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PHTY2101 EOS > B3 L35: Pelvic & Acetabular Fractures > Flashcards

B3 L35: Pelvic & Acetabular Fractures Flashcards

1
Q

What are 5 functions of the pelvis?

A
  1. provide stability
  2. allow us to walk
  3. support in sitting
  4. large stable base of support (BOS)
  5. provide protection for all pelvic and abdominal structures (intestine, colon)
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2
Q

Is there a large or small amount of movement (nutation or counter-nutation) of the pelvis (sacroiliac joint)? What is the degree of movement?

A

Small amount of movement

2-3 degrees

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3
Q

Where is the pelvis mostly reinforced? Why?

A

Reinforced by ligaments, muscles POSTERIORLY

This is because this is where most force goes through (when WB)

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4
Q

What are the 3 parts of the bone that make up the coxa? Which part takes most the the weight during sitting?

A
  1. Ischium
  2. Pubis
  3. Ilium
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5
Q

What happens when there is a fracture of the pelvis? Be specific (2).

A
  1. Loss of stability
  2. Vertical instability (do not WB, flex/ext is fine) Rotational instability
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6
Q

What is the Young-Burgess system for pelvic fractures?

A

Classification system based on direction of force

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7
Q

What are the 4 classifications of a pelvis fracture in the Young-Burgess system?

A
  1. AP compression (APC)
  2. Lateral compression (LC)
  3. Vertical shear (VS)
  4. Combination
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8
Q

What are 2 features that AP compression (Young-Burgess system) fracture classified by?

A
  1. pubic diastases
  2. vertical #’s of pubic rami
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9
Q

What is the AP compression (Young-Burgess system) fracture caused by? Give 2 examples.

A

Caused by frontal collision (A-P force)

  1. Car vs pedestrian
  2. MB vs pole
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10
Q

What happens in an AP compression (Young-Burgess system) fracture? Where are 3 features of seperation/fracture?

A
  1. Hemipelvis bones seperated (due to direction)
  2. separation at pubic symphysis (PS), SIJ
  3. fracture through pubic rami
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11
Q

What are the 3 severity classifications (Young-Burgess system) of an AP compression pelvis fracture?

A
  1. APC 1
  2. APC 2
  3. APC 3
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12
Q

What are 3 characteristics of an APC 1 (pelvis fracture) based on the Young-Burgess system?

A
  1. Less than 2.5 cm of pubic diastases either at the symphysis or through vertically oriented rami fractures
  2. SI joints and posterior ligaments remain intact
  3. Stability is maintained (still have both vertical and rotational stability and no much restrictions)
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13
Q

How should an APC 1 (pelvis fracture) based on the Young-Burgess system be managed?

A

Conservatively

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14
Q

What are 4 characteristics of an APC 2 (pelvis fracture) based on the Young-Burgess system?

A
  1. Pubic diastases exceeds 2.5 cm
  2. Divergent SIJ widening
  3. Posterior ligaments disrupted except post SI ligament
  4. Rotationally unstable (which can cause further separation), vertically stable
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15
Q

What are 3 characteristics of an APC 3 (pelvis fracture) based on the Young-Burgess system?

A
  1. Uniform SIJ widening (>2.5cm)
  2. Complete posterior ligament disruption
  3. Vertically and rotationally unstable
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16
Q

In an AP compression pelvic fracture, what is the pubic diastasis in an APC 1,2 and 3?

A

APC 1: <2.5cm

APC 2: >2.5cm

APC 3: >2.5cm

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17
Q

In an AP compression pelvic fracture, are the posterior ligaments intact or disrupted in an APC 1,2 and 3?

A

APC 1: Intact

APC 2: Disrupted

APC 3: Disrupted

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18
Q

In an AP compression pelvic fracture, are the SIJ ligaments intact or disrupted in an APC 1,2 and 3?

A

APC 1: Intact

APC 2: Intact

APC 3: Disrupted

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19
Q

In an AP compression pelvic fracture, is the fracture stable in an APC 1,2 and 3? Be specific with vertical and rotational stability.

A

APC 1: Yes

APC 2: vertical- yes; rotational- no

APC 3: vertical- no; rotational- no

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20
Q

What are 2 features that lateral compression (Young-Burgess system) fracture classified by?

A
  1. horizontal pubic rami #’s
  2. locked symphasis
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21
Q

What is the AP compression (Young-Burgess system) fracture caused by? Give 2 examples.

A

Side on road accident or fall from height onto side

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22
Q

What are the 3 severity classifications (Young-Burgess system) of a lateral compression pelvis fracture?

