leziuni traumatice ale coloanei cervicale proximale (o – c2)
DESCRIPTION
LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2). CHIRURGIE SPINAL Ă - CURS 3. Coloana cervicală proximală (înaltă) prezintă o anatomie unică, cu elemente osoase solide şi ligamente puternice. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/1.jpg)
LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE
(O – C2)
CHIRURGIE SPINALĂ - CURS 3
![Page 2: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/2.jpg)
Coloana cervicală proximală (înaltă) prezintă o anatomie unică, cu elemente osoase solide şi ligamente puternice.
Este alcătuită din articulaţiile O-C1 şi C1-C2 (structuri osteo-ligamentare) + structuri neurovasculare
Funcţii – tranziţie între craniu şi coloana vertebrală
- protecţia măduvei
- permite o mare parte a mobilităţii regiunii – strâns legată de sistemul vizual
Lezarea presupune traumatisme semnificative (decelerări bruşte, direct trauma la nivelul craniului sau feţei)
Leziuni traumatice concomitente – la 10-20%
Leziuni neurologice – rare, dar grave
![Page 3: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/3.jpg)
ANATOMIE
1. Occiput
• Partea scuamoasă – post. de foramen magnum şi fuzează rostral cu osul parietal la niv. suturii lambdoide
• Opistion – demarcarea mediană post. a foramen magnum
• Condilii occipitali – se articulează cu atlas. Anterior – canalul hipoglos, în lateral – foramenul jugular (v jugulară int şi nv IX, X, XI).
• Basion - demarcarea mediană anterioară a foramen magnum
![Page 4: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/4.jpg)
2. Atlas
![Page 5: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/5.jpg)
3.Axis
![Page 6: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/6.jpg)
![Page 7: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/7.jpg)
4. Ligamente
a. Craniocervicale externe – lig nuchal
- membrana occipito-atlantoidiană ant + post
- membrana atlanto-axoidiană ant + post
![Page 8: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/8.jpg)
b. Craniocervicale interne
- Localizate anterior de măduvă, în 3 straturi
Mb. Tectoria
Lig cruciform
Lig apicale, alare
![Page 9: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/9.jpg)
5. Structuri neurovasculare
a. Măduva
b. Arterele vertebrale
![Page 10: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/10.jpg)
![Page 11: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/11.jpg)
![Page 12: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/12.jpg)
![Page 13: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/13.jpg)
![Page 14: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/14.jpg)
Biomecanică
O-C1 – flexie-extensie 15-35°
Flexia – limitată de impactul basion – vf. odontoidei
Extensia – limitată de impactul occiput – arc post atlas
C1-C2 - flexie-extensie 5-20°
- rotaţia 35° - limitată de lig alare controlaterale
Translaţii – 2mm O-C1
- 3mm C1-C2
Mecanisme de producereAdams – 155 pacienţi decedaţi în accidente de trafic
- 12 – dislocaţii O-C1 + lez c-c
- 14 – dislocaţii C1-C2
- 6 – fx odontoidă
- 21 – lez ligamentare – lig alare -20
![Page 15: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/15.jpg)
Evaluarea pacientuluiClinic
• măsuri de resuscitare
• Dureri locale, limitaea mişcărilor, crepitaţii, semne neurologice
• !!! Pacientul comatos
• Ex clinic – neurologic – scala ASIA, nv cranieni VI, VII, IX, XI, XII
• Leziuni asociate c-c, faciale
Evaluare Rx, CT, IRM, Rx dinamice
Stabilitatea
Leziuni osoase, ligamentare, mixte
![Page 16: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/16.jpg)
CLASIFICAREA. După localizarea leziunii Leziuni ligamentare 1. dislocaţii occipito-cervicale (O-C1) 2. leziuni ligament transvers 3. luxaţii rotatorii C1-C2 Fracturi izolate 1. fx condil occipital 2. fx C1 (mase laterale, inel) 3. fx odontoidă Leziuni osteo-ligamentare
B. După nivelul leziunii 1. occiput (fx condil) 2. O-C1 ligamentare (luxaţii O-C1) 3. C1 (fx inel) 4. C1-C2 ligamentare (lez lig transvers) 5. C2 (fx odontoidă, hangman etc)
C. După gradul de stabilitate 1. Stabile 2. cu instabilitate tardivă 3. instabile
![Page 17: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/17.jpg)
Fractura condililor occipitali
• leziuni puţin frecvente, 90% unilaterale
• Produse prin mecanism de compresiune axială sau deceleraţie bruscă
• Clinic – dureri suboccipitale, cervicale înalte, limitarea mişcărilor
- semne neurologice
• Rx , CT
• Clasificare Anderson Montesano
1988
• Tratament
– imobilizare în guler cervical 6-8 săpt.
