【专题文献之骨盆骨折】—骨盆骨折：回顾过去50年治疗
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骨盆骨折：回顾过去50年的治疗
Abstract: The past 50 years have been a time of rapid progress in the controlof mortality and morbidity of pelvic fracture. Early understanding of theanatomic features of the fracture and the potential for major, life-threateningarterial hemorrhage in a small proportion of patients led to multidisciplinaryapproaches designed to control hemorrhage and temporarily stabilize thefracture. Progress in the diagnosis and management of lower urinary tractinjuries has resulted in maintenance of urinary continence and sexualfunction in a large proportion of patients with pelvic fracture-associatedurinary tract injury. Finally, de?nitive open reduction and ?xation of thefracture has led to permanent pelvic stability and pain-free walking in mostpatients. With successful combination of these approaches, survival andreturn to a satisfactory level of function is now the rule rather than theexception for patients with severe pelvic fracture.
摘要：在过去的五十年对于控制骨盆骨折的死亡率和并发症去的速进步。及时了解骨折的解剖特点以及一小部分患者存在威胁生命的大动脉血管出血，以设计多种不同方法控制出血以及展示固定骨折。在诊断和治疗低位泌尿系损伤方面去的进步，对于大部分骨盆骨折伴有泌尿系损伤的患者维持尿路连续和性功能具有作用。最后，最终切开复位以及骨折固定对于可致大部分患者骨盆稳定以及无痛行走。今天的治疗原则是成功联合多种方法保证存活以及满意的功能水平，但是除外严重骨盆骨折患者。
Key Words: Pelvic, Fracture, Hemorrhage, Fixation, Genitourinary injuries.
关键词：骨盆，骨折，出血，固定，泌尿生殖系损伤
As the Journal of Trauma celebrates the 50 years ofpublication, it is appropriate to review the key develop-ments in the management of pelvic fracture. It is safe to saythat there is probably no other injury for which the treatmenthas undergone such an evolution as pelvic fracture, yet thesuccessful treatment of pelvic fracture remains one ofthe most dif?cult clinical problems in the management of theinjured. Fifty years ago, the importance of retroperitonealbleeding associated with pelvic fracture and the dif?culty ofdiagnosing and treating it was ?rst being recognized and anactive debate ensued regarding the relative merits of explor-ing the hematoma1 ligating the hypogastric arteries2 or non-operative management with aggressive resuscitation andblood transfusion.3 Numerous reports demonstrated that di-rect operative attempts to control bleeding by exploration ofthe pelvic hematoma were complicated by the inability toidentify discrete bleeding sources and often resulted in oper-ative death by exsanguination. Direct attempts at bilateralhypogastric artery ligation had similar results. The classicpostmortem studies of Huittinen and Sla ¨tis4 demonstratedthat pelvic bleeding usually comes from lacerations to severalsmall- and medium-sized vessels within and around cancel- lous bone that would be almost impossible to ?nd in a largehematoma with active bleeding. In addition, these studiesshowed that the retroperitoneal bleeding associated with pel-vic fracture was most often from venous tributaries thatshould eventually stop bleeding if the hematoma was leftundisturbed and only occasionally from an artery that prob-ably would not. From these observations, the principle de-veloped that pelvic retroperitoneal hematomas associatedwith pelvic fracture should not be explored and a search foralternative means to control hemorrhage ensued.
值创伤杂志出版50周年之际，有必要回顾一下骨盆骨折治疗取得的重要进步。确切说可能没有一种损伤的治疗能像骨盆骨折一样经历如此进展，然而在处理损伤方面，成功治疗骨盆骨折仍旧是最棘手的临床难题之一。50年前，首先认识到腹膜后出血的重要性以及诊断和治疗的困难，主要的争议在于探查血肿，结扎下腹部动脉血管与积极液体复苏和输血的保守治疗相比，那种方法更具有相对优势。大量报道证明，通过探查骨盆血肿试图控制出血的直接手术，由于不能明确分离出出血点变得更为复杂，并且经常由于书中大出血导致死亡。试图直接结扎下腹壁动脉有相似的结果。Huittinen和Slatis尸体解剖研究证实骨盆出血通常来自松质骨内或者周围许多小到中等血管出血，，几乎不可能发现大血肿内的活动性出血。另外，一些研究显示伴有腹膜后出血的骨盆骨折经常来自静脉属支，静置不要处理通常最终会停止出血，偶尔来自动脉的出血不会停止。通过这些观察，治疗伴有腹膜后血肿的骨盆骨折治疗原则已经形成：不要探查，寻求其他办法控制出血问题。
During the 1970s and 1980s, a new technology led tothe development of three therapeutic modalities to treat pelvicfracture hemorrhage without opening the pelvic hematoma:the pneumatic antishock garment (PASG) has been replacedby various pelvic binders, external pelvic ?xation, and angio-graphic embolization. Because the majority of bleeding in thepelvis is from multiple small veins and cancellous bone, theidea of splinting or compressing the pelvis was an attractiveone. The PASG was introduced to accomplish this and wasshown to be remarkably effective.5 External pelvic ?xationwas attractive because it could reduce pelvic volume and alsostabilize the pelvic fracture, and this approach graduallyreplaced the PASG. Subsequently, several cadaver studiesshowed that the effect of external ?xation on reducing pelvicvolume was much less than previously thought with the resultthat today the PASG is virtually obsolete and external ?xationhas been largely replaced by a variety of temporary pelvicbinders used only during the initial resuscitation phase ofcare. Although these techniques are quite effective for pa-tients with venous bleeding, patients with arterial hemorrhagedo not respond to wrapping techniques. Angiographic embo-lization of pelvic arterial bleeding was shown to be effectivefor these patients and associated with a low complicationrate.6–9 This approach has been adopted as the preferredmethod for controlling persistent pelvic fracture bleeding bymost trauma centers. The key to success of angiographic embolization remains the ability to have available, at alltimes, the appropriate personnel and equipment to performthe procedure in a patient with ongoing active arterial hem-orrhage. The most formidable challenge remaining is themore than occasional need to treat bleeding arising simulta-neously in more than one site. A variety of recent protocolshave used intraoperative angiography, operative pelvic pack-ing of the extra peritoneal pelvic retroperitoneum through thespace of Retzius, and angiographic embolization of multiplesites to address this problem. The degree to which thesetechniques are used varies between institutions depending onavailable resources and it remains to be seen which will work the best.
