骨盆骨折血管损伤的解剖学基础及影像学研究
摘要
目的:出血是不稳定性骨盆骨折的严重并发症,休克率达30%,死亡率高达60%。尽管出血来源一直被认为主要有以下四个方面:破裂的动脉,静脉,骨折边缘,软组织。但具体的出血来源仍难于确定,是动脉出血还是静脉出血,是大血管损伤还是小血管损伤,何者为主仍在争论。血管损伤的机制也不完全清楚。有的作者认为骨盆骨折的骨折线可预测血管损伤,有的学者认为骨折线与血管损伤不相关。关于骨盆骨折血管损伤的治疗也一直存在争论,有的学者认为腹部外伤患者均应摄骨盆X线片,有的学者认为每个腹部外伤患者均摄X线片不但浪费时间,而且增加患者费用,建议对清醒患者经体格检查可除外骨盆骨折,仅对所有昏迷的下腹外伤患者摄骨盆X线片。有的学者认为骨盆骨折患者应先行CT扫描,了解出血的危险性,再进一步处理。有的学者建议对血压不稳的骨盆骨折患者直接行动脉造影进行诊断及治疗。有的学者建议对不稳定骨盆骨折伴休克的患者,均应在入院后30分钟内行骨盆外固定架固定,但有的学者认为行外固定架固定需在手术室操作,浪费时间,应先处理危机生命的血管损伤,可先用床单等行快速简单的包裹。
本实验拟通过对骨盆的解剖学研究,对骨盆的血管进行分类,了解骨盆血管与骨盆壁的关系,骨盆动静脉与骶丛神经、骨盆韧带之间的关系,预测易损伤的血管及易损伤血管的部位,探讨骨盆骨折血管损伤的机制。通过回顾性的分析55例骨盆骨折伴血管损伤患者的影像资料,探讨骨折部位、骨折分类、受伤机制与血管损伤的相关性。
方法:1.解剖学研究:本课题以20具国人尸体骨盆为研究对象,为1年左右防腐标本,均为成年人,男18具、女2具,无骨盆畸形、肿瘤及骨折。采用前后双侧入路进行解剖,首先去除腹壁,切除盆腔壁层腹膜,切除直肠,将膀胱推向前方,首先观察髂总动脉与髂总静脉关系,行走特点及与后方脊椎关系。测量髂总动静脉起点口径及到后壁距离,测量方法是用一克氏针测量该处动静脉表面到骨壁垂直距离,然后减去该处动静脉厚度或直径,即为该处动静脉后壁到骨壁距离,每一点测三次取其平均值。
Objectives: The hemorrhage is a serious complication of instability pelvic fracture. The shock rate is 30%, the mortality rate is 60%. Although originations of hemorrhage have been thought as follows: the arterial disruption, vein disruption, fracture border, soft tissues, the real originations can't be identification. Is artery or vein injuried ? Is big vessel or small vessel injuried ? which is still a problem. Some scholars think that fracture pattern can predict arterial injury, another scholars think that it can't. There are also many arguments about the diagnosis and treatments of the pelvic fracture with hemorrhage. Some scholar think that patient with pelvic facture should take X-ray and CT before taking angiography, another don't think so. The controversy remains over optimal initial management, Some think that instability pelvic fracture patients with hemodynamic instability should be taken immediate external fixation (EX FIX). Others feel ongoing hemodynamic instability indicates arterial bleeding, and prefer early angiography (ANGIO) before EX-FIX. Our aim is that study the relations of iliac vessel's branches with pelvic sides and lumbosacral plexus and pelvic ligaments by anatomy of pelvic cadaveris. We retrospectively analysis 55 patients of pelvic fracture with hemorrhage, discuss the relations of fracture location, classifications and vessels' injury. Discussing the mechanisms of vessel injury and methods of diagnose and treatment of the pelvic vessels injuries.Methods: The study was performed in 20 formalin-fixed specimens of Chinese cadaver pelvises .We observed the relationship of the patterns of the iliac arterial branches and type with the pelvic ligaments and sacral nerves, and observed the location of the pelvic vessels on the pelvic sides, and measured the vertical distance from vessels to pelvic sides, and observed the
collateral circulations of the pelvic arteries. The results were recorded by mapping, taking pictures. The iliac vein were studied as above. From 1999.1-2003.10 , 55 patients with pelvic artery injuries were observed. The patient ages ranged from 21 to 52 years of age(mean,34.5), and 42 were male, 13 were female. Of 55 patients, 28 patients were struck by automobiles, 12 patients suffered crush injures , 9 patients fell from heights, 6 patients were involved in other accident. Mean injury severity score was 39±16 with a range from 16 to 66. All patients were hypotensive with systolic blood pressures less than 90 mmHg on arrival to hospital. The average amount of blood transfusion was 2886 ml. All patients underwent iliac artery angiography. According to pelvic fracture X-ray : posterior pelvic fracture 21, anterior pelvic fracture 12, fracture of acetabulum 6, combined pelvic fracture 16.Results: The results of anatomy: The diameter of the pelvic vessels which were shorter than 3 mm were iliolumbar arteries and veins, lateral sacral arteries and veins, obturator arteries and veins. The diameter of pelvic vessels from 3 to 5mm were superior gluteal arteries