Κακώσεις Ιερού Οστού - Sacral injuries
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Transcript of Κακώσεις Ιερού Οστού - Sacral injuries
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SACRAL SACRAL
FRACTURES FRACTURES
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PELVIC ANATOMY ANTERIOR VIEW PELVIC ANATOMY ANTERIOR VIEW
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PELVIC ANATOMY POSTERIOR VIEW
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PELVIC ANATOMY INLET VIEW
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SACRUM ANATOMY
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SACRUM ANATOMY
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POSTERIOR WALL OF PELVIS
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LATERAL WALL OF PELVIS
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SACRAL PLEXUS
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SACRAL PLEXUS
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SACRAL PLEXUS
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SACRUM FRACTURES – NERVE ROOTS
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SACRUM FRACTURES – DENIS CLASSIFICATIONSACRUM FRACTURES – DENIS CLASSIFICATION
ZONE IAcross sacralNeurological injuries
•due to superior migration of fragments•6% of the whole•lumbrosacral plexus L5,S1 (24%)•Femoral nerve
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ZONE II
• Through the neuroforamina
• Neurological injuries L5, S1 (50%)
• Unilateral sacral anesthesia• Incontinence• Flaccid bowel and bladder• impotence
• Evaluation • Achilles reflex• Bulbocaverosus reflex• Rectal tone
SACRUM FRACTURES – DENIS CLASSIFICATION
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SACRUM FRACTURES – DENIS CLASSIFICATION
ZONE III
• through the body of the sacrum
• Neurological injuries
• 56% of the whole• Cauda equina• Neurogenic bladder• Saddle anesthesia• Loss of sphincter tone• Bowel, bladder dysfunction 70%
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MISCELLANEOUS FRACTURES
• Transverse fractures
• From landing on the buttocks
• U shaped fractures
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• One hand is placed on the iliac crest
• The other hand applies traction to the leg
Displacement in vertical plane
PHYSICAL EXAMINATION
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RADIOGRAPHIC INVESTIGATION
• AP radiographs, inlet and outlet views
• Difficult – complex shape (50% are missed)
• Findings – low lumbar transverse process fractures
- asymmetrical sacral foramen
- irregular trabeculation of the lateral
masses
• Sacral arcuate lines asymmetry: uncomplicated
sacral frx
disorganized: comminuted
sacral frx
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RADIOGRAFIC INVESTIGATION
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• The most accurateThe most accurate
• Especially for transverse fracturesEspecially for transverse fractures
• Useful for detecting large defects as tarlov cystsUseful for detecting large defects as tarlov cysts
• Diagnosis of coexisting malignant lesionsDiagnosis of coexisting malignant lesions
CT SCAN
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CD SCAN
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• The most sensitive
in detection of fractures
- soft tissue edema
- marrow changes
MRI
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TREATMENT
ZONE I
• Without neurologic deficits and stable
• Symptom relief
• Bed rest (7-10 days)
• Log-rolled
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TREATMENT
ZONE II and III
• Without neurologic deficits
• Bed rest for 4-8 weeks
• Weight bearing at 4-8 weeks on the fractured side
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TREATMENT
ZONE III
• Without neurologic deficits
• Observation: neuropraxia that will resolve
• Symptoms beyond 6-8 weeks: foraminal decompression
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TREATMENT
ZONE III
• With neurologic injury
• Aggressive radiologic examination
• Early posterior
decompression
forReturn of – bowel, bladder
control
Reserval of foot drop
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COMPLICATIONS OF CONSERVATIVE
TREATMENT
• chronic pain
• sacroiliac joint arthritis
• changes in the alignment on the sacrum
• bowel, bladder disability
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DETERMINATION OF FRACTURE STABILITY
• Stable fractures
• Impacted vertical fracture
• Nondisplaced fracture of posterior sacroiliac complex
• Fracture of the upper sacrum
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DETERMINATION OF FRACTURE STABILITY
• Unstable
• Fracture diastasis of more than 0,5 – 1cm along with an anterior unstable injury
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SURGICAL INDICATION
• posterior or vertical displacement or both (>1cm)
• Rotationally unstable pelvic ring injuries
• Sacral fractures with unstable pelvic ring that requires mobilization
• Neurological injury
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PROCEDURE PRONE POSITION
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PERCUTANEOUS ILIOSACRAL SCREW FIXATION
• For unilateral sacral fractures zone I or zone II
• Under fluoroscopic control the reduction is obtained and
held by iliac screws (cannulated)
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OPEN REDUCTION AND INTERNAL FIXATION
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MISCELLANEOUS CASES
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CASE 4
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CONCLUSION
• Neurological deficities
• Stable Fractures : conservative treatment
• Unstable Fractures : operative treatment
• Neurologic injury :posterior decompression
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