- în leziuni instabile sau asociate
cu leziuni cervicale – artrodeză
occipito-cervicală
![Page 18: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/18.jpg)
LUXAŢII OCCIPITO-CERVICALE (O-C1)
Leziuni rare, prin hiperflexie – distracţiune (high-impact blunt trauma)
• Instabile, grave – deces; compresiune, torsiune a măduvei + nv cranieni + a vertebrală
• Frecvenţa – 8-19%
• Dg – Rx – uneori dificil de interpretat, asociate cu TCC grave
- ↑ ţesuturi moi prevertebrale, ↑ distanţei basion-odontoidă, separare condili occipitali – mase laterale C1
- CT
- IRM
![Page 19: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/19.jpg)
![Page 20: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/20.jpg)
![Page 21: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/21.jpg)
![Page 22: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/22.jpg)
![Page 23: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/23.jpg)
![Page 24: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/24.jpg)
Tratament – iniţial imobilizare halo ( nu guler, tracţiune!)
- chirurgical – artrodeză occipito-cervicală
![Page 25: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/25.jpg)
![Page 26: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/26.jpg)
![Page 27: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/27.jpg)
![Page 28: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/28.jpg)
![Page 29: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/29.jpg)
Fracturile atlasului
• 5% fx izolate, 10-20% asociate cu alte leziuni cervicale
• Mec de producere – compresie axială, hiperextensie
• Asociate cu leziuni ale ligam transvers
• Rx, CT
![Page 30: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/30.jpg)
• ≥ 6,9mm - ruptura lig transvers - instabile
![Page 31: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/31.jpg)
![Page 32: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/32.jpg)
![Page 33: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/33.jpg)
![Page 34: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/34.jpg)
![Page 35: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/35.jpg)
Leziunile ligamentului transvers
• Leziuni instabile
• Hiperflexie
![Page 36: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/36.jpg)
![Page 37: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/37.jpg)
![Page 38: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/38.jpg)
![Page 39: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/39.jpg)
![Page 40: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/40.jpg)
INSTABILITĂŢI ATLANTO-AXOIDIENE C1-C2
“nonphysiologic motion C1-C2”
• Se produc datorită leziunilor ligam transvers sau ligam alare, apof odontoide, arc anterior atlas, mase laterale atlas
• Cele mai frecvente – subluxaţii anterioare prin ruptura ligam transvers
- verticale, posterioare, laterale, rotaţionale
Mecanisme de producere
• Instabilitatea C1-C2 – prin lezarea structurilor (arc anterior C1, odontoida, ligam transvers, ligam alare)
• Fx odontoidă – deplasate anterior/posterior
• Lezarea ligam transvers – ant/post (84kg forţă)
• Forţe verticale (fx C1) – asociate cu instabilităţi cranio-cervicale (30-50%)
• Instabilitate rotaţională – leziuni ligam alare
- sdr. Grisel
- luxaţia posterioară C1-C2 (distracţiune)
![Page 41: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/41.jpg)
Diagnostic
Rx - ↑ ADI
- modificarea liniei spinolaminare C1-C2-C3
- ↑ distanţei interlaminare C1-C2
A-P – modificarea simetriei mase laterale
![Page 42: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/42.jpg)
Rx dinamice
![Page 43: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/43.jpg)
![Page 44: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/44.jpg)
Clasificare – fcţ de direcţia de deplasare şi tipul leziunii osteo-ligamentareA. Anterioare 1. Ruptura ligam transvers2. Fx odontoidă3. Instabilitate occipito-cervicală asociată4. Jefferson fx instabilăB. Posterioare 1. Fx odontoidă2. Luxaţii post C1-C2 (tip IV Fielding)C. Laterale1. Fx masă laterală C12. Fx masă laterală C23. Ruptura ligam alar unilateralD. Rotatorii1. Subluxaţii C1-C2 (Fielding I)2. Rupturi ligam transvers 3-5mm (Fielding II)3. Rupturi ligam transvers + alar >5mm (Fielding III)E. Verticale 1. Rupturi ligam alar + mb tectoria
![Page 45: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/45.jpg)
Subluxaţii rotatorii C1-C2
• Leziuni ligamentare, mai frecvente la copii şi adolescenţi
• Clinic – dureri cervicale , poziţie caracteristică “cocked-robin”
![Page 46: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/46.jpg)
• Rx profil, CT
![Page 47: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/47.jpg)
![Page 48: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/48.jpg)
• Rx “open-mouth”- asimetrie C1-C2 mase laterale
![Page 49: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/49.jpg)
Instabilitatea rotatorie
clasificarea Fielding
![Page 50: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/50.jpg)
Tratament – repaus, imobilizare, miorelaxante
- tracţiune
- chirurgical – lez ireductibile, recurente, lez ligam transvers
