骨盆骨折的影像学诊断

0 Trauma Pelvic Atlas of Pelvic Fractures Dorothy Tamayo, Harvard Medical School Year III Gillian Lieberman, MD Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 1 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 1. Case presentation of a patient 2. Menu of diagnostic tests for pelvic trauma 3. Imaging and findings from patient 4. Normal pelvic anatomy 5. Abnormal pelvic anatomy of our patient 6. Statistics of pelvic fractures 7. Common pelvic fractures classificaton 8. Examples of common pelvic fractures on radiograph 9. Classification of our patients fracture Table of Contents 2 Dorothy Tamayo, MS3 Gillian Lieberman, MD Patient is a 21-year-old woman who was struck by a motor vehicle at high speed, while crossing the street. By report she was thrown approximately 100 feet. She arrived intubated and sedated. Stable after receiving 4 L of crystalloid, packed red blood cells and FFP Patient Presentation 9.19.2011 Image from Bidmc PACS 3 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Menu of Diagnostic Tests for Pelvic Trauma Ultrasound: Check for hemoperotoneum Plain radiograph: Inlet, outlet and Judet (oblique) views CT scan: Gold standard Retrograde cystourethrogram: If suspected GU trauma Diagnostic peritoneal aspirate: If hemodynamically unstable 4 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Portable chest CT head w/o contrast CT C-spine w/o contrast CT chest w/contrast CT abd and pelvis w/contrast Foot xray Patient requires full-body CT scan Imaging Obtained for Our Patient Image from Bidmc PACS 5 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Pelvic fractures Spinous process fracture C6-T4 R Pneumothorax Lacerated liver Comminuted fracture of humerus Sternoclavicular dislocation Multiple rib fractures Imaging Findings from Our Patients 6 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Normal Pelvic Anatomy Posted by Dr.Sunil http://basicxray.blogspot.com/ 7 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Normal Pelvic Anatomy: Contours Iliopectineal Line Ilioischial Line Anterior Acetabular Wall Posterior Acetabular Wall Obturator Foramen http://www.ajronline.org/cgi/content-nw/full/187/4/915/FIG3 8 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Normal Pelvic Anatomy: Ligaments Sacrotuberous Ligament Sacrospinous ligament Sacroiliac ligament Pubic symphysis http://en.wikipedia.org/wiki/File:Gray319.png 9 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Pelvic fracture present in: Bilateral superior and inferior pubic rami Sacroiliac joints Sacrum Abnormal Pelvic Anatomy of Our Patient Images from Bidmc PACS 10 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Most common mechanism of pelvic fracture: MVA 58% Pedestrian struck by vehicle 22% Falls 30% Associated injuries with pelvic trauma: Venous hemorrhage 38% Visceral injury 17% Bladder/urethra injury 6% Nerve deficits 15% Thoracic aorta rupture 1% Statistics on Pelvic Trauma www.uptodate.com+adult-pelvic-trauma; James Fiecht 11 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Most Common Fractures of the Pelvis Lateral Compression AnteroPosterior Compression Vertical Shear Injury www.uptodate.com+adult-pelvic-trauma; James Fiecht The blue arrows illustrate the force direction. A) Lateral compression injuries with subsequent bilateral involvement as forces increase; B) Anteroposterior injuries with progression of injury; C) Vertical shear injury. Burgess, AR, Eastridge, BJ, Young, JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma, 1990, 30:848. 12 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Lateral Compression Fracture: Type I Most common A) Type I lateral compression fracture with bilateral superior and inferior rami fractures and left sacral fracture. B) Inlet view showing greater detail of the pelvic ring disruption. C) Outlet view illustrating greater detail of the sacral fracture in addition to the bilateral rami fractures. Images from Jim Fiechtl, MD. www.uptodate.com+adult-pelvic-trauma; James Fiecht Sacral fracture on side of impact 13 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Lateral Compression Fracture: Type II Crescent “Iliac wing” Crescent fracture on side of impact A) Type II lateral compression fracture with left sided rami and sacral fractures. B) CT scan illustrating the classic crescent fracture pattern. Images from Jim Fiechtl, MD. 14 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Lateral Compression Fracture: Type III “Wind swept pelvis” “crescent and open book” Type I or II crescent injury with contralateral open book injury (B) Anteroposterior plain radiograph; (C) CT scan. Images from Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, 15 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 AP Compression Fracture: Type I Usually less than 2cm spread with intact posterior Pelvic ring ligaments (B) Plain radiograph with outlet view. Images from: Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta 16 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 AP Compression Fracture: Type II Opening of sacoiliac joint, sacrotuberous, and sacrospinous ligaments AP radiograph; Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, P (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. 17 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 AP Compression Fracture: Type III Complete disruption of sacroiliac joint (B) AP radiograph; from: Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, P (Eds) 18 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Vertical Shear Stress Fracture Wide pubic symphysis, broken SI ligament with unilateral or bilateral rami fracture (B) AP radiograph; (C) 3-dimensional reconstruction from a CT scan. from: Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, P (Eds), Lippincott Williams & Wilkins 19 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Patient’s Injury Classified Vertical Shear: broken SI ligament with bilateral rami fracture Images from Bidmc PACS 20 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Surgery to Stabilize Our Patient’s Pelvis Image from Bidmc PACS 21 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Follow up Removal of Hardware and Stabilization of SI Joints Image from Bidmc PACS 22 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Summary Lateral Compression AnteroPosterior Compression Vertical Shear Injury www.uptodate.com+adult-pelvic-trauma; James Fiecht Burgess, AR, Eastridge, BJ, Young, JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma, 1990, 30:848. With our patient showing evidence for vertical shear 23 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 Thanks! Dr. Gillian Lieberman, Course Director Emily Hanson, Educational Coordinator Daniel Barkhuff, MS3 involved in case 24 Dorothy Tamayo, MS3 Gillian Lieberman, MD 9.19.2011 References Bramos A Velmahos GC, Butt UM, Fikry K, Smith RM Chang Y. Predictors of bleeding from stable pelvic fractures. SourceDivision of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005 Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta- analysis. J Bone Joint Surg Br 2005 Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008 Sathy AK, Starr AJ, Smith WR, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am 2009 Balogh Z, King KL, Mackay P, et al. The epidemiology of pelvic ring fractures: a population-based study. J Trauma 2007 Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br 2005 http://www.ajronline.org/cgi/content-nw/full/187/4/915/FIG3 Slide Number 1 Slide Number 2 Slide Number 3 Slide Number 4 Slide Number 5 Slide Number 6 Slide Number 7 Slide Number 8 Slide Number 9 Slide Number 10 Slide Number 11 Slide Number 12 Slide Number 13 Slide Number 14 Slide Number 15 Slide Number 16 Slide Number 17 Slide Number 18 Slide Number 19 Slide Number 20 Slide Number 21 Slide Number 22 Slide Number 23 Slide Number 24 Slide Number 25