pelvic trauma (incl. femoral head and hip dislocation) Flashcards
Sacral Fractures
- Common in pelvic ring injuries ( _____%)
- ____% are associated with neurologic injury
- Frequently missed:
◾___% in patients who are neurologically intact
◾___% in patients who have a neurologic deficit
** Under-diagnosed and often mistreated fractures that may result in neurologic compromise **
- 30-45%
- 25%
- Frequently missed
◾75% in patients who are neurologically intact
◾50% in patients who have a neurologic deficit
Sacral Fractures
- Epidemiology
- Prognosis
a. Presence of a __________ is the most important factor in predicting outcome
b. Mistreated fractures may result in? (4)
Epidemiology
◾Young adults: as a result of high energy trauma
◾Elderly: as a result of low energy falls
- Prognosis
a. Neurologic deficit
b. Mistreated fractures may result in: ◾lower extremity deficits ◾urinary dysfunction ◾rectal dysfunction ◾sexual dysfunction
Sacral Fractures
Classification
Denis classification [Zone 1 - 3]
Zone 1= lateral to foramina
◾most common (50%) ◾nerve injury rare (5%) ◾usually occurs to L5 nerve root
Zone 2= through foramina
◾may be stable OR unstable
◾Zone 2 fx with shear component HIGHLY UNSTABLY
Zone 3=medial to foramina into the spinal canal
◾ highest rate of neuro deficit (60%) ◾bowel, bladder, and sexual dysfunction
Other Fracture patterns include
(i) Transverse (◦higher incidence of nerve dysfunction)
(ii) U-type sacral fractures (◦results from axial load ◦represent spino-pelvic dissociation ◦high incidence of neurologic complications)
Sacral Fractures
Radiographs
- only show ____% of sacral fractures
- Recommended views (3)
- Additional views (1)
- Findings (2)
- 30%
- Recommended views
◾AP pelvis
◾Inlet view= best assessment of sacral spinal canal and superior view of S1
◾Outlet view= provides true AP of sacrum - Additional views
◾cross-table lateral - Findings
◾L4 or L5 transverse process fractures
◾asymmetric foramina
** MRI when neural comprimise is suspected **
Sacral Fractures: Treatment
Op vs non-op
- Nonoperative: indications
◾<1 cm displacement and no neurologic deficit
◾insufficiency fractures - Operative: Indications
◾displaced fractures >1 cm (incl. late displacement)
◾soft tissue compromise
◾persistent pain after non-operative management - Surgical fixation with decompression: Indications
◾any evidence of neurologic injury
Sacral Fractures : Surgical treatment
- Options include (4)
Percutaneous screw fixation
◾Screws may be placed as sacroiliac, trans-sacral or trans-iliac trans-sacral ◾useful for sagittal plane fractures
Beware of:
2. _______ nerve root
- _________ of fracture
- May cause _________
- (i) Percutaneous screw fixation (ii)Posterior tension band plating (iii) Iliosacral and lumbopelvic fixation (iv)Decompression of neural elements
Beware of :
2. L5 nerve root
- Avoid overcompression of fracture
- May cause iatrogenic nerve dysfunction
*** Note: ◾does not allow for removal of loose bone fragments ◾do not use in osteoporotic bone
Ilium Fractures
stable or unstable generally?
Typical pattern ?
