骨盆髋臼骨折——骨盆骨折 — 分类及治疗指南（from dxy）

dr.qinan · 发表于 2011-1-5 15:01:15

European Journal of Radiology 74 (2010) 16–23
Pelvic fractures — A guide to classi?cation and management
骨盆骨折 — 分类及治疗指南
S.J. Slatera,b, D.A. Barrona,c
a Department of Radiology, Leeds Teaching Hospitals, Leeds, UK
b Radiology Academy, Leeds General In?rmary, Jubilee Wing, Great George St., Leeds LS1 3EX, UK
c Musculoskeletal Radiology Dept, Leeds General In?rmary, Jubilee Wing, Great George St, Leeds LS1 3EX, UK

abstract
摘要
Pelvic fractures are common in polytrauma and continue to pose a dif?cult management dilemma for even the most experienced clinicians. Due to the high energy mechanisms involved, there are often multiple other injuries and many specialists may be involved. Deriving an effective management strategy relies on early diagnosis and prioritisation of the most immediately life-threatening injuries. Contrary to ATLS advice, CT can be used to facilitate this even in the haemodynamically unstable patient. This article de?nes the role of CT in pelvic fractures and provides an overview of fracture classi?cation.
骨盆骨折在多发创伤中较为常见，仍然给即使是经验最丰富的医师造成一个艰难的治疗困境。由于涉及高能损伤机制，通常合并其他部位多发伤，需要各科专家联合诊治。获得一个有效的治疗方案有赖于早期诊断并优先治疗最直接危及生命的损伤。与高级创伤生命支持(ATLS)相对，CT能够用来促进这些方案的实施，即使对于血流动力学不稳的患者亦适用。本文阐述了CT在骨盆骨折中的作用并提供骨折分类之概述。

1. Introduction
1. 介绍
Pelvic fractures are common in polytrauma and continue to pose dif?cult management dilemmas for even the most experienced clinician. Patients often sustain multiple other injuries due to the high energy mechanisms involved and management requires a multidisciplinary team. Many patients require immediate resuscitation and the standard ATLS pathway, with an ‘ABC’ approach, should be adopted. Most articles on pelvic fractures place great emphasis on fracture classi?cation and only mention the complications in passing. In reality, the order of priority should be:
1. Recognition of life-threatening injuries;
2. Recognition of acute injuries;
3. Fracture classi?cation which aids in directing surgical management whilst also arousing suspicion for undetected associated injuries.
骨盆骨折在多发创伤中较为常见，仍然给即使是经验最丰富的医师造成一个艰难的治疗困境。由于涉及高能损伤机制，患者通常合并其他部位多发伤，需要多学科综合小组共同诊疗。许多患者需要采用ABC方式立即进行复苏和标准ATLS路径。多数关于骨盆骨折的文章主要强调骨折分类，仅附带提及并发症。实际上，优先次序应该是：
1. 识别危及生命的损伤；
2. 识别急性损伤；
3. 骨折分类可协助指导外科治疗，同时也可引起对未被发现的相关损伤的怀疑。

This review offers guidance on effective use of early imaging to identify the most pertinent injuries and provide a sound platform for which to plan management. In particular, the acute complications of pelvic fractures will be discussed with subsequent reference to speci?c fracture patterns. An algorithm for management is proposed incorporating the use of early CT and thereby challenging current advice from the ATLS.
该综述对辨别最密切相关的损伤早期影像学检查有效应用提供指导，并为诊疗计划的实施提供一个良好的平台。尤其是骨盆骨折的急性并发症将于随后提到的骨折具体类型一并讨论。一条诊疗法则建议尽早结合应用CT并因此对ATLS的通用意见提出挑战。

2. Mechanism and resuscitation
2. 损伤机制和复苏
Pelvic fractures usually result from high energy trauma,although occasionally there may be a trivial mechanism of injury. In such cases, clinicians should be alert to possible underlying bone pathology. However, for the majority, the high energy mechanism results in a high rate of associated injuries. ATLS advice is thus to concentrate on the ABC (airway, breathing, circulation) method of resuscitation [1]. It is vital to look for other potentially life-threatening injuries rather than simply concentrating on the pelvic injury.
骨盆骨折通常由高能创伤引起，尽管偶尔可能由轻微损伤机制引起。在这些病例中，临床医师应该对可能潜在的骨病理改变有所警觉。然而，对于大多数患者，高能机制导致高比率的多发伤。因此ATLS建议集中于ABC(气道，呼吸，循环)复苏方法[1]。发现其它潜在危及生命的损伤而不是单纯集中于骨盆损伤是至关重要的。

