Damage to the spine, pelvis

PRPROFESSOR OFESSOR

Fishchenko Vladimir AlexandrovichFishchenko Vladimir Alexandrovich

BASHINSKIY GENNADIY BASHINSKIY GENNADIY PETROVICHPETROVICH

Among spinal injuries Among spinal injuries most noteworthy damage most noteworthy damage to the vertebrae to the vertebrae themselves. Early themselves. Early diagnosis of the spine is diagnosis of the spine is very important to provide very important to provide the correct and timely the correct and timely fast aidfast aid

Late diagnosis may cause Late diagnosis may cause worsening of spinal cord injury worsening of spinal cord injury and quickly lead to secondary and quickly lead to secondary damage to the spinal cord and its damage to the spinal cord and its rootsroots

The cause of delayed diagnosis The cause of delayed diagnosis of spinal injuries is usually of spinal injuries is usually underestimating the severity of underestimating the severity of the damage. It should be the damage. It should be remembered that the diagnosis remembered that the diagnosis of a back injury, ligament of a back injury, ligament damage, etc. can be considered damage, etc. can be considered only after it is completely only after it is completely excluded the diagnosis damage excluded the diagnosis damage of the vertebral bodyof the vertebral body

Damage to the vertebral bodies Damage to the vertebral bodies are more common in the are more common in the indirect mechanism of injury: indirect mechanism of injury: the axial load on the spine, the axial load on the spine, sharp or excessive flexsion sharp or excessive flexsion and its extensionand its extension . .

Sometimes there may be two or even Sometimes there may be two or even three types of loads. For example, the three types of loads. For example, the combination of a sharp flexion and combination of a sharp flexion and extension of the cervical spine when extension of the cervical spine when hit by a car, braking, etc.hit by a car, braking, etc.

IIn adults, the most damaged by the n adults, the most damaged by the lower neck and upper chest vertebrae, lower neck and upper chest vertebrae, the lower thoracic and upper lumbar the lower thoracic and upper lumbar vertebrae (the transition zone of one of vertebrae (the transition zone of one of the physiological curvature of the the physiological curvature of the other).other).

Dislocation are more common in the Dislocation are more common in the cervical region, while in the thoracic cervical region, while in the thoracic and lumbar region we can see and lumbar region we can see fractures and fracture- dislocation.fractures and fracture- dislocation.

Damage to the vertebral bodies are Damage to the vertebral bodies are divided into: stable and unstable. The divided into: stable and unstable. The instability called those injuries for instability called those injuries for which there is a tendency to shift the which there is a tendency to shift the vertebrae, which is observed in vertebrae, which is observed in posterior ligamentous complex posterior ligamentous complex (interspinous, (interspinous, suprasupraspinous, yellow spinous, yellow ligaments and intervertebral joints).ligaments and intervertebral joints).

Rear ligamentous complex also Rear ligamentous complex also damaged at fracture-dislocations of the damaged at fracture-dislocations of the vertebrae, with wedge compression by vertebrae, with wedge compression by more than half the height of the more than half the height of the vertebral bodyvertebral body

Stable fractures are rarely associated Stable fractures are rarely associated with the pressure of the contents of the with the pressure of the contents of the spinal canal, and in unstable injuries is spinal canal, and in unstable injuries is always aalways a danger danger of such a of such a compressioncompression

It is also unstable so-called flexion - It is also unstable so-called flexion - rotation fracture. The most common rotation fracture. The most common fractures of the vertebrae - wedge fractures of the vertebrae - wedge compression and the abruption compression and the abruption anterosuperior and anteroinferior angle anterosuperior and anteroinferior angle - are stable fractures.- are stable fractures.

classification of fractures classification of fractures of the spine in the of the spine in the degree of compressiondegree of compression 1 degree -1 degree -

height of the vertebral body is height of the vertebral body is reduced to one-thirdreduced to one-third2 Degree - half2 Degree - half3 Degree - more than half3 Degree - more than half

