1、Fracture of Spine & Pelvis 脊柱、骨盆骨折,Tips of This Talk,Really difficult and complex Plenty of new words Even hard for residents Seat back Have fun Ask questions Following the brain storming Forget the test,Spinal fractures 脊柱骨折,The Injury of the spine 脊柱创伤,Fractures and dislocations of the spine are s
2、erious injuries that most commonly occur in young people Nearly 43% of patients with spinal cord injuries sustain multiple injuries,Anatomy of Vertebral Column,The three columns of the spine /脊柱的三柱理论,The anterior column (A),Anterior longitudinal ligament/前纵韧带 Anterior part of the vertebral body/椎体前部
3、 Anterior portion of the annulus fibrosis/纤维环,The middle column (B),Posterior longitudinal ligament/后纵韧带 Posterior part of the vertebral body Posterior portion of the annulus /纤维环,The posterior column (C),Bony Ligamentous posterior elements,CLASSIFICATION- Magral,The mechanistic classification Compr
4、ession Vertical /垂直压缩 Flexion Distractive Flexion (Chance)/屈曲分离型 Rotational /旋转型 Distractive Extension /伸直分离型,CLASSIFICATION,Stable spinal fracture Gentle to middle compressive F , the posterior column is intact Unstable spinal fracture 2/3 column Splintered F, middle column, spinal canal narrow Wit
5、h dislocation,CLASSIFICATION,Compression F I-1/3, II-2/3, III-3/3 Splintered F Avulsion F Chance F F-Dislocation,Evaluation of Spinal Injury /脊柱损伤的诊断,HISTORY Mechanism of injury /受伤的机制 Common causes: motor vehicle accidents, falls, diving accidents, and gunshot wounds PHYSICAL EXAMINATION Watchtouch
6、press listen move NEUROLOGICAL EVALUATION /神经系统评估,NEUROLOGICAL EVALUATION/神经系统评估,Sensory, motor, and reflex function, is important in determining prognosis and treatment,感觉、运动、反射-决定预后和治疗,Roentgenographic Examination /X线,The initial-a lateral view of the cervical spine/颈椎侧位片 & anteroposterior views o
7、f the chest and pelvis/胸部、骨盆正位片 Easy missed: the odontoid process /齿状突or the cervicothoracic junction颈胸段 Cervic PTS-Anteroposterior, lateral, right / left oblique projections/斜位,Standard radiographs of the cervical spine,Lateral view,Anteroposterior view,Oblique projections,Odontoid process,Flexion-
8、extension views,Other 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 of the spinal canal /椎管,Computed tomography (CT),Cervical Spine
9、 Injuries,Vulnerable to injury/容易受伤 Two particular areas: C1 to C2 and C5 to C7 40% of neurological damage 10% -no obvious roentgenographic evidence of vertebral injury/椎体无损伤,Guideline,Spinal alignment can be obtained by skeletal traction through spring-loaded Gardner-Wells tongs or a halo ring Open
10、 reduction and stabilization if spinal realignment cannot be obtained by traction,Nonoperative 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 Immobilization),Operative Treatment,Unstable
11、 injuries of the cervical spine, with or without neurological deficit, generally require operative treatment Open reduction and internal fixation,Injuries to Upper Cervical Spine (Occiput to C2),Jefferson F(Anterior & Posterior arch F) Rotary Subluxation of C1 on C2 Dens Fracture Hangman F,atlas/寰椎(
12、C1) -an anterior arch fracture Treatment: Immobilization in a plaster (head to chest) or rigid cervical orthosis 12 weeks,Jefferson F,Rotary Subluxation of C1 on C2.,Uncommon in adults By motor vehicle accidents Torticollis and restricted neck motion- often not recognized at initial evaluation An op
13、en-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 Traction & C1-2 Fusion operation,Odontoid fractures,Type I injury demonstrates an avulsion fracture of the tip of the odontoid Type II fractur
14、es are located at the waist of the odontoid Type III fractures extend caudally into the cancellous bone of the body of the axis,Dens Fracture- odontoid fractures,Type I - uncommon, and even if nonunion occurs after inadequate immobilization, no instability resultsneck orthosis for 6-8 weeks Type II