Assoc with ? [3]
- Most are unstable fractures
- Typically progress from iliac crest to greater sciatic notch
- Iliac wing fractures have high incidence of associated injuries
◦open injuries
◦bowel entrapment
◦soft tissue degloving
Ilium Fractures
Anatomy - Osteology
- pelvic girdle is comprised of :
- ilium
a. 2 important anterior prominences
◾anterior-superior iliac spine (ASIS) ◾origin of: [2]
◾anterior-inferior iliac spine (AIIS) ◾origin of: [2] - Posterior prominences
a. Posterior-superior iliac spine (PSIS) : located 4-5 cm lateral to the ___ spinous process
- pelvic girdle is comprised of
◾sacrum
◾2 innominate (coxal) bones
◾each formed from the union of 3 bones: ilium, ischium, and pubis
2a. origin of sartorius and transverse and internal abdominal muscles
2b. origin of direct head of rectus femoris and iliofemoral ligament (Y ligament of Bigelow)
- Posterior prominences
a. posterior-superior iliac spine (PSIS)
◾located 4-5 cm lateral to the S2 spinous process
b. posterior-inferior iliac spine (PIIS)
Ilium Fractures
- Treatment : Nonoperative
◾indications - Operative
◾indications
Treatment
•Nonoperative ◦mobilization with an assist device ◾indications
◾nondisplaced fractures
◾isolated iliac wing fractures
•Operative ◦open reduction and internal fixation ◾indications
◾displaced fractures of ilium
Ilium Fractures
classification
No specific classification for iliac wing fractures
Generally described as specific subtypes of more common classification systems
Ilium Fractures
Tile Classification
Tile Classification
◾stable (intact posterior arch)
◾A1-1: iliac spine avulsion injury
◾A1-2: iliac crest avulsion
◾A2-1: iliac wing fractures often from a direct blow
◾partially stable (incomplete disruption of posterior arch)
◾B2-3: incomplete posterior iliac fracture
◾unstable (complete disruption of posterior arch)
◾C1-1: unilateral iliac fracture
Ilium Fractures
Operative Techniques
Wound Management
- evaluate all wounds for: [2]
Operative Techniques
Wound Management
1. evaluate all wounds for
◾soft tissue disruption or internal degloving injury
◾possible soft tissue or bowel entrapment in the fracture site
Addit:
◦ prophylactic antibiotics as appropriate
◦ serial debridements as necessary
Ilium Fractures
Operative Techniques
Open Reduction Internal Fixation
- approach [3]
- Timing
- approach
i. posterior approach
ii. ilioinguinal approach
iii. Stoppa approach (lateral window) - Recommend early reconstruction
◾single pelvic reconstruction plate or lag screw along the iliac crest
◾supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim or sciatic buttress
◾ coordination with trauma team- injury to bowel may require diversion procedures
- plan surgical intervention with trauma team to minimize recurrent trips to the operating room
Ilium Fractures
Complications [4]
- Malunion with deformity of the iliac wing
- Internal iliac artery injury
- Bowel perforation
- Lumbosacral plexus injury
SI Dislocation & Crescent Fractures
Spectrum of injuries that include [3]
Spectrum of injuries that include
- incomplete (Sacroiliac) SI dislocation
◾rotationally unstable - complete SI dislocations
◾vertically and rotationally unstable - SI fracture-dislocation (crescent fracture)
SI Dislocation & Crescent Fractures
Spectrum of injuries: details
- incomplete (Sacroiliac) SI dislocation
- complete SI dislocations
- SI fracture-dislocation (crescent fracture)
incomplete (Sacroiliac) SI dislocation
◾posterior SI ligaments remain intact
◾rotationally unstable
complete SI dislocations
◾posterior SI ligaments ruptured
◾vertically and rotationally unstable
SI fracture-dislocation (crescent fracture)
◾iliac wing fracture that enters the SI joint
◾injury to posterior ligaments vary
◾combination of vertical iliac fx and SI dislocation
◾posterior ilium remains attached to sacrum by posterior SI ligaments
◾anterior ilium dislocates from sacrum with internal rotation deformity
◾when ilium fragment remains with sacrum it is termed a crescent fracture
SI Dislocation & Crescent Fractures
- mechanism of injury
- pathoanatomy
a. pelvic stability determined by:
•Prognosis is primarily based on:
- mechanism of injury
◾lateral compression force
◾usually high energy
2a. degree of injury to posterior structures
2b. Iliac wing fractures may be associated with open wounds and may involve bowel entrapment
3. Prognosis - primarily based on accurate and stable reduction of SI joint
SI Dislocation & Crescent Fractures
Classification
No classification system specifically for SI injury
◦ included in Young- Burgess and Tile classification of pelvic fractures
◦ crescent fractures described as LC-2 injury according to Young-Burgess
SI Dislocation & Crescent Fractures
- Treatment : Operative
a. details - acute management
b. indications for ORIF - Anterior ring ORIF
◾indications - Anterior and posterior ring ORIF
◾indications - ORIF of ilium
◾indications
1a. immediate skeletal traction
1b. indications ◾vertical translation of the hemipelvis
- anterior ring ORIF ◾indications ◾incomplete SI dislocations with pubic symphyseal diastasis
- anterior and posterior ring ORIF ◾indications ◾complete SI dislocations ◾vertically unstable require anterior and posterior pelvic ring fixation
- ORIF of ilium ◾indications ◾crescent fracture ◾required to restore posterior SI ligaments and pelvic stability
SI Dislocation & Crescent Fractures
Complications [3]
- DVT ◦35%-50%
- Neurological injury
- Loss of reduction and failure of fixation
Hip Dislocation
- Epidemiology / incidence
- mechanism
- Hip joint inherently stable due to ?
