骨盆骨折的影像学表现

11 Imaging of Pelvic FracturesImaging of Pelvic Fractures Christina Christina BoultonBoulton Harvard Medical School, Year IIIHarvard Medical School, Year III Gillian Lieberman, MDGillian Lieberman, MD Christina Boulton, 2004 Gillian Lieberman, MD May 2004 Images: Borril et al. Orthoteers Orthopedic Education Resource. http://www.orthoteers.co.uk/. WheelessWheeless CR. CR. WheelessWheeless’’ TexbookTexbook of of OrthopaedicsOrthopaedics. . http://http://www.wheelessonline.comwww.wheelessonline.com 22 OutlineOutline  Pelvic Anatomy ReviewPelvic Anatomy Review  Introduction to Pelvic Fractures, Introduction to Pelvic Fractures, Associated Injuries and ComplicationsAssociated Injuries and Complications  Our PatientOur Patient  Pelvic Imaging ModalitiesPelvic Imaging Modalities  Pelvic Fracture ClassificationPelvic Fracture Classification  SummarySummary Christina Boulton, 2004 Gillian Lieberman, MD Image: WheelessWheeless CR. CR. WheelessWheeless’’ TexbookTexbook of of OrthopaedicsOrthopaedics. . http://http://www.wheelessonline.comwww.wheelessonline.com 33 Pelvic Anatomy Review Pelvic Anatomy Review -- BonesBones Sacral Strut Posterior Column Anterior Column Obturator Foramen Neural Foramen ILIUM IPR SPR SI Joint Christina Boulton, 2004 Gillian Lieberman, MD Image: Gray, Henry. 1918.Image: Gray, Henry. 1918. 44 Pelvic Anatomy Review Pelvic Anatomy Review -- LigamentsLigaments Sacrotuberous Ligament Ventral Sacroiliac Ligaments Iliolumbar Ligament Sacrospinous Ligament Dorsal Sacroiliac Ligaments Christina Boulton, 2004 Gillian Lieberman, MD Image: Gray, Henry. 1918.Image: Gray, Henry. 1918. 55 Pelvic Anatomy Review Pelvic Anatomy Review –– IIIIII Christina Boulton, 2004 Gillian Lieberman, MD Images: Gray, Henry. 1918.Images: Gray, Henry. 1918. The bony pelvis lies in close proximity to numerous vascular, neural and soft tissue structures that are vulnerable during pelvic ring disruption. 66 Introduction to Pelvic FracturesIntroduction to Pelvic Fractures  33--4% of all 4% of all FxFx, usually associated with significant trauma, usually associated with significant trauma  Types of Pelvic FractureTypes of Pelvic Fracture –– Lower Energy: Avulsion & Lower Energy: Avulsion & AcetabularAcetabular FxFx –– Higher Energy: Ring DisruptionsHigher Energy: Ring Disruptions  Stable vs. Unstable (33%), Open vs. ClosedStable vs. Unstable (33%), Open vs. Closed  Rule of Rings Rule of Rings –– usually >1 disruption, breaks occur at weakest pointsusually >1 disruption, breaks occur at weakest points  Mechanism of InjuryMechanism of Injury –– Requires significant force, e.g. MVA (50Requires significant force, e.g. MVA (50--60%), Motorcycle Crash (1060%), Motorcycle Crash (10-- 20%), Pedestrian Struck (1020%), Pedestrian Struck (10--22--%), Fall (8%), Fall (8--10%), Crush (310%), Crush (3--6%)6%)  Morbidity & Mortality Morbidity & Mortality –– Adult mortality 10Adult mortality 10--15% (secondary to retroperitoneal hemorrhage, 15% (secondary to retroperitoneal hemorrhage, infection)infection) –– Mortality approaches 50% if Mortality approaches 50% if hypotensivehypotensive on presentation, ~30% if open on presentation, ~30% if open fracturefracture –– Significant decrease in morbidity and mortality with prompt stabSignificant decrease in morbidity and mortality with prompt stabilization ilization of unstable pelvic fracturesof unstable pelvic fractures –– Pelvic Pelvic FxFx more common in patients <55yrs but have increased morbidity more common in patients <55yrs but have increased morbidity and mortality in patients >55yrsand mortality in patients >55yrs Christina Boulton, 2004 Gillian Lieberman, MD 77 Associated Injuries & ComplicationsAssociated Injuries & Complications  Vascular Injuries + Hemorrhage (40%)Vascular Injuries + Hemorrhage (40%)  Nerve (10%) Nerve (10%) –– Sciatic, Femoral, Sciatic, Femoral, ObturatorObturator, , LumbosacralLumbosacral Plexus esp. roots S1Plexus esp. roots S1--5 5  Organ Injuries (rare) Organ Injuries (rare) –– Liver, Spleen, GILiver, Spleen, GI  GU system: Bladder/Urethral Rupture (10GU system: Bladder/Urethral Rupture (10--15%)15%)  Chronic PainChronic Pain  ArthritisArthritis  Immobility Immobility –– increase risk for PE, all pelvic increase risk for PE, all pelvic fracture patients should be fracture patients should be anticoagulatedanticoagulated once once hemorrhage stabilized.hemorrhage stabilized. Christina Boulton, 2004 Gillian Lieberman, MD 88 Our Patient: MS, 77yo F struck by carOur Patient: MS, 77yo F struck by car  Documented 20min LOCDocumented 20min LOC  IntubatedIntubated at scene and transported to at scene and transported to BIDMC ED via Life FlightBIDMC ED via Life Flight  HypotensiveHypotensive during transport and given during transport and given IVFsIVFs, stable VS on arrival at ED, stable VS on arrival at ED  In ED: multiple injuries noted to head, CIn ED: multiple injuries noted to head, C-- spine, upper and lower extremities, pelvis spine, upper and lower extremities, pelvis noted as stable to palpationnoted as stable to palpation Christina Boulton, 2004 Gillian Lieberman, MD 99 Patient MS: Trauma SeriesPatient MS: Trauma Series  Findings:Findings: –– Minimally Minimally displaced displaced fractures of R fractures of R inferior and inferior and superior pubic superior pubic ramirami –– Sacrum not Sacrum not well visualizedwell visualized –– Sacral Sacral FxFx seen seen on CT scouton CT scout Christina Boulton, 2004 Gillian Lieberman, MD Image: PACS, BIDMC 1010 Pelvic Imaging TechniquesPelvic Imaging Techniques  Plain FilmsPlain Films -- Trauma SeriesTrauma Series -- Inlet & Outlet ViewsInlet & Outlet Views -- JudetJudet (Oblique Views) (Oblique Views) -- acetabularacetabular fracturesfractures  Pelvic CT Ortho Protocol Pelvic CT Ortho Protocol –– highlights bone detailhighlights bone detail  MRI MRI –– usually modality of choice for detailed imaging of usually modality of choice for detailed imaging of joints and ligaments in other circumstancesjoints and ligaments in other circumstances  FAST Exam FAST Exam –– utility only for intrautility only for intra--abdominal or retroabdominal or retro-- peritoneal blood collectionsperitoneal blood collections  Other StudiesOther Studies -- Retrograde Retrograde urethrogramurethrogram or CT or CT cystogramcystogram if exam suggests if exam suggests injury to GU systeminjury to GU system -- ArteriographyArteriography for minor persistent hemorrhage or hematomafor minor persistent hemorrhage or hematoma Christina Boulton, 2004 Gillian Lieberman, MD 1111 Pelvic Imaging Pelvic Imaging –– Plain FilmsPlain Films  Trauma SeriesTrauma Series –– Used for initial Used for initial evaluationevaluation –– Detects pelvic Detects pelvic fxfx 90% 90% of timeof time –– Good for: Good for: ramirami fxfx, , pubic pubic symphysissymphysis, large , large hematomas hematomas –– Bad for: Bad for: ligamentousligamentous injuries, subtle injuries, subtle displacements esp. displacements esp. axial, sacral fracturesaxial, sacral fractures Christina Boulton, 2004 Gillian Lieberman, MD Image: WheelessWheeless CR. CR. WheelessWheeless’’ TexbookTexbook of of OrthopaedicsOrthopaedics. . http://http://www.wheelessonline.comwww.wheelessonline.com Supplemental Case 1: Symphyseal Diastasis, Sacral Fx 1212 Pelvic Imaging Pelvic Imaging –– Plain Films IIPlain Films II  Inlet ViewInlet View –– best demonstrates ring configuration of best demonstrates ring configuration of pelvis, narrowing/widening of diameter of pelvis, narrowing/widening of diameter of ringring –– evaluates for evaluates for posterior displacementposterior displacement of of pelvic ring or opening of pubic pelvic ring or opening of pubic symphysissymphysis  Outlet ViewOutlet View –– evaluates for evaluates for vertical shiftvertical shift of pelvisof pelvis –– proximal/distal displacements of anterior or proximal/distal displacements of anterior or posterior portion of ringposterior portion of ring –– sacrum appears in its longest dimension, sacrum appears in its longest dimension, w/ neural foramina evident. w/ neural foramina evident.  