and veins, inferior gluteal arteries and veins, internal pudendal arteries and veins. The diameter of pelvic vessels which were bigger than 5mm were common iliac arteries and veins, internal iliac arteries and veins, external iliac arteries and veins. The vertical distance from pelvic vessels to pelvic sides which were greater than 10mm were common iliac arteries and veins, internal iliac arteries and veins, external iliac arteries and veins, which were smaller than 10mm were iliolumbar arteries and veins, obturator arteries and veins, lateral sacral artery, superior gluteal arteries and veins, inferior gluteal arteries and veins. The differences had significant (p<0.05). The length of the left iliac common artery was 44.17+/-7.28mm, and the length of right iliac common artery was 41.28+/-6.74mm.The left was longer than the right (p<0.05). The length of the left external iliac artery was 105.42+/-7.13mm, and the length of right external iliac artery was 11.63+/-7.23mm. The right was longer than the left (p<0.05). The diameter of the pelvic arteries which the left compared
with the right had no significant differences. According to the classification by Zhong shizhen about the patterns of the branches of the internal iliac artery, the internal iliac artery were classified into 5 types: type I was 22 sides (25%), type II 8 sides (17.5%),type III 8 sides (17.5%), type IV 2 sides (5%), type V 1 side (2.5%). In 87.5% cases the superior gluteal artery passed through iliolumbar plexus , and in 52.5% cases the inferior gluteal artery passed through iliolumbar plexus. In all the cases , we found the circumflex of iliolumbar- deep iliac circumflex artery.There are widely vascular anastomosis between the iliac arterial blanches. They can be divided into three types: (1) The communicating anastomosis, the diameter bigger than 2mm. They are iliolumbar artery and superior gluteal artery, superior gluteal a and obturator artery, obturator artery and external iliac artery. (2) The direct anastomosis, the diameter between 1-2mm..They are lumbar artery and iliollumbar artery, iliollumbar artery and deep iliac circumflex artery, between obturator arteries. (3) The network anastomosis, the diameter small than lmm.There are widely vascular anastomosis between the iliac vein blanches. The become vein plexus. We observe the main vein plexus that are relation to the pelvic fracture .They are sacral vein plexus, bladder vein plexus, posterior pubic vein plexus.Of 55 patients, 50 patients suffered injury of internal artery or its branches, 3 patients with occlusion of the external iliac artery, 1 patient with external iliac artery disruption, 1 patient with occlusion of common iliac artery, 3 cases died, mortality rate was 5.45%. The injured vessels were common iliac artery 1, external iliac arteries 4, internal iliac arteries 2, superior gluteal arteries 42, iliac lumber arteries 24, lateral sacral arteries 24, inferior gluteal arteries 8, obturator arteries 15, pudendal arteries 6. There were 64 injured vessels in posterior pelvic fracture and 17 in anterior pelvic fracture, hree patients with occlusion of the external iliac artery, twenty-three patients with the disruption of the internal iliac artery branches. Three casese died. According to the Yongth-Bergess' classification : type LC8 cases, type APC
