Pelvis kırılganlık kırıkları

Özet

Pelvis kırılganlık kırıkları çoğunlukla osteoporotik kemikte düşük enerjili travma sonrasında, belirgin deplasman olmadan gelişir ve yaşlı hastada kalça-bel ağrısının nedeni olabilir. BT, pubik ramus bulgusunun yanında sakrum, SI eklem ve iliak kanatlardaki posterior halka lezyonlarını arayarak paternin bütününü ortaya koyar. Sakral kırıklar ince, sklerotik veya bilateral olabilir; BT negatif olsa da klinik şüphe sürüyorsa kemik iliği ödemini göstermek için MR gerekebilir. Posterior halka hasarının atlanması yaralanmanın stabilitesinin eksik değerlendirilmesine yol açar.

Faz ve pencere

Kontrastsız tanısal

Kontrastsız pelvik BT kırık çizgisi, skleroz, deplasman ve halka devamlılığını değerlendirir; kemik iliği ödemini MR kadar duyarlı göstermez. Pelvis BT’nin çok düzlemli rekonstrüksiyonları kırıkların yayılımını değerlendirmeye yardımcı olur; sakral yetmezlik kırıklarında dikey bileşenlere yatay bir bileşen eşlik ederek H tipi patern oluşturabilir.

Önerilen pencereler: Kemik (G 1800 / M 400), Yumuşak doku (G 400 / M 40).

BT bulguları

• Pubik üst veya alt ramusta ince kortikal kesinti, impaksiyon ya da çevresel kallus
• Sakral ala boyunca foraminaların lateralinde dikey kırık hattı ve çevresinde skleroz
• İki sakral aladaki dikey kırık bileşenlerine yatay bir bileşen eşlik edebilir; bu görünüm H tipi kırık paternini oluşturur.
• Sakrum, SI eklem veya iliak kemikte anterior halka kırığına eşlik eden posterior halka hasarı
• Fragil kemikte minimal deplasman, kortikal çökme veya trabeküler impaksiyon
• Osteoporotik kemik yoğunluğu kaybı ve eski kırıklara bağlı deformite
• Belirgin deplasmanda çevre dokularda hafif şişlik izlenebilir; ancak büyük hematom ve visceral yaralanma yüksek enerjili travmada beklenir, FFP'de nadirdir.

Ölçütler ve sınıflamalar

Rommens-Hofmann FFP

Rommens–Hofmann FFP: tip I yalnız anterior halka (Ia tek, Ib iki taraflı); tip II deplase olmayan posterior halka yaralanmalarıdır: IIa'da anterior halka kırığı yoktur; IIb'de sakral ala kompresyon/crush yaralanmasına anterior halka kırığı eşlik eder; IIc'de anterior halka kırığına deplase olmayan tam sakral, sakroiliak veya iliak posterior kırık eşlik eder. Tip III anterior halka kırığıyla birlikte deplase tek taraflı posterior halka (IIIa ilium, IIIb sakroiliak/crescent, IIIc sakrum); tip IV deplase bilateral posterior halka (IVa bilateral iliak veya sakroiliak yaralanma, IVb U/H tipi spinopelvik ayrışma, IVc farklı posterior instabilitelerin birleşimi).

Normalde

Normal kemik penceresinde sakral ala trabekülleri kesintisiz, sakral korteks düzgün ve iki SI eklem aralığı benzer genişliktedir; pubik ramusların kortikal sınırı da tam izlenir. Kırık şüphesinde aynı düzeyin karşı tarafını ve ardışık kesitleri kıyaslayarak sklerotik dikey alar hattı, ramus korteksindeki çentiği ve halka boyunca ikinci bir kesiyi ara.

Ayırıcı tanı

Metastatik sakral lezyon

akut radyoterapi sonrası veya sistemik malignitede sıklıkla görülür ve kırılganlık kırıklarından ayırılması gereklidir; BT'de kırılganlık kırıkları genellikle SI ekleme paralel lineer hatta ve çevresinde skleroz gösterirken, metastazlar odaksal yıkıcı özellikler gösterebilir.

Sakroiliit

eklem yüzlerinde erozyon, skleroz ve eklem aralığı değişikliği yapar; tipik dikey sakral kırık hattı oluşturmaz.

Osteitis condensans ilii

iliak tarafta üçgensi, periartiküler skleroz vardır; kortikal kırık veya sakral alar hat yoktur.

Akut travmatik halka kırığı

daha keskin kortikal ayrılma, belirgin fragman ve yumuşak doku yaralanmasıyla öne çıkar; kemik kırılganlığı bağlamı olmayabilir.

Tuzaklar

• Yalnız pubik ramusu raporlayıp sakrumu incelememek posterior halka bileşenini kaçırır; her iki sakral ala ve SI eklemi koronal kemik rekonstrüksiyonunda tara.
• Sakral yetmezlik kırıklarında BT'de lineer veya eğrisel hipoatenuasyon çizgileri ve çevresinde skleroz görülür; bu özellikler kırık hattını tanımlar.
• BT'de hat seçilmemesi kemik iliği ödemini dışlamaz; devam eden fokal sakral ağrıda MR ile okült yetmezlik kırığı araştırılır.

Kendini dene

1. Düşük enerjili düşme sonrası BT'de pubik ramus kırığı ve deplasmansız, ön ve arka korteksi kesen tam sakral ala kırığı var. FFP alt tipi hangisine uyar?

   • FFP IIc
   • FFP Ia
   • FFP IIIc
   • FFP IVb
   Cevabı göster

   FFP IIc. Anterior halka kırığına eşlik eden deplase olmayan tam sakral kırık FFP IIc ile uyumludur. Ia yalnız anterior halkayı, IIIc deplase tek taraflı sakral hasarı, IVb U/H tipi spinopelvik ayrışmayı tanımlar.

2. Pubik ramus kırığı görülen yaşlı hastada BT'de sakral alar sklerotik çizgi seçilmiyor; ağrı sürüyor. En olası sonraki tanısal açıklama?

   • Okült sakral yetmezlik kırığı
   • Osteitis condensans ilii
   • Sakroiliit
   • Sakral metastaz
   Cevabı göster

   Okült sakral yetmezlik kırığı. Fragil kemikte deplase olmayan sakral yetmezlik hattı BT'de silik kalabilir; MR kemik iliği ödemini yakalayabilir. Diğer seçeneklerde eklem yüzü değişikliği ya da fokal destrüktif lezyon beklenir.

İlgili konular

• Denis zon 3 ve transvers sakral kırık

Kaynaklar

Bu sayfadaki 39 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 10 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez. İçerik yapay zekâ destekli bir süreçle güncel literatüre göre cümle cümle kaynaklarla karşılaştırıldı, ancak uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.