fract lombare
DESCRIPTION
ortopedieTRANSCRIPT
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Fracturile coloanei toracale
si lombare
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Fracturile rahidiene
Frecventa : 64 la 100.000 locuitori
Rahis lombar : 46 %
cu tulburari neurologice : 7 %
(mortalitate 4 %)
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• C1-C2 : 8 %
• C3 - C7 : 13 %
• D1 - D10 : 7 %
• D10 - L2 : 55 %
• L3 - L5 : 17 %
Localizarile fracturilor de rahis
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Circumstante:
•Cadere de la intaltime
•Accidente rutiere
•Accidente de munca
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• Majoritatea – fracturi prin tasare (stabile)
• Instabilitatea poate fi provocata de: – Ruptura ligamentelor posterioare – Fracturile apofizelor spinoase – Fractura unei fatete – Fractura unui pedicul– Fractura cominutiva de corp v.
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Prognosticul depinde de considerentele statice si neurologice
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Radiografii simple
RMN este cerut in cazul discordantei radio-clinice
←Leziuni de parti moi
Hematom canal medular Contuzie medulara
Compresie discala
Leziuni disco-ligamentare
Mielografie si Tomodensitometrie cand RMN-ul nu este disponibil
Imagistica
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Leziune prin COMPRESIUNE (tip A dupa Magerl)
Leziune anterioara izolata
Tasare cuneiforma (A1)
Separare (A2)
Cominutie (A3)
± leziuni asociate Fracturi ale lamelor
Subluxatii articulare
Cresterea distantei interpediculare
Analiza radiologica
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Leziune prin COMPRESIUNE (tip A dupa Magerl)Leziune anterioara izolata
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Leziune prin DISTRAGERE POSTERIOARA(tip B dupa Magerl)
Leziuni ligamentare : (B1)
largirea spatiului interspinos
Subluxatia articularelor
Leziuni osoare : (B2)
orizontale – lame sau istmuri
marirea spatiului peretelui posterior
Analiza radiologica
Spondylolisthésis
Pur traumatic
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Exemplu de luxatie unde mecanismul principal a fost distragerea posterioara
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Leziune prin DISTRAGERE ANTERIOARA
(tip B dupa Magerl)
Leziuni ligamentare: (B1)
Cascarea discului anterior Cresterea spatiului intersomatic
Leziuni osoase :(B2) Leziune de corp vertebral deschis catre anterior
± translatii posterioare
Analiza radiologica
Tear drop
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Leziuni prin ROTATIE
(tip C dupa Magerl)
Decalajul spinoaselor
Luxatie articulara unilaterala
Deplasare rotatorie a corpilor vertebrali (asimetrie)
Analiza radiologica
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Leziuni grave prin combinare rotatie+compresie+distragere
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Tratamentul fracturilor prin tasare
Tasare anterioara
Perete posterior conservat
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In fractura prin tasare anterioara =20%
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1. Repaos la pat cateva saptamani pe perna lordozanta.
