【作者】 杨光；

【导师】 张英泽；

【作者基本信息】 河北医科大学 ， 外科学（专业学位）， 2014， 硕士

【摘要】 目的：回顾性研究骶骨骶骨Ⅱ区骨折移位程度与骶神经损伤的关系。骶骨Ⅱ区骨折是骨折线累及骶骨孔的骨折。根据骶骨Ⅱ区骨折在冠状面上不同程度的移位，将其分为压缩骨折（A型）和分离骨折（B型）两亚型。骶骨不同部位骨折，神经损伤的发生率也不同，其中骶骨Ⅱ区骨折并发神经损伤病例占到了23%（19/81）。骶骨骨折断端移位方向和程度，与骶神经损伤的发生有密切关系。然而，经检索Medline、中国知网等数据库，未能查及骶骨Ⅱ区骨折移位程度与骶神经损伤关系之间的量化研究，需要对此进行深入的研究探讨。本研究通过回顾性分析骶骨Ⅱ区骨折患者肌电图及病历查体资料，在CT图像上测量骨折移位程度，探讨Denis Ⅱ区压缩骨折和分离骨折两亚型特点，并分析两亚型骨折不同移位方向和程度与骶神经损伤的关系，为骶骨Denis Ⅱ区骨折的诊治提供参考依据。方法：1一般资料利用病案查询系统，查询河北医科大学第三医院2005年1月至2008年12月间收治的骶骨Ⅱ区骨折患者。纳入标准：年龄>18岁，术前X线和CT图像诊断为骶骨Ⅱ区骨折的患者，患者伤后意识清楚。排除标准：既往有L5、S1、S2神经根及骶丛神经损伤病史，既往有周围动脉炎、神经退行性病变、糖尿病等导致周围神经病变的疾患病史。记录其年龄、性别、损伤侧别、合并伤、致伤原因等病历资料。调阅患者神经肌电图检查报告和体格检查记录，判断是否发生神经损伤。2影像学检查利用图片存档及通讯系统（PACS）调取患者术前X线和CT图像，观察是否移位。根据骶骨Ⅱ区骨折在CT图像冠状面上移位方向，将病例划分为压缩骨折和分离骨折两种亚型，根据亚型分型，将患者分为压缩骨折组和分离骨折组。应用RadiAnt DICOM Viewer软件在骨盆CT的横截面图像上测量侧方压缩或者侧方分离骨折的最大移位距离以及前后移位的最大移位距离，并在冠状面图像上测量骨折上下移位的最大距离。分别统计出两组伴有前后移位、左右移位和断端旋转移位的骨折例数。3统计学处理应用SPSS11.5统计学软件，采用t检验分别比较压缩组和分离组中伴有神经损伤与不伴有神经损伤病例的骨折压缩或者分离最大移位的计量资料。采用χ2检验分别比较压缩骨折组和分离骨折组中有骶神经损伤病例与无神经损伤病例伴有的骶骨骨折上下移位、前后移位和旋转等计数资料是否存在差异。设定P<0.05为具有统计学差异。结果：本次研究总共纳入62例骶骨Ⅱ区骨折，包括男41例，女21例，平均年龄35.55（18~57）岁，左侧30例，右侧26例，双侧6例。40例伴有合并损伤，其中锁骨骨折4例，肋骨骨折3例，腰椎椎体骨折16例，胫腓骨骨折5例，肱骨骨折3例，踝关节损伤5例，股骨骨折6例，髋臼骨折7例，尺桡骨骨折2例，趾骨骨折3例，肩胛骨骨折2例。患者平均ISS评分为22（99-42）分。致伤原因包括：车祸伤33例、砸伤8例、高处坠落伤11例、意外摔伤7例、不明原因的外伤3例。本次研究所收集的病例，所有骶骨骨折冠状面上均有移位，其中44侧为压缩移位，设定为压缩骨折组。24侧围分离移位，设定为分离骨折组；45侧骶骨骨折伴有前后方向的移位，23侧伴有旋转移位。共有20例患者伴有骶神经损伤，受损区域为L5至S2所支配区域。1压缩骨折组压缩骨折组中，15侧骨折伴有神经损伤，经测量平均压缩距离为（7.43±2.98）mm；29侧骨折无神经损伤，平均压缩距离为（4.40±3.02）mm；伴有神经损伤骨折的压缩距离与无神经损伤组比较差异具有统计学意义（P=0.003）。伴神经损伤病例中，13侧骨折伴有前后移位，2侧无前后移位，无神经损伤病例中，16侧伴有前后移位，13侧无前后移位；两组中是否伴有前后移位比较差异具有统计学意义（P=0.037）。伴神经损伤病例中，10侧骨折断端存在旋转移位，5侧断端无旋转移位。无神经损伤病例中，4侧骨折断端有旋转移位，25侧断端无旋转移位。两组中骨折断端是否存在旋转移位比较差异具有统计学意义（P=0.001）。2分离骨折组8侧伴有神经损伤，骨折平均距离为（8.24±5.51）mm，16侧骨折无神经损伤，平均分离（6.91±2.78）mm；两组骨折分离距离比较差异无统计学意义（P=0.437）。在伴发神经损伤病例中，6侧伴有前后移位，2侧无前后移位；在无神经损伤病例中，10侧伴有前后移位，6侧无前后移位；两组中是否伴有前后移位比较差异无统计学意义（P=0.535）。在伴有神经损伤病例中，6侧骨折断端有旋转，2侧断端无旋转；无神经损伤病例中，3侧骨折断端旋转，13侧断端无旋转；两组中骨折断端是否有旋转移位比较差异具有统计学意义（P=0.007）。结论：1骶骨Ⅱ区压缩骨折的压缩程度与骶神经损伤有关。2压缩骨折同时伴有前后移位或骨折断端旋转移位更易伴发神经损伤。3分离骨折的分离程度与骶骨神经损伤无显著关系。4分离骨折同时伴有断端旋转移位时易引发骶神经损伤。更多还原

【Abstract】 Objective: To retrospectively analyze the relationship between thedisplacement degree of Denis II sacral fractures and the injury of sacral nerves.Denis Ⅱ fracture zone is fracture line involving sacral pore fracture, in viewof the sacrum fracture Ⅱ area all have different degrees of displacement onthe surface of the coronary, it can be divided into compression fracture andseparation fracture of two subtypes. At different positions of the sacrumfracture, different incidence of nerve injury, including Ⅱ area of the sacrumfracture nerve injury cases accounted for23.5%(19/81).Sacrum shift directionand degree is related to the sacral nerve injury. However, By searchingMedline, Chinese knowledge network, such as database, failed to find thequantitative research data of the relationship between the degree of Denis Ⅱfracture displacement and sacral nerve injury, need to