Fraction of the pelvis.

Question 1

what causes pelvis ring fracture ?

Answer 1

typically high energy blunt trauma

mortality rate up to 50 percent if open fracture

Question 2

what increases the mortality with pelvis ring fracture ?

Answer 2

systolic BP less than 90 
age more than 60 
increased injury severity score and revised trauma score
need for transfusion 
APC 3 score

Question 3

what is the revised trauma score ?

Answer 3

15-13 - GCS
90 mmhg - SBP
10-29 - RESP R
= 4

9-12 - GCS
75-89mmhg
>30 RR
= 3

6-8 -GCS
50-75mmhg
6-9 - RR
=2

4-5
1-49mmhg
1-5 RR
=1

Question 4

what are the orthopaedic and non orthopaedic related injury to pelvic ring fracture ?

Answer 4

chest injury
long bone
spine

non orthopaedic
urogenital - sexual dysfunction
head and abdominal

Question 5

what are the prognosis in pelvic ring injury ?

Answer 5

high prvelance in poor outcome and chronic pain

the poor outcome is associated with -
SI joint separation of more than 1 cm
high degree of initial displacement
leg length discrepancy of 2cm

Question 6

what is the classification of young burgees for pelvic ring ?

Answer 6

YOUNG BURGEES

anteroposterior compression

APC I
Symphysis widening < 2.5 cm

APC II
Symphysis widening > 2.5 cm. Anterior SI joint diastasis . Posterior SI ligaments intact. Disruption of sacrospinous and sacrotuberous ligaments.

rotationally unstable but vertically stable because the posterioir SI is not injured

APC III
Disruption of anterior and posterior SI ligaments (SI dislocation).
Disruption of sacrospinous and sacrotuberous ligaments.
associated with vascular injury

(requires the highest blood transfusion and patient in shock)

= externally rotated

=======
more common and good prognosis

Lateral Compression (LC) caused by internal rotation force to the pelvis

LC I
Oblique or transverse ramus fracture
ipsilateral anterior sacral ala compression fracture.

LC II
Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture).

LC III
Ipsilateral lateral compression and contralateral APC (windswept pelvis).
one of the iliac crest in internal rotation wheel the rest in external rotation

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Vertical Shear (VS)

Vertical shear Posterior and superior directed force.
Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%

all ligaments are disrupted and it is vertically and rotationally unstable

Question 7

what are the clinical features associated with pelvic ring fracture ?

Answer 7

pain and inability to bear weight

abnormal lower extremity position such as external rotation of one or both legs

or limb length discrepancy

hematoma or ecchymosis
flank pain
perineal laceration
devolving - morel - lavallee lesion

clinically if the leg is externally rotated , x rays shows open book fracture = AP type 3

neurological
lumbar sacral plexus injury rule out (L5-S1
rectal exam evaluatione sphincter tone and perirectal sensation

urogenital exam
gross heamturia

vaginal and rectal examinations

Question 8

what is the initial management for pelvic ring fractures ?

Answer 8

common sources of hemorrhage -majority comes from cancellous bone or lumbar venous plexus - leading to retroperitoneal hematoma

uncommon source - arterial - superior gluteal most common and then internal pudendal

treatment -
PRBC (packed red blood cells ) : FFP : platelets
ideally transfused 1:1:1

pelvic binder for open book fracture (APC 3) - NOT NEEDED IN LC
should be over the greater trochanters for effect indirect reduction
do not place over iliac crest/abdomen
transition to alternative fixation as soon as possible
prolonged pressure from binder or sheet may cause skin necrosis
early pelvic binding and CT have been associated with underestimation of pelvic ring instability

for lateral compression if the patient dies it is for head injury not blood loss
LC tye 3 - high incidence for bowel injury

to know between LC and APC you need to know the orientation of the pubic rami if it is transverse or oblique fracture = internal rotation = check = LC = check for head injury

if apc = watch for bleeding

==========

external fixation
indications :pelvic ring injuries with an external rotation component (APC, VS, CM)
or
unstable ring injury with ongoing blood loss
pins inserted into ilium

Question 9

what re the definitive treatmnet according to the classification of pelvic ring fracture ?

