Pelvik halka ve sakrum yaralanması

Özet

Yüksek enerjili künt travmada pelvik halka kırığı; büyük hacimli kanama, mekanik instabilite ve mesane ya da üretra yaralanmasıyla birlikte olabilir. BT, ön ve arka halka hasarını, asetabulum eklem yüzüne uzanımı ve sakral kanal-foramen ilişkisini çok düzlemli gösterir; kontrastlı seriler hematom içindeki aktif damar kanamasını aramaya yarar. Arka halka lezyonu yalnızca ön halka kırığı görüldüğü için dışlanamaz; sakral foraminal veya kanal uzanımı nörolojik açıdan kritik olabilir. Bu bileşenler gözden kaçarsa kanama kaynağı ve kırığın kapsamı eksik raporlanabilir.

Faz ve pencere

Kemik algoritması tanısal

Aksiyel ince kesitler ile koronal ve sagittal kemik rekonstrüksiyonlarında pubik ramus, simfiz, iliak kemik, sakrum ve asetabulum korteksinde kırık hattı, impaksiyon, basamaklanma ve fragman deplasmanı seçilir; sakral hattın foramen veya kanala uzanımı bu serilerde haritalanır.

Arteriyel tanısal

İntravenöz kontrast sonrası arteriyel seride pelvik hematom içinde aort yoğunluğunda damar dışı kontrast odağı aktif arteriyel kanamayı düşündürür; iyi sınırlı, yuvarlak bir damar kesesi psödoanevrizma olabilir. Odağın damar kesiti ya da kemik fragmanı olmadığını komşu kesitlerle doğrulayın.

Portal tanısal

Portal venöz/geç seri, hematom içindeki kontrast odağının büyüyüp çevreye yayılıp yayılmadığını ve pelvisteki eşlik eden yumuşak doku yaralanmalarını gösterir; fazlar arası artan göllenme aktif ekstravazasyon lehinedir.

Önerilen pencereler: Kemik (G 1800 / M 400), Yumuşak doku (G 400 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Pubik ramus veya simfiz hasarı — kortikal süreksizlik, ramuslarda yer değiştirme ya da simfiz ekleminde travmatik genişleme.
• Arka halka kesintisi — sakral ala/korpus kırığı, sakroiliak eklem ayrışması veya posterior iliak kemik kırığı; ön halka bulgusuyla aynı tarafta olup olmadığını izleyin.
• Hemipelvis seviye farkı — koronal planda bir tarafın kraniokaudal yer değiştirmesi dikey kayma bileşenini gösterir.
• Asetabular eklem uzanımı — kırık hattı tavan, kolon ya da duvardan eklem yüzüne ulaşır; eklem içi fragman ve yüzey basamağı ayrıca vurgulanır.
• Sakral foraminal uzanım — kırık hattı nöral foramenle kesişir veya fragman foramen konturunu daraltır.
• Sakral kanal daralması — santral fragman ya da deplasman kanal lümenine taşar; transvers bileşen eşlik ediyorsa spinopelvik ayrışma paterni araştırılır.
• Pelvik hematom — prevezikal, presakral veya yan pelvik duvarda kanama yumuşak doku penceresinde belirir; yayılımı kırık tarafı ve kompartımanla eşleştirilir.
• Damar odağı — hematom içindeki arteriyel kontrast odağı, sonraki serideki boyut ve biçim değişimiyle birlikte aktif kaçak veya psödoanevrizma yönünden sınıflanır.

Ölçütler ve sınıflamalar

Young–Burgess pelvik halka sınıflaması

Young–Burgess sınıflaması, mekanizma ve posterior halka/bağ hasarına göre ilerler; APC I'de anterior halka yırtılması ve kısmi posterior tutulum, APC III'te ise anterior ve posterior kompleksteki tam kopukluk tanımlanır. Bu 2,5 cm sınırı tek başına sınıf belirlemez: posterior halka/bağ bulguları da değerlendirilmelidir; pelvik binder ayrışmayı gizleyebilir. LC I–III lateral kompresyonun halka ve bağ hasar paternlerini, VS dikey kaymayı, kombine tip birden fazla kuvvet yönünü tanımlar.