3. ATLS guidance
3. ATLS指导
Airway;
Breathing;
Circulation;
Disability;
Exposure;
Trauma radiographs (CXR, pelvis XR).
气道；
呼吸；
循环；
失能；
暴露；
创伤放射学检查(胸部X线检查，骨盆X线检查)。

4. Acute imaging
4. 急诊影像学检查
The most recent ATLS protocol (2009) advises a series of trauma radiographs (chest and pelvis) for polytrauma patients as adjuncts to the primary survey, though there is mounting opinion that they add little in the stable patient where CT will be performed anyway[2,3]. The rationale for the pelvic radiograph is because of the high risk of bleeding from pelvic fractures.
最新ATLS草案(2009)建议对多发伤患者进行一系列作为初步检查附属项目的放射学检查，尽管越来越多的观点认为这对于必行CT检查的稳定患者意义不大[2,3]。对骨盆进行X线检查的道理在于骨盆骨折常合并出血的高风险。

Pelvic radiographs increase radiation exposure, can cause delays and have been shown to lack sensitivity in detection of fractures with ?gures quoted to be around 67–68% [2,3]. The role of the pelvic radiograph is certainly diminishing and, provided there is access to prompt CT, there is an argument to omit them from the initial management plan completely.
骨盆X线检查增加了患者射线接受剂量，并可引起病情延误，引用的数字显示，大约67–68%的骨盆骨折X线检查敏感度不足[2,3]。假如有使用快速CT的机会，骨盆X线检查的作用势必逐渐减小，有观点认为应将其从初步诊疗计划中完全忽略。

Integrating a trauma CT (head, spine, chest, abdomen and pelvis)into the resuscitation algorithm enables a fast, early diagnosis and facilitates further management (Fig. 1a–c). This allows full evaluation of the patient, in addition to giving detailed images of the bony pelvis and any associated complications.
将创伤CT检查(头、脊柱、胸部、腹部和骨盆)整合到复苏法则中能够快速、早期作出诊断并有助于实施进一步诊疗(图. 1a–c)。除了提供骨性骨盆和任何相关并发症的详细影像外，尚能够对患者做出全面评估。

图1：(a–c) 遭受高速公路交通事故的男性患者，到达急诊室时已出现血流动力学不稳，平片显示耻骨支、骶骨和右股骨多发骨折(a)。由此推测可发生继发性出血，CT显示左硬膜外出血、颅骨骨折合并气颅(b, 箭头所示)。尚有一处未曾预料到的复杂肝损伤，造影剂外溢(c, 箭头所示)。无活动性骨盆出血。

Many patients with pelvic injuries are haemodynamically unstable. Current ATLS advice that CT is contraindicated in these patients can be challenged. At present ATLS recommends FAST scanning (focussed assessment sonography in trauma) or DPL (diagnostic peritoneal lavage) and a pelvic radiograph for such patients [1]. Neither ultrasound or DPL will demonstrate the source of the bleeding, nor can they assess the retroperitoneum or pelvic musculature and the radiograph will demonstrate only the bony anatomy. CT, by contrast, assesses all of these areas very well and very quickly.
许多骨盆损伤的患者存在血流动力学不稳。最新ATLS对此类患者禁忌行CT检查的建议受到挑战。目前ATLS推荐对此类患者行FAST扫描(对创伤患者集中评估超声检查)或DPL(诊断性腹膜腔灌洗)和骨盆X线检查[1]。超声或DPL既不能确认出血源，也不能评估腹膜后隙或骨盆肌肉组织状况，并且X线片仅能证实骨结构情况。CT则不同，能够准确、快速的评价所有这些部位。