Diagnosis of vertebral Diagnosis of vertebral fractures and dislocationsfractures and dislocations The most common complaint of The most common complaint of

patients early after injury is a pain in patients early after injury is a pain in the injured spine, which spans 2-3 the injured spine, which spans 2-3 vertebrae. Pain may be local or vertebrae. Pain may be local or radicularradicular

When viewed from the back should When viewed from the back should first pay attention to changes in the first pay attention to changes in the physiological curvature of the spine. physiological curvature of the spine. True hump is rare, but the decrease of True hump is rare, but the decrease of lumbar lordosis or increase thoracic lumbar lordosis or increase thoracic kyphosis is often observedkyphosis is often observed

In fractures the lumbar vertebrae can In fractures the lumbar vertebrae can be a pain in the abdomen and some be a pain in the abdomen and some muscle tensionmuscle tension anterior abdominal anterior abdominal wall. This is due to the presence of wall. This is due to the presence of retroperitoneal hematoma retroperitoneal hematoma accompanying fracture.accompanying fracture.

The presence of retroperitoneal The presence of retroperitoneal hematoma, irritation or damage to the hematoma, irritation or damage to the solar plexus and border symptomatic solar plexus and border symptomatic trunk carried to the emergence of " trunk carried to the emergence of " the clinic false "acute abdomen", which the clinic false "acute abdomen", which can be so severe that sometimes have can be so severe that sometimes have to resort to a diagnostic laparoscopy or to resort to a diagnostic laparoscopy or laparotomy.laparotomy.

For the differential diagnosis between For the differential diagnosis between the clinic false "acute abdomen", the clinic false "acute abdomen", abdominal syndrome in fractures of the abdominal syndrome in fractures of the lumbar vertebrae and damage to the lumbar vertebrae and damage to the organs of the abdominal cavity, you organs of the abdominal cavity, you can use vertebra anesthesia by can use vertebra anesthesia by ShnekShnek..

Anesthesia performed with the patient on Anesthesia performed with the patient on his side. 12-14 cm long needle is his side. 12-14 cm long needle is introduced at 6 cm away from the spinous introduced at 6 cm away from the spinous processes of the lumbar vertebrae and processes of the lumbar vertebrae and broken promote vertebral body at an angle broken promote vertebral body at an angle of 35 degrees to the plane of the back. At of 35 degrees to the plane of the back. At a depth of 5-8 cm needle usually rests on a depth of 5-8 cm needle usually rests on the transverse process. Surpassing its top, the transverse process. Surpassing its top, the needle move further the midline.the needle move further the midline.

The movement of the needle precede the The movement of the needle precede the introduction of a 0.5% solution of introduction of a 0.5% solution of novocaine. At a depth of 8-12 cm needle novocaine. At a depth of 8-12 cm needle rests in the body of broken vertebra. rests in the body of broken vertebra. Confirmation of this will leak out of the Confirmation of this will leak out of the needle novocaine stained with blood. needle novocaine stained with blood. Here are administered 10 ml of a 1% Here are administered 10 ml of a 1% solution of novocaine. The needle is solution of novocaine. The needle is removed.removed.

If after a few minutes of anesthesia by If after a few minutes of anesthesia by ShnekShnek you can notice you can notice regression of regression of symptoms of "acute abdomen", you symptoms of "acute abdomen", you can think of that syndrome is caused can think of that syndrome is caused by a fractured vertebra.by a fractured vertebra.

Fairly constant symptom of spinal injury Fairly constant symptom of spinal injury is increased pain in the back straight is increased pain in the back straight when lifting the leg with the supine when lifting the leg with the supine position. But this symptom is position. But this symptom is characteristic not only of vertebral characteristic not only of vertebral fractures in the lumbar region, but also fractures in the lumbar region, but also for any back injuries in general, including for any back injuries in general, including bruises, sprains and back muscles etcbruises, sprains and back muscles etc

In order that would differentiate a In order that would differentiate a fracture of the body of the lumbar or fracture of the body of the lumbar or lower thoracic vertebrae from the back lower thoracic vertebrae from the back of soft tissue injury and fractures of the of soft tissue injury and fractures of the transverse processes, there should be transverse processes, there should be palpated spinous processes while palpated spinous processes while lifting straight feet from a lying position lifting straight feet from a lying position on the back (a symptom of Silin).on the back (a symptom of Silin).