25cases, type VS lOcases, type CM 12 cases. The superior gluteal artery disruptions were 32 cases, acute artery embolizations 23 cases , the successful incidence was 95.55%.Conclusions: According to the diameter of pelvic vessels, the pelvic vessels were classified into three kinds: (1) small diameter vessels (D<3mm): iliaclumber artery, lateral sacral artery, obturator artery. (2) medium diameter vessels (3mm5mm): common iliac artery and vein, internal iliac artery and vein, external iliac artery and vein. According to the distance from vessels to pelvic sides, the pelvic vessels were classified into two sorts: (1) close bone vessels(distance<10mm): iliolumbar artery and vein, lateral sacral artery and vein, obturator artery and vein, superior gluteal artery and vein, inferior gluteal artery and vein, internal pudendal artery and vein. (2) distant place artery ( distance >10mm): common iliac artery and vein, internal iliac artery and vein, external iliac artery and vein. 2. The mechanisms of pelvic vessels injury were classified into direct injury and indirect injury. In direct injury, the injury was caused by the chips of fractures, while indirect injury was caused by displacing of the sempelvises. The direct injured arteries were iliolumbar artery, lateral sacral artery, obutator artery, superior gluteal artery, inferior gluteal artery. The indirect injured arteries were superior gluteal artery, inferior gluteal artery, internal pudendal artery, common iliac artery, internal iliac artery, external iliac artery. 3. The direct injury was associated with the place and degree of pelvic fractures, while indirect injury was associated with the displacing of hemipelvis and classification of pelvic fractures. During the management of the pelvic artery injury, we supposed that injured arteries should be embolized superselectively. 5. The pelvic anatomic characteristics were associated with the injured vessels. The superior gluteal artery, which passed through sacral nerve plexus and had a small angle out of the pelvis, was liable to be injured, while inferior gluteal artery, which had a bigger angle out of the pelvis, had a lower injured incidence. The pelvic
ligaments can protect the pelvic arteries from being injured.The locations of causing pelvic vessels: (1) Sacroiliac joint: At this place , the internal iliac arteries and veins through over each other, and are banded by nerves and ilium . The have small mobility. So when demi-pelvis displace, they easily are injured. (2) Anterior sacrum: Aacral fracture cause lateral sacral arteries and veins. (3 ) Greater sciatic notch: The superior gluteal vessels near the bone, and easily injured. (4) Superior rami of pubis: There are anastomosis of obturator vessels and inferior epigastric vessels, when pubic fracture , they are easily injured. 0 7.The pelvic vessels are injured which are caused often by type APC II ■> III and type VS fractures. Solitarius vessels injury are caused by local pelvic fracture.The pelvic arterial injury should be treated as follows: (1) When internal artery are injured, besides internal iliac artery, the deep iliac circumflex artery, communicating branch of external iliac artery and obturator artery, lateral sacral artery should be embolised . (2) When superior gluteal artery are injured, besides superior glutea artery, the superior gluteal artery, iliolumbatr arter should be embolised. 3 ) When iliolumbar artery are injured, besides iliolumbar artery, the deep iliac circumflex artery, superior gluteal artery should be embolised . (4) When lateral sacral artery are injured, besides lateral sacral artery, the other lateral sacral artery, medium sacral artery should be embolised .(5)When inferior gluteal artery are injured, besides inferior gluteal artery, the superior gluteal artery, internal pudendal artery, lateral femoral circumflex artery and obturator artery, lateral sacral artery should be embolised (6) When obturator artery are injured, besides obturator artery, communicating branch of external iliac artery and obturator artery should be embolised. The anterior sacral venous plexus, bladder venous plexus, posterior pubis venous plexus are easily injured when pelvic fractures. The ascending lumbar vein which through out lumbar nerve 4 and 5 is easily injured when sacral ala fracture. The anterior sacral venous plexus is easily injured when sacral fracture. The posterior pubis venous plexus are easily injured when pubic fractures.