Huber-Wagner et al. showed an association between increased survival and early full body CT in polytrauma when compared to targeted body CT [6]. No adverse effects were attributable to CT, though obviously radiation dose and intravenous contrast are potential concerns. There were several limitations to the study however, and the authors admit their ?ndings show associations rather than causalities. Average time to CT from admission was between 35 and 46min with the emphasis placed on an easily accessible CT scanner near the trauma room. This is vital if CT is to be used in management algorithms for unstable patients.
Huber-Wagner等的研究显示，与特定部位CT检查相比，对多发伤患者早期行全身CT检查与增加的生存率之间存在相关性[6]。尽管存在明显的辐射剂量和静脉造影剂的潜在问题，CT检查并无不良反应。然而由于研究本身的局限性，作者承认其发现显示为相关性而非因果关系。重点放置容易接近的CT扫描装置于创伤病房附近，自入院到CT检查的平均时间在35 ~ 46分钟之间。至关重要的是CT是否用于不稳定患者的诊疗。

It is proposed that CT is elevated to the ‘third tier’ alongside circulation in the ATLS algorithm for management of haemodynamically unstable patients. This holds numerous advantages:
- Locating the primary source of bleeding quickly;
- Allowing earlier angiography and embolisation for arterial haemorrhage;
- Guiding the vascular radiologist to the likely bleeding vessel, thereby allowing selected angiography and improving sensitivity for detection of haemorrhage when compared to angiography from a larger proximal vessel. This also reduces unnecessary ‘runs’, minimising the use of contrast and radiation exposure;
- Reducing the number of transfused units thereby lowering the risk of DIC and other transfusion related complications;
- Identifying other organ injuries early;
- Reducing the number of unnecessary laparotomies.
建议在血流动力学不稳患者的ATLS诊疗规则中将CT检查提升至第三级与循环并列。其优点如下：
- 快速定位出血来源；
- 能够早期行血管造影术并对出血的动脉进行栓塞止血；
- 引导血管造影医师定位可能出血的血管，从而选择性血管造影，与起自更近端的血管造影相比可改善检测出血的敏感度。这也可减少不必要的“行程”，将造影剂和射线照射剂量最小化。
- 减少输血量，降低DIC和其它输血相关并发症的风险；
- 早期发现其他器官损伤；
- 减少不必要的剖腹探查。

5. Vascular injuries
5. 血管损伤
In pelvic fractures, the most common life-threatening complication is bleeding.Where there is haemodynamic instability, pelvic fractures are reported to have a high mortality rate of up to 60% [4] (Fig. 2a–c). CT can quickly and accurately reveal the presence or absence of haemorrhage with an accuracy quoted in the region of 90% [7].
对于骨盆骨折，失血为最常见的危及生命的并发症。由于存在血流动力学不稳，报道称骨盆骨折的死亡率高达60%以上[4] (图2)。CT能够快速准确的显示出血或未出血情况，其准确率接近90%[7]。

图(2)：(a–c) 不稳定性骨盆骨折(a, 箭头所示)。CT显示造影剂外溢(b, 箭头所示)。血管造影术显示广泛性出血(c, 箭头所示)。随后患者行血管栓塞止血。

Three sources of bleeding are recognised in pelvic fractures,arterial, venous and bleeding from cancellous bone. Management of these different sources varies greatly. It is generally accepted that venous and cancellous bleeding is managed by initial stabilization of the fracture to facilitate tamponade. In such cases, close monitoring is advised as young patients in particular can appear stable or metastable despite ongoing arterial haemorrhage.
可识别的骨盆骨折出血源有3种，动脉、静脉和骨折端松质骨出血。不同的出血源其处理方式迥异。对于静脉和松质骨出血的处置，通用做法是稳定骨折促使填塞压迫止血。在这种情况下，建议对年轻患者行密切监测，特别是即使存在进行性动脉出血却状态表现稳定或相对稳定患者。

Arterial bleeds are commonly from the superior gluteal and the internal pudendal arteries. The greater sciatic foramen is a common exit pathway form any pelvic vessels and any fracture involving this area incurs a higher risk of bleeding. The superior gluteal artery is at risk of laceration from the sharp fascia of the piriformis muscle as it enters the greater sciatic foramen. The internal pudendal artery also exits the pelvis here but re-enters through the lesser sciatic foramen. It is injured in anterior–posterior compression fractures where there are inferior pubic rami fractures or fractures involving the lesser sciatic foramen. Therefore the fracture location can be used to predict which artery has been injured.
动脉出血通常来自臀上动脉和阴部内动脉。坐骨大孔是骨盆血管共同的走行通道，此部位发生骨折出血风险极高。梨状肌进入坐骨大孔处筋膜锐利，增加了臀上动脉撕裂的风险。阴部内动脉亦在此处出骨盆并通过坐骨小孔再次进入，前后挤压型骨折包括耻骨下支骨折或涉及坐骨小孔的骨折可致其损伤。因此，骨折部位可用于预测那种动脉受到损伤。

