第75章-骨盆及髋臼骨折(王满宜)(《外科学》8年制第2版配套)

第75章骨盆及髋臼骨折FracturesofPelvisandAcetabulum王满宜北京积水潭医院FracturesofPelvisPelvicpathology:Undisplaced/minmallydisplaced/displaced:StablefracturePartiallystablefracture(rotational)Completelyunstable(rotationalandvertically/translationally)IsolatediliacwingfracturesUndisplacedpubicramiifracturesTransversefracturesofsacrumbelowpelvicringOscoccygisfracturesAllpelvicligamentsintact!Unstablepelvicfractures:Partiallystable:Rotationallyunstable:External/internalrotation(lateralcompression)Flexion/extensionAbduction/adductionCompletelyunstable:Rotationallyandvertically(translationally)unstablePartiallystablepelvicfractures:Rotationallyunstable:OpenbookfracturesexternalrotationLateralcompressionfracturesinternalrotationExternalrotation:Mechanismsofinjury:PosteriorcrushDirectpressureASISExternalrotationthroughfemur(s)Rupturesymphysis/sacrospinouslig./anteriorsacroiliacligAlwaysposteriorandinterossessacroiliacligamentsintact!Externalrotationallyunstablefracture:Partiallystablepelvicfractures:Disruptionofsymphysisonly:SlightexternalrotationWideningofsymphysismax.2.5cm=OpenbookinjuryExternalrotationallyunstablefractures:Partiallystablepelvicfracture:Disruptionofsymphysis,sacrospinousligamentandanteriorsacroiliacligament:OpenbookinjuryMassiveexternalrotationPSISabutssacrum:ExternalrotationalinstabilityExternalrotationallyunstablefractures:Partiallystablepelvicfracture:Disruptionofsymphysis,sacrospinousligament,allsacroiliacligaments:Openbookinjurywith:MassiveexternalrotationFlexionTransitiontovertical/translationalinstabilityInternalrotation:Mechanismsofinjury:DirectpressuretoiliaccrestForceagainstgreatertrochanterfemoralheadacetabulumForceparalleltosacralplanethroughSI.joint(s)Internalrotationallyunstablefractures:Partiallystablepelvicfracture:CrushoflateralsacrumDisruptionofposteriorsacroiliacligamentAlwaysanteriorlesion:TranssymphysealTranspubicLateralcompressioninjuryAlwayspelvicfloorintact!Verticalshear:Mechanismsofinjury:Forceperpendicularto:SacralplaneSI-jointplane(s)Rotationallyandvertically(translationally)unstablefractures:Completelyunstablepelvicfractures:Alwayscompletedisruptionof:PosteriorcomplexPelvicfloorAnteriorcomplexCompletelyunstablefractureRotationallyandvertically(translationally)unstablefractures:Completelyunstablepelvicfracture:Alwayscompletedisruptionof:Posteriorcomplex:LigamentousSI-jointfracture-dislocationTransiliacfractureTransalar/transforaminalsacralfractureS1/S2transversefractureAnteriorcomplex!Applicableclassifications