JudetJudet (Oblique) Views(Oblique) Views –– External View: External View: -- shows shows ilioischialilioischial line line posterior column & anterior wall.posterior column & anterior wall. –– Internal View: Internal View: -- shows shows iliopectinealiliopectineal line anterior column & posterior wall. line anterior column & posterior wall. Christina Boulton, 2004 Gillian Lieberman, MD Images: Borril et al. Orthoteers Orthopedic Education Resource. http://www.orthoteers.co.uk/. 1313 Retrograde Retrograde UrethrogramUrethrogram Christina Boulton, 2004 Gillian Lieberman, MD Image: WheelessWheeless CR. CR. WheelessWheeless’’ TexbookTexbook of of OrthopaedicsOrthopaedics. . http://http://www.wheelessonline.comwww.wheelessonline.com Supplemental Case 2: Bladder rupture with contrast extravasation Retrograde injection of contrast material into bladder via urethra 1414 Pelvic Imaging Pelvic Imaging -- CTCT  UsesUses -- Good visualization of subtle fractures, AP displacementGood visualization of subtle fractures, AP displacement -- Useful if pt. not able to be positioned adequately for Useful if pt. not able to be positioned adequately for special viewsspecial views -- CT faster now than in past so not contraCT faster now than in past so not contra--indicated in indicated in early trauma work upearly trauma work up -- Many multiMany multi--trauma pts will already be bound for CTtrauma pts will already be bound for CT -- Coronal and Coronal and saggitalsaggital reconstructions useful for reconstructions useful for understanding understanding spacialspacial relationships of fragmentsrelationships of fragments -- CT CT CystogramCystogram alternative to retrograde alternative to retrograde urethrogramurethrogram to to r/or/o bladder injury bladder injury -- Operative planningOperative planning Christina Boulton, 2004 Gillian Lieberman, MD Image: PACS, BIDMC 1515 Our Patient (MS): Pelvic CTOur Patient (MS): Pelvic CT Christina Boulton, 2004 Gillian Lieberman, MD Comminuted Fx R Sacral Ala with mild distraction of fragments, small surrounding hematoma, R SI joint slightly ectatic posteriorly Image: PACS, BIDMC 1616 Our Patient (MS): Pelvic CTOur Patient (MS): Pelvic CT Christina Boulton, 2004 Gillian Lieberman, MD R Sacral Fx with posterior displacement of sacral wing, hematoma Image: PACS, BIDMC 1717 Our Patient (MS): Pelvic CTOur Patient (MS): Pelvic CT Christina Boulton, 2004 Gillian Lieberman, MD Comminuted Fx of R inferior pubic ramus, mild distraction of fragments Image: PACS, BIDMC 1818 Our Patient (MS): Pelvic CTOur Patient (MS): Pelvic CT Christina Boulton, 2004 Gillian Lieberman, MD L pubic bone fx @ pubic symphysis + associated small hematoma Image: PACS, BIDMC 1919 Our Patient (MS): Pelvic CTOur Patient (MS): Pelvic CT Coronal ReconstructionCoronal Reconstruction Christina Boulton, 2004 Gillian Lieberman, MD R Sacral Ala Fx, superior displacement, Fx R inferior pubic ramus Image: PACS, BIDMC 2020 Our Patient (MS): ArteriogramOur Patient (MS): Arteriogram Bilateral iliac artery arteriogramBilateral iliac artery arteriogram Crisp, uniform vessel outlineCrisp, uniform vessel outline No contrast No contrast extravasationextravasation Arteriogram of small branch of R Arteriogram of small branch of R internal iliac internal iliac Contrast Contrast extravasationextravasation  vessel vessel embolizedembolized