Debate has raged over the management of arterial haemorrhage for many years. Some advocate external ?xation and pelvic packing for arterial and venous haemorrhage and reserve angiography only for more stable patients where ongoing bleeding is suspected [8].Others propose external ?xation followed by angiography if the patient remains unstable [9]. Some argue that external ?xation provides no additional advantage over pelvic wrapping [10]. Equally,angiography has been said to be time-consuming and inhibits concurrent treatment of associated injuries [11], unlike pelvic packing in theatre [8]. One group expressed concerns over complications associated with angiography, in particular sepsis when subsequently proceeding to operative ?xation of the fracture [12].
关于动脉出血治疗的激烈争论已持续多年。一些人主张行外固定和骨盆包裹以控制动、静脉出血，血管造影术仅用于怀疑进行性出血但状态更稳定的患者[8]。另一些人建议如果患者状态不稳，于外固定后行血管造影术[9]。一些人认为外固定并不比骨盆包裹术提供更多的益处[10]。同样，也有人认为不同于在手术室行骨盆包裹术[8]，血管造影术耗时且限制了对相关损伤的及时治疗[11]。一个研究组表达了对血管造影术相关并发症的关注，特别是随后进行骨折内固定时并发的败血症[12]。

However, angiography has been utilised to good effect, with a reported success rate of 85–100% in bleeding cessation [13–16].Despite this, several of these studies have shown a high mortality rate associated with angiography. This is partly due to the group of patients treated. Those recruited for embolisation have arterial bleeding and are also likely to have signi?cant concurrent injuries.The success of angiographic embolisation is also highly dependant on early intervention and patients who undergo prompt embolisation have improved mortality rates [4,15]. Where there are no other life-threatening injuries there is a strong case to argue that angiography should be the intervention of choice [10,16,17].
然而，应用血管造影术已获得良好效果，报道的止血成功率达85–100%[13–16]。尽管如此，诸多研究显示与血管造影术相关的死亡率较高。这部分归因于所治疗患者的状况。因动脉出血而行动脉栓塞术的患者可能也存在严重的合并伤。血管栓塞术的成功主要依赖于对患者的早期干预，行快速栓塞术的患者死亡率有所改善[4,15]。有充分的理由认为，无其他危及生命的损伤存在时，血管造影术应是首选诊疗措施[10,16,17]。

This then gives the clinician the problem of working out as soon as possible which type of bleeding the patient has got. Clearly early recognition of arterial bleeding is desirable as in these cases angiography and embolisation should precede all other interventions.
这使得临床医师面临如何尽快查明患者出血类型的问题。显然，在这些病例中，早期识别动脉出血是必需的，动脉造影和栓塞术应早于所有其它干预措施。

Integrating CT into the resuscitation protocol therefore will not only serve to identify all of the patient’s injuries but can potentially differentiate the different types of pelvic bleed [18]. To achieve this both arterial and portal venous phase imaging should be employed where pelvic bleeding is suspected. Contrast extravasation identi?ed on both phases is likely to be arterial whereas extravasation seen only on the portal venous phase is consistent with venous bleeding.
将CT检查融入复苏草案将不仅有助于鉴别患者全部损伤，而且可能区分骨盆腔出血的类型[18]。要达到此目的，动脉期和门静脉期成像应选取骨盆可疑出血处。造影剂于两期均见外溢可能是动脉出血，反之，仅门静脉期外溢符合静脉出血的表现。

Therefore if the patient has multiple other injuries then the operating room may well be the preferred treatment option. The same applies to venous and cancellous pelvic bleeds. If however there are isolated arterial bleeds then clearly angiography, where available, if preferable.
因此，如果患者合并多重其它损伤，手术治疗可能是首选。这同样适用于骨盆腔的静脉和松质骨出血。然而，如果合并单独动脉出血，如果具备条件，明显应行血管造影检查。

