| Objective:1. Investigate the clinical manifestation of posterior pelvic ring fracture complicated with lumbosacral plexus injury.2. Investigate the diagnosis strategy of posterior pelvic ring fracture complicated with lumbosacral plexus injury.3. Summarize and analyze the therapeutic effect of different ways treating the patients diagnosed with posterior pelvic ring fracture complicated with lumbosacral plexus injury, then explore the best treatment protocol.Method:During the period between January 1,2005 and January 1,2013,205 pelvic fractures were admitted to the traumatic orthopedic ward of Shandong Provincial hospital, and 43 patients (28 male,15 female; mean age 36.3years) were diagnosed with posterior pelvic ring fracture complicated with lumbosacral plexus injury. The mechanisms of injury were vehicle accident in 28 cases, bruise in 2 cases, falling down in 6 cases, explosion in 1 case, crush in 6 cases. According to Tile’s pelvic fracture classification, type A was 3 cases, type B was 15 cases, type C was 25 cases. According Denis’s sacral fracture classification, type Denis Ⅰ was 2 cases, type Denis Ⅱ was 13 cases, type Denis Ⅲ was 16 cases.39 cases of all patients were closed pelvic fracture, among of which 7 cases were old pelvic fracture, while the other 4 cases were open pelvic fracture. ISS score ranges from 16 to 43, with an average score of 22.2. Every patient was treated following first aid principle of pelvic fracture, and they all were diagnosed with pelvic fracture complicated with lumbosacral plexus injury referring to patients’ clinical manifestations, imageological examinations, EMG results and so on once their condition became stable. Then all of their lumbosacral plexus nerve root segments were located by their clinical manifestation such as feeling barrier or/and motor barrier, and they all got feeling score and motor score according to ASIA standard.11 of the 43 patients were given conservative treatment about nerve root injury, while the other 21 had their injured nerve roots depressed, including 10 cases of anterior approach depression,17 cases of posterior approach depression,5 cases of anterior approach depression combined with posterior approach. 36 cases were reduced and fixed, including 4 external fixations (2 external fixations as terminal fixation and 2 external fixations turned into iliolumbar fixation),5 internal fixations with M-shaped plates through posterior approach,13 lumbo-iliac internal fixations,9 internal fixations with reconstruction double plates through anterior approach of sacroiliac joint,9 internal fixations with sacroiliac screw, meanwhile 15 cases anterior ring of pelvic ring internal fixed.Results:(1) The clinical character of posterior pelvic ring fracture complicated with lumbosacral plexus injury43 patients with lumbosacral plexus injured had the feeling barrier or/and motor barrier of lower limbs and saddle area.52 sides of lower limbs had hypesthesia, and 9cases (conservative group in 1,depression group in 8)showing double lower limbs paresthesia.4 sides(conservative group in 1,depression group in 3)showed radioactive pain of of lower limb.15 sides (28.85%) of them showed the feeling barrier of the common peroneal nerve injured,30 sides (57.69%) of them showed the feeling barrier of the common peroneal nerve injured combined with tibial nerve injured,6 sides (11.54%) showed the feeling barrier of femoral nerve injured,21 sides(40.38%) showed the feeling barrier of posterior femoral cutaneous nerve injured. The area of lower limbs ruled by segment L2 to segment S2 had its feeling effected, and 5 sides (9.61%) of nerve root L2 nerve root,5 sides (9.61%) of L3 nerve root,6 sides (11.54%) of L4 nerve root,24 sides (50.00%) of L5 nerve root,31 sides (59.61%) of S1 nerve root,21 sides (40.38%) of S2 nerve root damaged.48 sides of lower limbs had motor barrier, and 9cases (conservative group in 1,depression group in 8)showing double lower limbs’motor barrier.11 sides (22.92%) of them had muscles’ strength ruled by the common peroneal nerve,30 sides (62.50%) of them had muscles’ strength decreased ruled by the common peroneal nerve combined with tibial nerve,5 sides (10.42%) of them had muscles’ strength decreased ruled by femoral nerve,2 sides (4.17%) had gluteus medius, gluteus minimus’s strength decreased ruled by superior clunial nerve. The muscles of lower limbs ruled by segment L2 to segment SI had their muscles strength decreased, and 5 sides (10.42%) of nerve roots L2 damaged,5 sides (10.42%) of L3 nerve roots damaged,24 sides (50.00%) of L4 nerve roots damaged,25sides (52.08%) of L5 nerve roots damaged,30 sides (62.50%) of S1 nerve roots damaged.18 cases showed hypesthesia in saddle area, incontinence, sexual dysfunction.(2) The comparison of clinical therapeutic effect of different ways treating lumbosacral plexus injury.The lumbosacral plexus of patients who had their nerve roots depressed had proven injured in operation, and 13 cases of them showed depression by bony fragments in sacral canal,4 cases had their sacral foramina constricted,9 cases of them showed lumbosacral trunk’s depression by fragments or callus,1 case showed lumbosacral trunk entrapped in fracture interspace,5 cases showed depression by bony fragments in sacral canal combined with lumbosacral trunk’s depression.40 patients of these two groups were followed-up, with an average follow-up time of 18 months (12-46). The fractures of 35 patients were clinically healed at 10.8 (8-15) weeks, while 1 case showed malunion with the result that one leg was shorter than the other.According to ASIA standard, preoperative feeling score of lower limbs of conservative group averaged 30.77, and following-up feeling score averaged 33.08, increased by 2.13. Preoperative feeling score of lower limbs of depression group averaged 29.69, and following-up feeling score averaged 34.46, increased by 4.77. T test showed statistical difference between the increment of the two group.According to ASIA standard, preoperative motor score of lower limbs of conservative group averaged 18.80, and following-up motor score averaged 21.13, increased by 2.33. Preoperative motor score of lower limbs of conservative group averaged 16.18, and following-up motor score averaged 22.63, increased by 6.45. T test showed statistical difference between the increment of the two group, and the increment of depression group was higher than that of conservative group.Considered the lower limbs’function of lumbosacral plexus integrally, and evaluated the healing function of lumbosacral plexus with MCRR standard introduced by British institute of neurosurgery as the reference. The conservative group showed 4 excellent,4 good,2 acceptable,1 poor, with the rate of excellent and good being 70.00%. The depression group showed 19 excellent,12 good,5 acceptable,2 poor, with the rate of excellent and good being 82.05%. The the result of the two group showed no difference.The 18 cases showing hypesthesia in saddle area, incontinence, sexual dysfunction had 9 cases completely recovered,5 cases partially recovered,4 cases no changed.Conclusion:1. The clinical manifestations of the posterior pelvic ring fracture complicated with lumbosacral plexus injury mainly showed the symptoms of the injured common peroneal nerve, nearly 60% with the symptoms of injured tibial nerve, 40% with pudendal nerve injured, sometimes with the symptoms of femoral nerve injured. The injured segments of nerve roots mainly distributed from L4 to S2, and the rate of L4 sensory branches injured was lower than that of L4 motor branches. 2. When posterior pelvic ring fracture coincided with above clinical manifestations, we should study patient’s imageological examinations and EMG carefully, judging whether the lumbosacral plexus had been destroyed or not.3. In general, the depression of lumbosacral plexus showed no advantages than conservative treatment therapy. The analysis of feeling score increment, motor score increment of depression group showed dvantage than that of conservative group. |
PDF Full Text Request