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1、,环 椎 骨 折 Ring vertebral fractures,贺州广济医院骨二科 朱福良,环枢椎后面观,环枢椎前面观,环椎：位于枕骨下、周围韧带的保护作用，骨折相对发生较少 Sherk HH, Nicholson JT. Fractures of the atlas. J Bone Joint Surg (Am) 1970;52:101724环椎骨折占：所有脊柱骨折的 12% 颈椎骨折 2 - 13% 严重的颈痛，但没有神经症状Scharen S, Jeanneret B. Atlas fractures. Der Orthopade 1999;28(5):38593. Sherk HH
2、, Nicholson JT. Fractures of the atlas. J Bone Joint Surg (Am) 1970;52:101724.,1822 年 Sir Astley Cooper首先描述 Cooper A. A treatise on dislocations, and on fractures of joints. London, United Kingdom, Longman, Hurst Rees, Orme Browne, E. Cox and Son, 1822:542.1920年Geoffrey Jefferson 报道环椎骨折 Jefferson G.
3、 Fracture of the altas vertebra: Report of four cases and a review of those previously reported. Br J Surg. 1920;7:407422.,发生机制,轴向压力或过伸损伤 Jefferson G. Fracture of the altas vertebra: Report of four cases and a review of those previously reported. Br J Surg. 1920;7:407422.Punjabi 、Sandler 报道过伸时轻度轴向压力
4、就可以引起寰椎骨折 Punjabi MJD, Sandler A. Cervical spine kinematics and instability, in Clark CR, Ducker TB; Cervical Spine Research Society Editorial Committee (eds): The Cervical Spine. Philadelphia, Lippincott-Raven, 1998:5557.,分型,单纯前弓骨折 单纯后弓骨折 (最常见) 合并前后弓粉碎性骨折 (Jefferson fracture) 单纯侧块骨折 横突骨折Levine AM,
5、Edwards CC. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop Relat Res. 1989;239: 5368.,typically occur at the junction of the posterior arch and the lateral masses most vulnerable where the arch is thinned and where the vertebral artery courses 常发生在后弓与侧块连接处：骨细、颈动脉跨过,单纯后弓骨折，容易漏诊,La
6、teral mass fractures usually consist of a fracture line anterior and posterior to the joint surface . Openmouth radiograph demonstrates displacement of 1 C1 lateral mass on C2 with normal anatomic relationship of the contralateral side可能导致枕骨髁向骨折间隙内半脱位 侧块不稳定容易导致斜颈畸形,经关节面的侧块骨折,Jefferson骨折。一个典型的四部分骨折，2
7、骨折在前环和2骨折在在后环。 横韧带的完整性决定了骨折的稳定性 该Jefferson骨折很少导致因向外移位骨折类型的神经损伤,Jefferson fracture机制图,Jefferson骨折分型: a 4部分骨折，b 部分骨折，c 部分骨折,稳定型 Jefferson-Fracture,不稳定型Jefferson骨折导致动脉栓塞,C1前弓骨折通常发生在轴向平面通过的结节，并代表颈长肌撕脱。这些伤害发生在过伸时刻。,前弓水平骨折 (arrow) 合并齿状突骨折 (curved arrow) 伴脱位,横突骨折可以是单侧或双侧，一个侧向屈曲损伤造成对侧撕脱骨折,临床表现,外伤病史枕下颈痛颈痛或颈部
8、僵硬 无神经症状,辅助检查,标准颈椎正侧位片 颈椎张口位片 Computed tomography (CT) ： 冠状位 、矢状位重建 Magnetic resonance imaging (MRI): 评估横韧带损伤，椎动脉,横向（环椎横韧带）损伤标志着不稳定环椎侧块的骨折超越C2的侧块6.9mm，横韧带很可能被损伤Spence KF, Decker S, Sell KW. Bursting atlantal fracture associated with rupture of the transverse ligament. J Bone Joint Surg Am. 1970;52:5
9、43549.,保守治疗,侧块移位不超过 7 mm ，无旋转不稳定 单纯前弓、后弓骨折 撕脱性骨折 横突骨折颈围制动 812 周 Isolated Fractures of the Atlas in Adults. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery 2002;50(Suppl. 3):S1204 (chapter 16),保守治疗,粉碎性或明显移位的侧块骨折可以先行颈矫形支具或牵引复位，复位后用halo vest固定Levine AM, Edwa
10、rds CC. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop Relat Res. 1989;239: 5368.,手术治疗,不稳定 Jefferson 骨折，侧块移位大于 8.1mm提示横韧带损伤 粉碎性Jefferson 骨折 : internal fixation (osteosynthesis), occiput-C1 fusion or C1-C2 fusion.,手术方法,C1-C2 融合： C1 侧块 和 C2 椎弓根钉棒Magerl 钉辅助侧块复位 、减少动脉损伤Tan J, Li L, S
11、un G, et al. C1 lateral mass-C2 pedicle screws and crosslink compression fixation for unstable atlas fracture. Spine. 2009;34:25052509.,手术方法,C1侧块钉棒固定: 有效复位并可靠固定Heiko Koller , Herbert Resch, Mark Tauber. A biomechanical rationale for C1-ring osteosynthesis as treatment for displaced Jefferson burst fractures with incompetency of the transverse atlantal ligament. Eur Spine J (2010) 19:12881298,双侧后路侧块钉棒系统固定,Thank You !,