The axial load on the vertebra is The axial load on the vertebra is allowed only with the patient lying in a allowed only with the patient lying in a light tapping on the heels or the light tapping on the heels or the pressure on the head. Rough axial pressure on the head. Rough axial load on the spine and load on the spine and ddetermination of etermination of volume of movement especially in the volume of movement especially in the upright position of the patient, are not upright position of the patient, are not allowed.allowed.

Conservative treatment:Conservative treatment:Method of single repositioning followed Method of single repositioning followed by the imposition corset;by the imposition corset;Functional method;Functional method;The method of gradual repositioning The method of gradual repositioning followed by the imposition corsetfollowed by the imposition corset

One-step repositioning is carried out at a safe One-step repositioning is carried out at a safe anesthetic. The simplest method is by Boehler anesthetic. The simplest method is by Boehler when Interspinous span over a broken when Interspinous span over a broken vertebra at a depth of 2-4 cm injected 20 ml of vertebra at a depth of 2-4 cm injected 20 ml of 0.5% solution of novocaine. Better pain relief 0.5% solution of novocaine. Better pain relief reaches properly performed anesthesia reaches properly performed anesthesia by by ShnekShnek, but it is technically difficult and should , but it is technically difficult and should not be performed because of the budding not be performed because of the budding traumatologist possible complications. Local traumatologist possible complications. Local anesthesia supplemented subcutaneous anesthesia supplemented subcutaneous analgesicsanalgesics

Fractures of the bones of the Fractures of the bones of the pelvispelvis Damage to the bones of the pelvis is Damage to the bones of the pelvis is

4-7% of all fractures and are a group 4-7% of all fractures and are a group of serious injury. Damage to the pelvis of serious injury. Damage to the pelvis may be accompanied by the most may be accompanied by the most severe shock caused by irritation of severe shock caused by irritation of the rich reflexogenic zones and the rich reflexogenic zones and massive bleeding into the tissues of massive bleeding into the tissues of the spongy bone (more than 2 liters)the spongy bone (more than 2 liters)

One of the functions of the pelvis - the One of the functions of the pelvis - the transfer of the trunk load on the lower transfer of the trunk load on the lower limbs (supporting the pelvis) is due to limbs (supporting the pelvis) is due to the integrity of the pelvic ring. Pelvic the integrity of the pelvic ring. Pelvic ring formed by the sacrum, the body of ring formed by the sacrum, the body of the ilium, pubic and ischial bones the ilium, pubic and ischial bones (excluding the ischial tuberosity), pubic (excluding the ischial tuberosity), pubic and sacroiliac joint.and sacroiliac joint.

A. Boundary value A. Boundary value fracturesfractures This damages the pelvic bones are not This damages the pelvic bones are not

involved in the formation of the pelvic involved in the formation of the pelvic ring. This group includes broken spinal ring. This group includes broken spinal process, process, tuber of ischiumtuber of ischium, coccyx, , coccyx, transverse fracture of the sacrum transverse fracture of the sacrum below the sacroiliac joint, fractures of below the sacroiliac joint, fractures of the iliumthe ilium

Marginal fracturesMarginal fractures

The mechanism of injury is the directThe mechanism of injury is the direct    Fractures of the iliac wing, after brief     Fractures of the iliac wing, after brief compression of the pelvis.compression of the pelvis.    Fractures of the anterior spine may     Fractures of the anterior spine may be during heavy muscle tension.be during heavy muscle tension.    Fractures of the sacrum below the     Fractures of the sacrum below the sacroiliac joint and coccyx occurs sacroiliac joint and coccyx occurs when falling on the buttockswhen falling on the buttocks