本实验拟通过对骨盆的解剖学研究,对骨盆的血管进行分类,了解骨盆血管与骨盆壁的关系,骨盆动静脉与骶丛神经、骨盆韧带之间的关系,预测易损伤的血管及易损伤血管的部位,探讨骨盆骨折血管损伤的机制。通过回顾性的分析55例骨盆骨折伴血管损伤患者的影像资料,探讨骨折部位、骨折分类、受伤机制与血管损伤的相关性。
方法:1.解剖学研究:本课题以20具国人尸体骨盆为研究对象,为1年左右防腐标本,均为成年人,男18具、女2具,无骨盆畸形、肿瘤及骨折。采用前后双侧入路进行解剖,首先去除腹壁,切除盆腔壁层腹膜,切除直肠,将膀胱推向前方,首先观察髂总动脉与髂总静脉关系,行走特点及与后方脊椎关系。测量髂总动静脉起点口径及到后壁距离,测量方法是用一克氏针测量该处动静脉表面到骨壁垂直距离,然后减去该处动静脉厚度或直径,即为该处动静脉后壁到骨壁距离,每一点测三次取其平均值。
Objectives: The hemorrhage is a serious complication of instability pelvic fracture. The shock rate is 30%, the mortality rate is 60%. Although originations of hemorrhage have been thought as follows: the arterial disruption, vein disruption, fracture border, soft tissues, the real originations can't be identification. Is artery or vein injuried ? Is big vessel or small vessel injuried ? which is still a problem. Some scholars think that fracture pattern can predict arterial injury, another scholars think that it can't. There are also many arguments about the diagnosis and treatments of the pelvic fracture with hemorrhage. Some scholar think that patient with pelvic facture should take X-ray and CT before taking angiography, another don't think so. The controversy remains over optimal initial management, Some think that instability pelvic fracture patients with hemodynamic instability should be taken immediate external fixation (EX FIX). Others feel ongoing hemodynamic instability indicates arterial bleeding, and prefer early angiography (ANGIO) before EX-FIX. Our aim is that study the relations of iliac vessel's branches with pelvic sides and lumbosacral plexus and pelvic ligaments by anatomy of pelvic cadaveris. We retrospectively analysis 55 patients of pelvic fracture with hemorrhage, discuss the relations of fracture location, classifications and vessels' injury. Discussing the mechanisms of vessel injury and methods of diagnose and treatment of the pelvic vessels injuries.Methods: The study was performed in 20 formalin-fixed specimens of Chinese cadaver pelvises .We observed the relationship of the patterns of the iliac arterial branches and type with the pelvic ligaments and sacral nerves, and observed the location of the pelvic vessels on the pelvic sides, and measured the vertical distance from vessels to pelvic sides, and observed the
collateral circulations of the pelvic arteries. The results were recorded by mapping, taking pictures. The iliac vein were studied as above. From 1999.1-2003.10 , 55 patients with pelvic artery injuries were observed. The patient ages ranged from 21 to 52 years of age(mean,34.5), and 42 were male, 13 were female. Of 55 patients, 28 patients were struck by automobiles, 12 patients suffered crush injures , 9 patients fell from heights, 6 patients were involved in other accident. Mean injury severity score was 39±16 with a range from 16 to 66. All patients were hypotensive with systolic blood pressures less than 90 mmHg on arrival to hospital. The average amount of blood transfusion was 2886 ml. All patients underwent iliac artery angiography. According to pelvic fracture X-ray : posterior pelvic fracture 21, anterior pelvic fracture 12, fracture of acetabulum 6, combined pelvic fracture 16.Results: The results of anatomy: The diameter of the pelvic vessels which were shorter than 3 mm were iliolumbar arteries and veins, lateral sacral arteries and veins, obturator arteries and veins. The diameter of pelvic vessels from 3 to 5mm were superior gluteal arteries and veins, inferior gluteal arteries and veins, internal pudendal arteries and veins. The diameter of pelvic vessels which were bigger than 5mm were common iliac arteries and veins, internal iliac arteries and veins, external iliac arteries and veins. The vertical distance from pelvic vessels to pelvic sides which were greater than 10mm were common iliac arteries and veins, internal iliac arteries and veins, external iliac arteries and veins, which were smaller than 10mm were iliolumbar arteries and veins, obturator arteries and veins, lateral sacral artery, superior gluteal arteries and veins, inferior gluteal arteries and veins. The differences had significant (p<0.05). The length of the left iliac common artery was 44.17+/-7.28mm, and the length of right iliac common artery was 41.28+/-6.74mm.The left was longer than the right (p<0.05). The length of the left external iliac artery was 105.42+/-7.13mm, and the length of right external iliac artery was 11.63+/-7.23mm. The right was longer than the left (p<0.05). The diameter of the pelvic arteries which the left compared