![Page 51: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/51.jpg)
Instabilităţi verticale
![Page 52: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/52.jpg)
![Page 53: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/53.jpg)
![Page 54: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/54.jpg)
![Page 55: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/55.jpg)
![Page 56: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/56.jpg)
![Page 57: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/57.jpg)
![Page 58: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/58.jpg)
Instabilităţi posterioare
Caz 1
![Page 59: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/59.jpg)
Caz 2
![Page 60: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/60.jpg)
![Page 61: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/61.jpg)
![Page 62: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/62.jpg)
![Page 63: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/63.jpg)
![Page 64: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/64.jpg)
• Caz 3
![Page 65: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/65.jpg)
![Page 66: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/66.jpg)
Fracturile de apofiză odontoidă
• Frecvenţa – 8-10%
• De obicei benigne, însă 10% - asociate cu SCI
• Asociată cu alte leziuni – 10-20% (fx arc posterior C1)
Mecanism de producere – la tineri – prin acceleraţie-deceleraţie bruscă
- la vârstnic – prin căderi
Biomecanic – forfecarea anterioară – forţele aplicate în direcţie anterioară tensionează ligam transvers – fx odontoida (10% din fx însoţite de leziuni ale ligam transvers)
- forfecarea posterioară – arcul anterior C1 forţează odontoida – fx
Forţele rotaţionale – rol important
Diagnostic – cea mai frecventă fx ce scapă dg iniţial !!!
Clinic – dureri cervicale proximale
- dificultăţi de deglutiţie (hematom retrofaringian)
- senzaţie de instabilitate clinică cranio-cervicală
Rx profil, open-mouth, CT
![Page 67: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/67.jpg)
Clasificare Anderson – D’Alonzo
![Page 68: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/68.jpg)
Roy-Camille
![Page 69: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/69.jpg)
![Page 70: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/70.jpg)
![Page 71: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/71.jpg)
![Page 72: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/72.jpg)
![Page 73: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/73.jpg)
![Page 74: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/74.jpg)
Tratament
Iniţial – imobilizare – tracţiune
- halo
Tip I – imobilizare în guler cervical 6 -8 săpt
Tip II – tratament controversat (conservativ – rată ↑ de eşec; chirurgical - ↓ mobilităţii, complicaţii)
• Fără imobilizare – pseudartroză 100%
• Cu halo-vest – 15-85%
• Pseudartroza – deplasare >5mm (Clark, J Bone Joint Surg, 1985)
- deplasare >6mm (Hadley, Neurosurgery, 1988)
- tip IIa (cominuţie la nivelul fx) – Hadley
- tip oblic-anterior (Aebi, Spine, 1989)
- tracţiune prelungită
- vârsta ↑
- interpoziţia ligam transvers
![Page 75: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/75.jpg)
• Prognostic bun – cu traiect transversal, fără cominuţie, deplasare < 5mm
Tratament – imobilizare în Minerva, halo-vest 12 săpt., controale periodice
- alternativ – osteosinteză cu şurub anterior
Indicaţiile tratamentului chirurgical:
• Fx deplasate > 5mm
• Cominuţie
• Angulaţie
• Tip oblic anterior
• Lez neurologice asociate
• Lez pulmonare asociate
Opţiuni terapeutice chirurgicale (pacient tânăr)
1. Osteosinteza cu şurub anterior
2. Fuziune (artrodeză) posterioară C1-C2
![Page 76: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/76.jpg)
Osteosinteza cu şurub anterior
• Limitare parţială a mobilităţii
• Succes 90%
• Complicaţiile abordului anterior înalt (5-20%)
• Risc scăzut de lezare neurologică (Montesano, Spine, 1991)
• Teoretic, 2 şuruburi controlează mai bine rotaţia în focar; totuşi, nu există diferenţe semnificative între utilizarea a 1 sau 2 şuruburi (Sasso, Spine, 1993; McBride, Spine, 1995; Jenkins, J Neurosug, 1998)
Artrodeza posterioară C1-C2
• Fixarea transarticulară C1-C2 (Magerl, Harms)
• Artrodeza Gallie, Brooks – stabilizare insuficientă, deplasări posterioare secundare, reducere marcată a mobilităţii, complicaţii neurologice, necesită imobilizare postop
![Page 77: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/77.jpg)
![Page 78: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/78.jpg)
![Page 79: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/79.jpg)
![Page 80: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/80.jpg)
![Page 81: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/81.jpg)
Fracturile de odontoidă la vârstic
• Mecanism de producere – căderi, low-velocity trauma
• Asociată cu morbiditate/mortalitate ↑ (asemănătoare fx şold)
• Tratamentul conservativ (imobilizare, tracţiune, halo) – prost tolerate
• Tratam chirurgical – la pacienţi “sănătoşi” – artrodeză posterioară C1-C2 (fixare transarticulară)
- la cei cu tare – imobilizare simplă (pseudartroză!)
