骨盆新月形骨折知多少？

河南省洛阳正骨医院（河南省骨科医院） 髋中心

河南省骨科微创工程技术中心

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骨盆新月形骨折知多少？

What’s more in pelvic crescent fractures？

要知道“新月形骨折”为何物，我们先来看看“新月”作何解释，接下来看看“新月形骨折”出处的原意，再来看看各家之言，最后得出我们自己的结论。

一、“新月”（crescent moon）作何解释？

此“新月”（crescent moon）非天文月相之“新月”（new moon），前者弯弯以致情意绵绵，后者淡淡以致肉眼难见。在维基百科（Wikipedia）中收索“crescent moon”得到“a lunar phase waxing until 7 days after or waning since 7 days before the new moon”，意为月相中天文新月之后7天的waxing crescent（峨眉月）或之前7天的waning crescent（残月）。

再来看看权威的韦氏词典（Webster dictionary）对crescent moon的解释：1. the moon at any stage between new moon and first quarter and between last quarter and the succeeding new moon when less than half of the illuminated hemisphere is visible（科学解释，与维基百科意同）；2. the figure of the moon at such a stage defined by a convex and concave edge（形象化解释，有一个凸缘和凹缘的月亮形态）。

二、“新月形骨折”（crescent fracture）的原意

“新月形骨折”这一名词来源于Andrew R. Burgess和Jeremy W.R. Young等学者的在骨盆损伤临床实践中的工作总结，在他们《Pelvic ring disruption: effective classification system and treatment protocols》一文中有详尽的叙述。摘抄原文如下：

A crescent fracture is created by a lateral force fracturing the iliac wing at or near the anterior border of the sacroiliac (SI) joint, the remainder of the ilium having rotated medially from this point at the time of impact, leaving a small crescent-shaped segment of posterior ilium firmly attached to the sacrum via the strong posterior SI ligaments.

The crescent fracture, produced by LC (internal rotation) forces to the pelvic ring, manifests as a distinctive posterior iliac wing segment that remains attached to the sacrum. Its crescent shape is composed of two edges, the relatively straight edge being the anterior fracture line and the curved edge being the most posterior portion of the iliac crest up to and including both posterior iliac spine; frequently, the curved edge also includes the most posterior portion of the roof of the greater sciatic notch. The fracture pattern thus created spares the posterior SI ligaments, forming a strong connection between the sacrum and the fragment.

翻译如下：

新月形骨折是由侧方暴力导致的位于或邻近骶髂关节前缘的髂骨骨折，髂骨的残部在暴力作用当时发生内旋移位，留下一小块新月形髂骨后部骨块借骶髂后韧带与骶骨牢固相连。

新月形骨折，由侧方挤压（内旋）暴力所致，以与骶骨相连的髂骨后份骨块为独特表现。该骨块的新月外形由两个边缘组成，相对平直的边缘为前方的骨折线，弧形边缘则为包括髂后上下棘在内的髂嵴后份，通常，弧形边缘也囊括坐骨大切迹顶狐的后份。骶髂后韧带将此新月型骨块与骶骨强力连接在一起。

三、“新月形骨折”的各家之言

1. Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas主编的《Fractures of the pelvis and acetabulum: principles and methods of management》4th edition

Crescent fractures

Fracture dislocations ofthe sacroiliac joint with dislocation of the inferior sacroiliac joint and fracture through the posterior iliac crest have been termed “crescent” fracture dislocations.

译文：骶髂关节下份脱位合并髂嵴后份骨折的骶髂关节骨折脱位被称为“新月形”骨折脱位。

又多出了“新月形”骨折脱位这样一个伪概念。

The posterior lesion is, in some cases, confined to the ilium just anterior tothe sacroiliac joint and sometimes is a fracture dislocation of the sacroiliac joint with the fracture in the ilium being of varying size, producing the so-called crescent fracture.

译文：后环损伤，在一些病例中仅仅局限于恰恰位于骶髂关节前方的髂骨骨折，有时则表现为有着不同大小髂骨骨折块的骶髂关节骨折脱位，从而产生了所谓的“新月形骨折”。

2.Wade R Smith, Bruce H Ziran, Steven J Morgan主编的《Fractures of the Pelvis and Acetabulum》

Crescent Fractures

When the posterior pelvic disruption passes through the lower portion of the sacroiliac joint and exits through the ilium, this is known as a “crescent fracture.” A portion of the iliac wing remains attached to the sacrum by means of the sacro-iliac ligaments. The piece of bone fractured from the iliac wing resembles a crescentic moon, hence the term (Fig. 3A-H). The most common mechanism of injury is lateral compression, resulting in the wing being impinged against the dense sacral bone (22). These fractures are rotationally unstable, and are classified as lateral compression type II in the Young-Burgess classification system (23).