Ridicare progresiva fara ajutor
Reeducarea coloanei prin intarirea muschilor paravertebrali in extensie
2. Corset termo-formabil in lordoza (3 luni) 2. Corset termo-formabil in lordoza (3 luni) cu ridicare progresiva si reeducarecu ridicare progresiva si reeducare
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Tratamentul fracturilor lombare cu tasare mai mare de 20°
Reducere in lordoza pe masa sau cadru metalic special urmat de confectionarea unui corset gipsat
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Procedeul BÖHLER
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Procedeul BÖHLER
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Confectionarea corsetului gipsat
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Corsetul are 3 puncte de sprijin: stern, pube, lombar
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Vindecarea obisnuita a fracturilor prin tasare
• Protectie prin corset 3-4 luni
• Reeducare musculara sub corset si dupa indepartarea lui
• Consolidarea prezinta de obicei o tasare reziduala
• Uneori lombalgii
Exemple de tasari reziduale tolerate subiectiv
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Tratament identic pentru fracturile dorso-lombare
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Aspecte sechelare
Pensare laterala Pensare anterioara Tasare simpla anterioara
L2
D 9
D 8
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Fractura lombara cu tasare de peste 30%:
Se trateaza prin reducere ortopedica Boehler, urmata de imobilizare in
corset
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Deformarea canalului rahidian
= risc neurologic evolutiv risque ←prin luxatii unilaterale articulare
Prin ingustarea canalului m. si compresiunii medulare
Deplasarea posterioara a peretelui posterior > 50%
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Tratamentul fracturilor cominutive
Trebuie sa tina cont de posibilitatea ingustarii canalului medular de catre fragmente osoase provenite din corpul vertebral sau
arcul posterior
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Fractura cominutiva fara deplasarea posterioara a peretelui posterior
Consolidare fara cifoza
Consolidare cu cifoza si pierdere in inaltime
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Sechele uzuale dupa fracturi cominutive:cifoza
Consolidare cu pierderea inaltimii c.v. si cifoza
L2
D7
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Sechele uzuale dupa fracturi cominutive:cifoza
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Sechele dupa fractura cominutiva tratate ortopedic
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Tomografie
Sechele uzuale dupa fracturi cominutive:cifoza si ingustarea canalului
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Discul este expulzat posterior si comprima maduva
Compresiune prin fragment osos
Tratamentul fracturilor cominutive mielice este chirurgical
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Tulburari neurologice
Elemente compresive ale canalului medular
evidentiabile prin scanner si RMN
Compresiune prin deplasarea corpilor
vertebrali
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Fracturi cominutive
Elemente compresibile vizibile pe Scanner si RMN
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Tulburarile neurologice
Motricitate L2 : flexia coapseiL3 : extensia genunchiului L4 : extensia gleznei L5 : extensia degetelor picioarelor S1 : flexia plantara
Zona ano-perineala
Clasificare ASIA
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Controlul vezical
• Fibrele n. care controleaza automatismul detrusorului si sfincterului se afla in S2 si S3
• Golirea vezicala si mictiunea sunt transmise de catre creier centrilor sacrati
• Daca maduva este sectionata proximal de S2 este pierdut controlul voluntar insa functia vezicala persista gratie centrilor sacrati
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Este uneori indicat :
1. Pentru eliberarea canalului rahidian
2. Reducerea deformarii 3. Stabilizarea leziunii
Tratamentul chirurgical
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Prima optiune : Abord posterior
Reducerea deformarii
Eliberarea canalului rahidian = laminectomie
Stabilizare OSTEOSINTEZA ± GREFA
Tratamentul chirurgical
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A 2-a optiune: Abord anterior
Reducerea deformarii
Eliberarea canalului rahidian pe cale anterioara cand exista o cominutie importanta
corectie mai buna
recuperare neurologica superioara
risc chirurgical mai mare
StabilizareOSTEOSINTEZA antrioara
± GREFA
Tratamentul chirurgical
Abordul anterior poate singur sau asociat cu abordul posterior
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Fractura - luxatie D7 pe D8 cu compresiune medulara (vizibila mielografic): paraplegie
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Acelasi caz de compresiune posterioara si osteosinteza cu placi insurubate (Roy Camille)
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Reducerea unei luxatii L5-S1 si osteosinteza cu doua placi insurubate + artrodeza intersomatica realizata pe aceiasi cale
de abord
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Luxatie L4-L5 tratata prin osteosinteza cu placa insurbata fara artrodeza. Recidiva deplasarii dupa indepartarea materialului de
osteosinteza
Compresiunea cozii de cal
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Tijele Harrington permit distragerea si reducerea marilor deplasari dar pot induce cifoza
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Placa insurubata (Roy-Camille) + grefa anterioara
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Artrodeza pentru tratarea unei fracturi-luxatii in « picatura » L5-S1: artrodeza intersomatica posterioara
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Osteosinteza cu compresiune posterioara pentru leziuni prin distragere posterioara
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Procedeul Cotrel-Dubousset
Alte sisteme de osteosinteza prin insurubarea pediculilor
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Procedeul Kluger
Alte sisteme de osteosinteza prin insurubarea pediculilor
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Procedeul Spitalului Tenon
Alte sisteme de osteosinteza prin insurubarea pediculilor
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Corectarea calusurilor vicioase in cifoza cu stenoza evolutiva a canalului
Vertebrectomie anterioara si grefa dupa distragere