![Page 82: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/82.jpg)
![Page 83: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/83.jpg)
Fracturile de odontoidă la copil
!!! Dificil de diagnosticat şi diferenţiat de sincondroza C2
• Cartiljul de creştere – situat la joncţiunea odontoidă –corp C2
- fuzionează la 11 ani
• Deplasările –rare – dg dif dificil
• Tratament – imobilizare în halo-vest
- chirurgical – în leziuni instabile, fx deplasate, ireductibile
![Page 84: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/84.jpg)
![Page 85: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/85.jpg)
![Page 86: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/86.jpg)
![Page 87: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/87.jpg)
Fracturi corp vertebral C2
![Page 88: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/88.jpg)
Clasificarea Benzel 1994
![Page 89: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/89.jpg)
Tip I ( coronally oriented vertical)• Traiect de fx orientat în plan coronal la niv porţiunii post a corpului vertebral
• 4 mecanisme de producere:
a. Extensie + compresiune axială
![Page 90: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/90.jpg)
b. Hiperextensie + compresiune axială
![Page 91: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/91.jpg)
c. Flexie + compresiune axială
d. Flexie + distracţiune
![Page 92: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/92.jpg)
Tip II ( saggitally oriented vertical)
![Page 93: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/93.jpg)
Tip III ( horizontal rostral)- Asemănătoare fx odontoidă tip III
Diagnostic – Rx, CT
- ! Căutăm semne de lezare a a. vertebrale
Stabilitatea leziunii – caracteristici CT (deplasare, angulaţie)
- rx dinamice
Tratament - majoritatea – conservativ – guler, halo
- chirurgical – artrodeză posterioară C1-C2 – în leziuni instabile
![Page 94: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/94.jpg)
Traumatic spondylolisthesis of the axis(fractură-luxaţie C2-C3, “hangman’s fx”)
Fractură bilaterală prin C2 pars interarticularis/pediculi
Schneider – prima descriere la cei spânzuraţi (judiciar)
![Page 95: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/95.jpg)
Mecanism de producere – hiperextensie + impact frontal
- fx la nivelul istmului + lez disc C2-C3
- componenta de flexie (frecvent angulate anterior)
- rotaţie + înclinare laterală
Simptomatologie
• Semne de lezare cranio-facială
• Semne neurologice – rare (canal larg)
• Dureri locale, contracturi musculare, impotenţă fcţ relativă
• Lezarea arterei vertebrale
![Page 96: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/96.jpg)
![Page 97: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/97.jpg)
![Page 98: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/98.jpg)
![Page 99: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/99.jpg)
![Page 100: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/100.jpg)
CLASIFICARE
Efendi
Edwards – Levine
Tip I
Tip II
Tip IIA
Tip III
![Page 101: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/101.jpg)
![Page 102: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/102.jpg)
Tratament
• Tip I– tratam conservativ –imobilizare în orteză cervico-toracală
• Tip II – reducere (tracţiune) şi imobilizare în halo-vest
• Tip IIa – reducere + imobilizare în halo-vest
- dacă nu se reduce – chirurgical – posterior
- anterior
• Tip III – instabile - chirurgical
![Page 103: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/103.jpg)
![Page 104: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/104.jpg)
![Page 105: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/105.jpg)
![Page 106: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/106.jpg)
![Page 107: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/107.jpg)
![Page 108: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/108.jpg)
![Page 109: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/109.jpg)
COMPLICAŢII
• Morbiditate + mortalitate semnificative• Mortalitatea – la locul accidentului - în timpul spitalizării iniţiale - la vârstnic cu fx odontoidă – 23-26%• Leziuni neurologice – asociate cu tulburări respiratorii – intubaţie + suport
respirator - uneori necesită traheostomie