Answer 9

APC1 - non operative . protected weight bearing
pelvic binder

APC2 - anterior symphyseal plate
or
external fixatior with or without posterioir fixation

APC3 - anterior symphyseal multi-hole plate
or external fixator and posterioir stabilisation with SI screws or plate

20 percent of APC need angiography also embolisation WHILST lc no need for ANGIOGRAPHY

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Lc1 - non operative , protected weight bearing

LC2 - open reduction and internal fixation of the ilium
iliosacral screws (percutaneous)
good for sacral fractures and SI dislocations
L5 nerve root injury complication

LC3 - posteriori stabilisation :
with anterior SI plating ; risk of L4 and L5 injury

and percutaneous or open based SI screws or plate

====

vertical shear

posteriori stabilisation with plate or SI screws
perceutanous or open based

=====

do diverting colostomy in open pelvic fractures - especially with extensive perineal injury or rectal involvement with extensive perineal injury or rectal involvement

Question 10

what re the main complications of pelvic ring fractures ?

Answer 10

apc bleeding - shock

urogenital injuries

• posterioir urethral tear - MOST COMMON
• bladder rupture

= diagnosis with retrograde urethrocystogram

suprapubic catheter placement
surgical repair

with this there are long term complications such as - urethras stricture
impotence
anterioir pelvic ring infection
incontinence

=====

neurological injury
L5 nerve root at risk - L5 nerve root runs on top of sacral ala
with iliosacral screw or plate

L5 is primarily evaluated by extensor hallucis longus function

great toe dorsiflexion problems
or dropped foot

risk of L4 and L5 injury
L4 is tested with tibialis anterior

esp anterioir subcuteanous pelvic fixation may give rise to LFCN injury (most common) or femoral nerve injury.

===

DVT and PE
- in 60 percent dvt!!!

prophylaxis is essential
inferior vena caval filtre
LOW MOLECULAR WEIGHT HEPARIN
mechanical compression

====

infection
rik factor - obesity , diabetes , prolonged operation time and ICU stay

Question 11

what re the different type of sacroiliac dislocation and what causes them ?

Answer 11

incomplete sacroiliac joint dislocation - posterior SI ligament (most important) intact causing rotational instability

complete SI dislocation
vertical and rotational unstable

SI fracture dislocation
iliac wing fracture which enters the SI joint and injury to the posterior SI joint varies but posterior ilium remains attached to scar and anterior allium dislocates with internal rotation deformity
and when the ilium fragment remains with the sacrum it becomes a crescent fracture

aetiology - lateral compression force and usually high energy

Question 12

what is the treatmnet for sacroiliac joint dislocation

Answer 12

operative
immediate skeletal traction - for vertical translation

anterior ring fixation ORIF - incomplete SI dislocation with pubic symphyseal disatais

anterioir and posterioir ring fixation through ORIF
- for complete dislocation

ORIF of ilium for crescent fracture
ilioscaral screws or plates

Question 13

what are some features of sacral fractures ?

Answer 13

common in pelvic ring injuries (30-45%)
25% are associated with neurologic injury
frequently missed

Question 14

causes of sacral fractures ?

Answer 14

young adults
as a result of high energy trauma
motor vehicle accident or fall from height most common

elderly
as a result of low energy falls

Question 15

what is the classification of sacral fractures ?

Answer 15

DENIS CLASSIFICATION

zone 1 
fracture lateral to foramina/ ala 
most common (50%)
nerve injury rare (5%)
usually occurs to L5 nerve root

zone 2
fracture through foramina
may be stable vs. unstable
zone 2 fracture with vertical shear force is highly unstable
unstable fractures have increased risk of nonunion and poor functional outcome

in zone 2 fractures there is 30 percent of sacral nerve injury

zone 3
fracture medial to foramina into the spinal canal
highest rate of neurologic deficit (60%)
bowel, bladder, and sexual dysfunction
affects the caudal equina

it is off two types - longitudinal or transverse = u shaped
results from axial loading
represent spino-pelvic dissociation between S2-S3
high incidence of neurologic complications

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transverse sacral fractures
higher incidence of nerve dysfunction

Question 16

what is the clinical presentation of sacral fractures ?