20世纪70年代到80年代，一种新的技术导致形成三种之来哦骨盆骨折出血的方法而无需切开骨盆血肿：充气抗休克衣（PASG）已经被多种骨盆带代替，骨盆外固定架，血管造影栓塞。由于骨盆主要出血来自于许多小静脉以及松质骨，挤压或者加压的方法很有效。PASG用于达到这种作用，并且显示出明显疗效。由于骨盆外固定能够回复盆腔容量同时能固定骨折，也是一种有效方法，并且这种方法逐渐替代PASG。随后，许多尸体研究显示外固定在恢复盆腔容积方面的效果小于预先设想，以及如今PASG实际上已经被放弃的结果，外固定已经被暂时使用骨盆带代替（仅在最初复苏治疗阶段）。尽管这些方法对于静脉出血的患者很有效，但是对于动脉出血的患者包扎缠绕技术没有效果。对于盆腔动脉出血的患者，血管造影栓塞显得有效并且较小的并发症发生率。在很多创伤中心这种方法已被选为控制持续骨盆骨折出血的首选方法。血管造影栓塞成功的关键仍在于有任何时候能够完成这种手术的人员和设备，来处理持续活动性出血。最可拍的挑战仍旧在于经常需要控制不止一处同时出血。最近多种治疗方案已经使用术中血管造影，通过Retzius间隙进行腹膜外骨盆腹膜后手术填塞压迫以及多个出血点的血管造影栓塞来解决这个问题。不同治疗中心这些技术运用程度依赖于可以使用的资源，这种技术看起来仍旧是一种有效方法。
The second major advance in the treatment of patientswith pelvic fracture was the development of technology,allowing accurate reduction and ?xation of the pelvic frac-ture. During the 1980s and 1990s, it became clear that openreduction and internal ?xation of pelvic fractures had mark-edly superior functional results than either prolonged tractionor external pelvic ?xation. The latest developments includethe use of percutaneous pin techniques, which limit themorbidity of posterior approaches to the pelvis. As a result,the principal issues currently facing pelvic fracture care areprompt management of other associated life-threatening in-juries and limitation of morbidity from pelvic fracture itself.In the review that follows, we will provide additional detailrelevant to the management of severe pelvic fracture empha-sizing the contributions that have appeared in the Journal ofTrauma.
治疗骨盆骨折的另一项重要进展在于技术进步，允许对骨盆骨折进行精确复位和固定。20世纪80年代至90年代，很明显，与长期牵引或者外固定相比，切开复位内固定治疗骨盆骨折取得明显较好的功能结果。最新技术包括使用经皮螺钉技术，减少骨盆后方入路的并发症。因此，处理骨盆骨折面临的主要问题在于及时处理其他威胁生命的损伤，降低由于骨盆骨折而致的畸形。在下面的叙述中，关于治疗严重骨盆骨折我们将提供另外详细论述。
EPIDEMIOLOGY
流行病学
Pelvic fracture is encountered in 10% of patientsadmitted to urban trauma centers in North America.10 Re-ported overall mortality rates for these patients vary, but thereis a broad agreement that death as a direct result of the pelvicfracture occurs in 1% of the patients admitted with thisinjury. Pelvic fracture-related mortality occurs in 15% ofpatients who sustain pelvic fracture as a component of amultiple, severe injury pattern. Most patients with pelvicfractures are injured by blunt force impacts caused by motorvehicle crashes. Patients with heavy force transfer causingdisplaced pelvic fractures (that carry an associated increase inrisk for pelvic fracture bleeding) are more likely to be injuredbecause of auto-pedestrian collisions, motorcycle crashes,and falls from heights 15 feet. Important risk factors forincreased mortality and morbidity risk because of pelvicfractures are increased patient age (due, at least in part, toosteoporosis); female gender (probably because of decreasedresistance of pelvic bones and ligaments to forced disrup-tion); and increased impact forces. Certain vehicle crashcharacteristics are also associated with pelvic fracture. Theseinclude lateral impacts, particularly when the striking vehicleis larger and heavier than the impacted vehicle and lack ofrestraint use.
在北美城市创伤中心接受的病人中约有10％的患者为骨盆骨折。报道显示这些患者的总体死亡率不同，但是在一方面是一致的：遭受这种损伤的患者中有小于1％的病人直接死于骨盆骨折。遭受严重复合伤伴有骨盆骨折的患者与骨盆骨折相关的死亡率小于15％.大部分骨盆骨折的患者受伤源于摩托车相撞所致的钝性挤压。自行车、摩托车相撞或者从高于15米的高处跌落时，由于重力转换使伤者更易遭受移位型骨盆骨折（相应增加骨盆骨折出血的风险）。一些重要的风险因素增加死亡和畸形风险，患者年龄增加骨盆骨折风险增加（至少一部分患者，由于骨质疏松）；女性（可能由于盆骨和韧带对抗破裂的力量降低）；挤压力量增加。一些汽车相撞的事件也会发生骨盆骨折。通常这些情况包括侧方挤压，尤其是与被撞汽车相比，碰撞汽车大而重，并且缺乏制动机制。
I MPORTANT ANATOMIC CONSIDERATIONS
重要解剖要点
The pelvic ring is a major supporting structure inhumans that permits bipedal walking in an upright posture.The ring is made up of three bones (right ilium, left ilium, andmidline dorsal sacrum), which are held together by strongligaments. The iliac bones are formed by the fusion of theembryonic iliac, ischium, and pubic bones. The sacrum is animportant component of the dorsal axial skeleton. The ace-tabula, bony complexes where the hip joints articulate bilat-erally, are anatomically part of the pelvis, but fractures ofthese structures will not be discussed in this section. Majorneural, vascular, and visceral structures reside within thebony pelvis and within the sacrum. These include the rectum,bladder, vessels of the iliac, obturator, femoral arterial andvenous systems, internal reproductive organs in women, andportions of the lower urinary tract in men. The distal branches of the spinal motor, sensory, and autonomic nerves arelocated within the sacrum and enter the pelvic visceral spacevia the sacral foramina. Pelvic fracture hemorrhage can occurbecause the arteries and veins of the internal iliac system andthe presacral venous plexus are located just anterior to theligaments that bind the iliac bones to the sacrum and are,therefore, subject to injury by forces that disrupt these liga-ments. Motor and sensory nerves, particularly the sciatic,femoral, and obturator nerves, are vulnerable to injury be-cause of proximity to the pelvic bones and ligaments. Auto-nomic nerves supplying the reproductive organs are found inthese same areas. Therefore, it is not surprising that neuro-logic injury gives rise to painful walking; paresthesias, mus-cle weakness, and sexual dysfunction are the most importantsources of long-term disability after pelvic fracture. Theproximity of the bladder and urethra to the anterior compo-nents of the pelvic ring exposes these structures to injurywhen there are fractures of the pubic bones.
