DAMAGE TO THE SPINE AND PELVIS
Damage to the spine occur by the forces of considerable size and are among the most
serious injuries of the musculoskeletal system . Spinal trauma fractures in the overall structure of
the bones in adults ranges from 2.2% to 20.6 %. Damage complicated neurological disorders are
more common in nyzhnohrudnomu and lumbar spine and make up 39.2 % and 48.5 %, respectively.
Epidemiological data indicate that spinal injury is more common in young men, and poor outcomes
make up a significant percentage . About 43 % of patients with vertebral - spinal cord injury are
multiple and combined injuries, making it difficult to diagnose and selecting the appropriate
treatment strategy .
Causes and mechanisms of damage to the spine. In the initial stages of diagnosis of spine
injuries is of paramount importance clarify the circumstances of the injury. Causes damage to the
spine and spinal cord are often falling from height ( katatravma ), road traffic accidents , diving
with a bang his head on the bottom of ponds, cargo fall on different parts of the spine, sports
injuries and more.
There are direct and indirect mechanisms of injury. In the direct mechanism of the effort is
applied to the spine (blow with a blunt object or compression in the direction back to front ),
leading to shock and damage to the isolated posterior structures of the spine. When indirect
mechanism of injury damage resulting from forcible flexion or extension of the cervical , thoracic
and lumbar (sharp and sudden forced flexion of the trunk cross-sectional or tilt of the head, and the
so-called movement of the whip , when the car hit the back of head sharply deflected back with a
sharp forced extension of the neck and the subsequent sharp bending it), rotation - rotation ( during
sports fighters with incorrect or inept receptions with the rotation of the head), compression (
traumatic force in this mechanism operates strictly on the vertical axis of the spine , provided that at
the time the force cervical or lumbar lordosis physiological adjusted - there are compression- clastic
or explosive vertebral fractures ) of changes ( occur when the force strictly in the frontal or sagittal
plane and more in the rigid spine when the lower part of the spine has a solid base) and the
stretching. Leading in tension is inertial motion of the upper half of the body relative to the fixed
lower half . Most often it occurs at a fixed torso belt when riding in a car. When moving the upper
half of the body inertia occurs stretching the lumbar spine, intervertebral disc rupture occurs , the
anterior and posterior longitudinal ligaments, all structures posterior copula- bags system and
sometimes the spinal cord. Each of these mechanisms of injury may act as isolation and in various
combinations , leading to some form of damage to the spinal column.
The nature of the violation of integrity anatomical structures of the spine distinguish the
following types of damages:
1. Damage to ligaments (isolated or multiple breaks capsular - ligamentous apparatus );
2. Fractures of the vertebral ( compression , horizontal , vertical, tear-off , debris ,
explosives ). When compression fractures reveal grade 3 compression (I degree - reducing the
height of the vertebral body or anterior less than half the height of the adjacent vertebrae , II degree
- reducing the height of the vertebral body or anterior half of the height of the adjacent vertebrae ,
III degree - reducing the height of the vertebral body or its anterior part , more than half the height
of the adjacent vertebra );
3. Damage from the rupture of the intervertebral disc annulus fibrosus and nucleus
pulposus displacement ;
4. Fractures of the posterior vertebral rings ( brackets, articular , transverse and spinous
processes );
5. Subluxation , dislocation and dislocation - perelomo vertebrae , accompanied by a shift
in the axis in the sagittal or frontal plane deformity of the spinal canal ;
6. Traumatic spondylolisthesis .
Damage to the spine and spinal cord are divided into open and closed ( pellet and fire ).
Open injury involving violation of the integrity of the skin in the projection of the spine at the level
of the injury .
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Damage to the upper cervical spine ( segment C1- C2 ) are divided into dislocation of
atlanto- occipital joints, fracture Atlanta " bursts " ( Jefferson fracture ), subluxation and dislocation
Atlanta ( Kinbeka dislocations ) in combination with a fractured odontoid process of C2 vertebra
and traumatic spondylolisthesis C2 vertebra.
With injuries of thoracic and lumbar spine and cervical spine from C3- C7 level using a
universal classification proposed by Magerl in 1994 , based on pathological criteria. According to
her, the most common types of fractures are characterized by the main mechanisms of action of
forces on the spine - compression (A) tension (B) and rotary - axial torsion (C).
Type A Damage resulting from compression , with damaged anterior vertebra and having
explosive compression fractures of bodies.
Damage in this type tend to have a stable ligamentous apparatus intact or damaged
structures observed isolated posterior reference complex ( nadostystoyi and mizhostystoyi
communication, neural , joint or transverse processes , vertebral bodies parentheses ). Be destroyed
only elements of the anterior column of the spine . The rear wall of the vertebra remains intact .
Neurological violations are rare.
Damage type B arise as a result of compression and tensile strength , with damaged
anterior and posterior pillars of the spine. There flexion- extensor fractures, "explosive fracture " of
rear break ligaments ( capsule duhovidrostkovyh joints , yellow, inter-and nadostystoyi
relationships, sometimes involving the extensor muscles of the back and fascia ). Damage to the
anterior and middle column is characterized by rupture of intervertebral disc. Posterior capsular
rupture , characterized by the emergence of connected structures subluxations, dislocations articular
processes, their possible fracture. Also damaged ligaments can be combined with compression
fractures of the vertebral bodies of various kinds - and explosive debris . Damage of this type are to
unstable and often accompanied by the development of neurological symptoms.
Damage type C belong to the most difficult . They arise as a result of compression,
distraction and rotation, and are accompanied by damage to the three supporting structures of the
spine in which the usually observed neurological disorders.
