractive Extension (DE)Distractive Extension (DE) Lateral Flexion (LF)Lateral Flexion (LF) Compressive Flexion (CF)Compressive Flexion (CF) 第二十七頁，共七十七頁。27TIPS InstabilityInstabi

17、lity Stretch TestStretch Test第二十八頁，共七十七頁。28Goals of TreatmentTreatment 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 第二十九頁，共七十七頁。29Guideline Spinal alignme

18、nt 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第三十頁，共七十七頁。30Nonoperative Nonoperative TreatmentTreatment Many cervical spine injuries can be treated without surgery

19、Immobilization in a rigid cervical orthosis for 8 to 12 weeks may be sufficient (Halo Vest ImmobilizationHalo Vest Immobilization)第三十一頁，共七十七頁。31Operative TreatmentOperative Treatment Unstable injuries of the cervical spine, with or without neurological deficit, generally require operative treatment

20、Open reduction and internal fixation are indicated to obtain stability and allow early functional rehabilitation 第三十二頁，共七十七頁。32Principles of operation The injury must be clearly defined before surgery by plain roentgenograms, high-resolution CT scanning with sagittal and coronal reconstruction, or M

21、RI Laminectomy has a limited roleCompression 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 stabil

22、ization with internal fixation and bone grafting are indicated第三十三頁，共七十七頁。33Injuries to Upper Cervical Injuries to Upper Cervical Spine (Occiput to C2)Spine (Occiput to C2) Rotary Subluxation of C1 on C2Rotary Subluxation of C1 on C2 Dens FractureDens Fracture 第三十四頁，共七十七頁。34Rotary Subluxation of Rot

23、ary Subluxation of C1 on C2.C1 on C2.Uncommon in adults By motor vehicle accidents Torticollis and restricted neck motion- often not recognized at initial evaluationAn open-mouth odontoid roentgenogram may reveal the wink sign caused by overriding of the C1-2 joint on one side and a normal configura

24、tion on the other side CT A halo ring or operational-a halo vest 8 to 12 weeks第三十五頁，共七十七頁。35Odontoid fractures齒狀突骨折Type I injury demonstrates an avulsion fracture of the tip of the odontoidType II fractures are located at the waist of the odontoidType III fractures extend caudally into the cancellou

25、s bone of the body of the axis第三十六頁，共七十七頁。36Dens Fracture-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 lar

26、ge cancellous base and heal without surgery in 90% of patients第三十七頁，共七十七頁。37 Type II odontoid fracture. A solid C12 fusion was demonstrated第三十八頁，共七十七頁。38Internal Fixation of Internal Fixation of Upper Cervical SpineUpper Cervical Spine Hot & Spice Recent advances in internal fixation have allowe

27、d its use in the cervical spine第三十九頁，共七十七頁。39Traumatic Spondylolisthesis Traumatic Spondylolisthesis of the Axis (Hangman of the Axis (Hangman Fractures)Fractures) Incurred during the hanging of criminalsMotor vehicle accidents with hyperextension of the headThe occiput is forced down against the po

28、sterior arch of the atlas, which in turn is forced against the pedicles of C2(Axis) 第四十頁，共七十七頁。40A 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 plai

29、n radiographs, the axial CT images confirm bilateral fractures through the narrow part of the pars (small arrows)Type IIa hangmans fracture第四十一頁，共七十七頁。41C: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

30、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第四十二頁，共七十七頁。42Lower Cervical Spine (C3-7)Lower Cervical Spine (C3-7) The primary goals of treatm

31、ent Realign the spine Prevent loss of function of uninjured neurological tissue Improve neurological recovery Obtain and maintain spinal stability Obtain early functional recovery 第四十三頁，共七十七頁。43 Compression flexion injuries第四十四頁，共七十七頁。44Flexion compression injury第四十五頁，共七十七頁。45Thoracic and Lumbosacra

32、l FracturesThoracic 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

33、-dislocations because it fails to relieve the anterior compression and increases spinal instability 第四十六頁，共七十七頁。46 This flexion-distraction injury (seat belt fracture) was the result of an automobile accident第四十七頁，共七十七頁。47第四十八頁，共七十七頁。48The Spinal Cord Injury脊髓損傷 4,500 years ago- was described as “a

34、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第四十九頁，共七十七頁。49Spinal Cord Injury Overall, 85% of patients with a spinal cord injury w

35、ho 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 第五十頁，共七十七頁。50Spinal shock脊髓休克 Rarely lasts l

36、onger than 24 hours, it may last for days or weeksA positive bulbocavernosus reflex or return of the anal wink reflex- indicates the end of spinal shockIf 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

37、 prognosis is poor for recovery of distal motor or sensory function 第五十一頁，共七十七頁。51Spinal Cord 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 t

38、otal 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. 第五十二頁，共七十七頁。52Spinal Cord SyndromesSpinal Cord Syndromes Resulting from incomplete traum

39、atic 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. 第五十三頁，共七十七頁。53Spinal C

40、ord SyndromesSpinal Cord SyndromesCentral cord syndrome - a quadriparesis involving the 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 c

41、ord syndrome Posterior cord syndrome A mixed syndrome Conus medullaris syndromeCauda equina syndrome第五十四頁，共七十七頁。54第五十五頁，共七十七頁。55Pelvic 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 join

42、t 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第五十六頁，共七十七

43、頁。56Clinical 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 exam

44、ination第五十七頁，共七十七頁。57Clinical FindingsA plain anteroposterior pelvic radiograph -inlet and outlet views Judets oblique views -acetabulum Ct scanning - further delineate Vascular and urologic imaging may also be required第五十八頁，共七十七頁。58TreatmentAssociated injuries -take precedence over treatment of the

45、 pelvic fractureHemorrhage 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第五十九頁，共七十七頁。59Associated InjuriesHemorrhage-

46、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,

47、femoral, obturator, pudendal, or superior gluteal). Most of-neurapraxia type- favorable outcome, 10% permanent neurologic sequelaeUrogenital injuries第六十頁，共七十七頁。60Location of FracturesThe pelvic ringThe acetabulum 第六十一頁，共七十七頁。61Injuries to The Pelvic Ring3% for all fractures.wide spectrum: avulsion f

48、racture 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; dis

49、rupted, both rotationally and vertically unstable第六十二頁，共七十七頁。62Classification 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

50、 and vertically unstable 第六十三頁，共七十七頁。63Type 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 第六十四頁，共七十七頁。64Treatment of Type A Conser

51、vative treatment- usually sufficient Symptomatic, with bed rest and analgesia, early ambulation, and weight bearing as tolerated. 第六十五頁，共七十七頁。65Type B Fracture Involve the pelvic ring in two or more sites- create a segment that is rotationally unstable but vertically stableType B1: open-book fractur

52、es 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) 第六十六頁，共七十七頁。66Treatment of Type B B Symptomatic treatment Reduction-lateral

53、 compression Manipulation under general anesthesia Reduction can be maintainted A hip spica But more often external or internal fixation is currently favored第六十七頁，共七十七頁。67第六十八頁，共七十七頁。68Type C Both rotationally and vertically unstable Result from a vertical shear mechanism, like a fall from a height

54、第六十九頁，共七十七頁。69Treatment of Type 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 requiredThe surgical technique is demanding, and there is a significant risk of complications. 第七十頁，共七十七頁。70Complications 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