DIAGNOSTIC ÎNTÂRZIAT • Variaţii anatomice• Suprapuneri elem osoase – vizualizare dificilă• Integritatea ligamentară• Asociate cu alte leziuni cervicale (20-30%)DETERIORĂRI NEUROLOGICE• Rare, doar asociate cu o leziune nediagnosticată (75%, Budshuk, 1993)• Necesită evaluare rx + IRM imediate• Hematoame epidurale, lez vasculare• Tratam – metilprednisolon, decompresiune, reducere, stabilizare
![Page 110: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/110.jpg)
LEZIUNI VASCULARE
• Mult mai frecvente decât sunt apreciate (Friedman, Am J Roentgenol, 1995)
• Consecinţele clinice ale leziunilor izolate sunt incerte, deşi cazurile de stroke sau deces, deteriorări neurologice s-au observat secundar post lez a vertebrală şi tromboză a bazilară
• Luxaţii occipito-cervicale, luxaţii rotatorii C1-C2, fx cu implicarea foramen transversarium
PSEUDARTROZA
• Cel mai frecvent după fx odontoidă tip II – necesită tratam chirurgical
PIERDEREA REDUCERII
• După tratam conservativ
• Luxaţii O-C1, lez ligam transvers, fx odontoidă, hangman’s fx
• Necesită controale rx repetate, în ortostatism – TRATAM CHIRURGICAL
DURERI CRONICE, DISABILITĂŢI
![Page 111: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/111.jpg)
LEZIUNI COMPLEXE C1-C2
Incidenţă – 3% din totalul leziunilor cervicale
- 43% din totalul fx C1
- 16% din totalul fx C2
Mai frecvente la copii – accidente rutiere şi la vârstnici – căderi
Tratament – conservativ – 50% eşuat
- CHIRURGICAL
![Page 112: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/112.jpg)
![Page 113: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/113.jpg)
Opţiuni tratament chirurgical
• Tratament chirurgical fcţ de leziunea C2 (Dickman , J Neurosurg, 1989)
![Page 114: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/114.jpg)
• Tratament chirurgical fcţ de leziunea C2-C3 (Apostolides, J Neurosurg , 1997;
Weller, Surg Neurolog, 1997)
![Page 115: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/115.jpg)
Complex C1+C2 caz 1
![Page 116: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/116.jpg)
![Page 117: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/117.jpg)
![Page 118: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/118.jpg)
![Page 119: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/119.jpg)
Caz 2
![Page 120: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/120.jpg)
![Page 121: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/121.jpg)
![Page 122: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/122.jpg)
![Page 123: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/123.jpg)
Caz 3
![Page 124: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/124.jpg)
![Page 125: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/125.jpg)
![Page 126: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/126.jpg)
![Page 127: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/127.jpg)
![Page 128: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/128.jpg)
![Page 129: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/129.jpg)
Caz 4
![Page 130: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/130.jpg)
![Page 131: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/131.jpg)
Caz 5
![Page 132: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/132.jpg)
![Page 133: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/133.jpg)
Caz 6
![Page 134: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/134.jpg)
![Page 135: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/135.jpg)
Caz 7
![Page 136: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/136.jpg)
![Page 137: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/137.jpg)
Caz 8
![Page 138: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/138.jpg)
![Page 139: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/139.jpg)
Caz 9
![Page 140: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/140.jpg)
![Page 141: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/141.jpg)
Caz 10
![Page 142: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/142.jpg)
![Page 143: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/143.jpg)
Caz 11
![Page 144: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/144.jpg)
![Page 145: LEZIUNI TRAUMATICE ALE COLOANEI CERVICALE PROXIMALE (O – C2)](https://reader038.vdocuments.site/reader038/viewer/2022102510/56813bf5550346895da53fe4/html5/thumbnails/145.jpg)