Answer 16

Symptoms
peripelvic pain

palpation
test pelvic ring stability by internally and externally rotating iliac wings

palpate for subcutaneous fluid mass indicative of lumbosacral fascial degloving (Morel-Lavallee lesion)

perform vaginal exam in women to rule-out open injury

neurologic exam:
rectal exam
light touch and pinprick sensation along S2-S5 dermatomes  
perianal wink
bulbocavernosus and cremasteric reflexes

cauda equina- affecting bladder , bowel and sexual function

vascular exam
distal pulses -if different consider ankle-brachial index or angiogram

Question 17

why is sacral fractures had to diagnose ?

Answer 17

Radiographs
only show 30% of sacral fractures
recommended views
AP - 
INLET AND OUTLET VIEW
lateral

CT
diagnostic study of choice

MRI
recommended when neural compromise is suspected

Question 18

what is the treatment for sacral fractures ?

Answer 18

Nonoperative

progressive weight bearing +/- orthosis
plus use crutches or a walker

indications :
<1 cm displacement and no neurologic deficit

==========

Operative
surgical fixation
indications:
displaced fractures >1 cm
soft tissue compromise
persistent pain after non-operative management
displacement of fracture after non-operative management

surgical fixation with decompression
indications :
any evidence of neurologic injury

for zone 1 
Percutaneous screw fixation
screws may be placed as sacroiliac, trans-sacral or trans-iliac trans-sacral 
useful for sagittal plane fractures
beware of L5 nerve root

for zone 2
fixation may not hold because it is difficult and it may displace after fixation = high chance of fracture displacement , nonunion , poor functional outcome

posterioir tension band plating used in addition to iliosacral screws

the best technique is combined iliosacral and lumbopelvic fixation = triangular fixation
pedicle screw fixation in lumbar spine
iliac screws
longitudinal and transverse rods to connect both of these components

Question 19

what re the complications for sacral fractures ?

Answer 19

Venous thromboembolism
often as a result of immobility

Iatrogenic nerve injury

Question 20

iliac wing fracture has high incidence with what other injuries ?

Answer 20

OPEN INJURY
BOWEL ENTRAPMENT
SOFT TISSUE DEGLOVING

Question 21

what is the classification for iliac wing fracture ?

Answer 21

No specific classification for iliac wing fractures
maybe TILE CLASSIFICATION (used also in pelvic ring fractures)

anterioir superior iliac spine avulsion - due to pull of sartorius muscle
or anterioir inferior iliac spine avulsion - due to rectus femoralis

iliac bone be part of acetabular fracture

can be part of pelvic fracture

unstable vertical shear fracture and complete disruption on the posterioir arch complex = if not treated promptly can lead to non union , malunion and leg length discrepancy

isolated iliac wing fracture - vertically and rotationally stable and usually treated conservatively
it can be serious if communiuted - with soft tissue injury = morel lavalee lesion

ileum fracture which extends to the greater sciatic lnotch - may have arterial injury and lumbosacral plexus injury

Question 22

what is the treatmnet for iliac wing fracture ?

Answer 22

Nonoperative
mobilization with an assist device

indications
nondisplaced fractures
isolated iliac wing fractures

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Operative
open reduction and internal fixation
indications
displaced fractures of ilium

incase of open fracture the patient may need colostomy and ANTBIOTICS PROPHYLAXIS AS SOON AS POSSIBLE

pelvic reconstruction plate or lag screws along iliac crest
supplemented with second reconstruction plate or lag screes at the level of pelvic brine or sciatic buttress

injury to bwel may need diversion