15、-the most common, 36% nonunion rate for both displaced and nondisplaced fractures Traction & plaster or Halo, or OP Type III -a large cancellous base and heal without surgery in 90% of patients Orthosis or plaster for 12 weeks,Type II odontoid fracture. A solid C12 fusion was demonstrated,Internal F
16、ixation of Upper Cervical Spine,Hot & Spice Recent advances in internal fixation have allowed its use in the cervical spine,Hangman Fractures （Traumatic Spondylolisthesis/滑脱 of the Axis ),Incurred during the hanging of criminals Motor vehicle accidents with hyperextension of the head vertebral body
17、moving forward, Arch moving backward,A 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.,Hangmans fracture,Satisfactory closed reduction could be achieved in a halo using an ext
18、ended head position,Nonoperative treatment of hangmans fracture Traction & plaster or orthosis,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 maintain spinal stability Obt
19、ain early functional recovery,Compression flexion injuries Common C4-5 OR C5-6,Flexion compression injury,C3-7 Treatment,Non-op Plaster or orthosis, Halo Ring Op Decompression Front or back Fusion,Thoracic and Lumbosacral Fractures,The treatment of unstable fractures and fracture-dislocations of the
20、 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,This flexion-d
21、istraction injury (seat belt fracture) was the result of an automobile accident,Spinal Cord Injury 脊髓损伤,The Spinal Cord Injury Superman,4,500 years ago- was described as “a disease one cannot treat” . Paralysis remains incurable Improved care has allowed patients with a spinal cord injury better fun
22、ction, improved quality of life, and prolonged survival Experience and research continue,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 age and sex without spinal cord injury
23、 Regional trauma centers and increased training of paramedics and emergency medical technicians- survival increased,Spinal shock,lasts for 1-6 weeks A positive bulbocavernosus reflex/ 球海绵体反射or return of the anal wink reflex/肛门反射- indicates the end of spinal shock If no motor or sensory function belo
24、w 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,Spinal Cord Syndromes /An incomplete spinal cord injury,Definition An incomplete spinal cord injury is one in which some
25、 motor or sensory function is spared distal to the cord injury When the bulbocavernosus reflex / 球海绵体反射is positive and no sacral sensation or motor function has returned, the paralysis will be permanent and complete in most patients.,Spinal Cord Syndromes,Resulting from incomplete traumatic lesions
26、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.,Spinal Cord Syndromes,Anterior cord
27、 syndrome Posterior cord syndrome Central cord syndrome 中央脊髓综合症 Brown-Squard syndrome 半切综合症,Anterior cord syndrome,Partial paralysis of upper extremity In lower extremity, loss of motor functions, but maintain deep pressure and position sensory/深感觉压力和位置觉存在,Posterior cord syndrome,Below the injury le
28、vel, loss of sensory functions, but maintain motor functions 损伤平面以下，感觉消失而运动存在,Central cord syndrome/中央脊髓综合症,A quadriparesis/四肢瘫 involving the upper extremities to a greater degree than the lower/上肢重,Brown-Squard syndrome/半切综合症,Half of the spinal cord- motor weakness on the side of the lesion and the
29、 contralateral loss of pain and temperature sensation,Complete spinal cord injury,total motor and sensory loss distal to the injury,Conus medullaris syndrome,Spinal cord S3-5-Lumbar 1 Motor and sensory function in lower extremity may normal Loss sensory function around sacrum, perineum/ 鞍区 Loss bulbocavernosus reflex/球海绵体反射or the anal wink reflex/肛门反射,Diagnosis,NEUROLOGICAL EVALUATION Sensory Motor Reflex function Important in determining prognosis and treatment,感觉、运动、反射-决定预后和治疗,