译文：经髂骨骨折的骨盆后环损伤累及骶髂关节的低位部分，就形成所谓的“新月形骨折”。髂骨翼骨折块借骶髂韧带连接于骶骨，形似新月，因而得名（图3A-H，选B及D）。可致使髂骨与骶骨撞击的侧方挤压暴力是最常见的损伤机制。这种骨折有旋转不稳定性，在Young-Burgess骨盆骨折分型系统中属LC-II型。

3.S. Terry Canale, James H. Beaty主编的《Campbell’s Operative Orthopaedics》12th editon

For fracture-dislocations of the sacroiliac joint (the so-called crescent fracture; Young and Burgess type LC II), the fracture can be reduced and fixed anteriorly or posteriorly, with or without hardware trans-fixing the sacroiliac joint.

译文：对于骶髂关节骨折脱位（即所谓的“新月形骨折”，也即Young-BurgessLC-II型骨盆骨折），其骨折部可通过前方或后方（入路）进行复位固定，骶髂关节可固定或不固定。

骶髂关节骨折脱位即所谓的“新月形骨折”，表述不精确，严格来讲，经髂骨的骶髂关节骨折脱位才是“新月形骨折”。

4.Charles M. Court-Brown, James D. Heckman, Margaret M. McQueen, William M. Ricci, Paul Tornetta III主编的《Rockwood & Green’s Fractures in Adults》8th editon

… the typical LC II has an iliac wing fracture or the “crescent” fracture, which is a fracture dislocation of the SI joint through the iliac wing…

译文：…典型的LC-II型骨盆骨折有着一个髂骨骨折部或者说是“新月形骨折”，后者是经髂骨的骶髂关节骨折脱位…

此“新月形骨折”的表述才算贴切。

The posterior lesion can be represented by a sacral fracture, SI joint dislocation, crescent fracture (SI fracture-dislocation), or an iliac wing fracture.

译文：骨盆后环损伤可表现为骶骨骨折、骶髂关节脱位、“新月形骨折”（骶髂关节骨折脱位）或者髂骨翼骨折。

此处的髂骨翼骨折应该是位于骶髂关节前方且累及坐骨大切迹的骨折。

四、“新月形骨折”的真面目

追本溯源，Andrew R. Burgess和Jeremy W. R. Young最有发言权。原著者关于“新月形骨折”的本意有几个不争的事实：①骨折由侧方暴力导致，②髂骨骨折线可位于或邻近骶髂关节前缘，③小块新月形髂骨后部骨块借骶髂后韧带与骶骨牢固相连，④新月形骨折块直边在前，为骨折线，弧边在后，包括髂后上下棘甚至部分坐骨大切迹，⑤髂骨骨折远端在损伤当时发生内旋。

要知道，Young-Burgess骨盆骨折分型系统出自162例有着完整资料的骨盆损伤病例，其中LC-II仅12例（7.4%），就算是LC-III型【15例（9.3%）】中有可能也存在“新月形骨折”，其最高例数为12+15=27（16.7%），根本无法将“新月形骨折”的形态学及影像学表现尽可能全面地包括在内并阐述清楚。有没有髂骨骨折线基本完全位于骶髂关节前方而骶髂关节稳定或者骨折线完全位于骶髂关节后方（不经骶髂关节）而骶髂关节不稳定等情况呢？

所以说，为知者要知其根本，为学者要学其要义，动态地发展地学，灵活地用。相信，我们心中已然对骨盆“新月形骨折”有了清晰的再认识。

最后，对于目前书籍和文献资料中比较容易混淆的概念加以梳理，请大家通过学习和思考加以明晰：

骶髂关节脱位：是单纯的脱位？包不包括骨折脱位？

骶髂关节骨折脱位：具体是经何部位的骨折脱位？

还是让我们表述的确切些吧！！！

1. 经髂骨的骶髂关节骨折脱位；

2. 经骶骨的骶髂关节骨折脱位；

3. 经髂骨且经骶骨的骶髂关节骨折脱位。