骨盆环是人体重要解剖结构，允许双足直立行走。三块骨组成此环（右侧髂骨，左侧髂骨以及骶背侧正中线），这三个结构由坚强韧带连接。髂骨由胚胎时期的髂骨，坐骨以及耻骨融合构成。骶骨是背侧中轴骨骼的重要组成部分。髋臼（双侧髋关节连接的骨性复合结构）是骨盆的解剖部分，但是这些结构的骨折不在此讨论。重要神经、血管以及内脏结构在骨性盆腔以及骶骨内部。包括直肠，膀胱，髂血管，闭孔，股动脉以及静脉系统，女性内生殖器官，以及男性部分低位泌尿系统。脊髓运动，感觉以及自主神经的远端分支位于骶骨内部，通过骶前孔进入盆腔脏器间隙。由于髂内动静脉系统以及骶前静脉丛恰好位于连接骶骨和髂骨韧带前方，因此由于致使这些韧带的破裂的外力可以是这些血管遭受损伤，故而骨盆骨折会发生出血。运动和感觉神经由于靠近盆骨以及韧带结构容易遭受损伤，尤其是坐骨神经、股神经以及闭孔神经。在这些区域可以发现支配生殖器官的自主神经。因此，由于神经损伤发生发生行走疼痛，感觉异常，肌力降低以及性功能障碍，这些是骨盆骨折后长期功能障碍的原因。膀胱以及尿道接近骨盆环前方结构，耻骨骨折时容易损伤这些结构。
PELVIC FRACTURE CLASSIFICATION
骨盆骨折分型
The most frequently used pelvic fracture classi?cationsystem is the one modi?ed and published by Burgess et al.11This system grades pelvic injury based on the estimateddirection of the major force vector (lateral compression,anterior compression, vertical shear, and combined) and thedegree of bony displacement. Displacement of pelvic skeletalelements is a function of fracture of the bones and disruptionof the ligaments of the pelvis. In general, vascular injuriesthat produce pelvic hemorrhage tend to cluster in the groupsof fractures associated with the largest degree of bonydisplacement as determined by plain pelvic radiograph orcomputerized tomography imaging.12,13 However, fractureclassi?cation has limited utility in predicting the risk ofbleeding for individual patients because, as noted by Sarin etal.,14 a signi?cant proportion of patients with high-gradepelvic fracture do not have pelvic fracture hemorrhage. Con-versely, 50% of patients with signi?cant pelvic arterialhemorrhage have relatively minor appearing nondisplacedfractures at the time of pelvic x-ray. For the surgeon evalu-ating and setting management priorities for patients withhigh-impact trauma resulting in pelvic fracture, a compositeapproach that includes assessment of injury mechanism,physical examination, and physiologic data indicative ofsigni?cant, ongoing bleeding and imaging will be necessaryto identify patients who have ongoing pelvic fracture-associ-ated bleeding.15
最常使用的骨盆骨折分型系统由Burgess等制定修改和发表。这个系统依据估计的主要外力矢量方向（侧方挤压，前方挤压，垂直剪切以及混合外力）以及移位的程度对骨盆损伤分级。骨盆骨性结构的移位是由于骨折所致以及骨盆韧带断裂所致。通常导致骨盆出血的血管损伤易于发生于伴有较大程度移位的骨折分组中（可以通过骨盆正位以及CT成像来决定移位的程度）。如Sarin等所述由于很多分级高的患者并没有发生骨盆出血，因此这个骨折分型在预测每名患者出血风险方面受到限制。相反，约有50％的患者有明显骨盆动脉出 血在骨盆X线上显示为相对较小程度移位。对高能量损伤所致骨盆骨折，外科医生评估和制定治疗方案要优先考虑，一个复合全面的治疗方法包括损伤机制评估，体格检查，反应严重持续性出血的生理指标数据以及影像学检查，这些对于伴有持续性出血的骨盆骨折是有必要的。
INITIAL ASSESSMENT OF PATIENTS WITH PELVIC FRACTURES
骨盆骨折患者的初级评估
As mentioned earlier, most patients who sustain pelvicfractures have only minor injuries. As understanding of the riskfor signi?cant pelvic fracture has become more re?ned, datahave been presented that supports a selective approach to imag-ing of the patient who is awake, alert, and able to cooperate in aphysical examination. Computed tomography (CT) imaging hasbeen shown to be a very sensitive means of detecting pelvicfractures and identifying the wide variety of potential associatedinjuries that often accompany the pelvic fracture and have become indispensable in the care of these patients. In recentexperience using rapid multislice helical scanners, head topelvis images can be obtained rapidly in intervals of 5millimeters to 7 millimeters. Computer-assisted reconstruc-tions of these images can provide high-resolution views thatcan guide plans for operative interventions needed for pelvicreconstruction and other associated injuries. There are recentdata from an analysis of patients in a European traumaregistry that suggest incorporation of whole-body CT imag-ing into the initial resuscitation of severely injured patients isassociated with improved survival.16 This observation is par-ticularly pertinent for patients with evidence of ongoinghemorrhage when the pelvic fracture adds a potential bleed-ing site that may be treated more effectively in the angio-graphic suite rather than the operating room. Relying on theultrasound Focused Abdominal Sonography for Trauma(FAST) examination to make this determination can result inthe patient ending up in the wrong place because of its poorspeci?city. However, careful clinical judgment and a fullunderstanding of the imaging capabilities of each individualinstitution are necessary to support the decision to transport apotentially unstable patient to the CT scanner.