Damage to the spine divided into stable and unstable. Based on the concept of
sustainability F. Denis in 1983 proposed a model of the spine, according to which the bone and
ligaments of the spine is divided into three columns. Anterior column model is formed from the
anterior longitudinal ligament, the anterior part of the annulus fibrosus of the intervertebral disc and
the front of the vertebral bodies. The average column includes rear longitudinal connection
posterior part of the annulus fibrosus and posterior part of the vertebral bodies . Posterior column
consists of the posterior bone complex ( root arcs duhovidrostkovi joints, spinous and transverse
processes ) and communication.
To stable include such damage, unless there is a shift of the structures of the spine during
normal movements. The spinal cord does not corrupt and immediate threat of trauma is not. A
typical example of such an injury - compression fracture wedge-shaped vertebral body , if the
decrease in its height does not exceed 1 /2.
In contrast , the volatile attribute damage when there is danger of further displacement of
the structures of the spine threatening compression of the neuro - vascular lesions of the spinal
canal . This results in the destruction of at least two supporting columns of the spine. Considered
unstable injuries of the posterior ligamentous complex infringement ( mizhostystyh over the
spinous and yellow tie) , intervertebral joints, as well as violations in the area of the so-called
middle column which directly topographically close to the spinal canal There are two types of
instability : acute (which occurs immediately after the injury ) and chronic ( developing over time
and turns the appearance or increase in post-traumatic spinal deformity and the development and
deepening of neurological disorders ).
Signs of instability consider having neurological symptoms , reduction on radiographs in
the lateral projection of the height of the vertebral body compression fractures by more than 25% of
cervical and 50 % for the thoracic and lumbar or horizontal displacement of more than 3.5 mm. The
instability is also shown posttraumatic kyphosis in the cervical region of more than 30 °, and in the
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thoracic and lumbar - more than 20 °. Dislocation or subluxation is also referred to as unstable
injuries.
Besides damage to the spine divided into uncomplicated and complicated . Complicated
damage - damage to the structures of the spine combined with spinal cord and its roots. Sometimes
as a result of an injury is objective evidence of damage to the spine may be absent or not detected ,
and neurological disorders are manifested in different forms. In this embodiment relates to damage
and complications arising from the closed spinal cord injury.
The level of spinal cord injury and cauda equina injury are in the cervical , thoracic ,
lumbosacral spinal cord, cauda equina roots .
Damage to the cervical spine. Damage to the upper cervical vertebrae are highlighted in
separate anatomical area and divided into fractures, sprains and perelomovyvyhy .
Fractures of the upper cervical vertebrae. Fracture of C1 vertebra ( atlas ). Fracture of the
atlas ( Jefferson fracture ), resulting from the axial load at which the annular Atlanta bursts like a
bagel, and its lateral masses diverge outward.
Fractures of the odontoid vertebra appendix C2 ( Axis ). This type of damage may be at
offset broken tooth at an angle across the width and shift of the tooth with Atlanta and head forward
or backward. Fracture of tooth Axis refers to serious and dangerous injuries. For large displacement
process with the first vertebra possible fatal outcome due to compression of the medulla oblongata.
The turning point of the arc Axis (traumatic spondylolisthesis or " hangman fracture ").
This breakthrough is the result of a sharp axial load and pererazgibanie . Thus there is a fracture of
the leg brace Axis and shift his body with the above posted spine and head forward . Offset body
may be minimal, but there may be dislocation in the width of the body of C3 compressed spinal
posterior arch Atlanta.
Dislocations and fracture-dislocations of upper cervical vertebrae.
Rotary subluxation of Atlas - the most frequent variant damage atlanto -axial joints, which
often occurs in children as a result of a sharp turn of the head and the athletes during the fight.
Dislocations of Atlas. Damage occurs when falling from a height on the head as a result of
tooth fracture Axis , rupture of the transverse ligament Atlanta or slipping a tooth from the crosslinking of the front , back less , atlas subluxation . Thus Atlanta with his head moves forward .
Damage to the middle and lower cervical vertebrae. Among the injuries of the cervical
level C2- C7 (the most mobile part of the spine ) are more common subluxation , dislocation and
perelomovyvyhy vertebrae. Dislocations occur due to excessive flexion, extension and rotation.
There unilateral and bilateral dislocations , sprains front , very rarely - rear .
If you bend the vertebral body located above move forward relatively lower lying and
articular surface shifted upwards - there is subluxation . If the action of forces continues , there is a
riding dislocation in which the articular processes face the top, and then shift the lower articular
process of the vertebra that vyvyhnuvsya in upper vertebrates clipping lower lying vertebra , is
formed by dislocation that grappled . When such damage damaged intervertebral disc can migrate
toward the spinal canal and cause serious neurological disorders of the spinal cord and its elements.
Extensor damage as opposed to bending is usually completed samovpravlennyam .
Fractures of the C2 - C7 vertebrae. Among fractures often appear damaged vertebral
bodies as a result of the force at the axis of the spine. There are Compression and debris ("
explosive " ) and tear-off fractures. If the compression- clastic fracture fragments may be a shift
back toward the spinal canal , neurological disorders of varying severity.
Dislocations and perelomovyvyhy in the cervical related to unstable and damaged
segments of the spinal cord at this level for the most serious and prognostically unfavorable .
Damage to the thoracic and lumbar spine . Damage to the spine in the thoracic and lumbar
levels are characterized by a great variety of violations of the integrity of vertebral and
paravertebral anatomical structures that are often localized in the XI, XII and thoracic I and II of the
lumbar vertebrae - in the transition zone of rigid thoracic to lumbar mobile .
With a sharp bend and there are isolated discontinuities nadostystyh and mizhostystyh
connection , broken spinous processes . As a result of direct action and sudden excessive muscle
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contraction per square back that is attached to the ribs 12 and transverse processes I-IV of the
lumbar vertebrae, the transverse processes fractures appear .
As a result, direct application of force or pererazgibanie spine fracture parentheses may be
without bias and with a shift toward the spinal canal , resulting in spinal cord injury and its
elements.