- Epidemiology ◦rare, but high incidence of associated injuries
◦mechanism is usually young patients with high energy trauma
2. Hip joint inherently stable due to ◦bony anatomy ◦soft tissue constraints including ◾labrum ◾capsule ◾ligamentum teres
Hip Dislocation
anatomic classification
Anatomic classification
1. Posterior dislocation (90%)
◾occur with axial load on femur, typically with hip flexed and adducted (axial load through flexed knee - eg. dashboard injury)
◾position of hip determines associated acetabular injury (increasing flexion and adduction favors simple dislocation)
- anterior dislocation
◾associated with femoral head impaction or chondral injury
◾occurs with the hip in abduction and external rotation
◾inferior (“obturator”) vs. superior (“pubic”) ◾hip extension results in a superior (pubic) dislocation ◾Clinically hip appears in extension and external rotation
◾flexion results in inferior (obturator) dislocation ◾Clinically hip appears in flexion, abduction, and external rotation
Hip Dislocation
Posterior dislocation (90%)
assoc with ? [5]
2. Associated with ◾osteonecrosis ◾posterior wall acetabular fracture ◾femoral head fractures ◾sciatic nerve injuries ◾ipsilateral knee injuries (up to 25%)
Hip Dislocation
Treatment : Emergent
- closed reduction within ____ hours
- Indications
- contraindications
- 6 hrs
- indications ◾acute anterior and posterior dislocations
- contraindications
◾ipsilateral displaced or non-displaced femoral neck fracture
Hip Dislocation
Rx Operative
open reduction and/or removal of incarcerated fragments
1. indications
indications ◾irreducible dislocation ◾radiographic evidence of incarcerated fragment ◾delayed presentation ◾non-concentric reduction ◾should be performed on urgent basis
Hip Dislocation
Rx Operative
ORIF
◾indications
indications
◾associated fractures of :
i. acetabulum
ii. femoral head
iii. femoral neck -> should be stabilized prior to reductionHip Dislocation
Complications
- Post-traumatic arthritis
a. up to __% for simple dislocation, markedly increased for complex dislocation
Femoral head osteonecrosis
2a. Femoral head osteonecrosis = __to__% incidence
2b. AVN Increased risk with _______ ?
- Sciatic nerve injury
a. __to__% incidence
b. associated with _______ - Recurrent dislocations
a. less than ___%
1a up to 20% for simple dislocation, markedly increased for complex dislocation
2a. 5-40% incidence
2b. Increased risk with increased time to reduction
3a. 8-20% incidence
3b. associated with longer time to reduction
- Recurrent dislocations ◦less than 2%
Acetabular Fractures
a
Femoral head fractures
a
Pelvic Ring Fractures
1, Mechanism
- Mortality rate __to__% for closed fractures, as much as ___% for open fractures
- ________ is leading cause of death overall
- increased mortality associated with: (5)
- Mechanism typically high energy blunt trauma
- Mortality rate 15-25% for closed fractures, as much as 50% for open fractures
- hemorrhage is leading cause of death overall ◾closed head injury is the most common for lateral compression injuries
- Increased mortality associated with
◾systolic BP <90 on presentation
◾age >60 years
◾increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
◾need for transfusion > 4 units
◾higher Young-Burgress classification grade
Pelvic Ring Fractures
Associated injuries
◦chest injury in up to \_\_% ◦long bone fractures in \_\_% ◦sexual dysfunction up to \_\_% ◦head and abdominal injury in \_\_% ◦spine fractures in \_\_%
◦chest injury in up to 63%
◦long bone fractures in 50%
◦sexual dysfunction up to 50%
◦head and abdominal injury in 40%
◦spine fractures in 25%
Pelvic Ring Fractures
Prognosis : high prevalence of poor functional outcome and chronic pain
- poor outcome associated with : (7)
1. poor outcome associated with ◾SI joint incongruity of > 1 cm ◾high degree initial displacement ◾malunion or residual displacement ◾leg length discrepancy > 2 cm ◾nonunion ◾neurologic injury ◾urethral injury
Pelvic Ring Fractures
Pediatric pelvic ring fractures
children with open triradiate cartilage have different fracture patterns than do children whose triradiate cartilage has closed
◾if triradiate cartilage is open ?