in-depth study. Thisstudy through the analysis of lateral sacral II data, measuring the degree offracture displacement on CT images, Denis type II fracture displacement ofdifferent direction and degree of relationship with sacral nerve damage,provide a reference for diagnosis and treatment of sacral Denis type IIfracture.Materials and Methods:General Information:Using medical record query system query from January2005toDecember2008Denis Ⅱ area of the sacrum fracture patients. Inclusioncriteria: patient age>18years of age, preoperative diagnosis of X-ray and CTimage Ⅱ area of the sacrum fracture patients, patients with clearconsciousness after injury. Exclusion criteria: past medical history have L5and S1, S2nerve root and sacral plexus nerve injury, peripheral arteryinflammation, neural degeneration diseases, diabetes and so on lead to disease of peripheral neuropathy. Record their age, gender, injury location,combination of injury and causes, Read the nerve muscle electromyographyexamination report and physical examination records, determine whethernerve damage has occurred.Image examination:Use of picture archiving and communication system (PACS) patientswith preoperative X-ray and CT images to be obtained, observe whether theshift. According to Ⅱ area of the sacrum fracture displacement direction, onthe surface of the coronary CT image can be divided into compression fractureand separation fracture of two subtypes, on the basis of divided the patientsinto compression fracture and separation of fracture groups. ApplicationRadiAnt DICOM Viewer software on the cross section of a pelvic CT imagemeasuring lateral compression or separation of maximum displacementdistance and Anterior-posterior shift maximum displacement distance, And onthe coronal image measuring a maximum distance of fracture shift up anddown. Statistics of the two groups anterior-posterior displacement, left andright shifting and rotation displacement of fracture cases.Statistical treatment:Application support SPSS11.5statistical software, using t testcompression and separation group were compared with and withoutneurological damage cases of fracture in the biggest shift compression orseparation. By chi-square test two groups were compared with sacral nerveinjury without sacral nerve injury cases with sacral fractures of up and downdisplacement, anterior-posterior shift and rotation displacement distance datasuch as whether there is a difference. Set P <0.05for the difference wasstatistically significant.Result: The study included62cases of sacral fracture Ⅱ area, including41cases of male, female21cases, the average age of35.55(18~57), on theleft side of the30cases, on the right side of26cases,6cases on both sides.40patients with combined injuries, including4cases of clavicle fracture of ribfracture3cases,16cases of lumbar vertebral fracture,5cases of tibiofibula fracture,3cases of humerus fracture, ankle injury in5cases,6cases offemoral fracture,7cases of