如上所述，大部分骨盆骨折的患者只有轻微损伤.对于严重骨盆骨折风险的理解已经变的更加完善，资料显示出对于清醒，反应灵敏，能够配合完成体格检查的患者采用有选择性的影像检查方法。CT检查在发现骨盆骨折以及确定经常伴随骨盆骨折发生的多种潜在伴随损伤方面，表现为一种非常敏感的检查方法，并且在治疗这些患者过程中显得不可或缺。最新经验显示，运用快速多层螺旋CT扫描，能够迅速获得5-7mm层距从头到盆部的图像。计算机辅助下对这些图像重建，能够提供高清晰的图像，指导制定手术治疗骨盆骨折以及相关损伤的治疗计划。对于来自欧洲创伤机构的患者分析资料，建议对于严重损伤的患者进行初步拯救时配合进行全身CT扫描，有助于提高生存率。这项建议对于伴有明显进行性出血的患者特别有用，对于骨盆骨折同时有出血点的患者，于在手术室治疗相比，在血管造影室的之治疗更为有效。依赖腹部创伤部位的超声声影会（FAST）导致患者生命终止在错误的地方。因此一个能够进行仔细临床诊断和理解影像资料的治疗机构应该支持这样的决定-将不稳定的患者送去进行CT扫描。
DETECTION AND MANAGEMENT OF INJURIES TO THE LOWER URINARY TRACT
发现、治疗下尿道损伤
Fractures of the pubic bones are often associated withinjuries to the lower urinary tract. Bjurlin et al.17 recentlyfound that of 1,400 patients with pelvic fracture in the NTDB, 4% had a bladder injury and 2% had a urethral injury withmales having twice the incidence of each injury than females.Bladder rupture usually occurs because of anterior compres-sion forces transmitted in a ventral to dorsal direction or fromlateral compression forces that displace the pubic bone in alateral to medial direction catching the bladder wall on thebone ends. Straddle injuries and forces that produce thighabduction are important causes of perineal trauma and ure-thral injury. Urethral injury is a common complication ofpelvic trauma that, if untreated, may lead to signi?cantlong-term morbidity. Segments of the urethra that are near thepubic rami and the puboprostatic ligaments are particularlyvulnerable, and the injury usually occurs at the junction of themembranous and bulbar urethra. Careful physical examina-tion of these patients searching for signs of injury is para-mount. The examination should seek out suprapubic pain andtenderness, perineal ecchymosis, laceration, and/or tender-ness, blood at the urethral meatus, and blood or periprostatichematoma discovered on digital rectal examination. Urethralinjury is not con?ned to male patients only! In women withsuspected pubic bone fractures, vaginal examination to ex-amine the urethra for blood or laceration is necessary. Thephysical examination, although valuable, is not foolproof. Asigni?cant proportion of patients found to have urethral injury will not have positive physical ?ndings. A cautious attempt toplace a bladder catheter is indicated. If resistance is felt, aretrograde urethrogram is performed. Although CT is com-monly used for the initial imaging evaluation of patients withmultiple injuries, urethral injury is better assessed and clas-si?ed by using urethrography. Complete urethral imaging is especially important at presentation because the insertion of atransurethral bladder catheter may exacerbate an existinginjury (e.g., cause a partial urethral tear to become a completetransection). In the acute setting, when a posterior urethraldisruption is suspected, retrograde urethrography should beperformed. Posterior urethral disruptions can be managedacutely by realignment of the urethra over a urethral catheteror by placement of a suprapubic catheter for bladder drainageonly. If the latter approach is chosen, the distraction defectbetween the two ends of the urethra often scars and becomes?brotic, blocking the urethra and bladder emptying. Once?brosis has stabilized, the patient can undergo posteriorurethroplasty. In most cases, this procedure can be performedvia a perineal approach in a single-stage surgery. The resultsof this single-stage perineal urethroplasty are excellent, and apatent urethra can be reestablished in the majority of menwho undergo surgery.18–20
耻骨骨折的患者经常伴有下尿道损伤。Bjurlin等最近发现，14000例骨盆骨折的患者中4％有膀胱损伤，2％有尿道损伤，并且男性发生这种损伤的风险是女性的两倍。通常由于腹侧向背侧传导的挤压暴力导致膀胱破裂或者来自侧方暴力致使耻骨断裂骨折端向内侧移位刺破膀胱。骑跨伤的力量造成大腿外展，这是造成会阴部损伤的重要因素。尿道损伤是骨盆骨折的常见并发症，如果未经处理，会导致长期严重后遗症。靠近耻骨支和前列腺上韧带的尿道阶段最脆弱，损伤经常发生在膜部和球部连接处。对这些患者进行仔细的体格检查发现损伤的征象至关重要。体格检查应该寻找耻骨上疼痛和压痛，会阴部瘀斑、撕裂或者压痛，尿道口出血，直肠指检发现出血或者前列腺周围血肿。尿道损伤不仅仅限于男性患者！对于怀疑耻骨骨折的女性患者，有必要进行会阴部检查检测是否有尿道出血或者撕裂。体格检查尽管很有价值，但不是万无一失。一部分存在尿道损伤的患者并没有阳性体征的发现。谨慎的做法是置入膀胱导尿管，如果感到有抵抗，有必要进行逆行尿路造影检查。尽管对于多发伤的患者最初通常进行CT检查，尿路造影是评估和分类尿道损伤较好手段。即时的完整尿路显影尤其重要，因为经尿道插入膀胱输尿管可能会加重已经存在的损伤（致使部分撕裂变成完全横断）。在急救情形下，如果怀疑后尿道损伤，应该进行逆行性尿路造影。后尿道破裂可以通过尿道输尿管恢复尿道的连续性或者仅仅进行耻骨上置管膀胱引流进行紧急处理。如果选择后一种方法，尿道两断端间牵开的缺陷经常会形成疤痕和纤维化，阻止尿道和膀胱的排空。一旦纤维组织稳定，要进行后期尿道成形术。大多数情况下，通过会阴部入路一期完成此种手术。这种一期经会阴部尿路成形效果很好，在大多数进行这种手术的男性患者会重新建立一个完整的尿道。
Although suprapubic cystostomy and delayed repair ofthe urethral disruption are time-honored approach, cliniciansnow understand that it takes many months for the ?broticstricture to stabilize and the long-term presence of a supra-pubic catheter delays or even prevents de?nitive open reduc-tion and internal ?xation (ORIF) of the pelvic fracture. IfORIF of the pelvic fracture is delayed or cannot be done,signi?cant disability because of pain on walking is the result.In a recent study, Hadjizacharia et al.21 showed that patientsundergoing immediate endoscopic repair had an average timeto spontaneous voiding of 35 days compared with 229 daysfor patients undergoing delayed repair and had a signi?cantlydecreased rate of stricture formation (14% vs. 100%). More-over, all patients with delayed therapy required formal sur-gical urethroplasty, whereas the two patients with stricturesafter early endoscopic realignment required only outpatientclinic dilatation.