A new management algorithm is proposed for pelvic fractures incorporating early CT (Table 1).
一项新的诊疗规则建议，骨盆骨折早期行CT检查(表1)。

表1：骨盆骨折诊疗基本规则。注意：如果患者存在其它危及生命的损伤需紧急处置，该措施可能不适用。
6. Urological injury
6. 泌尿系损伤
This is a well recognised complication particularly where there is separation of the pubic symphysis or a fractured pubic ramus.
这是一种众所周知的并发症，特别是存在耻骨联合分离或耻骨支骨折时。

Injuries to the bladder range from contusions to bladder rupture.Most bladder ruptures are extraperitoneal with intraperitoneal ruptures resulting from blunt trauma to a distended bladder or iatrogenic causes. Occasionally, bladder injury may be suspected on plain radiography when there is a ‘pear-shaped’ bladder, with a paralytic ileus and loss of obturator fat planes. However, the diagnosis is con?rmed by a retrograde cystogram or preferably CT cystography.
膀胱损伤的程度包括挫伤和膀胱破裂。多数膀胱破裂由钝性创伤累及膨胀的膀胱或医源性因素引起的腹膜内和腹膜外破裂。X线平片可偶然发现可疑膀胱损伤的表现，包括 “梨形”膀胱征合并麻痹性肠梗阻或闭孔脂肪层面消失。然而，确诊尚需逆行膀胱造影X线片或更精确的CT膀胱造影检查。

Typically, a retrograde cystogram will depict a ‘?ame-shaped’ contrast extravasation into the perivesical fat and occasionally into the thigh or anterior abdominal wall. In intraperitoneal ruptures,contrast will extravasate into the paracolic gutters and will be seen outlining small bowel loops. On CT, it is important to distinguish urinary contrast extravasation from vascular extravasation.For this reason, cystography should be performed after intravenous contrast CT or angiography to avoid obscuring any vascular extravasation (Fig. 3a and b).
膀胱破裂行逆行膀胱造影的典型X线片表现为“火焰形”造影剂外溢至膀胱周围脂肪，偶尔外溢至大腿或前腹壁。对于腹膜内破裂，造影剂外溢至结肠旁沟并可见小肠环形轮廓。在CT片上，重点是区分泌尿系和血管造影剂外溢。因此，膀胱造影应在静脉注射造影剂或血管造影术之后进行以避免任何血管性外溢而引起误诊。

图3：(a，b) 窗户清洁工自梯子上坠落。不稳定性骨盆骨折，膀胱逆行造影X线片表现腹膜外造影剂外溢，提示膀胱破裂。

Urethral injuries are more common in men and typically occur in the membranous urethra in the region of the urogenital diaphragm.A retrograde urethrogram can be performed if there is clinical suspicion. Clearly, this should be performed before attempts at urinary catheterisation if there is any concern for urethral trauma.
尿道损伤在男性患者中更为常见，典型者发生在泌尿生殖膈附近的尿道膜部。如果临床怀疑尿道损伤应进行逆行尿道造影检查。显然，如果有任何可疑的尿道损伤，应该在试图导尿之前进行造影。

7. Neurological injury
7. 神经损伤
Neurological injuries may be an early or late complication of pelvic fractures but are often overlooked in the busy trauma setting. Bladder, bowel and erectile dysfunction are some of the potentially devastating consequences, which are often permanent. The reported prevalence of neurological de?cit following pelvic fracture is approximately 10% [19]. The fracture pattern obviously determines both the risk and nature of neurological injury. For example transverse sacral fractures can cause intraspinal and intraforaminal nerve root injury, as discussed later. Sciatic nerve injuries may occur if the fracture involves the greater sciatic notch or the posterior acetabulum.
神经损伤作为骨盆骨折的早期或晚期并发症常在忙碌的创伤科被忽视。膀胱、肠和勃起功能障碍是一些潜在的灾难性后果，通常为永久性。骨盆骨折后神经功能障碍报道的发病率约为10%[19]。显然，骨折类型决定神经损伤的风险和性质。例如骶骨横行折能够引起骶管内和骶孔内神经根损伤，这些在后面讨论。如果骨折累及坐骨大孔或髋臼后柱则可引起坐骨神经损伤。