with the right had no significant differences. According to the classification by Zhong shizhen about the patterns of the branches of the internal iliac artery, the internal iliac artery were classified into 5 types: type I was 22 sides (25%), type II 8 sides (17.5%),type III 8 sides (17.5%), type IV 2 sides (5%), type V 1 side (2.5%). In 87.5% cases the superior gluteal artery passed through iliolumbar plexus , and in 52.5% cases the inferior gluteal artery passed through iliolumbar plexus. In all the cases , we found the circumflex of iliolumbar- deep iliac circumflex artery.There are widely vascular anastomosis between the iliac arterial blanches. They can be divided into three types: (1) The communicating anastomosis, the diameter bigger than 2mm. They are iliolumbar artery and superior gluteal artery, superior gluteal a and obturator artery, obturator artery and external iliac artery. (2) The direct anastomosis, the diameter between 1-2mm..They are lumbar artery and iliollumbar artery, iliollumbar artery and deep iliac circumflex artery, between obturator arteries. (3) The network anastomosis, the diameter small than lmm.There are widely vascular anastomosis between the iliac vein blanches. The become vein plexus. We observe the main vein plexus that are relation to the pelvic fracture .They are sacral vein plexus, bladder vein plexus, posterior pubic vein plexus.Of 55 patients, 50 patients suffered injury of internal artery or its branches, 3 patients with occlusion of the external iliac artery, 1 patient with external iliac artery disruption, 1 patient with occlusion of common iliac artery, 3 cases died, mortality rate was 5.45%. The injured vessels were common iliac artery 1, external iliac arteries 4, internal iliac arteries 2, superior gluteal arteries 42, iliac lumber arteries 24, lateral sacral arteries 24, inferior gluteal arteries 8, obturator arteries 15, pudendal arteries 6. There were 64 injured vessels in posterior pelvic fracture and 17 in anterior pelvic fracture, hree patients with occlusion of the external iliac artery, twenty-three patients with the disruption of the internal iliac artery branches. Three casese died. According to the Yongth-Bergess' classification : type LC8 cases, type APC
25cases, type VS lOcases, type CM 12 cases. The superior gluteal artery disruptions were 32 cases, acute artery embolizations 23 cases , the successful incidence was 95.55%.Conclusions: According to the diameter of pelvic vessels, the pelvic vessels were classified into three kinds: (1) small diameter vessels (D<3mm): iliaclumber artery, lateral sacral artery, obturator artery. (2) medium diameter vessels (3mm
ligaments can protect the pelvic arteries from being injured.The locations of causing pelvic vessels: (1) Sacroiliac joint: At this place , the internal iliac arteries and veins through over each other, and are banded by nerves and ilium . The have small mobility. So when demi-pelvis displace, they easily are injured. (2) Anterior sacrum: Aacral fracture cause lateral sacral arteries and veins. (3 ) Greater sciatic notch: The superior gluteal vessels near the bone, and easily injured. (4) Superior rami of pubis: There are anastomosis of obturator vessels and inferior epigastric vessels, when pubic fracture , they are easily injured. 0 7.The pelvic vessels are injured which are caused often by type APC II ■> III and type VS fractures. Solitarius vessels injury are caused by local pelvic fracture.The pelvic arterial injury should be treated as follows: (1) When internal artery are injured, besides internal iliac artery, the deep iliac circumflex artery, communicating branch of external iliac artery and obturator artery, lateral sacral artery should be embolised . (2) When superior gluteal artery are injured, besides superior glutea artery, the superior gluteal artery, iliolumbatr arter should be embolised. 3 ) When iliolumbar artery are injured, besides iliolumbar artery, the deep iliac circumflex artery, superior gluteal artery should be embolised . (4) When lateral sacral artery are injured, besides lateral sacral artery, the other lateral sacral artery, medium sacral artery should be embolised .(5)When inferior gluteal artery are injured, besides inferior gluteal artery, the superior gluteal artery, internal pudendal artery, lateral femoral circumflex artery and obturator artery, lateral sacral artery should be embolised (6) When obturator artery are injured, besides obturator artery, communicating branch of external iliac artery and obturator artery should be embolised. The anterior sacral venous plexus, bladder venous plexus, posterior pubis venous plexus are easily injured when pelvic fractures. The ascending lumbar vein which through out lumbar nerve 4 and 5 is easily injured when sacral ala fracture. The anterior sacral venous plexus is easily injured when sacral fracture. The posterior pubis venous plexus are easily injured when pubic fractures.
引文
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2 李淑芬,邓三权均,李群.骨盆壁动脉与骨盆骨折关系.煤矿医学.1982年(增刊2) 1-4
3 潘兵,张光健。髋臼区的横断层解剖及意义。中国临床解剖学。1994;12(2):138-140
4 Barksdule PA, Elkins TE. An anatomic approach to pelvic hemorrhage during scraspinous ligament fixation of the vajnal vault. Am J obstet Grynecol. 1998; 91(5): 715-718
5 刘美音,刘执玉.髂总动脉与髂外动脉的测量.解剖学报.1990;13(1):50
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