Tile stabilite sınıflaması

Özet

Yüksek enerjili travmada pelvis halkasının stabilitesi, tek bir kırık hattından çok posterior sakroiliak kompleksin ne ölçüde bozulduğuyla anlaşılır. Klasik Tile sınıflaması bu anatomik sürekliliği BT'de görülen kemik ve eklem yaralanmalarıyla ilişkilendirerek stabil, rotasyonel instabil ve hem rotasyonel hem dikey instabil örüntüleri ayırır. BT, özellikle sakrum, sakroiliak eklem ve posterior iliak kemikte grafide örtülebilen yaralanmaları ve halka üzerindeki ikinci hasar odağını gösterir. Posterior halka hasarı atlanırsa yaralanmanın instabil bileşeni ve eşlik edebilen kanama ya da nörolojik risk eksik raporlanabilir.

Faz ve pencere

Kontrastsız tanısal

Kemik penceresinde pubik simfiz, iki pubik ramus, sakral ala, sakroiliak eklemler ve iliak kanatlar birlikte izlenir; posterior eklem aralığı, kortikal süreksizlik ve hemipelvisin kraniokaudal ya da ön-arka ötelenmesi stabilite örüntüsünü gösterir. İnce kesitli aksiyal ve koronal/sagittal rekonstrüksiyonlu BT, pelvis halkası sınıflaması için standart görüntüleme yöntemidir.

Kemik algoritması tanısal

Standart BT protokolünde aksiyal, koronal ve sagittal rekonstrüksiyonlar birlikte kullanılarak posterior halka yer değiştirmesi, sakral kırık morfolojisi, sakroiliak eklem uyumsuzluğu ve ön halka kopması doğrudan görüntülenebilir.

Önerilen pencereler: Kemik (G 1800 / M 400).

BT bulguları

• Posterior sakroiliak kompleks sürekliliği — posterior SI eklem aralığı ve sakral/iliak korteks boyunca kesinti olup olmadığını belirleyin.
• Rotasyonel instabilite — Tile sınıflamasında rotasyonel ayrışma tahmini için pubik simfiz ve sakroiliak eklem genişlemesi işaretleri kullanılır.
• Hemipelvisin kraniokaudal yer değiştirmesini (örn. cranial migration) ve posterior halkada oluşan dikey instabiliteyi değerlendirin.
• Posterior ark kırığı — sakral ala, sakral foramenler, iliak kanat ve sakroiliak eklem boyunca kırık-disosiyasyon odağını izleyin.
• Anterior halka eşliği — pubik ramus veya simfiz hasarını posterior yaralanmayla aynı tarafta ve karşı tarafta eşleştirin.
• Halka boyunca ikinci hasar — belirgin bir kırığın karşısında sakrum, SI eklem veya pubik ramusta gizli ikinci kesintiyi araştırın.
• Eşlik eden yumuşak doku bulgusu — hematom, ekstravazasyon şüphesi ve mesane komşuluğundaki yaralanmayı kemik örüntüsünden ayrı kaydedin.

Ölçütler ve sınıflamalar

Tile A

Posterior sakroiliak kompleks korunmuştur; halka fizyolojik yük altında stabil kabul edilir.

Tile B

Posterior kompleks kısmen bozulmuştur; halka rotasyonel olarak instabil, dikey yönde görece stabildir.

Tile C

Posterior kompleks tam kesintiye uğramıştır; hem rotasyonel hem dikey instabilite vardır.

AO/OTA pelvis halka sınıflaması (2018 compendium)

AO/OTA 2018 Compendium pelvis halkası için ayrı kodlu, morfoloji ve instabiliteyi birlikte ele alan bir sınıflamadır. Bu kodlar klasik Tile A/B/C ile bire bir eşdeğer değildir; raporda kullanılan sistemin adı ve kendi kodu belirtilmelidir.

Normalde

Normal BT'de sakrum iki iliak kemikle simetrik sakroiliak eklemler üzerinden eklemleşir; pubik simfiz ve ramuslar kesintisiz ön halkayı tamamlar. İki tarafın SI eklem aralıklarını, sakral korteksin devamlılığını ve iliak kanatların aynı kraniokaudal seviyede oluşunu karşılaştırarak travmatik açılma veya translasyonu arayın.

Ayırıcı tanı

İzole iliak kanat kırığı

SI eklem ve sakrum sağlam, halka posterior bağlantısı korunmuş olabilir.

İzole pubik ramus kırığı

tek başına stabil görünse de sakrum ve SI eklemde gizli eşlikçi hasar özellikle aranır.

Sakral yetmezlik kırığı

sıklıkla ala içinde sklerotik/ince vertikal çizgiler bulunur; akut yüksek enerjili halka ayrışması eşlik etmeyebilir.

Sakroiliit veya dejeneratif SI değişiklik

eklem yüzlerinde kronik skleroz, erozyon ya da osteofit vardır; akut hemipelvis ötelenmesi beklenmez.

Tuzaklar

• Anterior halka kırığını tek odak sanıp arka halkayı bırakmayın; halka mekanizması nedeniyle sakral ala ve SI eklemi aynı incelemede tarayın.
• Tile tipi yalnız pubik simfiz açıklığına göre atanamaz; posterior bağ kompleksinin kemik ve eklem bütünlüğünü esas alın.
• Yatış pozisyonu, pelvik binder ve redüksiyon görünür deformiteyi azaltabilir; kırık morfolojisini ve eklem yüzü basamaklarını da inceleyin.
• BT morfolojisi klinik bağ gevşekliğini her zaman tek başına kanıtlamaz; kısmi posterior hasarda stabilite yorumunu kesinlik iddiası olmadan raporlayın.

Kendini dene

1. BT'de ön halka ayrışmasına eşlik eden kısmi posterior SI kompleks hasarı var; hemipelvis kraniokaudal konumunu koruyor. Tile tipi hangisidir?

   • Tile A
   • Tile B
   • Tile C
   • Denis zon 2
   Cevabı göster

   Tile B. Tile B posterior kompleksin kısmi bozulduğu ve dikey stabilitenin korunduğu örüntüdür. Tile A'da posterior kompleks sağlamdır; Tile C'de dikey instabilite de vardır. Denis zon 2 sakral kırığın foramene göre yerini tanımlar.

2. Pubik ramus kırığı görülen hastada stabiliteyi sınıflamak için hangi ek bulgu en belirleyicidir?

   • Sakroiliak eklem ayrışması
   • Obturator internus hacmi
   • Femur başı sklerozu
   • İliopsoas tendon kalınlığı
   Cevabı göster

   Sakroiliak eklem ayrışması. Posterior sakroiliak kompleksin bütünlüğü Tile stabilite ayrımının temelidir. Diğer seçenekler pelvis halkasının posterior mekanik sürekliliğini göstermez.

Kaynaklar

Bu sayfadaki 47 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 4 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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