◾if triradiate cartilage is open the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption
◾for this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment
Pelvic Ring Fractures
Radiographs : inlet
- technique
- Ideal for visualising ?
- technique
◾xray beam angled 40° caudad (may be as little as 25 degrees)
◾adequate image when S1 overlaps S2 body - ideal for visualizing
◾anterior or posterior translation of the hemipelvis
◾internal or external rotation of the hemipelvis
◾widening of the SI joint
◾sacral ala impaction
Pelvic Ring Fractures
Radiographs : outlet
- technique
- Ideal for visualising ?
- outlet technique
◾xray beam angled ~40° cephalad (may be as much as 60 degrees)
◾adequate image when pubic symphysis overlies S2 body - ideal for visualizing
◾vertical translation of the hemipelvis
◾flexion/extension of the hemipelvis
◾disruption of sacral foramina and location of sacral fractures
Pelvic Ring Fractures
Classification : Tile Classification
Tile classification
A: stable
◾A1: fracture not involving the ring (avulsion or iliac wing fracture)
◾A2: stable or minimally displaced fracture of the ring
◾A3: transverse sacral fracture (Denis zone III sacral fracture)
B - rotationally unstable, vertically stable
◾B1: open book injury (external rotation)
◾B2: lateral compression injury (internal rotation) ◾B2-1: with anterior ring rotation/displacement through ipsilateral rami
◾B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)
◾B3: bilateral
C - rotationally and vertically unstable
◾C1: unilateral ◾C1-1: iliac fracture
◾C1-2: sacroiliac fracture-dislocation
◾C1-3: sacral fracture
◾C2: bilateral with one side type B and one side type C
◾C3: bilateral with both sides type C
Pelvic Ring Fractures
Classification :Young-Burgess Classification
- APC
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.)
APC III
(Disruption of anterior and posterior SI ligaments (SI dislocation). Disruption of sacrospinous and sacrotuberous ligaments.APCIII associated with vascular injury)
- Lateral Compression (LC)
i. LC type 1
Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture
ii. LC type 2
Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture
iii.LC type 3
Ipsilateral lateral compression and contralateral APC (windswept pelvis).
Common mechanism is rollover vehicle accident or pedestrian vs auto. - Verical Shear (VS)
Posterior and superior directed force.
Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%
Pelvic Ring Fractures
Bleeding & Initial Treatment
- Bleeding Source (broad) [5]
- common sources of hemorrhage (Pelvis)
a.
b. - uncommon sources of hemorrhage
a.