Christina Boulton, 2004 Gillian Lieberman, MD Images: PACS, BIDMC 2121 Pelvic Imaging Pelvic Imaging –– Follow UPFollow UP  Post ORIF Plain FilmsPost ORIF Plain Films –– Often done in OROften done in OR  CT or Plain Films post CT or Plain Films post external fixationexternal fixation –– To check correct anatomic To check correct anatomic relationshipsrelationships  Artifact Reduction CTArtifact Reduction CT –– Subtracts hardware artifactSubtracts hardware artifact  JudetJudet (Oblique) Views(Oblique) Views –– To follow To follow acetabularacetabular fracturesfractures Christina Boulton, 2004 Gillian Lieberman, MD Image: WheelessWheeless CR. CR. WheelessWheeless’’ TexbookTexbook of of OrthopaedicsOrthopaedics. . http://http://www.wheelessonline.comwww.wheelessonline.com Purpose: To determine if pelvic re-alignment procedures have brought bones back to anatomic position and evaluate callous formation & healing Intra-operative Portable Supine Pelvic Xray of Unstable Fx s/p ORIF 2222 Pelvic Pelvic FxFx Classification SystemClassification System  Multiple classification systems in useMultiple classification systems in use  Young System: 4 general categories, Young System: 4 general categories, based on mechanism of injurybased on mechanism of injury –– Lateral Compression (LC ILateral Compression (LC I--III)III) –– Anterior/Posterior Compression (APC IAnterior/Posterior Compression (APC I--III)III) –– Vertical Shear (VS)Vertical Shear (VS) –– Combined Mechanical (CM)Combined Mechanical (CM)  Hemorrhage predominantly with APC & VS Hemorrhage predominantly with APC & VS injuries, rare with LC injuriesinjuries, rare with LC injuries Christina Boulton, 2004 Gillian Lieberman, MD 2323 Lateral Compression FracturesLateral Compression Fractures  LC IILC II  MechMech: lateral : lateral compression to compression to iliumilium  Post. Injury = Post. Injury = ipsilateralipsilateral posterior posterior iliac fractureiliac fracture  USUALLY STABLEUSUALLY STABLE  LC ILC I  MechMech: lateral : lateral compression to compression to sacrumsacrum  Post. Injury = Post. Injury = ipsilateralipsilateral sacral sacral strut compression strut compression fracturesfractures  STABLESTABLE  LC IIILC III  MechMech: rollover : rollover  Post. Injury = LC Post. Injury = LC I/II + I/II + contralateralcontralateral AP compressionAP compression  UNSTABLEUNSTABLE Christina Boulton, 2004 Gillian Lieberman, MD KEY: Transverse Pubic Rami Fx/s + Ipsi- or Contralateral Posterior Injury Images: Borril et al. Orthoteers Orthopedic Education Resource. http://www.orthoteers.co.uk/. 2424 A/P Compression FracturesA/P Compression Fractures  APC IAPC I  MechMech: low/mod AP : low/mod AP force (e.g. sports)force (e.g. sports)  Injury: PS<2cm/ Injury: PS<2cm/ PR PR FxFx + anterior + anterior SI ligament stretchSI ligament stretch  STABLESTABLE  APC IIAPC II  MechMech: high energy : high energy AP forceAP force  Injury: PS>2cm/ PR Injury: PS>2cm/ PR FxFx + anterior SI + anterior SI ligament tear + torn ligament tear + torn ST, SS ligamentsST, SS ligaments  UNSTABLE, UNSTABLE, ““open open bookbook””  APC IIIAPC III  MechMech: very high : very high energy AP forceenergy AP force  Post. Injury: anterior Post. Injury: anterior AND posterior SI, SS AND posterior SI, SS & ST ligaments torn& ST ligaments torn  VERY UNSTABLEVERY UNSTABLE Christina Boulton, 2004 Gillian Lieberman, MD KEY: Syphysis diastasis OR Longitudinal Rami Fx +/- Post. Ligament Tear Images: Borril et al. Orthoteers Orthopedic Education Resource. http://www.orthoteers.co.uk/. 2525 Vertical Shear FracturesVertical Shear Fractures  S/I Displacement S/I Displacement often evident on often evident on PExPEx  Mechanism: fall from Mechanism: fall from significant height significant height  Injury: can be Injury: can be ligamentousligamentous only or only or involve fractures alsoinvolve fractures also  UNSTABLEUNSTABLE Christina Boulton, 2004 Gillian Lieberman, MD Images: Borril et al. Orthoteers Orthopedic Education Resource. http://www.orthoteers.co.uk/. 