中医骨科学外文版 (44).ppt

SpineClassification of Spinal InjuryCommonly classified by violence to injury:Direct violence:Relatively rare,including blows,collisions,bullet wounds and explosive injuries.In these cases,for cervical,thoracic and lumbar vertebrae,the transverse or spinous process fractures mostly occur;For sacral vertebrae,the transverse or comminuted fractures without displacement occur.The spinal cord is prone to injury.Flexion type:A kind of flexion compression injury Falling from a height and landing on the lower extremities or bottom,where there is upward transmission of violence,or weight falling from a height to the head will cause suddenly excessive flexion of the spine.In this case,the spine will flex forward with the middle column as the center,the anterior column and middle column being subjected to compression load and the posterior column to stretch load.When the stress limit is exceeded,the vertebral body will be damaged by compression,and then the violence will continue to cause fractures of the zygapophyseal joint and other appendages and ligament tear.The incidence rate is 90%,with 70%in the thoracic segment and lumbar segment.Indirect violenceFlexion-compression type:Mainly referring to the compression injury to anterior columnExtension type:It often occurs in cervical vertebra and lumbar vertebra.The patient falls on the back from a height,and the waist is blocked by obstacles,overstretching the spine,and resulting tear of anterior longitudinal ligament,separation of vertebral body and appendage fracture.Avulsion Fracture of Anterior and Inferior Edge of Vertebral BodyAvulsion Fracture of Anterior and Inferior Edge of Vertebral Body Caused by Cervical Extension InjuryVertical-compression type:It is a burst-type injury.When objects falling from a height strike the top of head longitudinally,or the top of the head vertically hits the ground during diving,and when one falls from a height and lands on his bottom,the compression of intervertebral disc can cause comminuted fracture to the vertebral body.The fracture fragments are burst around,especially that the posterior vertebral body cortex fracture causes the fracture fragments to protrude into the vertebral canal,resulting in vertebral canal deformation and spinal cord injury.The main reason is that the The main reason is that the middle column is damaged and middle column is damaged and the posterior fracture fragments the posterior fracture fragments usually protrude into the usually protrude into the vertebral canal.It mainly occurs vertebral canal.It mainly occurs in the cervical vertebra.in the cervical vertebra.Horizontal shear violence:A flexion-distraction-type(seat-belt-type)Horizontal shear violence:A flexion-distraction-type(seat-belt-type)injuryinjuryIt is mostly the flexion separation type shear injury.At the instant of crash,the patients lower body is fixed by the seat belt,while the upper torso moves forward sharply due to inertia.With the anterior column as the pivot,the posterior and middle columns are burst open due to stretch stress,resulting in horizontal rupture of the supraspinous-interspinous ligament-posterior longitudinal ligament-intervertebral disc,or horizontal fracture of the spinous process-vertebral plate-vertebral body.Usually,the spinal cord injury with large displacement is more common.Lateral flexion injuryWhen falling from a height,one lands on one side of his bottom.One side of the trunk is hit by heavy objects.In these cases,the vertebral body is subjected to compression fracture on one side and stretch stress on the opposite side,resulting in traction injury to the nerve root or cauda equina.Flexion rotation injury:The spine is subjected to the combined violent actions of flexion and rotation to one side,resulting in traction injury to the supraspinal ligament and interspinal ligament,tear of articular capsule on the opposite side of rotation axis,dislocation of zygapophysial joint,deformation of vertebral canal and compression of spinal cord.Flexion-rotation injury mechanismFlexion-rotation type(fracture and dislocation)Avulsion injuryThe sudden and uncoordinated contraction of muscles causes avulsion fracture of the spinous process or transverse process,with a relatively small displacement,and without damage to the stability of spine.Three-column Theory of SpineIn 1983,Denis proposed the concept of a three-column classification,suggesting that the stability of the spine depends on the integrity of the middle column and is not determined by the posterior ligamentous complex structure.Anterior column:anterior longitudinal ligament,anterior 1/2 of the vertebral body,anterior part of the intervertebral disc;Middle column:Lig.longitudinale posterius,posterior 1/2 of the vertebral body,posterior part of the intervertebral disc;Posterior column:vertebral arch,ligamentum flavum,interspinous ligament.In 1984,Ferguson refined the concept of three-column classification proposed by Denis,considering the anterior 2/3 of the vertebral body and intervertebral disc to be the anterior column and the posterior 1/3 to