尽管耻骨上膀胱切开和延迟修复断裂的尿道是一种经典的手术方法，但是临床医生认为纤维组织的稳定需要花费几个月时间以及长期的耻骨上置管，会延迟或者妨碍骨盆骨折的切开复位内固定手术。如果骨盆骨折的ORIF延迟或者不能进行，由于行走疼痛会造成严重的功能障碍。在最近的研究中Hadjizacharia发现立即进行尿道内镜下修复的患者一般需要35天时间达到自主排尿，相比延迟修复的患者需要229天时间，并且明显减少纤维组织的形成。重要的是所有延迟治疗的患者需要正规的外科尿道成形术，相反进行早期内镜下尿道成形的患者只有两例仅仅需要门诊进行尿道扩张。
Data are also clear that early realignment of the disruptedurethra in men and early de?nitive repair of the injured urethrain women are both associated with improved long-term sexualfunction.22 For these reasons, early, expeditious diagnosis andrealignment of urethral disruptions with avoidance of suprapubiccatheterization are preferred. Injury to the bladder neck inassociation with a disrupted prostatic urethra is a particularlytroublesome rare injury that can lead to chronic incontinence ifnot identi?ed early and has recently been successfully managedwith implantation of an arti?cial sphincter.23
数据资料也显示男性患者早期恢复尿道连续以及女性患者早期修复尿道损伤，都能够改善长期的性功能。考虑以上因素，首选早期，有效完整的诊断以及恢复尿道完整避免耻骨上置管引流。膀胱颈损伤常伴有尿道前列腺部得破裂，这是一个棘手的问题，但这种损伤及其少见，如果早期没有明确诊断会引起慢性尿失禁，最近可以通过人工括约肌移植成功治疗。
Gross hematuria discovered after spontaneous void-ing or after insertion of a Foley catheter is the mostcommon sign of bladder injury. CT cystogram with dis-tended bladder and postemptying views has replaced thetraditional retrograde cystourethrogram for the diagnosisof bladder injury. Extraperitoneal bladder ruptures canusually be managed with bladder drainage only unless thepatient is going to have abdominal exploration for otherreasons in which case, accessible bladder tears may bedirectly sutured. Intraperitoneal rupture of the bladder isan indication for abdominal exploration and suture repairof the bladder. Laparoscopic bladder repair has been re-ported, but there are not enough data available to analyzethe real value of this approach.
自主排尿后或者置入Foley导尿管后出现明显尿血是膀胱损伤最常见的征象。充盈和排空后CT造影图像已经取代传统逆行膀胱造影用于诊断膀胱损伤。腹膜外膀胱损伤通常可以通过膀胱造瘘进行处理，除非患者由于其他原因要进行腹部探查，此时可以对发现的膀胱破裂直接缝合。腹膜内膀胱破裂需要进行腹部探查，缝合修复膀胱。已经报道有腹腔镜下膀胱修复，但是缺乏有效数据来分析此种手术的实际价值。
PERINEAL INJURY AND OPEN PELVICFRACTURE
会阴部损伤和开放性骨盆骨折
Open pelvic fracture is a particularly troublesome prob-lem to deal with because the associated perineal lacerationmay involve the anus, rectum, vagina, and urethra and directcommunication with the pelvic fracture site can lead to earlydecompression of the pelvic hematoma and exsanguination orcontamination of the pelvic hematoma, leading to sepsis andmultiple organ failure. Moreover, later contamination of thefracture site or pelvic hematoma is possible because oftransmural laceration of the vagina or rectum or fecal soilingof the laceration when bowel activity resumes. Careful digitalrectal examination with selective sigmoidoscopy (either rigidor ?exible) will often disclose the extent of injury and allowan estimate of the risk for contamination and fecal soilage.Vaginal lacerations should be repaired. When injured, theanal sphincter complex should be reapproximated to thedegree possible. Large complex wounds should undergo dailydebridement and pulse irrigation in the operating room untilbedside dressing changes can be tolerated. Diverting colos-tomy may be necessary to prevent septic complications andwhen indicated should be performed within 48 hours ofinjury. Open pelvic fractures with lacerations in the groin orpubic area carry a much lower risk of fecal soilage andcolostomy will usually not be needed in this situation.