8. Fracture classi?cation
8. 骨折分类
Delineating the exact nature of the fracture is useful both for the orthopaedic surgeon and also in raising suspicion for associated injuries. Many studies have attempted to predict the risk of haemorrhage according to fracture pattern [4,20]. However, whilst unstable pelvic fractures are more frequently associated with haemorrhage, fracture pattern cannot be used to absolutely predict haemorrhage [10].
描述骨折的确切性质有益于骨科医师对损失的处置并提高对相关损伤的警觉性。许多研究试图依据骨折类型预测出血风险[4,20]。然而，不稳定型骨盆骨折更经常性的与出血相关联，因此骨折类型不能绝对地预测出血[10]。

9. Pelvic ring fractures
9. 骨盆环骨折
The pelvis is considered to be a ring structure comprised of three bones, the sacrum and two innominate bones. The posterior ring includes the sacrum, SI joints and iliac bones, whilst the anterior ring is comprised of the pubic bones and symphysis. The SI joints can be divided into anterior and posterior and are held together by the anterior and posterior sacroiliac ligaments. The posterior sacroiliac ligaments are the strongest in the body and are most important in maintaining pelvic stability. The sacrotuberous and sacrospinous ligaments provide additional support posteriorly.Conversely, the pubic symphysis anteriorly is weaker and more easily ruptured.
骨盆被认为是包含三块骨的环形结构，一块骶骨和两块髋骨。后环包括骶骨、骶髂关节和髂骨，前环包括耻骨及其联合。骶髂关节可分为前后两部分，通过前后骶髂韧带连接在一起。后骶髂韧带是人体最强韧的韧带，对维系骨盆稳定性最为重要。骶结节韧带和骶棘韧带提供额外的后方支撑。相反的，前方的耻骨联合薄弱，更容易发生断裂。

Two accepted classi?cation systems exist, the Young–Burgess and Tile systems [21,22]. The Young–Burgess system classi?es injuries according to the mechanism and severity. The Tile system arranges fractures into three main groups, stable, partially unstable and completely unstable. For the purposes of this review, the Young–Burgess system will be considered. There are three main patterns of injury:
? AP compression;
? Lateral compression;
? Vertical shear.
目前得到公认的有两种分类系统，Young–Burgess和Tile分类系统[21,22]。Young–Burgess系统根据损伤机制和严重程度分类。Tile系统将骨折主要分为3类，稳定型、部分不稳定型和完全不稳定型。由于本研究的目的，考虑使用Young–Burgess系统。损伤类型主要有3种：
? 前后挤压型
? 侧方挤压型
? 垂直剪切型

10. AP compression
10. 前后挤压型
AP compression fractures cause external rotation of one or both hemipelves, causing the iliac wings to move outwards. These injuries are characterised by pubic diastasis, either at the symphysis or through sagittal ramal fractures. Associated injuries may include sacroiliac joint diastasis and, less commonly, sacral fractures. AP compression injuries cause an increased pelvic volume with any resulting haemorrhage unlikely to tamponade spontaneously. Pelvic wrapping should therefore be a priority in early management.
前后挤压型骨折引起单或双侧半骨盆外旋转，引起髂骨翼向外移位。此型骨折以耻骨分离为特征，在耻骨联合处或矢状位穿耻骨支骨折。相关损失可能包括骶髂关节分离和不常发生的骶骨骨折。前后挤压型由于出血致骨盆腔容积增加，不太可能自发填塞。因此早期处置优先选用骨盆包裹法。

According to the Young–Burgess system, these injuries are classi?ed as follows:
AC 1: Pubic diastasis <2.5 cm, either at the symphysis or through sagittal ramal fractures;
AC 2: Pubic diastasis >2.5 cm and anterior SIJ disruption;
AC 3: Pubic diastasis >2.5 cm, anterior and posterior SIJ disruption.
根据Young–Burgess系统，此损伤分为以下几类：
AC 1型：耻骨分离<2.5 cm，于耻骨联合处或矢状位穿耻骨支骨折；
AC 2型：耻骨分离>2.5 cm，骶髂关节前部分离；
AC 3型：耻骨分离>2.5 cm，骶髂关节前后部均分离。