The most common fractures of the vertebral bodies ( compression, compression and
debris, explosives) and perelomovyvyhy vertebrae in which damaged the front and rear structure,
especially in the thoracolumbar spine , resulting from indirect trauma: axial load on the spine from
bending or bending and rotation). In this case, there are often unstable forms of damage with the
formation of kyphosis and shift the body of the vertebra above placed relatively lower lying ,
leading to deformation of the spinal canal and damage to structures.
Diagnosis . Patients with suspected spine injury requiring careful and comprehensive
examination which includes history taking (circumstances of injury ), in which a special place is
given to the mechanism of injury , clinical assessment and the use of additional methods of
examination.
The clinical diagnosis. The clinical examination of a patient with damage to the spine in
fresh cases should completely eliminate violent movements of the head and the body, especially the
axial load on the head and heels, as they may exacerbate the traumatic changes of the spine and the
anatomical structures of the spinal canal . Having abrasions, bruising , strains , information on the
mechanism of injury may help in identifying possible locations of damage.
The most common clinical symptom is pain , which may initially be spilled , and then
gradually limited area of damage. The intensity of pain can vary, depending not only on the severity
of bone damage, but also on the injured soft tissue structures of the spine. Often , especially when
combined trauma , the patient does not pay attention to the doctor for pain in the spine , leading to
diagnostic errors and the possible appearance or deepening of neurological complications at
different times after injury.
Depending on the level of damage to the spine pain may radiate to the occipital region,
arm, between the shoulder blades , along the spine in the area of the buttocks and lower extremities
, as well as in the anterior abdominal wall. When the pain of unstable injuries increases sharply at
the slightest movement. Clinical examination of a patient with damage to the spine is performed in
the supine position on a rigid base . On examination, attention is drawn to the forced position of the
head in the form of bending, tilting sideways rotation disappears cervical lordosis , kyphosis
appears . The destruction of the supporting structures of the vertebral- motor segment in the cervical
region may show instability of the head, in which secrete a hard level - head of the patient is not
kept and falls (symptom " hilyotynuvannya "). With an average degree of patient support head in
his hands , and with mild instability of the patient keeps his head still in relation to the body ( "the
head of the statue "). For injuries of thoracic and lumbar back during the inspection are paying
attention to the physiological lordosis and kyphosis , the emergence of lateral deformation, strain
paravertebral muscles in the form of walls along the spinous processes of the damaged department.
It's a reflex reaction that prevents abnormal mobility and displacement of fragments . Palpation (
superficial or deep ) along the line of spinous processes determine the level of damage , and the
paravertebral zone status long back muscles and pain in their transverse processes fractures.
Fracture transverse processes of the lumbar vertebrae also observed increased pain when trying to
lift the straight leg , and the greatest pain occurs at an inclination to the healthy side . Severe chest
trauma , spine may show clinic "acute abdomen" - pain in the abdomen and even a certain strain of
the anterior abdominal wall ), due to irritation of the solar plexus and pozacherevnoyu hematoma .
In some cases, the differential diagnosis can be a difficult task , requiring dynamic observation and,
in doubtful cases, it is possible , even the use of diagnostic celiocentesis ( laparoscopy ).
After inspection and palpation should proceed to check all kinds of sensitivity and the
possibility of movement in the joints of the upper and lower extremities. The presence of
neurological disorders is complicated by evidence of damage, high probability of instability at the
appropriate level . Fracture transverse processes is possible increased pain when going straight legs
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in the supine position until the appearance of symptoms " stuck five " - the inability to detach five
straight legs from the surface.
Complicated closed injury of the spine may occur following clinical forms :
- Concussion of the spinal cord - the most mild form of spinal cord injury , in which there
are only functional impairment that completely regress in time from a few minutes up to 5-7 days
after conservative treatment;
- Bruised spinal cord - along with functional disorders observed irreversible
morphological changes as kontuziynyh cells or anatomic interruption of the spinal cord . Clinically
bruised spinal cord injury in acute spinal shock manifested with symptoms of complete violation
conductivity and anesthesia below the level of injury;
- Compression of the spinal cord - can be caused by compression of the bone fragments or
items damaged intervertebral disc, vnutrishnohrebetnoyu hematoma ( epidural , subdural ,
intramedullary location) .
At the time of compression of the spinal cord is divided into:
- Acute compression - occurs at the time of injury and clinically different from the
slaughter of the spinal cord ;
- Early compression - develops within a few days after the injury and manifests the
emergence and deepening of disability ;
- Late compression - is through the months and years after the trauma caused by excessive
formation of callus , Rubtsov , adhesions in the spinal canal . Clinically manifested by progressive
myelopathy with having conductor and segmental disorder.
Clinical manifestations of complicated spinal injuries . Damage to the spinal cord ,
depending on the clinical symptoms and the degree of conductivity can be divided into:
- Syndrome of complete conduction spinal cord below the level of injury;
- Syndrome of partial conduction abnormalities , clinically manifested paresis or paralysis
of the muscles arefleksiya , disturbances of sensitivity below the spinal cord injury , disorders of
pelvic organs ;
- Segmental abnormalities in the form of muscle paresis , hyporeflexia , disorders of
sensation in the area of injury.
As a result of spinal cord injury spinal shock may occur (" physiological " break the spinal
cord ), which is clinically manifested temporary inhibition of reflex activity , flaccid paralysis ,
complete loss of sensitivity and disorders of pelvic organs ( urinary retention ), trophic disorders ,
the ability of the affected phrenic type breathing. The phenomena of spinal shock exacerbates the
lack of stability of the spine without spinal cord compression is removed bone fragments ,
hematoma or foreign body . A characteristic feature of this syndrome is reversible neurological
development disorders.