By tearing the anterior spine, tenderness in By tearing the anterior spine, tenderness in the area of separation, local swelling, a false the area of separation, local swelling, a false impression of shortening due to downward impression of shortening due to downward and outward displacement of the fragment.and outward displacement of the fragment.    Symptom-Lozinski (reverse) -    Symptom-Lozinski (reverse) -    when you try to bend the thigh during a     when you try to bend the thigh during a step forward there is a sharp pain in the area step forward there is a sharp pain in the area of the fracture due to muscle tension clip-on of the fracture due to muscle tension clip-on to the spine.to the spine.    The movement kicked back is significantly     The movement kicked back is significantly less pain, a patient walks back less pain, a patient walks back

B. Fractures of the pelvic ring B. Fractures of the pelvic ring without breaking its continuitywithout breaking its continuity

This bone fractures, forming the pelvic This bone fractures, forming the pelvic ring. The strength of the pelvic ring is ring. The strength of the pelvic ring is reduced, but the reference is stored as reduced, but the reference is stored as the two halves of the pelvis are the two halves of the pelvis are connected with the sacrum, both connected with the sacrum, both directly and through the other halfdirectly and through the other half

These injuries include:These injuries include:One or bilateral fractures same branch One or bilateral fractures same branch pubic bone;pubic bone;Single or bilateral fractures of the Single or bilateral fractures of the ischial bones;ischial bones;Fracture of one of the branches of the Fracture of one of the branches of the pubic bone on one side and the other pubic bone on one side and the other of the ischium.of the ischium.

Fractures of the pelvic ring Fractures of the pelvic ring without breaking its continuitywithout breaking its continuity

The mechanism of injury-line.The mechanism of injury-line.    Complaints: pain in the pubic area, in the     Complaints: pain in the pubic area, in the crotch on the side of injury.crotch on the side of injury.    Symptom-Gabai when turning from back to     Symptom-Gabai when turning from back to side-step the patient maintains a damaged side side-step the patient maintains a damaged side of the pelvis lower legs or feet healthy side, of the pelvis lower legs or feet healthy side, turning from a lateral position on the back of the turning from a lateral position on the back of the patient keeps this fixed position of both legs.patient keeps this fixed position of both legs.     Symptom "stuck heel" - the patient can not      Symptom "stuck heel" - the patient can not take his foot from the support line, but keeps take his foot from the support line, but keeps the limb elevated themselvesthe limb elevated themselves

B. Damage to the violation of B. Damage to the violation of the continuity of the pelvic the continuity of the pelvic ringring In such injuries each half of the pelvis is In such injuries each half of the pelvis is

soldered to the sacrum with only one soldered to the sacrum with only one side. Greatly disturbed the support side. Greatly disturbed the support function of the pelvis.function of the pelvis.Among these injuries :Among these injuries :Vertical fracture of the sacrum, or Vertical fracture of the sacrum, or fracture of the lateral mass of the fracture of the lateral mass of the sacrum;sacrum;Rupture of the sacroiliac jointRupture of the sacroiliac joint

Vertical fracture of the ilium;Vertical fracture of the ilium;. Fracture of both branches of the . Fracture of both branches of the frontal bone on one or both sides;frontal bone on one or both sides;. Fracture of the pubic and ischial . Fracture of the pubic and ischial bones on one or both sides (fracture of bones on one or both sides (fracture of the "butterfly");the "butterfly");. Rupture symphysis;. Rupture symphysis;

Damage to the solution of continuity with Damage to the solution of continuity with simultaneous front and back half-rings simultaneous front and back half-rings (like Malgeniya). With this type of injury is (like Malgeniya). With this type of injury is completely lost connection half of the completely lost connection half of the pelvis with sacrum. The support function pelvis with sacrum. The support function of the pelvis and half lost. Half of the of the pelvis and half lost. Half of the pelvis that is not related to the spine pelvis that is not related to the spine (sacrum to), under the thrust of the back (sacrum to), under the thrust of the back muscles and stomach moves up.muscles and stomach moves up.