AC 1 injuries are stable. AC 2 injuries are vertically stable but rotationally unstable due to anterior SIJ disruption—this is the classic ‘open-book’ fracture, where the intact posterior ligaments act as the ‘binding’ (Fig. 4). AC 3 injuries involve disruption of the posterior ligaments causing both vertical and rotational instability.
AC 1型损伤稳定。AC 2型损伤垂直稳定，但由于骶髂关节前部分离致旋转不稳，呈典型的“开书样”骨折，未受损的后方韧带充当“装订线”(图4)。AC 3型损伤包括后方韧带断裂引起垂直和旋转均不稳。

图4：AC 2型骨折。注意耻骨联合分离而后部韧带完整。此即为“开书样”骨折。

11. Lateral compression
11. 侧方挤压型
This is the most common type of pelvic fracture [22]. Lateral forces cause internal rotation of the hemipelvis. This results in coronal ramal fractures, contralateral SIJ disruption and central acetabular fractures. Unlike AP compression fractures, lateral compression injuries have a high association with sacral fractures, reported to be in the region of 88% [22].
这是骨盆骨折最常见的类型 [22]。侧方暴力引起半骨盆向内旋转。这导致冠状位上耻骨支骨折，对侧骶髂关节分离和髋臼中央骨折。与前后挤压骨折不同，侧方挤压损伤与骶骨骨折高度相关，报道称大约为88%[22]。

Pelvic volume tends to reduce in lateral compression fractures,with haemorrhage more likely to tamponade spontaneously.Young–Burgess classi?cation is as follows:
LC 1: Ipsilateral ‘buckle’ sacral and coronal pubic rami fractures;
LC 2: Type 1 + ipsilateral iliacwing fracture or posterior SIJ disruption;
LC 3: Type 2 + external rotation of the contralateral hemipelvis±contralateral saggital ramal fractures.
Type 1 fractures are stable, types 2 and 3 are rotationally unstable but vertically stable owing to the intact posterior sacroiliac ligaments (Fig. 5a and b).
由于出血能够自发填塞，侧方挤压型骨折骨盆容积倾向于减少。Young–Burgess分类如下：
LC 1型：同侧骶骨扭转，冠状位耻骨支骨折；
LC 2型：1型+同侧髂骨翼骨折或后部骶髂关节分离；
LC 3型：2型+对侧半骨盆外旋转±矢状位耻骨支骨折。
1型骨折稳定，2型和3型由于骶髂后韧带完整表现旋转不稳而垂直稳定(图5a- b)。

图5：(a 和 b) LC2型骨折。注意右侧耻骨支骨折和骶粗隆骨折。骶骨骨折在CT片上更容易辨认(b, 箭头所示)。

12. Vertical shear
12. 垂直剪切型
Vertical shear injuries are vertically and rotationally unstable owing to disruption of the posterior ligaments. Often the vertical force is the femur, which causes vertically orientated ramal fractures anteriorly and ligamentous injury posteriorly. The hemipelvis is shifted cranially. A subtle sign of instability is a fracture of the tip of the transverse process of L5, caused by avulsion of the iliolumbar ligament. There is a high rate of associated injuries to the torso and spine and a high rate of haemodynamic instability (Fig. 6).
垂直剪切型损伤由于后方韧带断裂而致垂直和旋转不稳。垂直力通常来自股骨，引起前方垂直方向的耻骨支骨折和后方韧带损伤。半骨盆向头侧移位。不稳定骨折的一项敏感指征是L5横突尖骨折，由髂腰韧带撕裂伤引起。此型骨折躯体和脊柱合并伤以及血流动力学不稳比率较高(图. 6)。

图6：垂直剪切型骨折。垂直方向耻骨支骨折，右半骨盆朝头侧移位。垂直和旋转不稳。

13. Complex fractures
13. 复杂骨折
Not uncommonly, pelvic fractures may display features of more than one pattern of injury but the same rules of stability apply.
并不罕见，骨盆骨折的特征表现出可能不止一种损伤类型，但适用同样的稳定性原则。