In this regard, the vital question of differential diagnosis between traumatic and
neurogenic shock , especially in polytrauma . Unlike typical traumatic shock , skin of hands and
feet are usually warm during the examination turns hypotension and bradycardia. These differences
primarily relate to the fact that the cause of neurogenic shock is a violation of neurological
regulation, whereas typical symptoms of traumatic shock are realized through other pathogenic
mechanisms .
Additional methods of research. After the clinical examination in the diagnostic algorithm
includes additional methods that specify the level and nature of damage to the structures of the
spine. Diagnostic algorithm for complex instrumental studies in acute spinal cord injury begins to
implement radiographs ( spondylohramy ) in two standard ( anteroposterior and lateral )
projections, which gives an indication of the presence or absence of damage to the bone structure of
the spine , but does not provide information on the status of soft tissue structures of the spine.
To detect damage in the area of C1 - C2 vertebral radiographs necessary in the direct
projection through an open mouth. The presence of neurological disorders and radiological signs of
damage to the bone structure of the spine requires mandatory further study of the spine by the
method of X-ray computed tomography ( CT) and magnetic resonance imaging ( MRI ), which
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allows you to specify the level and extent of damage to the spinal cord, soft tissues, intervertebral
discs.
Also used for the diagnosis ascending or descending myelography , CT- myelography ,
lumbar puncture to determine the patency of subarachnoid space and cerebrospinal fluid
composition .
Treatment of injuries of the spine.
Assist victims in the prehospital phase aimed at preventing further injury while
transporting the patient to the hospital. Almost every victim should be regarded as a potential
patient with unstable and complicated injuries of the spine. Depending on the circumstances of the
injury at the scene of the victim is necessary to distance from potential hazards , life-threatening
(center open fire, explosion hazard , etc.) . Sum of the patient must use at least three people. The
victim is placed on the hard noschi or shield in the supine position . The body of the victim is fixed
to the board , the chairman additionally taxed on both sides with sand bags and fixed wide cloth
tape. Unacceptable to the patient and plant lay it on its side. If you suspect an injury of the cervical
spine immobilization spend hard Headholders . The patient in the supine position should ensure
maintenance of physiological cervical and lumbar lordosis using rolled in a shaft wear. The
situation is necessary to evaluate the function of respiration and circulation , as necessary to carry
out resuscitation to restore vital functions, protyshokovi events. If the patient is conscious, possible
initial assessment as to damage the spine and spinal cord (complaints of pain , weakness and
numbness in the extremities , the presence of spinal deformity , muscle tone , sensitivity ).
Hospital stage of care. The objective of the stage providing skilled or specialized
assistance to victims of injuries of the spine is the definitive diagnosis using appropriate additional
methods as well as develop and implement an appropriate treatment strategy .
During the hospitalization of the victim to the hospital continue antishock therapy ,
correction of respiratory and hemodynamic catheterization of the bladder and the central vein. In
parallel, the diagnosis is made using additional methods : spondylohrafiya , lumbar puncture with
likvorodynamichnymy tests, myelography , MRI and CT scans . Consult a therapist, neurologist and
urologist.
With complicated spinal injuries administered methylprednisolone scheme , a broad
spectrum antibiotic , analgesic , neuroprotective , noootropni agents, anticoagulants , antioxidants,
symptomatic treatment.
Methods of treatment of spinal injuries and the reasons for their choice. The main goal of
treatment - restoration of normal topographic anatomical relationships between the spine and the
spinal cord by removing vertebral dislocation and maintenance of the injured vertebral segment at
the position reached by the correction for the entire period of reparative regeneration.
Fundamentally treatments spinal injuries can be divided into conservative and operative .
Choice of treatment depends on the results of the survey and the correct interpretation of the data.
Treatment of injuries of the cervical spine. Stable damage to the cervical spine (isolated
rupture of the anterior longitudinal ligament , fractures without displacement plate brackets or
lateral masses and spinous processes fractures without displacement and angular deformation)
treated conservatively fiksatsiynym method , making immobilization of the cervical spine rigid
collar or neck- breast corset for 2-3 months.
Subluxation , dislocation , perelomovyvyhy vertebra (especially complicated by
compression of the spinal cord and its roots ) required as soon as possible by simultaneous
reduction of manual closed reduction method ( Richet - Hyutera based on the principle of the lever
action ), the slow extraction whiplash loop Hlissona forced or skeletal traction for parietal humps .
Further conservative treatment includes external immobilization of the cervical thoraco- cranial
dressing in light ekstenziyi position for 3-4 months. Uncomplicated oskolchasti compression and
fractures of the cervical vertebrae without evidence of fracture locking plate and disk corruption are
treated with conservative methods of imposing thoraco- cranial cast for 2-3 months. Then fixation is
carried out by the collar trenches within 1-2 weeks, conducted exercise, muscle massage .
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Dislocations and perelomovyvyhy cervical vertebrae, which are not eliminated by closed
reduction, as well as explosive fractures with displacement of the fragments into the spinal canal ,
complicated by spinal cord compression and the growth of disability , require immediate ( within
the first 4-6 hours) surgery. During surgery performed open reposition , anterior decompression ,
resection of the broken vertebral body replacement of defect transplants from various materials.
Treatment of injuries of thoracic and lumbar spine.
Conservative treatment is indicated in stable uncomplicated lesions , which are hallmarks
of the ventral body height loss of at least 50 %, kyphotic deformity less than 20 °, no signs of
damage to the rear of the reference set ( compression , stable explosive fractures of the vertebral
bodies and isolated damage to the posterior structures). In marked and persistent pain syndrome
treatment is prolonged bed rest with adequate anesthesia. Later the patient gradually vertykalizuyut
in standard corset and spend gymnastics.