acetabulum fracture, foot radius fractures in2cases, toe bone fracture3cases,2cases of scapula fracture. For patients withan average of ISS score22(9-42points). Causes include car accident injury33cases, blunt trauma8cases, high falling injury11cases, accidental fall in7cases,3cases of unknown cause trauma. All sacral fractures coronal planewere displacement, for compression of44fractures displaced (compressionfracture group), for the separation of24fractures displaced (separationfracture group); Have a anterior-posterior45fractures displaced,23fractureswith rotating shift (table1). This group of patients with20cases with nervedamage, damaged area is L5~S2control area.Compression fracture group:15fractures with nerve damage, and the average compression distance(7.43+2.98) mm;29fractures without neurological damage, the averagecompression distance was (4.40+3.02) mm; The fractures compressiondistance is similar between the two groups was statistically significant (P=0.003). With nerve injury cases,13fractures with anterior-posteriordisplacement,2fractures without anterior-posterior displacement. No nerveinjury cases,16fractures with anterior-posterior displacement fracture,13fractures without anterior-posterior displacement，there is a comparisondifference in the two groups was statistically significant (P=0.037). Withnerve injury cases,10fractures with rotation displacement fracture,5fractureswithout rotation; displacement fracture. No nerve injury cases,4fractures withrotation displacement fracture,25fractures without rotation displacementfracture. Compare the difference was statistically significant(P=0.001)(table2).Separate fracture group:8fractures with nerve damage, average separation distance (8.24+5.51)mm;16fractures without neurological damage, and the average separationdistance (6.91+2.78) mm; The two groups comparison difference has nostatistical significance (P=0.437). With nerve injury cases,6fractures with anterior-posterior displacement fracture,2fractures without. No nerve injurycases,10fractures with anterior-posterior displacement fracture,6fractureswithout; comparison difference in the two groups has no statisticalsignificance (P=0.535). Accompanied by nerve injury cases,6fractures withrotation displacement,2fractures without rotation; No nerve injury cases,3fractures with rotation displacement,13fractures without rotation; The twogroups comparison difference was statistically significant (P=0.007)(table3).Conclusion: we found that the degree of compression fractures highlyassociated with sacral nerve injuries, and it is much easier to have nerveinjuries when the fracture is present with both front and rear shifts or rotationdisplacement in compression fracture cases. On the other hand, in separationfractures, there is no significant relationship between the separation level andthe sacral nerve injuries, but the separation of fractures with end rotating shiftwill more likely cause the sacral nerve injuries.更多还原