开放性骨盆骨折是一个需要处理的麻烦问题。由于伴随的会阴部撕裂可能涉及肛门、直肠、阴道和尿道，并且直接与骨盆骨折部位相沟通，造成骨盆血肿早期减压以及出血或者污染骨盆血肿，因其毒血症和多器官衰竭。并且，骨折部位或骨盆血肿后期污染可能由于直肠或者阴道透壁性撕裂或者肠蠕动恢复后粪便漏出。仔细的直肠指检同时有选择乙状结肠镜检查（可以弯曲或者不能弯曲）通常会发现损伤的程度，能够评估感染和粪便污染的风险。阴道撕裂应该修复。肛门括约肌群应该恢复到接受的水平。严重的复合伤应该在手术室进行日常清创和压力灌注冲洗，直至包扎伤口敷料达到能够接受的程度。有必要进行转移性结肠造瘘防止发生毒血症并发症，如果有必要要在受伤后48小时内进行。伴有腹股沟部或者耻骨区域撕裂伤开放性骨盆骨折的患者有较低的风险发生粪便污染，通常这些部位没有必要进行结肠造瘘。
DETECTION AND MANAGEMENT OF PELVIC FRACTURE HEMORRHAGE
发现和处理骨盆骨折血肿
The most challenging patients with pelvic fracture arethose who arrive in hemorrhagic shock. The presence of apelvic fracture in the hemodynamically unstable patient addsanother important source of bleeding to all the other potentialsources of hemorrhage associated with high-force blunt in-jury. Signi?cant blood loss from pelvic fracture is possiblebecause of the rich arterial and venous channels within thepelvis, the plentiful blood supply of the pelvic bones, and thefact that tissue pressure within the pelvic retroperitoneum islow, permitting accumulation of substantial volumes of bloodbefore tissue pressure rises suf?ciently to tamponade bleed-ing. Life-threatening hemorrhage can occur because of dis-ruption of the branches of the internal iliac artery within thepelvis. Branches of the internal pudendal artery are com-monly the source of bleeding in these patients. Detection ofbleeding suf?cient to justify intervention is based on physi-ologic variables indicative of ongoing bleeding, the fracturepattern disclosed on pelvic imaging, and the presence ofassociated signi?cant injuries. Pelvic fracture hemorrhageoccurs in the setting of major force transfer. This usuallymeans that the surgeon is confronted with several potentialbleeding sites necessitating rapid assessment. Unfortunately,there is no de?nitive way to analyze whether pelvic fracture bleeding is present without either going to CT scan oroperative exploration. Major cavitary bleeding in the chestcan usually be identi?ed or excluded with plain anterior-posterior chest radiograph. FAST ultrasound examination isthe initial rapid test used to assess for intraperitoneal bleed-ing. If FAST ultrasound discloses intraabdominal ?uid, thenthere is usually intraperitoneal source of hemorrhage. Intra- peritoneal bladder rupture can lead to a false-positive test,and occasionally, the blood is actually from a ruptured ret-roperitoneal hematoma. In addition, there may also be pelvicfracture-associated hemorrhage, which is the primary sourceof hemorrhage and is best treated in angiography. Nonethe-less, in a patient with signs of ongoing blood loss (variableblood pressure, tachycardia alternating with intervals ofbradycardia, hematocrit 30%, arterial pH 7.2 that isresistant to blood and ?uid therapy) and a positive FAST examination, abdominal exploration is usually chosen as theprimary intervention. Pelvic fracture bleeding is approachedwhen abdominal sources have been controlled and/or a largeor expanding pelvic hematoma is found at operation. Unfor-tunately, a negative FAST ultrasound examination does notrule out an intra abdominal source of hemorrhage and haspoor speci?city as an indirect test for pelvic hemorrhage.Ideally, a CT scan evaluation is performed, which can delin-eate all sources of hemorrhage and allow an informed plan ofcare to be developed. Unfortunately, as discussed earlier, notall patients respond suf?ciently to resuscitation to allow asafe trip to CT scan in all institutions. If a patient is toounstable to go to CT scan and has a negative FAST exami-nation, pelvic hemorrhage must be assumed and treatedexpeditiously. Later, repeat FAST ultrasound imaging can bedone if no pelvic bleeding site is discovered or signsof ongoing bleeding persist even after pelvic bleeding is controlled.
最具有挑战性的是骨盆骨折伴有出血性休克的患者。血流动力学不稳定的患者增加钝性暴力所致骨盆血肿出血的风险。严重骨盆骨折出血可鞥由于以下因素：盆腔富集丰富的动静脉通道，盆骨血供丰富，盆腔腹膜后组织压较低，在组织压上升至足以阻止出血前能够集聚大量的血液。由于盆腔内部髂内动脉分支断裂会出现威胁生命的出血。阴部内动脉分支通常是这些患者出血的原因。依据生理指标变化显示持续出血，骨盆平片上显示骨折类型以及伴随的严重损伤来发现出血证据确定进行治疗。暴力传导的过程造成骨盆血肿。这就需要外科医生面对一些潜在出血点能够做出迅速的评估。不幸的是，在没有CT扫描或者手术探查情况下没有明确的方法来分析是否存在骨盆骨折出血。胸腔大容量出血通常可以通过胸部正位平片来确定或者排除。FAST超声检查是一种评估腹膜内出血迅速方法。如果FAST超声发现腹膜内液体，通常源自腹膜内出血。腹膜内膀胱破裂会导致假阳性结果，偶尔出血来自腹膜后血肿破裂。另外骨盆骨折相关的血肿是出血重要来源，可以通过血管造影给予处理。存在持续失血征象的患者（血压变化不稳定，心动过速与心动过缓交替间歇发生，血细胞压积<30％，动脉血pH<7.2并且对输血和输液治疗无效）并且FAST超声检查存在阳性结果，腹部探查作为主要的干预措施。当腹部的出血点已经得到控制，手术中发现较大或者正在扩张的盆腔血肿，可以处理骨盆骨折出血。不幸的是，FAST超声检查并不能排除腹腔出血，并且作为盆腔血肿的间接检查手段特异性较低。理想状态下，进行CT扫描检查能够发现所有出血点，并据此作出治疗计划。不幸的是，如前所述，在所有的医疗机构并不是所有的患者都会对复苏治疗有反应，允许以安全的方式进行CT扫描。如果患者不够稳定而不能进行CT扫描，并且FAST超声检查显示阴性结果，必须推测可能存在盆腔出血并给予有效治疗。随后，如果没有发现盆腔出血，或者盆腔出血得到控制有仍存在持续出血的征象，重新进行FAST超声检查。
The approach to pelvic bleeding is chosen based on thetype of pelvic fracture, the resources available in the individ-ual institution, and the rapidity of bleeding. The availableapproaches to pelvic fracture bleeding include measures todecrease pelvic volume and thus increase pelvic retroperito-neal tissue pressure (pelvic C-clamp, external ?xator, orcompression device), angiography with embolization, andpelvic gauze packing.