14. Sacral fractures
14. 骶骨骨折
Commonly overlooked, sacral fractures should be considered as part of the pelvic ring. Notoriously dif?cult to visualise on plain radiography, these fractures have a high association of potentially devastating neurological injury and should not be missed. Depending on the exact site of fracture, the rate of complication differs greatly.
常被忽视，骶骨骨折应被视作骨盆环的一部分。众所周知，由于该骨折难以在平片上显示，潜在性地与毁灭性神经损伤高度相关，因此不应漏诊。由于取决于骨折的确切位置，并发症的发生率差别很大。

A classi?cation system has been devised to help predict the risk of neurological impairment [23]:
Zone 1: Involving the sacral ala lateral to sacral foramina. This can cause L5 nerve root impingement, with approximately 6% sustaining neurological injury [23].
Zone 2: Involving the neuro foramina which can cause unilateral sacral anaesthesia. No involvement of the central sacral canal.
Zone 3: Involving the body of sacrum. This injury has a high association with neurological compromise (approx. 56% [23]), and may result in cauda equina syndrome.
一种分类系统被设计用来协助预测神经损伤的风险[23]：
1区：包括骶骨翼侧至骶孔。可引起L5神经根损失，大约6%将遗留神经损伤后遗症。
2区：包括神经孔，引起单一骶区感觉缺失。不包括中央骶管。
3区：包括骶骨体。此处损伤与神经损伤高度相关(大约56%[23])，可引起马尾综合征。

Transverse fractures are less common, but can also result from high energy trauma. Transverse fractures above S4 have a high rate of associated neurological injury, whereas the risk below this level is low. These fractures can cause intraspinal and intraforaminal nerve root compromise (Fig. 7a and b).
横行折不常见，但可由高能创伤引起。S4以上横行折合并神经损伤几率高，而此节段以下神经损伤风险低。此型骨折可引起椎管内和骶孔内神经根损伤(图. 7a and b)。

图7：(a 和 b)男性,酒后坐下过猛致骶骨骨折。此种低能损伤机制增加了对潜在骨质减少的关注。这种骨折在前后位平片上难以发现，但这种特殊的损伤在侧位片上更明显(b, 箭头所示)。

Rarely, there may be a U-shaped sacral fracture. Highly unstable, this involves longitudinal fractures through the foramina bilaterally and a transverse fracture with subsequent spino-pelvic dissociation. As a result, there is a high rate of associated neurological injury.
还有一种罕见的U型骶骨骨折。高度不稳，包括穿双侧骶孔的纵行骨折以及合并脊柱-骨盆分离的横行骨折。因此，合并神经损伤的几率很高。

In the presence of low impact injury, there should be high suspicion for an insuf?ciency fracture. Modern multi-detector CT will identify most sacral fractures.However, some are more easily identi?ed on MRI where one may see the classic ‘Honda sign’ (Fig. 8).
对于低能撞击伤，应高度怀疑存在不全骨折的可能。现代多排CT将能够鉴别几乎全部的骶骨骨折。然而，一些骨折可能会在MRI影像上显示经典的“Honda征”(图. 8)，而更易鉴别。

图8：老年女性患者，冠状位STIR序列MRI，“Honda征”(箭头所示)证实骶骨不全骨折。注意双侧骶骨翼典型的垂直和水平高强度信号。

15. Conclusion
15. 结论
Pelvic fractures result from high energy trauma and are often associated with multiple injuries. The key to management lies in early detection of life-threatening and acute injuries. A common mistake in polytrauma is to diagnose and manage an unstable pelvic fracture before imaging the whole body. Multislice CT provides a reliable and rapid diagnosis even in the haemodynamically unstable patient and should not be delayed for management of the fracture. CT also offers detailed imaging of the bony pelvis. Knowledge of pelvic fracture patterns is valuable for surgical planning and reminding radiologists to reassess for potential complications.
骨盆骨折由高能创伤引起，通常合并多发伤。治疗的关键在于早期发现急性和危及生命的损伤。处理多发伤的一个普遍错误是在全身影像检查之前对不稳定型骨盆骨折做出诊断和治疗。即使对于血流动力学不稳的患者，多层螺旋CT亦能够做出可靠和快速的诊断，不应因处置骨折而延误检查。CT也显示骨性骨盆的详尽影像。对骨盆骨折类型的认识对于手术计划和提醒放射科医师再评估潜在并发症很有价值。

References(略)