:TILE1984/1991CCFAO/ASIF1996OTAmodificationofCCFAO/ASIF1996Additionalterms/definitions:Simple=uncomplicatedpelvicfracture:SofttissuesaroundpelvisclosedNolaceration:GUI/VisceraComplexpelvicfracture:SofttissuesaroundpelvisopenInvolvementof:GUIand/orvisceraTraumatichemipelvectomyTypeAfractures:stableTypeBfractures:partiallystableTypeCfractures:completelyunstableTILE1984/1991TypeAstablepelvicringfractures:TypeA1:AvulsionoftheinnominateboneTypeA2:StableiliacwingfractureorstableminimallydisplacedringfracturesTypeA3:TransversefracturesofthesacrumandcoccyxTILE1984/1991TypeBpartiallystablepelvicringfractures:TypeB1:OpenbookinjuryTypeB2:ThelateralcompressioninjuryTypeB3:BilateralBinjuriesTILE1984/1991TypeB1:Anterior-posteriorcompressioninjuryfracturesare“open-book”pelvicfracturesExternalRotationalInstabilityTheyaredividedintothreestagesTypeB2:Lateralcompressioninjurydividedinto:B2-1:Ipsilateral;B2-2:Contralateral(Bucket-Handle);B2-3:FourRamitypeTypeCcompletelyunstable(verticalshear)pelvicringfractures:TypeC1:UnilateralTypeC2:Bilateral,onesideB,onesideCTypeC3:BilateralClesionsTILE1984/1991TypeC2:BilateralonesideB,onesideCTypeC3:BilateralClesions骨盆的x-线评定RadiologicEvaluationofthePelvis骨盆的标准x-线评定前后位像入口位像出口位像Judet位像轴相断层像用于判定骨盆创伤的放射学方式平片常规断层扫描其它用于判断伴随的软组织和盆腔脏器损伤的辅助技术血管造影术磷酸锝骨扫描核磁共振影象1.投照方法患者仰卧于x线床上，射线垂直于骨盆中部和放射线板。前后位相2.可见的骨盆解剖标识耻骨联合耻骨上、下支髂嵴骶髂关节骶孔第五腰椎横突前后位相3.可见的髋臼解剖标识髂耻线髂坐线泪点髋臼顶髋臼前、后缘前后位相4.用于创伤诊断前后位相（1）前环损伤：耻骨支骨折耻骨联合撕裂耻骨支骨折合并耻骨联合撕裂。前后位相（2）后环损伤：骶骨骨折髂骨骨折骶髂关节脱位骶髂关节骨折脱位前后位相（3）骨盆不稳定的细微表现：移位的第五腰椎横突尖撕脱骨折---纵向骨盆不稳定移位的骶棘韧带在坐骨棘或骶骨外缘的撕脱骨折---旋转骨盆不稳定前后位相5.判断下肢长度差异前后位相通过测量双侧股骨头到骶骨轴线的垂线之距离.投照方法：患者仰卧于X线台上，射线从足侧指向耻骨联合与垂线约成40°角。出口位（2）用途有助于发现在骨盆平面上的向上移位观察骨盆矢状面的旋转是骶骨的标准前后位相出口位前、后骶骨孔在此投照位显得很圆，接近或累及骶孔的骨折也可看到。最佳地显示骶骨体部的骨折特别是横行的骨折。易于显示L5横突的撕脱骨折和骶骨外缘的骨折。（2）用途出口位（1）投照方法：患者仰卧于X线台上，射线从头侧指向骨盆中央与垂线约成40°角。入口位（2）特点：此种与骨盆入口相垂直的投射角度真正地显示了骨盆入口。X线与S2和S3椎体前缘位于同一平面，故在此投照位置，S2和S3椎体的前方皮质相重叠，在骶骨体前呈一条线。此线位于骶骨岬之后几毫米，是置放骶髂关节螺钉的最前限。入口位（3）用途：比其它投射方式更能清楚地显示在骨盆平面上骨折向前及向后的移位。常显示后骨盆环的最大移位。显示髂骨翼因外侧挤压伤而内旋或因前后挤压伤和剪式损伤所致的外旋入口位（3）用途：显示骶骨嵌压骨折或骶骨翼骨折（alafractures）显示坐骨棘(ischialspine)撕脱骨折入口位（1）重要性：增加诊断骨盆骨折有价值的依据彻底提高了对骨盆后方骨间韧带结构的诊断水平。骨盆CT（2）用途：清楚地描述骶骨骨折粉碎和骶髂关节分离的程度。更明确地显示半骨盆的旋转畸形及横向移位。清楚地显示骶骨分离、骶骨孔挤压、骶骨翼骨折。骨盆CT（2）用途：•若骶髂关节前和后方增宽诊断完全性不稳定性骶髂关节脱位。•有助于确定合并的髋关节骨折•用于靠平片不足以确诊的所有骨盆骨折和不稳定的患者。•用于确诊骨盆骨折（如耻骨支骨折）是否侵及邻近的髋关节。骨盆CT骨盆骨折分型（一）历史上的分型1.按解剖部位。2.按骨盆负重弓的完整程度。3.按骨盆环断裂的数目。4.按骨盆环的稳定程度。（一）历史上的分型5.按血液动力学状态。6.按致伤能量大小。7.按受伤机制。8.按后遗症。（二）这些分类方法的缺点：不全面引起混乱（因为各侧重点不同）无法比较疗效及预后1980年Pennaletal和Tile提出的分型方法：按导致骨盆环破裂的外力方向分型LC:(lateralompressionInjuries