The method is based on the one-stage repositioning maximum extension and restoration of
the height of the anterior vertebral body , affected by trauma, followed by immobilization
ekstenziynym corset to the consolidation of the fracture. This method is shown in stable
uncomplicated compression fractures of the vertebral bodies , but has a significant number of
contraindications ( ekstenziyni fractures, injuries middle column , perelomo , sprains and other
injuries are unstable ), and therefore its use is limited.
The method involves the gradual repositioning repositioning for the gradual
implementation of a landmark reklinuyuchyh rollers increase their height or special reklinators (
flexible metal shield with the device for the dosed reklinatsiyi , pnevmoreklinatory etc.). Within 1220 days , as in the functional method. But then performed the cast immobilization ekstenziynym as
in reklinatsiyi simultaneously . In content method similar to the one-stage method of repositioning ,
so the indications for their use almost similar.
Functional method, or a method of early mobilization, elaborate V. Horinevskoyu and EF
Drevinh in 1933 , shown in patients with stable compression fractures of the vertebral bodies .
Unlike the previous method functional method is gentle and has no contraindications such extensive
, but does not address post-traumatic deformities. The purpose of the method - a complete "
muscular " by spine immobilization and early therapeutic exercises using physiotherapy and
massage with disaster recovery in 5-6 months after the injury. Complex physiotherapist usually
consists of 4 periods ( 10 - 15 days) with increasing physical activity , the first three of which
require bed regime . The first of these ( 2-10 days after injury ) is gradually reklinatsiya vertebral
body by laying the patient on special rollers that act as declinators are assigned exercise general
health and character. The second stage (10 - 20 days after injury) involves movement of the upper
and lower limbs with the inclusion of the muscles of the back ( lifting the body on the elbows and
forearms, lifting lower extremities). In the third stage (20 - 60 days) performed primarily exercises
for back muscles and abdominal press directed towards the extension of the spine ( bending motion
toward the spine is strictly prohibited !) . During the fourth period ( 60 - 80 days after injury)
affected teaching dosed walking with the necessary posture.
The disadvantage of this method is a significant term in-patient treatment , including on
bed rest . Therefore, there is a case of this method , when a month after the injury , after all
requirements of the first three stages of the patient lift in soft " cast - spynorozhynachi ", except that
the extension assigned to exercise, but significantly reduces the time and mode of bed -patient
treatment.
Surgical treatment of injuries of thoracic and lumbar spine is indicated in unstable and
complicated lesions.
The goal of surgical treatment - decompression of spinal canal structures (rear , front ,
combined) to create conditions for maximum recovery of neurological , correction of post-traumatic
deformity of the spine , restore the stability of the spine by anterior and posterior spinal fusion . In
some cases, surgical treatment may be applied in stable fractures without neurological symptoms.
This is , in particular , with a significant degree of compression of the vertebral body , " explosive "
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clastic fractures. The purpose of intervention in this case is more reliable and controllable than with
conservative treatment , reposition and stabilize , an earlier start of rehabilitation patients.
Existing methods of surgical treatment of unstable and complicated spinal injuries may
involve both rear and front , surgical access. In particular, in various pathological conditions of the
cervical spine is a common intervention anterior decompression and interbody bone graft
korporodez with special locking plates.
In unstable injuries of the thoracic , lumbar and lumbosacral spine need for surgery due to
the possibility of secondary displacement with further increase of neurological symptoms. In such
cases, the so-called effective transpedicular fixation , which allows you to reposition and stabilize
the damaged segment and interbody korporodez .
Rehabilitation . Patients with spine injuries requiring medical, social and vocational
rehabilitation. In the acute phase of injury is made early medical rehabilitation in a hospital aimed at
the prevention of postoperative complications ( bedsores, contractures, urinary fistulas , etc.). In the
future, patients transferred to rehabilitation department , and then they are sent to a spa treatment in
a specialized sanatorium. Work aimed at rehabilitation of victims of employment in special
circumstances . The return of persons to the profession of physical labor should be addressed
individually. It is reasonable to represent these victims to MSEK with relevant decisions of
efficiency. Regarding general medical rehabilitation of such patients is advisable to recommend
treatment without undue physical stress , therapeutic exercise, aimed at supporting their own
muscular corset , swimming, in case of worsening pain - physical therapy courses .
With injuries of the spine with spinal cord injury rehabilitation prospects determined
possible level restore functionality. Many of those affected are disabled, the treatment is carried out
in specialized departments and spinal centers. It is necessary individual attention to all types of
rehabilitation of such patients , providing them with the means to travel , and where possible the
question of rehabilitation professional that under conditions improve and rehabilitation of the
affected society.
DAMAGE TO PELVIS
Damage to pelvis ( bone fractures , lacerations of the pelvic joints ) can be classified as
serious injuries of the musculoskeletal system as they are accompanied by high levels of mortality,
long-term disability and disability. This is due to the specificity of the anatomical structure of the
pelvis and the presence in this area of important structures of internal organs ( large vessels , nerve
plexus, intestine, urinary and genital organs ), which can be damaged by injuries this location. The
severity of injury is determined by pelvic pain syndrome , massive hemorrhage , traumatic shock,
damage to internal organs.
Among the damage of the pelvic bones occupy a special place acetabulum fractures with
or without dislocation hip dislocation , when the negative factors directly related to pelvic trauma ,
damage included the possible effects of the hip joint ( aseptic necrosis of the femoral head , posttraumatic coxarthrosis , etc.). Relevant orthopedic disorders.
Classification and mechanogenesis damage organs. According to the classification of AO /
ASIF, the pelvic ring can be roughly divided into two rings relative to acetabulum - back and front .
The rear half ring located behind the articular surface of acetabulum . It includes the buttocks,
sacroiliac joint , with its links and posterior ilium . It's part of the pelvis that loaded itself and
provides load transfer along the axis of the skeleton of the lower limbs.