2626 Combined MechanicalCombined Mechanical  Mechanism: multiple Mechanism: multiple forces from multiple forces from multiple directions, usually VS directions, usually VS + LC+ LC  Injury: combinationInjury: combination  High association with High association with severe trauma, severe trauma, hemorrhage and hemorrhage and multiple other injuriesmultiple other injuries  UNSTABLEUNSTABLE Christina Boulton, 2004 Gillian Lieberman, MD Images: Borril et al. Orthoteers Orthopedic Education Resource. http://www.orthoteers.co.uk/. 2727 Our Patient (MS) SummaryOur Patient (MS) Summary  MSMS’’ss InjuriesInjuries –– R superior & inferior pubic R superior & inferior pubic ramirami fxfx –– L pubic L pubic symphysissymphysis fxfx –– R sacral R sacral fxfx + R sacroiliac joint widening + R sacroiliac joint widening –– Pelvic hematomaPelvic hematoma  Classification Classification –– CM pelvic ring disruptionCM pelvic ring disruption  Complications Complications –– bleeding/hematoma, CT bleeding/hematoma, CT CystoCysto showed no bladder injury (not shown)showed no bladder injury (not shown)  Interventions Interventions –– arterial arterial embolizationembolization, external , external pelvic fixationpelvic fixation Christina Boulton, 2004 Gillian Lieberman, MD 2828 Pelvic Fractures: SummaryPelvic Fractures: Summary  Associated Morbidity & Mortality = HighAssociated Morbidity & Mortality = High  Associated Injuries & Complications = Common + Associated Injuries & Complications = Common + DangerousDangerous –– Injury to vessels, nerves, bladder and other organs Injury to vessels, nerves, bladder and other organs commoncommon –– LongtermLongterm FxFx complications complications e.ge.g chronic pain, chronic pain, immobility, arthritisimmobility, arthritis  Mechanism of injury can predict fracture pattern + Mechanism of injury can predict fracture pattern + associated injuries if you understand the anatomyassociated injuries if you understand the anatomy  Classification System: Classification System: –– Low Energy vs. High Energy (Ring Disruption)Low Energy vs. High Energy (Ring Disruption) –– Stable vs. Unstable, Open Vs. ClosedStable vs. Unstable, Open Vs. Closed –– Lateral Compression, A/P Compression, Vertical ShearLateral Compression, A/P Compression, Vertical Shear Christina Boulton, 2004 Gillian Lieberman, MD 2929 Pelvic Imaging: SummaryPelvic Imaging: Summary  Trauma Series KUB Trauma Series KUB -- Initial detection of Initial detection of FxFx  Inlet & Outlet Plain FilmsInlet & Outlet Plain Films –– Primarily used in characterization of fracture architecture and Primarily used in characterization of fracture architecture and for for follow upfollow up  JudetJudet Plain FilmsPlain Films –– Oblique views used for evaluation and follow up of Oblique views used for evaluation and follow up of acetabularacetabular fracturesfractures  Pelvic CT Ortho ProtocolPelvic CT Ortho Protocol –– Further characterization of Further characterization of FxFx, esp. degree of displacement and , esp. degree of displacement and detection of subtle sacral fracturesdetection of subtle sacral fractures –– Coronal & Coronal & saggitalsaggital reconstructions for specific positional reconstructions for specific positional relationshipsrelationships –– Artifact reduction protocol for evaluations Artifact reduction protocol for evaluations s/ps/p ORIFORIF –– Sensitive for detection of hematoma, organ injuries Sensitive for detection of hematoma, organ injuries  ArterogramArterogram –– Detection and Detection and embolizationembolization of active bleedsof active bleeds  CT CT