05032013 chan thuongxuong
TRANSCRIPT
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CHẤN THƢƠNG XƢƠNG
Ở TRẺ EM
Bs Nguyễn Anh Tuấn
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Khảo sát hình ảnh
X quang:
2 tƣ thế thẳng / nghiêng chuẩn. Hình chếch. Đúng chiều thế.
Lấy 2 khớp trên và dƣới. Khu trú: cổ tay, khuỷu, cổ chân.
Chất lƣợng hình ảnh.
Dấu trực tiếp:
Đƣờng gãy xƣơng
Gập góc vỏ xƣơng
Mảnh xƣơng rời
Bất thƣờng khớp
Dấu gián tiếp:
Đẩy lệch đƣờng mỡ quanh khớp (dịch trong bao khớp – khớp khuỷu, gối, cổ chân)
Mất tƣơng quan giải phẫu bình thƣờng.
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Khớp khuỷu
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Gối
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Cổ chân
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Chụp đối bên so sánh:
Nhân cốt hóa
Ống động mạch
Siêu âm:
Dịch trong khớp
Sụn
Tụ dịch dƣới màng xƣơng
Mất liên tục vỏ xƣơng
Scanner
Gãy phức tạp
Tìm dị vật trong khớp
Cầu xƣơng
MRI:
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PHÂN LOẠI GÃY XƢƠNG
Gãy thân – hành xƣơng
Gãy không hoàn toàn
Gãy lún
Gãy tạo hình
Gãy cành tƣơi
Gãy sợi tóc
Gãy hoàn toàn
Gãy tổn thƣơng sụn tiếp hợp
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Gãy thân xƣơng – hành xƣơng
Gãy không hoàn toàn:
Gãy lún: (+++)
Lún thân xƣơng vào hành xƣơng
Đƣờng tăng đậm độ
Gập góc bờ xƣơng
Tiên lƣợng tốt
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Gãy tạo hình:
Xƣơng quay, x. trụ, x. chày
Gãy xƣơng kế cận
Cong quá mức đoạn xƣơng
Không có hình ảnh đƣờng gãy
xƣơng – vô số đƣờng gãy nhỏ
Chẩn đoán khó – trễ
Chụp xƣơng đối bên so sánh
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Gãy “cành tƣơi”
Gãy 1 bờ vỏ xƣơng (gãy
tạo hình bờ đối bên)
Do lực xoắn
Tiên lƣợng tốt
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Gãy xƣơng dạng: “sợi tóc”
Thƣờng ở 2/3 dƣới xƣơng chày
Gãy xoắn, dƣới màng xƣơng,
không di lệch
Chẩn đoán khó – trễ:
X quang I: (-)
X quang II sau 7 – 10 ngày
X quang II sau 2 – 3 tuần
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Gãy hoàn toàn:
Không khác ngƣời lớn
Gãy xoắn, ngang, xéo
Di lệch (±)
Tổn thƣơng xƣơng song hành
Diễn tiến:
Tiên lƣợng tốt
Khả năng tự chỉnh cao
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Gãy tổn thƣơng sụn tiếp hợp
Cấu trúc sụn tiếp hợp
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Nguy cơ: tạo cầu xƣơng
Biến dạng xƣơng
Ngƣng tăng trƣởng chiều dài xƣơng
Phân loại Salter – Harris
Type I: physaire
Type II: metaphyso – physaire
Type III: epiphyso – physaire
Type IV: metaphyso-physo-epiphysaire
Type V: compression physaire
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Salter I:
Lành tính
5% ?
Chẩn đoán khó
Lâm sàng
X quang:
Dấu gián tiếp
Chụp so sánh
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Salter II:
Rất thƣờng gặp, 2/3
Hành xƣơng – sụn tăng trƣởng
Chi trên
Di lệch (±)
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Salter III:
10%
Đầu xƣơng – sụn tăng trƣởng
Gần cuối giai đoạn phát triển xƣơng
Xƣơng chày
Tiên lƣợng ?
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Salter IV
10%
Hành xƣơng – sụn – đầu xƣơng
Di lệch (++)
Thƣờng lồi cầu xƣơng đùi, đầu
dƣới xƣơng chày
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Salter V:
Gãy xẹp sụn tiếp hợp
Hiếm
Chẩn đoán khó:
Dấu gián tiếp
So sánh
Tiên lƣợng xấu
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Gãy phức tạp:
Gãy trên nhiều mặt phẳng
x quang: T/N/chếch
Salter II
Salter III
Salter IV
CT:
Các đƣờng gãy, mặt khớp,
mảnh xƣơng rời.
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Di chứng tổn thƣơng sụn tiếp hợp: cầu xƣơng
Chết các nguyên bào sụn – hàn xƣơng
Ngắn chi
Lệch trục xƣơng
Phát hiện sớm
X quang
CT
MRI
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MRI:
Xác định cầu xƣơng
Diện tích cầu xƣơng
Tình trạng sụn tăng trƣởng
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Một số đặc điểm gãy xƣơng theo vị trí
Bàn tay:
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Cổ tay:
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Vùng khuỷu
Dấu gián tiếp:
tụ dịch (máu) trong bao khớp (fat pad sign)
Lệch trục
Gãy mâm quay
Trật đầu xƣơng quay
Gãy Monteggia:
Gãy thân xƣơng trụ
Trật đầu xƣơng quay
Gãy trên lồi cầu
Gãy bong lồi cầu
Gãy bong đầu xƣơng ở trẻ sơ sinh
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Vùng gối:
Dấu tụ dịch trong bao khớp gối
Gãy xƣơng bánh chè
Gãy rứt lồi củ chày
Gãy gai mâm chày
Gãy xƣơng – sụn (osteochondral) lồi cầu xƣơng
đùi
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“sleeve fracture” – tendon patellaire
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Gãy rứt nhân cốt hóa
phụ
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Gãy xƣơng bệnh lý
Gãy xƣơng trên nền xƣơng bệnh lý
U xƣơng lành tính
Bất thƣờng bẩm sinh hệ xƣơng
Bất thƣờng di truyền
Tổn thƣơng nhiều xƣơng:
Viêm xƣơng tủy xƣơng
U mạch máu
Di căn (neuroblastoma, Wilms’)
Bệnh lý huyết học (Histiocytosis X, leukemia, lymphoma)
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Hội chứng trẻ bị hành hạ
Hội chứng Silverman
Gãy xƣơng nhiều vị trí / không chấn thƣơng
Hệ xƣơng bình thƣờng
Gãy xƣơng nhiều vị trí ở nhiều giai đoạn
Gãy hành xƣơng
Gãy nhiều cung sƣờn: cung trƣớc và cung sau
Nứt sọ
Gãy thân xƣơng: trẻ lớn
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Chấn thƣơng sọ não:
Nứt sọ
Xuất huyết dƣới màng cứng nhiều giai đoạn (+++)
Tổn thƣơng nhu mô não
Chẩn đoán phân biệt:
Bất thƣờng hệ xƣơng: chuyển hóa, loạn sản
Chấn thƣơng thật sự