The front half ring located in front of the articular surface of acetabulum . It includes
branches lonnyh bones and symphysis ( pubic junction ). The aperture of the pelvis , including
bumps and sacro- spinous ligament sacro- connecting rings are named and involved in ensuring
their stability. AO classification on the basis of these anatomical assumptions based on determining
the localization of damage ( presence or absence of damage to the rear rings ) and the degree of
stability of the pelvic ring.
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By type A related injuries, in which the integrity of the bone and ligaments rear rings are
not broken. This so-called stable pelvic injury . Stability is determined that the pelvic diaphragm
intact , the pelvis is able to resist ordinary physical activity without bias.
Type B includes damage of partially fractured posterior pelvic rings , in which may be a
rotary instability surrounding the vertical and transverse axes around . This is partly sustained
damage while preserving the integrity of partial bone and ligaments rear rings and in some cases an
intact pelvic diaphragm .
Type C provides a complete rupture of posterior rings in violation of his bony continuity
and communication elements, and as a consequence - the possible shift in three dimensions and
rotational instability. This unstable pelvic injury with complete loss of integrity of the bone ligament complex. Aperture always broken pelvis .
Each of these types is subdivided into subtypes (A1 , A2 , A3 , etc. ) that allows you to
detail each of the damage and choose an adequate treatment strategy.
According to the lines AO, acetabulum fractures have a separate classification ( rys.5.20 )
, given the specificity of these injuries and their treatment tactics .
Type A - fracture extends to the front or rear of the joint surface , except bone fragments
include more or less of the corresponding column. In all cases, the other column remains intact .
Type B - fracture line or part of it is placed transversely , part of the articular surface is
always associated with the ilium , transverse fractures of the forms can be " quite cross ", " T shaped " or include " pivpoperechnyk back and front of the column ."
Type C - fracture with damage to both the columns and the relevant parts of the articular
surface of the acetabulum . In this connection there is no fragment of the articular surface of the
ilium . These fractures can be extended to the sacroiliac joint .
According to the variability of damage , as in the above classification, each type (A, B, C)
is divided into subtypes (A1 , A2 , A3 , etc. . ) That contributes detail diagnosis and determines the
choice of treatment strategy .
Diagnosis of pelvic injuries . The clinical picture of pelvic injuries depends on the location
of the fracture, possible complications and associated injuries. Clarification of the mechanism of
injury , fracture detection characteristic signs and radiography in multiple projections can provide
an adequate quality and likelihood of diagnosis.
Examination of the pelvis can touch up the idea of the damage of a section of bone or
joints interosseous . Thus, in the case of a fracture of the pelvis anterior rings are often observed
bleeding in the scrotum, which was first described Destot. If the damage of the anterior and
posterior part of the pelvis may be a shift in the corresponding half of the pelvis in the proximal
direction due to muscle contraction , and its rotation out. Thus there is a relative shortening of the
lower limb on the side of injury. Changing the shape of the pelvis is possible and in fractures of the
ilium when the fragment is displaced laterally free or medial and proximal direction .
In order to clarify the localization of a possible fracture locations must apply palpation of
the pelvic region . To identify areas of damage to the bones of the pelvis to know the mechanism of
fracture and typical places . Usually performed palpation of the pubic symphysis , pubic and sciatic
branch bone front - upper spines and iliac crests , sacral area and the area of the sacroiliac joints,
which may identify abnormal mobility or local areas of pain.
Fracture of the sacrum , coccyx, acetabulum , anterior pelvic rings used digital
examination through the rectum. Rectal examination gives guidance to local pain , defines the
protruding part of bone fragments in fractures , which is especially important in fractures of the
sacrum to determine the displacement of fragments and in fractures of the acetabulum with central
dislocation of the hip.
Deep-seated part of the pelvis by conventional palpation is possible to investigate not so
resort to methods for the study of pathological mobility of the injured pelvis . Thus, the
compression of the pelvis in the transverse direction and the opposite diagnostic technique - cross
eccentric pressure, leading to increased pain at the fracture site .
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Fracture of the pelvis , as in fractures of the lumbar vertebrae , may occur "
psevdoabdominalnyy syndrome" , whose appearance caused by the presence zacherevynnoyi
hematoma. Should carefully examine these patients for appropriate differential diagnosis of an
injury or disease of the abdominal cavity.
It is important to note that the most well-known symptoms Horynevskoyi , Verneuil , Lara
et al. is not always reliable. Thus, the symptom of " stuck -five " (inability to " detach " from the
surface of the heel on the affected side, which is observed at the turn of the anterior pelvic rings ) in
the presence of bilateral fracture of the horizontal branch of the pubic bones can be positive only on
one side. A more adequate symptom sagittal instability that demonstrates unstable pelvic injury ,
but traumatic in its application .
In the presence of large hematomas in the ilium , and deep scratches symptoms of
transverse compression and breeding organs in general can not be verified due to local soft tissue
injury . Therefore, the clinical diagnosis of fractures of the pelvis widely adopted methods that are
based on the measurement . Comparative measurements of both halves of the pelvis and lower
extremities are held on the front upper iliac spines to the ankle from the front upper iliac spines to
the xiphoid process of the sternum.
Given that the shortening of the lower limb may also occur in hip fractures and fractures
of the acetabulum , the data can be verified by measurements on large ankles and swivels to the
front of the spine to the big swivel on the same side , and the sternum -clavicular joints to the front
upper iliac spines .
Clinical diagnosis in patients with pelvic injury in the acute period of injury in some cases
it may be some difficulties . This primarily relates to compounds breaks pelvis , including the most
complex - injury of the sacroiliac joints. The reasons for these difficulties should be especially
noted.
1. The severity of the general condition of the victims, who often arrive in a state of shock
, making it difficult and sometimes impossible to identify complaints circumstances and mechanism
of injury and clinical symptoms, which are based on the responses of the victim (localization of
pain , etc. . ). Decisive role in these situations play your X-ray study. But even on standard
radiographs of the pelvis breaks pelvic joints without bone fractures are not always defined in the
first hours after injury.