处理骨盆出血的方法选择依据骨盆骨折的类型，不同医疗机构可供使用的医疗资源以及出血的速度。能够有效控制骨盆出血的方法包括：减少盆腔容量以及增加盆腔腹膜后组织压的措施，（C型骨盆夹，外固定器，加压装置）血管造影栓塞，盆腔网状填塞物。
Signi?cant pelvic fracture bleeding can occur fromveins, bone edges, lacerated arteries, or combinations ofthese. Injuries to major pelvic arterial or venous trunks areunusual but occur occasionally and can be effectively man-aged with endovascular approaches. The more typical patientpresents with anterior compression, vertical shear, or com-bined type pelvic fracture with disruption of one or bothsacral-iliac ligamentous complexes. Separation of the pubicsymphysis by 1 cm to 2 cm is the rule. The recognition thatreapproximation of the separated pubic symphysis with a bedsheet placed around the pelvis just caudal to the anteriorsuperior iliac spines reduced pelvic volume and controlledbleeding in a signi?cant proportion of patients stimulatedefforts to permanently achieve this with devices such as thepelvic C-clamp and external ?xators. The pelvic C-clamp isapplied to the dorsal iliac bones, and the external ?xator isapplied anteriorly. These devices are favored, variably, bytrauma Orthopedic Surgeons. They can be applied in theemergency department, but many trauma Orthopedic Sur-geons prefer to place these in the operating room. The need totransfer the patient to the operating room without assurancethat the device will control bleeding has stimulated traumasurgeons to attempt other means of reducing pelvic volume. The simplest of these approaches is the bed sheet describedearlier. However, recently, a pelvic compression device(T-Pod Ping Medical, Richmond, British Columbia, Canada)has proven valuable for its ease of placement, lack of dis-placement with patient movement, and effective reduction ofpelvic volume.24 A satisfactory response to pelvic volumereduction is signaled by stabilization of blood pressure and heartrate and improvement of acidosis. If these do not occur within 30minutes to 1 hour of device placement, alternate approaches areindicated. Complications of pelvic compression include pressureinjury to the skin and fracture overcorrection. Pressure injury tothe skin can be avoided by removing the device within the ?rst36 hours after application or by periodically inspecting the skinfor injury. Follow-up imaging will disclose overcorrection.
严重的骨盆骨折出血来自静脉，骨块，撕裂动脉或者这几种结构兼有。大的盆腔动静脉损伤并不常见，但是偶尔也有发生，可以经血管内方法得到有效处理。更加典型的患者是遭受来自前方的挤压，垂直剪切，或者混合类型的骨盆骨折伴有一侧或者双侧的骶髂韧带复合体断裂。耻骨联合分离小于1-2cm是限度。环绕骨盆从尾骨至两侧髂前上棘环绕床单使分离的耻骨联合重新靠近，可以减少盆腔容量，对于一大部分患者能够控制出血，C型骨盆夹和外固定能够长久达到这种效果。C型骨盆夹置于髂骨背侧，外固定置于髂骨前侧。这些装置得到创伤骨科医生支持存在差异。这些装置可以在急诊科使用，但是很多创伤骨科医生选择在手术室使用这些装置。这就需要将患者转移至手术室，但是这些装置并不能保证一定能够控制出血，促使创伤骨科医生尝试其他方法减少盆腔容量。这些方法中最简单的办法是前面所述的床兜。尽管最近一种加压装置已经证明其价值，易于使用，患者移动时能够较少移位，有效减少盆腔容量。对于盆腔容量减少的满意反应是血压和心率稳定，酸中毒得到改善。如果这些装置固定30分钟-1小时后，没有发生上述反应，应该选择其他方法。骨盆加压的并发症是皮肤的压力损伤和骨折的过度矫正。在最初使用36小时后移除这些装置能够避免皮肤压力损伤或者周期观察皮肤情况。拍片随访可以显示是否存在过度矫正。
In most North American trauma centers, angiographywith embolization is the approach preferred for patients withrapid pelvic fracture bleeding and/or an inadequate responseto pelvic volume reduction. Guidance as to the generalocation of the pelvic bleeding site can be gained by observ-ing contrast extravasation on the pelvic CT images. Pelviccontrast extravasation is associated with an angiographicallydemonstrated bleeding site in 75% of patients. The choiceof angiography and embolization means that the patient has tobe transported to the angiography suite. This choice is noeasily made by most trauma surgeons but the alternativetransporting the patient to the operating room for pelvicpacking (discussed below) is not attractive either. It is criticathat all of the resources available within the trauma operatingroom be available in the angiographic facility during theprocedure. These include anesthesiology support, devices forthe rapid infusion of blood and blood products, monitoringdevices, and surgeon presence. Fortunately, this challenge isbecoming less burdensome in many institutions because of amove to equip angiographic suites for elective and emergencyendovascular procedures. If one or more bleeding sites can bedemonstrated, embolization will usually control these andpatient stability will result. Complications of embolizationinclude gluteal muscle necrosis (infrequent) that may prevenor delay ORIF. Rectal necrosis is a rare complication result-ing from bilateral internal iliac embolization.
在大多数北美创伤中心，对于骨盆骨折快速出血或者对骨盆容量减少缺乏足够反应的患者首选血管造影栓塞方法。通过对比观察骨盆CT图像上造影剂漏出指导了解盆腔出血点的总体位置。血管造影证实有出血点的患者中小于75％的可以通过对比观察造影剂漏出发现。选择血管造影栓塞意味着要将患者转移至造影室。很多床上医生不会轻易做出这种选择，而是选择转移至手术室进行骨盆填塞，尽管这种方法也不是很诱人。关键是在处理过程中所有在创伤手术室可以使用的资源在造影室也能够使用。这些包括麻醉支持，迅速输血的设备和血液制品，监测装备以及外科医生在场。幸运的是，在很多医疗机构这个挑战已经是很小麻烦，装备造影室能够进行择期或者急诊手术的行动已经开始。如果证实存在一个或者多个出血点，栓塞能够控制出血并且患者能够稳定下来。栓塞的并发症包括臀部肌肉的坏死（不经常发生），这会妨碍或者延迟ORIF。由于双侧髂内动脉栓塞导致直肠坏死是很少见的并发症。
Gauze packing of the pelvic retroperitoneum is analternative for patients when angiographic embolization is notreadily available. This approach has been used successfully inEurope,25,26 and there have been reports of successful use ofthis approach in the United States.27,28 The approach thatthese authors describe uses a lower midline incision into thespace of Retzius, the bladder is retracted, and gauze packs arepositioned in the dorsal and lateral pelvic retroperitoneum. Itis likely that similar exposure and access to the dorsal pelvicretroperitoneum could be achieved by unilateral or bilateraltransverse incisions in the infraumbilical lower abdomen. Areduction in pelvic fracture mortality from 40% (historicalcomparison group) to 25% using retroperitoneal gauze pack-ing complemented by angiography, and embolization hasbeen reported by this group. Additional con?rmatory clinicalexperience has not been forthcoming from other centers, todate, but a ?exible, multidisciplinary approach to pelvicfracture bleeding has been shown to improve mortality attrib- utable to pelvic fracture bleeding. Given the variability ofpatient presentations and available institutional resources, thebest results will be achieved when surgeons choose the safestand most ef?cient approach from all of the reported strategiesfor control of pelvic fracture bleeding.