A
  1. LC 1
  2. LC 2
  3. LC 3
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23
Q

What are 4 characteristics of a LC 1 (pelvis fracture) based on the Young-Burgess system?

A
  1. Ipsilateral anterior sacral impaction
  2. Ipsilateral horizontal pubic rami # (compressive force on SIJ = no contralateral effect)
  3. Posterior ligaments
  4. Pelvis stable
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24
Q

What are 4 characteristics of a LC 2 (pelvis fracture) based on the Young-Burgess system?

A
  1. Ipsilateral anterior sacral impaction
  2. Ipsilateral horizontal pubic rami fracture
  3. Ipsilateral fracture of iliac wing
  4. Pelvis rotationally unstable (flex/ext is not fine), vertically stable (WB is fine)
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25
What are 3 characteristics of a LC 3 (pelvis fracture) based on the Young-Burgess system?
1. Contralateral side effected, externally rotated (large enough to cause disruption) 2. LC II injury + contralateral injuries 3. Rotationally unstable, ? vertically stable/unstable (depend on how significant contralateral side..etc)
26
What are 4 characteristics of a vertical shear (VS) (pelvis fracture) based on the Young-Burgess system?
1. One hemipelvis is displaced vertically 2. Pubic symphasis separation or vertical pubic rami fractures 3. Disruption to sacroiliac region 4. Severe unstable injuries associated with soft tissue tearing & retroperitoneal bleeding (tearing of bladder and urethral structures)
27
What is a vertical shear (VS) (pelvis fracture) based on the Young-Burgess system caused by?
Fall from height onto 1 leg
28
What is the Bucholz Classification of pelvic fractures based on? What are 2 reasons why this classification is used?
assessment of stability 1. Instability is secondary to bony and ligamentous disruption of the pelvic ring 2. Degree of ligamentous disruption is a key to stability because fracture alone will not produce instability without associated displacement and ligamentous disruption.
29
Instability is secondary to ___ and _____ disruption of the pelvic ring
bony; ligamentous
30
Degree of ______ disruption is a key to stability because fracture alone will not produce instability without associated displacement and _____ disruption.
ligamentous; ligamentous
31
What is the benefit of the Bucholz Classification of pelvic fractures?
Very quick to assess and classify
32
What is the disadvantage of the Bucholz Classification of pelvic fractures?
Not very specific
33
What are the 3 severities of pelvic fractures in the Bucholz Classification?
1. Type I 2. Type II 3. Type III
34
What are 2 characteristics of a type II pelvic fracture in the Bucholz Classification?
1. Anterior fracture, partial disruption of posterior SI ligaments 2. Stable fracture, able to WB  Type
35
What are 2 characteristics of a type I pelvic fracture in the Bucholz Classification?
1. Anterior instability &partial posterior instability 2. Unstable fracture, ligaments intact
36
What is a characteristic of a type III pelvic fracture in the Bucholz Classification?
Complete anterior & posterior instability
37
What is the Tile Classification of pelvic fractures?
Most simplistic view of classification
38
What are the 3 severities of pelvic fractures in the Tile Classification?
1. Type A 2. Type B 3. Type C
39
What is a characteristic of a type A pelvic fracture in the Tile Classification?
Stable
40
What are 2 characteristic of a type B pelvic fracture in the Tile Classification?
1. Rotationally unstable 2. vertically stable
41
What are 2 characteristics of a type A pelvic fracture in the Tile Classification?
1. Rotationally unstable 2. Vertically unstable
42
What is the AO/OTA classification system of pelvic fractures based on? How are they classified based on?
Stability Groups and subgroups based on specific area of injury within pelvis
43
What are the 3 severities of pelvic fractures in the AO/OTA Classification system?
A: Stable B: Partially stable C: Completely unstable
44
What does a normal pelvis look like on imaging?
45
What does a fractured pubic rami look like on imaging? What can you see?
lost congruency of iliopectineal line
46
What are 2 types of common stable pelvic fractures?
1. Pubic rami fractures 2. Minimally displaced pubic symphysis fractures
47
What is the mechanism of injury (MOI) of stable pelvic fractures?
low energy forces, osteoporotic bone, fall in the elderly
48
What are the signs of a stable pelvic fracture?
pain in the groin especially on WB
49
What are 4 things that can be done as medical management of a stable pelvic fracture?
1. Usually non-operative 2. WBAT 3. Analgesia 4. Pelvic binder (APC I - \<2.5cm pubic diastasis)
50
What are 6 physiotherapy interventions for patients with a stable pelvic fracture?