2. The difficulty of detection in some cases, clinical symptoms, firstly , because of diffuse
pain in the pelvic region in the first 1-2 days after the injury , and secondly , because of lacking
symptoms actually breaks connections absence of pathognomonic signs (symptoms Verneuil , Lara
, Helimskoho , Karalina " slip " are both compounds in fractures and in fractures of the pelvis ) ,
and thirdly , because nasharovuvannya symptoms related fractures of the pelvis .
3. Diagnosis complicated by the existence of multiple and combined injuries , which in a
number of observations complicate the examination , masking the clinical picture of rupture joints
(damage to the lower - lumbar spine , hip , vnutrishnotazovyh bodies).
Given these complexities of clinical diagnostic methods in the diagnosis of injuries of the
pelvis become important additional methods of examination , including x-ray . The complexity of
the data analysis of radiological examination of the pelvis injuries associated with its threedimensional anatomy , except for the treatment of complex injuries of the pelvis requires accurate
knowledge of the nature and quantitative indicators landslides damaged fragments linked to the
nature and mechanism of injury and breach of the pelvic diaphragm.
The first step in renthendiahnostytsi damage radiograph of the pelvis is in a straight line
projection to include the entire pelvic ring and both hip joints.
Then found a violation of the integrity of the bone and bone fragments violation ratios and
the sacroiliac joints and lonnomu . To do this, use projection of " entering and exiting the pelvis ."
Radiographs should be done only in polipozytsiynyh styling. It can diagnose almost all
damage organs in the correctness of their implementation. There is a limited diagnostic capabilities
of classical radiological research method in the severity of the patient when needed, not wasting
time with transcriptions do a more thorough examination. For this there is a more modern method 216
spiral computed tomography, which not only allows more detail to evaluate the bone tissue , the
ratio of the joints and bones of the pelvis character displacement , but even to get 3 -D
reconstruction of the pelvic region . In the diagnosis of hip joint damage applied research on
mahnitnorezonansnomu tomography.
Identify damage the bladder or urethra allows contrast X-ray study of the introduction of
contrast through the urethra or that may be important when combined injuries ( suspected kidney
injury , and others. ) By excretory urography .
Thus , a complete diagnosis using modern research methods can detect the localization and
nature of the damage , which is the basis for developing appropriate treatment strategy .
Treatment of injuries of the pelvis should begin first aid to the injured site of injury . The
necessary components are its primary examination and clinical diagnosis.
The provision of pre-hospital care to remember when the possibility of traumatic shock ,
significant blood loss due to bone fractures and damage blood vessels, damage to internal organs,
which is very common in patients with fractures of the pelvis . Therefore , if the relevant evidence,
it is important to conduct adequate infuzionnoyi antishock therapy , immobilization others injured
segments , adequate pain ( with the possibility of damage to other organs and systems).
If you suspect damage important organs such transport is affected , providing warning of
increased pain , secondary displacement of fragments , the development or progression of traumatic
shock. The victim should be transported in the supine position on the stretcher hard , bending at the
hip and knee joints and mild abduction of the hip joint by pidkladennya cushion under the knee area
. It is advisable that an extra pidkladennya rollers to areas iliac wings . Absence or insufficient
immobilization of the pelvis in the acute period is a factor that increases the severity of the victims.
In bowl enclose prostyhny , the ends of which are connected crosswise projection pubic
joints . The role of fixing elements perform the folds of fabric applied . The simplicity and
uniformity of the proposed modification of the pelvic girdle allows them to take advantage
prehospital assistance.
Hospital stage treatment of patients with fractures of the pelvis includes detailed
diagnostics of all injuries to the detection of the dominant , the treatment of traumatic shock and
blood loss , monitoring the general condition of the patient , the treatment of injuries of internal
organs and their treatment of fractures of the pelvis .
At the stage of admission to hospital carried out a full clinical examination (including data
on the dynamics of the victim in the prehospital phase ), X-ray diagnostics. The feasibility and
timing of the application of other complementary techniques ( computed tomography , etc.).
Determined depending on the condition of the victim and the presence of other injuries. Due to the
trauma of internal organs , according to testimony provided by participation in the diagnosis and
treatment of related sciences specialists ( urologist , surgeon , etc.). .
Victims, delivered in a state of severe shock , with significant blood loss , perform the
blockade by Shkolnikov - Selivanov , but only after raising blood pressure to 80-90 mercury These
patients carry general anesthesia by intravenous narcotic analgesics or conducting surface
anesthesia.
Among the methods of treatment of fractures of the pelvis actually distinguish
conservative and operative methods.
Conservative treatment includes orthopedic styling and permanent method of skeletal
traction . Their positive feature is the non-invasive nature , the fact that tissue trauma . The
disadvantages are the lack of stable fixation of fragments of the pelvic bones , the inability to
complete repositioning for certain types of injuries , long bed regime and inpatient treatment ,
complications and hipodynamichnoho hipostatychnoho nature, difficult maintenance and more.
Submersible osteosynthesis screws or plates allows precise exercise bone fragments , most
patients begin to intensify . But because of the trauma he limited used in acute trauma.
An alternative operative fixation of fragments in fractures of the pelvis is the method of
external fixation . It is less traumatic , so it can be used even as a part of antishock complex, but
some types of fractures of the inferior internal osteosynthesis repozytsiynymy opportunities. The
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development of devices and methods of external fixation of the pelvis injuries aims to create
devices with capabilities stable fixation and reposition controlled .
Taking into account the use of several treatments for fractures of the pelvis , in practice,
the use of sound is differentiated approach to the choice of tactics and methods of treatment
depending on the location and severity of the injury , the general condition of the victim , the degree
of damage stability and classification of fracture type .