1. Bleeding Source ◦intraabdominal ◦intrathoracic ◦retroperitoneal ◦extremity (thigh compartments) ◦pelvic
- common sources of hemorrhage
a. venous injury (80%) (shearing injury of posterior thin walled venous plexus)
b. bleeding cancellous bone - uncommon sources of hemorrhage
a) arterial injury (10-20%)
◾superior gluteal most common (posterior ring injury, APC pattern
◾internal pudendal (anterior ring injury, LC pattern)
◾obturator (LC pattern)
Pelvic Ring Fractures
External fixation
- indications
- contraindications
- indications
◾pelvic ring injuries with an external rotation component (APC, VS, CM)
◾unstable ring injury with ongoing blood loss - contraindications
◾ilium fracture that precludes safe application
◾acetabular fracture
Pelvic Ring Fractures
External fixation: technique
- Pin insertion: supra-acetabular pin
- AIIS pins can place the _________ nerve at risk
- _______ screws with internal subcutaneous bar may be used
- Pin insertion: superior iliac crest pin
- Superior iliac crest pin insertion
- Pins inserted into ilium ◾supra-acetabular pin insertion
◾single pin in column of supracetabular bone from AIIS towards PSIS
–> obturator outlet view helps to identify pin entry point
–> iliac oblique view helps to direct pin above greater sciatic notch
–> obturator oblique inlet view helps to ensure pin placement within inner and outer table - lateral femoral cutaneous nerve
- pedicle screws
- Superior iliac crest pin insertion
◾multiple half pins in the superior iliac crest
◾place in thickest portion of ilium (gluteal pillar)
◾may be placed with minimal fluoroscopy
Pelvic Ring Fractures
Nonoperative : weight bearing as tolerated
- indications (4)
- Mechanically stable pelvic ring injuries including
i.) LC1
◾anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of posterior ring displacement
ii.) APC1
◾widening of symphysis < 2.5 cm with intact posterior pelvic ring
iii.) isolated pubic ramus fractures
iv.) parturition-induced pelvic diastasis
◾bedrest and pelvic binder in acute setting with diastasis less than 4cm
Pelvic Ring Fractures
Operative: ORIF
- indications [6]
- indications
◾symphysis diastasis > 2.5 cm
◾SI joint displacement > 1 cm
◾sacral fracture with displacement > 1 cm
◾displacement or rotation of hemipelvis
◾open fracture
◾chronic pain and diastasis in parturition-induced diastasis or acute setting >6cm
Pelvic Ring Fractures
Operative: ORIF
Techniques
1. Anterior ring stabilization
- Anterior and posterior ring stabilization
a) necessary in _____ injuries
b. Ipsilateral acetabular and pelvic ring fractures
- fix which first
Anterior ring stabilization
◾Single superior plate
◾apply through rectus-splitting Pfannenstiel approach
◾may perform in conjunction with laparotomy or GU procedure
2a. vertically unstable injuries
2b. reduction and fixation of the pelvic ring should be performed first
Pelvic Ring Fractures
Operative: ORIF
Techniques: Posterior ring stabilization
- anterior SI plating
◾risk of L4 and L5 injury with placement of anterior sacral retractors - iliosacral screws (percutaneous)
◾good for sacral fractures and SI dislocations
◾safe zone is in S1 vertebral body
-> outlet radiograph view best guides superior-inferior screw placement
-> inlet radiograph view best guides anterior-posterior screw placement
◾L5 nerve root injury complication with errors in screw placement
◾entry point best viewed on lateral sacral view and pelvic outlet views
◾risk of loss of reduction highest in vertical sacral fracture patterns - Posterior SI “tension” plating
◾can have prominent HW complications
Pelvic Ring Fractures
Complications
- Neurologic injury
◦L5 nerve root runs over sacral ala joint
◦may be injured if SI screw is placed to anterior
◦anterior subcutaneous pelvic fixator may give rise to LFCN injury (most common) or femoral nerve injury - DVT and PE
◦DVT in ~ 60%, PE in ~ 27%
◦prophylaxis essential ◾mechanical compression
◾pharmacologic prevention (LMWH or Lovenox)
◾vena caval filters (closed head injury) - Chronic instability
◦rare complication; can be seen in nonoperative cases
◦presents with subjective instability and mechanical symptoms
◦diagnosed with alternating single-leg-stance pelvic radiographs
4. Infection ◦risk factors include: ◾obesity ◾diabetes ◾delay in treatment ◾open fracture
Pelvic Ring Fractures
Complications
Urogenital Injuries
•Present in 12-20% of patients with pelvic fractures ◦higher incidence in males (21%)
•Includes
◦posterior urethral tear (most common urogenital injury with pelvic ring fracture)
◦bladder rupture (may see extravasation around the pubic symphysis ; associated with mortality of 22-34%)
•Diagnosis
◦made with retrograde urethrocystogram
◦indications for retrograde urethrocystogram include ◾blood at meatus
◾high riding or excessively mobile prostate
◾hematuria