Denis sakral kırık zonları

U veya H biçimli transvers bileşenli kırıklar, spinopelvik ayrışma ile seyreden yüksek riskli instabilite paternlerini işaret eder.

Normalde

Normal BT'de pubik simfiz ile bilateral sakroiliak eklem aralıkları uyumludur; sakrum ve asetabulum korteksleri kesintisiz, sakral foramenler ve kanal açık konturludur. Aynı düzeyde sağ ve sol hemipelvisin hizasını, eklem yüzlerinin düzgünlüğünü ve hematom bulunmayan pelvik yağ planlarını karşılaştırın.

Ayırıcı tanı

Sakral insüfisiyans kırığı

çoğunlukla osteoporotik zeminde alar skleroz ve ince kırık hattı oluşturur; eşlik eden yüksek enerjili halka deplasmanı beklenmez.

Eklem yüzüne uzanan kırık hatları, asetabular tavan veya kolonlarda basamaklanma ve fragmentasyon oluşturarak normal anatomik yapıdan ayrılır.

Pelvik yumuşak doku hematomu

kanamayı gösterir, fakat arteriyel seride damar dışı kontrast odağı yoksa tek başına aktif arteriyel kaynak anlamına gelmez.

Kemik fragmanının damar odağı taklidi

kemik penceresinde kortikal yoğunluk taşır ve kontrastlı seriler arasında damar gibi biçim değiştirmez.

Tuzaklar

• İzole pubik ramus kırığı görüntüsü arka halka bütünlüğünü kanıtlamaz; sakrum, SI eklemleri ve posterior iliak kanadı ayrı ayrı tarayın.
• Sakral kırık, aksiyel kesitte foramenle sınırlı sanılabilir; koronal ve sagittal planda kanal içi uzanım ile transvers bileşeni arayın.
• Hematoma bitişik damar kesiti veya kemik parçası kontrast odağına benzeyebilir; damar devamlılığını ve ardışık fazlardaki görünümünü kontrol edin.
• Mesane rüptürü rutin intravenöz kontrastlı pelvis BT'sinde dışlanamaz; pubik fragman ve perivezikal bulgular varsa retrograd BT sistografi gereksinimini belirtin.

Kendini dene

1. Pelvik travmada arteriyel seride hematom içinde kontrast odağı görülüyor ve geç seride bu alan büyüyor. Bu dinamik bulgu en çok aşağıdakilerden hangisini destekler?

   • Aktif arteriyel kanama
   • Venöz geri akım trombozu
   • Kemik nekrozu
   • Normal fizyolojik geri akım
   Cevabı göster

   Aktif arteriyel kanama. Kontrast odağının fazlar arasında büyümesi aktif damar dışı kaçağı gösterir; kas/yumuşak doku yaralanmaları bu fazlar arası kontrast davranışını oluşturmaz.

2. U veya H biçimli transvers bileşenli sakral kırıklar, hangi klinik durum ve prognostik risk ile güçlü şekilde ilişkilendirilir?

   • Spinopelvik ayrışma ve yüksek instabilite riski
   • İzole posterior halka stabilitesi
   • Genellikle konservatif tedavi gerektiren fragilite kırıkları
   • Sadece ön halka hasarı ile sınırlı travmalar
   Cevabı göster

   Spinopelvik ayrışma ve yüksek instabilite riski. U veya H biçimli transvers bileşenli kırıklar, spinopelvik ayrışma ile seyreden yüksek riskli instabilite paternlerini işaret eder.

Bu konunun yer aldığı turlar

• Politravma (tüm gövde) BT'si

İlgili konular

• Mesane yaralanması

Kaynaklar

Bu sayfadaki 43 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 6 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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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.