In stable fractures of the pelvis type A treatment is usually performed by orthopedic
conclusion by Volkovich . If the damage is the front of the pelvic ring ( pubic bone or buttocks )
patient laid on the bed with slightly bent legs and diluted (for better muscle relaxation ). To this end,
under the knee to enclose a high roller. The length of stay of the patient in bed and term strain on
the lower limbs depend on the nature and scope of damage. Fractures of the pelvic bones without
disrupting the continuity of the pelvic ring the patient can be activated in 4-5 weeks.
In cases of separation of the anterior superior spine of the ilium conservative treatment is
justified if detached fragment after the conclusion of patient repositioning and manual keeps in
touch with the parent bed. In other cases, surgical treatment is shown : repositioning and fixation of
the fragments screw or spokes imposed in different planes.
When perelomo - dislocations of the coccyx carried reposition fragments through the
rectum. In the late period of patients can be confusing pain in the tailbone or sacrum, which is an
indication for physical therapy or novocaine blockade .
By rotary unstable fracture type B include longitudinal ( frontal plane) fractures of the
ilium , the longitudinal (in the sagittal plane) and oblique fractures of the sacrum. Generally , the
mechanism of fracture line. Significant displacement of fragments is observed. The treatment is
carried out at the conclusion of Volkovich for a month.
Unilateral fractures of the pubic bone and the ischium - one of the most common variants
of fractures of the pelvis type B. Treatment of patients with fractures , usually as a conservative - on
a solid surface in a position for Volkovich . If you violate the integrity of the pelvic ring (eg,
unilateral fracture of the pubic bone and the ischium ) load on the legs may be no earlier 2-2.5
months after injury. Allow the patient to sit later than walking .
Fix chips and reduce the length of stay of the victim in bed with unilateral fractures of the
pubic bone and the ischium by using special soft waist developed in Donetsk Research Institute of
Traumatology and Orthopedics. It allows you to stably hold the two halves of the pelvis. At the end
of the acute period of injury on 7-10 days after the fracture , the patient with an applied girdle allow
walk using crutches, 10-14 days - discharged to outpatient treatment.
In the case of isolated rupture of the pubic symphysis with diastase to 2-2.5 cm of patients
treated with pelvic girdle . After the overlay zone allow the patient to get up ( with travel within the
first 2 weeks of using crutches ).
When you break the pubic symphysis , fractures of the pelvis anterior rings of diastase
over 2-2.5 cm, used open reposition the fixation wire fragments or plates, or closed reposition of
external fixation .
Breaks or fractures of the pubic symphysis anterior pelvis like " an open book " with
diastase over 2-2.5 cm ( B1 ), which is due vynykayutъ front - rear compression fractures involving
partial ventral sacro - iliac ligaments. In such cases, in order to stabilize the pelvis can be used
osteosynthesis spongy screw the method developed by the Kharkiv National Medical University (
rys.5.34 ).
By rotary - vertically unstable fractures include damage type C with complete violation of
the integrity of the pelvic ring with polygonal shifts and complex rotary dislocations in three
dimensions , which are the most complex in terms of repozitsiyi and stabilization. The most modern
way to treat them is a fixation , which aims to restore the ratio of bone fragments and stabilization
of metal structures in the consolidation of the fracture. To stabilize these injuries usually need to use
tabs ( external or internal) for both semirings organs simultaneously. Depending on the anatomy of
the injury, the degree of stability of the pelvis and relationships in the hip joint can be used as an
external extrafocal fixation and internal submersible .
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To select the optimal variant of conservative or operative treatment of fractures of the
acetabulum and predicting their results should be used AO classification .
Treatment of fractures of the acetabulum . Fractures of one column (type A)
prognostically favorable because the fracture line is usually not in the zone of axial loading and
creates a high risk of posttraumatic osteoarthritis . Such complications in most cases treated
conservatively , except for fractures rear or rear- upper edges acetabulum , accompanied by
instability of the hip joint, and the transition to the roof line of the fracture and displacement of
acetabular hollow pieces by more than 5 mm.
In transverse fractures (type B) may experience significant displacement of fragments that
need rapid repositioning fully recommended at high transverse or T -shaped fractures of acetabulum
. Conservative treatment may be effective only at low transverse fractures with little displacement
and destruction without roof acetabulum .
The most sophisticated prognostic and tactical aspects of damage to both columns ( type
C) , accompanied by the fragmentation of the roof of the acetabulum formation of free fragments or
significant displacement of fragments up to central perelomovyvyhu in the hip joint. Damage to the
hip type C to be the operative treatment of fractures except without bias .
It should be noted that fixation for fractures of the pelvis is a challenging and responsible
intervention that requires highly skilled surgeon to ensure proper metal and medicines. Performance
of Submersible osteosynthesis is also quite traumatic , making it possible only under conditions of a
certain stabilization of the general condition of the patient. If in certain circumstances
osteosynthesis is impossible or impractical , the treatment of unstable fractures of the pelvis with
displacement of fragments can be carried out by continuous skeletal traction .
Thus fractures of the anterior and posterior parts of the pelvic ring ( double vertical
fractures by Malgaigne ) and acetabulum fractures used skeletal traction for distal metaphysis hip or
tibial tuberosity at the position of the lower limb on the Boeler splint. In such cases, extraction lasts
2-2.5 months and closely combined with therapeutic exercises.
Elevation of bed and move using crutches in unstable fractures of the pelvis and
acetabulum allowed after 2.5-3 months after injury if treatment is carried skeletal traction and 4-6
weeks if the patient was operated on using submersible designs. Full load on the foot is allowed as
in acetabulum fractures and lesions in the sacroiliac joint in terms of 4-6 months. Combination
treatment resting area for damage and timely mobilization of joints with active exercise promotes
complementary growth of fragments in the correct position , the preservation of locomotor function
of the lower extremities, prevents ostearthritis.
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