MAY BEMAY BEBilateral fracture type Malgenya when Bilateral fracture type Malgenya when and the front and back D-rings are and the front and back D-rings are damaged on both sides;damaged on both sides;Unilateral or vertical, fracture type Unilateral or vertical, fracture type Malgenya - fracture of front and back Malgenya - fracture of front and back half-rings on the one hand;half-rings on the one hand;Oblique or diagonal fracture Melgenya - Oblique or diagonal fracture Melgenya - the front half ring broken one, and the the front half ring broken one, and the rear - on the other side;rear - on the other side;

rupture of the sacroiliac joint and rupture of the sacroiliac joint and symphysis;symphysis;

The combination of the symphysis The combination of the symphysis fracture with fracture back D-rings, or fracture with fracture back D-rings, or a combination of rupture sacroiliac a combination of rupture sacroiliac joint with a fracture of the front D-ringsjoint with a fracture of the front D-rings

Fractures of the acetabulum:

Fractures of the acetabulum:Fractures of the acetabulum:

Fracture edge of the acetabulum,(with a dislocated hip, often caudineural)Fracture of the bottom of the acetabulum,(with central dislocation of the hip)

The mechanism of injury, the lateral The mechanism of injury, the lateral compression of the pelvis in the compression of the pelvis in the trochanter.trochanter.    The clinic is smoothed, X-ray     The clinic is smoothed, X-ray examination is mandatory.examination is mandatory.    Treatment-conservative-skeletal     Treatment-conservative-skeletal traction. Acetabular fractures with central traction. Acetabular fractures with central dislocation of the hip-skeletal traction is dislocation of the hip-skeletal traction is applied along the axis of the thigh and the applied along the axis of the thigh and the side of the greater trochanterside of the greater trochanter

Damage to the pelvis in most cases Damage to the pelvis in most cases accompanied by a shock. Feature shock-accompanied by a shock. Feature shock-trauma pelvistrauma pelvis    except for the pain component, there is     except for the pain component, there is significant blood loss intrapelvic fat.significant blood loss intrapelvic fat.    Prior to transportation to a hospital is     Prior to transportation to a hospital is desirable to produce anesthesia fractures desirable to produce anesthesia fractures and establish anti-shock jet transfusion and establish anti-shock jet transfusion blood substitutes.blood substitutes.

Pain management of fractures of the pelvis:Pain management of fractures of the pelvis:Intrapelvic anesthetic techniqueIntrapelvic anesthetic techniqueIn the position of the patient on the back of 1 In the position of the patient on the back of 1 cm from the anterior iliac spine after skin cm from the anterior iliac spine after skin anesthesia injected a needle length of 14-15 anesthesia injected a needle length of 14-15 cm with a 0.25% solution of novocaine. The cm with a 0.25% solution of novocaine. The needle is advanced from front to back. This needle is advanced from front to back. This bevel of the needle should slide along the bevel of the needle should slide along the inner surface of the ilium. At a depth of 12-inner surface of the ilium. At a depth of 12-14 cm tip of the needle is in the iliac fossa, 14 cm tip of the needle is in the iliac fossa, here are administered 250-300 ml of a here are administered 250-300 ml of a 0.25% solution of novocaine.0.25% solution of novocaine.

Damage to the simultaneous Damage to the simultaneous violation of front and back half-violation of front and back half-rings (fracture type Malgenya)rings (fracture type Malgenya)

The mechanism of injury-indirect.The mechanism of injury-indirect.On examination, pelvic asymmetry half, the On examination, pelvic asymmetry half, the displacement of one of the halves of up to 2-3 displacement of one of the halves of up to 2-3 cmcmDetermination of displacement-distance Determination of displacement-distance compared to the xiphoid process to the anterior compared to the xiphoid process to the anterior spines on both sides.spines on both sides.

Symptoms Varneylya and Larrey (sharp pain Symptoms Varneylya and Larrey (sharp pain when squeezed or dilution of of the iliac wing.)when squeezed or dilution of of the iliac wing.)

treatmenttreatment

Removing the patient from shock Removing the patient from shock intraintrapelvicpelvic anesthesia. anesthesia.       

IIff displaced fracture, skeletal traction displaced fracture, skeletal traction for both lower limbsfor both lower limbs