be the middle column,which is currently the more unanimously accepted concept of three-column classification Any damage involving two columns or more structures are considered unstable damage.1.Medical history:Patients mostly had a history of serious trauma2.Symptoms:local swelling and pain after injury,paravertebral muscle tension on both sides of the injury,dyskinesia in all directions of the spine.Patients with thoracolumbar spine injury cannot stand and have difficulty turning over.3.Signs:Posterior convexity deformity is seen in distractive flexion injuries,with significant tenderness in the spinous process of the fracture on examination,altered interspinous distance(widening,narrowing,or skewing),and local swelling and bruising.Posterior process or angulation deformity.With or without sensory disturbance or dyskinesia.Key Diagnostic PointsTreatment Principles1.The first thing to do is to check whether there is compression of head,chest,abdomen and vertebral canal,spinal cord or nerve injury,and whether there is instability of spine.2.Stable fractures or relatively stable fractures with mild compression of vertebral canal or without compression or nerve injury should be treated conservatively.Unstable fractures and fractures with nerve injury should be treated by operation in time.3.Acute spinal cord injury should be positively treated with drugs before and after surgical treatment to reduce or prevent secondary damage and protect or promote the recovery of spinal cord functions.Treatment Methods1.On-site first aid and transfer:Any patient with suspected spinal fracture-dislocation should be treated with appropriate first aid on a case-by-case basis,including the administration of analgesics and antishock therapy,and escorted to a better-equipped hospital for further treatment as soon as possible.For simple non-displaced fractures,pillow-jaw belt traction is possible,with a typical weight of 3-5 kg.2.Cervical Traction Reduction and FixationSkull Skull traction traction is is the the mainstay mainstay of of non-surgical non-surgical treatment treatment of cervical vertebra fracture-dislocation.of cervical vertebra fracture-dislocation.The The weight weight of of traction traction can can be be determined determined according according to to the the need.need.The The initial initial weight weight is is 5-15 5-15 kg,kg,and and the the direction direction of of traction traction should should depend depend on on the the mechanism mechanism of of injury injury and and the the type type of of fracture.fracture.Once Once reduction reduction is is achieved,achieved,3-5 3-5 kg kg of of traction should be applied to maintain traction.traction should be applied to maintain traction.Stable flexion fracture-Reduction by lying on a hard bed or placing a pillow under the waist/back,fixation with a plaster-of-Paris jacket,functional exercise of lumbar muscles and back muscles(functional reduction).This method is safe and effective.Thoracolumbar vertebral fracture and dislocationThree-point reduction in the prone positionTwo-foot suspension hyperextension reductionKidney-support reductionUnstable flexion fracture Reduction by lying on a hard bed or placing a pillow under the waist/back.Comminuted fracture may cause low back pain in the future,so patients should be treated with surgical internal fixation or bone grafting with external fixation.Staying in bed for 2 months is required.Weight training exercise with a waist fixing strap.For those suffering from fracture of vertebral pedicle with spondylolishesis,the Harrington rods or pedicle screws are used for internal fixation.Staying in bed for 2 months is required.Extension type fracture-Avoiding hyperextension of spine,staying in bed for 2 months,or fixing with a plaster-of-Paris jacket.Thoracolumbar vertebral fracture and dislocationSurgical indications1.Within 10-14 days of injury,with or without paraplegia,or progressive worsening of paraplegia.2.Unstable burst-type fractures.3.Flexion-compression fractures in young patients with more than 1/2 of the anterior column compressed.4.Hyperextension separated fractures.5.Mild or moderate displacement of fractured or dislocated vertebral body.6.Vertebral body kyphosis or angulation greater than 30,with spinal instability.7.Fracture fragment above the lumbar 2 plane enters the vertebral canal and occupies more than 30%.8.With anterior spinal cord syndrome,whether in the vertebral canal,with partial or complete obstruction.9.Late tardive incomplete paralysis with compression.10.Systemic condition is fine,without cerebral,respiratory,circulatory complex injury complications.Surgical methodsAnterior approachPosterior approachCombined anterior and posterior approachAnterior fixation instrumentsAnterior platesDriving and location selection of vertebral screwsPosterior fixation instruments Screw-rod systemFunctional exercise of lumbar muscles and back musclesFigure 21-31 Three-point SupportingFigure 21-32 Arch-bridge SupportingFigure 21-30 Five-point Supporting1.Supporting with head and elbow.2.Support the upper body with the head.