1. Systems maintenance 2. Teaching bridge and block rolling 3. Mobility as per orders (usually WBAT) on appropriate aid (usually a rollator) * Time with optimal analgesia 4. Progress hip & knee strength exercises as pain decreases and mobility improves 5. Ensure a multidisciplinary, multi-factorial approach is used in the investigation of why this person fell * Address any balance deficits ( fracture is usually due to fall- is there balance problem?) 6. D/C when independently mobile with appropriate walking aid * Rehab vs DC from ward (control pain and increased function)
51
What are 3 characteristics of unstable pelvic fractures?
1. Fractures involving disruption to posterior ligaments 2. Multiple fractures of pelvic ring 3. Open book fractures
52
What is the most common way to manage an unstable pelvic fracture?
1. Usually require operative management 2. Sometimes managed with traction
53
What is the purpose of traction in a pelvic fracture (esp. unstable)?
decrease weight off pelvis- until fracture is stable
54
When would traction be used in a pelvic fracture? List 2 circumstances.
1. Used at expense of early mobilisation 2. Used when patient not appropriate for operative fixation 3. Until fracture becomes stable
55
What are the 2 aims of operative management?
1. Achieve reduction 2. Address leg length discrepancies (VS injuries)
56
What is an Ex Fix?
Anterior External Fixation
57
When would an Ex Fix be used?
temporary measure before internal fixation
58
What is an Anterior Internal Fixation? What are the 2 aims?
1. reduction of fracture 2. stabilisation of fracture
59
What is a Pelvic C Clamp – Posterior Ex Fix?
60
What is a Pelvic C Clamp – Posterior Ex Fix used for? 2 aims.
for SIJ instability compression of SIJ for healing to occur
61
What is the disadvantage of a Pelvic C Clamp – Posterior Ex Fix?
some complications- fusing of SIJ
62
What is a posterior internal fixation? What is the aim?
regain stability by compression
63
What are 3 components of the posterior internal fixation?
1. Posterior screw fixation 2. Reconstruction plate 3. Transiliac sacral bars
64
What are 5 factors that affect rehab and post-op management?
1. Degree of pelvic injury –WB areas affected or not 2. Associated injuries 3. Pain 4. WB progressions 5. ROM restrictions
65
What is the general timeline for rehab at the Royal Brisbane and Women's Hospital?
RIB first 48hrs --\> 6-8/52 TWB --\> 6/52 PWB/WBAT
66
What are 4 processes to follow when using skeletal traction?
1. Maintenance program – UL, non affected LL 2. Hip ROM exercises reclined as per orders 3. Traction 6-8/52, NWB 12/52 4. Split bed Mx (allows for some movement while in bed (can remove section of bed) Knee F/E, quads strengthening
67
When is skeletal traction used?
When patient is unsuitable for surgical treatment
68
What are 9 things to follow when post fixation operation?
1. As per post op orders 2. Increase sitting time within restrictions in prep to mobilise 3. Systems maintenance 4. Hip and knee flexion to pelvic tilt or within pain provided fixation is satisfactory. 5. May need tilt table to mobilise (adjust slowly to vertical) 6. can sometimes progress to FWB quickly 7. Associated injuries usually dictate the method and rate of mobilisation 8. On Drs orders split bed technique +/- bridging 9. Hydrotherapy to progress WB
69
Pelvic fractures are usually cause with ____ (high/low) impact/traumatic injuries associated with other, often severe injuries
high
70
Pelvic fractures are classified based on ___ of force and \_\_\_\_\_.
direction; stability
71
Stable fractures are managed \_\_\_\_(WBAT) while unstable require \_\_\_\_\_\_.Usually ____ (vertical/rotational) instability worse than ____ (vertical/rotational) instability (Ex fix & internal fixation).
conservatively; fixation; vertical; rotational
72
Rehab is ______ (fixed/variable) due to variability of fractures & associated injuries. Be guided by Dr’s orders
variable
73
Sitting creates ____ (anterior/posterior) wall pressure in acetabulum; __ and ____ causes anterio wall pressure
posterior; ER; Abd
74
What is the mechanism of injury of an acetabular injury?
Head of femur is driven into acetabulum
75
Fracture pattern depends on position of femoral head at time of impact. What are the 3 types of fracture patterns?
Direct lateral impact (fall from height, MVA) Impact anteriorly through knee (dashboard injury) Hip x-ray required when #calcaneum, #femur or severe knee injury
76
In a direct lateral impact (eg. fall from height, MVA), when the hip is in neural, what type of acetabular fracture is caused?
Transverse column fracture (anterior and posterior column)
77
In a direct lateral impact (eg. fall from height, MVA), when the hip is in ER and abd, what type of acetabular fracture is caused?
anterior column #
78