当血管造影栓塞不能立刻进行，盆腔腹膜后网状填塞对于患者来说是另一种选择。这种方法在欧洲已经成功使用，在美国也有成功使用的报道。作者描述这种方法采取低位近中线位置进入Retzius间隙，牵开膀胱，将网状填塞物置于盆腔腹膜后的背侧和外出。下腹部脐下双侧或者单侧横切口也能够同样显露和到达盆腔腹膜后的背侧。已经报道采用腹膜后网状填塞作为血管造影栓塞的补充已经将骨盆骨折的死亡率从40％降至25％.到目前为止，并没有来自其他中心明确的临床经验，但是灵活，多学科方法治疗骨盆骨折出血已经显示能够降低由于骨盆骨折出血而致的死亡率。考虑到患者的病情不同以及不同医疗机构资源不同，外科医生从报道处理骨盆骨折出血的策略中选择最安全有效地方法，能够取得最好的结果。
DEFINITIVE FIXATION OF PELVIC FRACTURES
骨盆骨折可靠的固定
Severe pelvic fractures will usually require open reduc-tion and internal ?xation using approaches that effectivelyrestore pelvic stability in both anterior and posterior elementsof the pelvic ring. Early de?nitive ?xation, particularly of theposterior elements, is a key component in the effort toeffectively rehabilitate injured patients, maximize the pros-pect for pain-free walking, and return patients to gainfulemployment.29 Long-term results of conservative treatmentof displaced and unstable pelvic fractures are poor andinclude signi?cant lifelong disability for the patient. Ad-vances in operative stabilization of pelvic f ractures havedecreased this disability.30
严重的骨盆骨折通常需要切开复位内固定术，以在骨盆环的前方和后方恢复骨盆的稳定性。尤其对于骨盆环后部结构，早期可靠固定是受伤患者有效康复的关键，能够最大程度实现无痛行走和获得工作能力。移位不稳定骨盆骨折保守治疗远期结果不佳包括终生严重活动能力丧失。骨盆骨折固定技术的进步已经减少活动功能丧失的发生。
Early aggressive fracture management using a combi-nation of internal and external ?xation techniques has becomestandard. Multidisciplinary protocols that control hemorrhageand manage other associated injuries as rapidly as possiblehave made it possible to prepare most patients for orthopedicstabilization of their pelvic fracture within 24 hours to 72hours of injury.31 Although the attempts to provide de?nitivefracture ?xation within 24 hours of injury became standardparticularly for femur fractures, this approach has been ques-tioned for pelvic fractures that are often accompanied bymultiple other injuries.32,33 Now it seems that the safestwindow for de?nitive operative internal ?xation is between 6days and 2 weeks after injury when the systemic in?amma-tory response has subsided and before callus formation limitsthe reduction.34
运用内外固定联合的方法进行早期积极骨折治疗已经成为治疗骨盆骨折的标准。尽可能快的采取多学科的方案控制出血和处理伴随的其他损伤是的大多数患者在受伤后24-72小时内都能准备接受骨盆骨折骨科固定。尽管尝试在受伤后24小时内进行可靠骨折固定变为标准，尤其是伴有股骨骨折患者，这种方案遭到质疑，由于骨盆骨折经常伴有多发伤。现在认为可靠固定的安全窗在受伤后6天-2周时间，此时系统炎症反应已经度过并且在限制复位的骨痂形成前。
Stable pelvic fractures are usually treated with bed restuntil the patient is tolerant of mobilization and weight bearingon the affected side. Once pelvic instability is diagnosed, theapproach to de?nitive stabilization depends on the fracturepattern. Direct stabilization of the posterior pelvis restorespelvic stability and usually eliminates the need to providefurther anterior ring ?xation. Anterior pelvic fractures result-ing from anterior/posterior compressive forces involving thepubic symphysis may be reduced and stabilized by eitherclosing the “book” with an anterior external frame or morecommonly by plating the symphysis. Most iliac wing frac-tures associated with hemipelvis instability require plate os-teosynthesis either through a retroperitoneal approach orthrough a lateral or posterior exposure to the iliac wing.Sacroiliac dislocation or sacroiliac joint fracture requiresreduction of the hemipelvis displacement and correction ofthe rotational mal-alignment. These dislocations are stabi-lized in most cases with plate and lag screw techniques.Bilateral sacroiliac dislocations and sacral fractures mayrequire signi?cant exposure and reduction techniques, fol-lowed by tension band plate stabilization using a posteriorreconstruction plate placed on the external posterior aspect ofthe pelvis, with screw stabilization in both the iliac wings, inaddition to iliac-sacral lag screw ?xation. Other types of posterior ?xation involve sacral bars, larger plate con?gura-tions, and combinations of posterior and anterior internal?xation.
稳定的骨盆骨折通常接受卧床休息的治疗直至能够容忍离床活动和伤侧负重行走。一旦确定为不稳定性骨盆骨折，依据骨折的类型选择可靠的固定方法。直接骨盆环后部固定能够恢复骨盆的稳定性同时消除进一步前环固定的需要。由于前后挤压暴力所致骨盆前部骨折常涉及耻骨联合可以通过外固定架以合书的方式或者更加常用的钢板固定的方法进行复位和固定。大部分髂骨翼骨折伴有半骨盆不稳定需要钢板接骨，可以通过腹膜后入路或者侧方或者后方入路显露髂骨翼。骶髂关节脱位或者骶髂关节骨折需要复位半骨盆移位和纠正对位对线不良。这些脱位在大多数情况下需要钢板或者拉力螺钉固定。双侧骶髂关节脱位和骶骨骨折可能需要清晰的显露和复位技术，采用张力带钢板固定，使用后侧重建钢板置于骨盆后外侧，将螺钉固定于双侧髂骨翼中，另外使用拉力螺钉固定骶髂关节。其他的后方固定方法包括骶骨棒，较大塑形钢板以及前方和后方联合内固定。
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