In a direct lateral impact (eg. fall from height, MVA), when the hip is in Ir and add, what type of acetabular fracture is caused?
post column #
79
With an impact anteriorly through knee (dashboard injury) what type of acetabular fracture is caused? What position will the force go through?
Posterior column injury (force through a flexed, IR hip) As knee flex ↑, post column affected more inferiorly & vice versa
80
Hip x-ray required when #\_\_\_ , # or severe ___ injury. Why?
calcaneum; femur; knee These injuries share similar MOI
81
What is the Letournel system for acetabular injuries?
has 5 simple and 5 complex classifications
82
What are the 5 simple (isolated) acetabular injuries in the Letournel system?
1. Posterior wall # 1. Most commo associated w dislocation 2. Posterior column # 3. Anterior wall # 4. Anterior column # 5. Transverse #
83
What are the 5 complex acetabular injuries in the Letournel system?
1. Posterior column w posterior wall # 2. Transverse w posterior wall # 3. T – type fracture # 4. Anterior column w posterior hemitransverse # 5. Both column #
84
What are 2 things that displacement of an acetabular fracture fragments leads to?
1. Articular incongruity of the hip joint 2. Abnormal pressure distribution on the articular cartilage surface
85
In the long term, what does an acetabular fracture lead to increased risk of?
rapid breakdown of the cartilage surface, resulting in OA
86
What is the main treatment goal for acetabular injuries?
Reduction and stable fixation of the fracture to achieve congruency between the femoral head & acetabulum
87
What are the 4 instances where non-operative management is used for acetabular injuries?
1. Minimal displacement (\<2mm of displacement) 2. Congruency of ball & socket spared 3. Elderly where closed reduction feasible 4. Medically unfit/unstable for surgery
88
What are 4 type of non-operative management in an acetabular injury?
1. NWB (non WB) /TWB (traction WB) for period 2. Closed reduction 3. Skeletal longitudinal traction +/- lateral traction 6-8 wks (Not appropriate in elderly- Bed rest detrimental) 4. Physiotherapy
89
What are 7 physiotherapy processes to include in non-operative management?
1. Hip ROM maintained during this period (Establish limits with Dr) 2. Pain limited static gluts, quads foot and ankle 3. Systems maintenance 4. Active-assisted hip/knee exs in line of traction 5. Split bed on Drs orders 6. Maintenance ex prog 7. PWB for 6/52 following traction
90
What are 5 indications for operative management in acetabular injuries?
1. Hip remains unstable after closed reduction 2. Failure of conservative Mx 3. Significant disturbance to congruency between femoral head & acetabulum 4. Associated femoral fracture 5. Retained bone fragments in joint
91
What are 2 indications for operative management, ORIF, in acetabular injuries?
1. Indicated for majority of elderly pts sustaining displaced fractures 2. Quality of reduction is single most important factor * \<2mm – 13% OA * \>2mm – 45% OA
92
What are 2 indications for operative management, delayed THA, in acetabular injuries?
1. Staged procedure following initial treatment 2. Salvage procedure following * Failed ORIF * Progressive OA following conservative Mx (only have a lifespan of 10-15yrs and only limited number of revisions)
93
What are 2 indications for operative management, acute THR, in acetabular injuries?
1. Shortest recovery time, early mobilisation, avoidance of subsequent operation 2. Used in conjunction with ORIF to stabilise columns
94
In acetabular injuries, do a acute ORIF with ___ if femoral head injury or reduction not attainable.
THR
95
What is the method of treatment if fracture characteristics predictive of anatomic articular reduction
ORIF
96
What is the method of treatment if fracture characteristics predictive of early post traumatic arthritis?
ORIF + acute THA
97
How should physiotherapy be managed in an ORIF? List 3 processes.
1. Limit WB as per Dr’s orders 2. Graded strengthening ex’s 3. Systems maintenance (respiratory, circulatory, MSK systems)
98
How should physiotherapy be managed in a THR? List 2 processes.
1. Refer to THR slides in elective LL surgery 2. Limited WB as still need column fractures to heal
99
In acetabular injuries, it is usually _ (high/low) impact/traumatic injuries associated with other, often severe injuries. What does this mean patients are predisposed to?
high; OA
100
What is classification of acetabular injuries based on? Give examples.
area of acetabulum effected (Post/ant, wall, column, transverse, combinations)
101
What are 2 non-operative management techniques for acetabular injuries?
1. TWB 2. NWB
102
When would operative management be used? give 3 examples of techniques.
Fixation required if poor reduction 1. ORIF 2. THR 3. combination

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