pelvic and acetabular fractures

PELVI-ACETABULAR FRACTURES

Chairman: Dr D R KalePresenter: Dr Sidharth Baheti

Introduction

• Pelvic fractures are potentially life threatening injuries with an increased incidence due to high velocity RTAs.

• Survivors are at a significant risk for morbidities like chronic pain, LLD, Sexual dysfunction etc

• 3-4 % of all fractures usually associated with significant trauma

Introduction

• Adult mortality 10-15%

• Mortality is ~50% if hypotensive on initial

presentation.

• Mortality is ~30% in open fractures

• Significant decrease in mortality and morbidity

if prompt stabilization of an unstable #

ANATOMY

The bony pelvis lies in close proximity to various vascular neural and soft tissue structures making these structures vulnerable in the event of pelvic ring disruptions

Historical perspective• These #s were historically managed conservatively

and many authors reported poor results.• Holdsworth (1948) in first described that pts with

pure SI dislocations fared worse than Illium/sacrum#.

• Slattis reported mortality as high as 17%• Several publications popularized use of external

fixators.• But later it became clear that Ex-Fix may be

adequate for anterior/lateral injuries but not for posterior injuries.

Clinical Evaluation

SUSPECTStart with ABCDsEvaluate for other injuries to head, chest,

abdomen and spineINSPECTION• Skin around the perineum• Bleeding PV/PR/PU• LLD and abnormal extremity rotation• Neuro-vascular status

Associated signs: - Roux's sign:

- a decrease in the distance from the greater trochanter to the pubic crest on the affected side in lateral compression frx;

- Earle's sign: - a bony prominence or large hematoma as well as tenderness on rectal examination;

Destot Sign

Moral Lavale Lesion

Palpation• Post---Haematoma/defect---SIJ or post #• ASIS: Pushed towards- IR stability, Apart- ER

stabiity• Lower extremity pushed for vertical stability

Imaging Pelvic Fractures• Plain Radiographs- AP view

Imaging Pelvic Fractures• Plain Radiographs- AP view

Pubic Rami #

Symphyseal Displacement

SIJ and Sacrum

Illiac #

L5 transverse process

Asso acet/proximal femur

2. Plain Radiographs- Inlet view

Anterior/posterior Displacement

of Sacrum, SIJ, Illium, symphysis

Rotational deformities of illium

Impacted sacral fractures

3. Plain Radiography Outlet view

Adequate image when pubic symphysis overlies S2 body

Imaging

CT scanGold standard for pelvic fractures. Detailed

information about anterior and posterior ring

MRILimited role.GU and Vascular structures

CLASSIFICATION of pelvic fractures

Young and Burgess ClassificationMost common classification usedBased on the mechanism of injury

Tile/AO Classification

Tile/AO ClassificationType A: STABLE

Tile/AO ClassificationType B: Rotationally unstable, Vertically stable

Tile/AO ClassificationType C: Rotation and vertically unstable

Sacral Fracture-Denis Classification

Miscellaneous Fractures

MALGAIGNE’s # STRADDLE #

Principles of Initial Management

• Suspect if high velocity RTA(car vs pedestrian; Motorcycle) or a fall from height(usually >15feet)

• Pelvis has no inherent stability and relies on ligamentous supports.

• Vascular structures are intimately associated with ligaments and are often injured.

German registry reported a drop in mortality from 11% to 6% after a protocol was established.

Circumferential Pelvic wrapping

• First patient; teague 1993,CA• CORR 1995• ATLS provider manual in 1997• Can be done with a bedsheet or a Pelvic

binder.

• Where to wrap??At the level of the Greater Trochanters

• How much force????150-170N

Pneumatic Anti-shock Garment

• Inflatable device traditionally used by the armed forces.

• Great value in transport and initial stabilization of patient; acts as a air splint

Disadvantages of PASG

• Risk of displacement in LC injuries• Restricts access to patient• Increased risk of compartment syndrome

External Fixation

• 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

Technique – theoretically works by decreasing pelvic volume – stability of bleeding bone surfaces and venous

plexus in order to form clot– pins inserted into ilium

• single pin in column of supracetabular bone from AIIS towards PSIS

– obturator outlet or "teepee" view to visualize this column of bone

– AIIS pins can place the lateral femoral cutaneous nerve at risk

• multiple half pins in the superior iliac crest– place in thickest portion of anterior ilium, gluteus medius

tubercle or gluteal pillar

– should be placed before emergent laparotomy

Angiography / Embolization

• Indications– controversial and based on multiple variables

including:– protocol of institution, stability of patient,

proximity of angiography suite , availability and experience of staff

– CT angiography useful for determining presence or absence of ongoing arterial hemorrhage (98-100% negative predictive value)

Non-Operative Management

• Lateral impaction type injuries with minimal (< 1.5 cm) displacement

• Pubic rami fractures with no posterior displacement

• Minimal gapping of pubic symphysis– Without associated SI injury– 2.5 cm or less, assuming no motion with stress or

mobilization– This number is not absolute, so other evidence of

instability (like SI injury) must be ruled out

Non-Operative Management

• X-rays are static picture of dynamic situation– It may be that the deformity is worse than seen on

X-rays taken– Stress radiographs may be helpful– Other evidence of instability should be sought

• Lumbar transverse process fractures• Avulsions of sacrotuberous/sacrospinous ligaments

Non-Operative Treatment

• Tile A (stable) injuries can generally bear weight as tolerated

• Walker/crutches/cane often helpful in early mobilization

• Serial radiographs followed during healing• Displacement requires reassessment of

stability and consideration given to operative treatment

Non-Operative Treatment

• Tile B (partially stable) injuries can be treated non-operatively if deformity is minimal

• Weight bearing should be restricted (toe-touch only) on side of posterior ring injury

• Serial radiographs followed during healing• Displacement requires reassessment of

stability and consideration given to operative treatment

Principles of Operative Treatment

• Posterior ring structure is important

• Goal is restoration of anatomy and enough stability to maintain reduction during healing

• Most injuries involve multiple sites of injury– In general, more points of fixation lead to greater

stability– This does NOT mean that all sites of injury need

fixation

Principles of Operative Treatment• Anterior ring fixation may provide structural

protection of posterior fixation

• If combined open and percutaneus techniques are used, the open portion is often done first to aid in reduction of the percutaneusly treated injury

• LETOURNEL’s Golden rule: Posterior stabilization to be done before anterior as posterior is the main weight bearing part.

Anterior Pelvic Ring Injuries

Indications for ORIF• Symphyseal dislocation >2.5cm(static or

dynamic)• To augment posterior fixation in vertically

dislaced fractures.• Locked symphysis.

Surgical Approach to the Anterior Pelvic Ring

Pfannenstiel Approach

•Supine Position•8 cm incision•A Foley catheter and nasogastric tube are inserted

•The cut edges of the rectus abdominal muscles superiorly to reveal the symphysis and pubic crest.

• If access to the back of the symphysis is required, use the fingers to push the bladder gently off the back of the bone

Symphyseal Dislocations

• Ant Ex Fix = Internal Fixation for controlling rotation but Internal fixation >>> for resisting vertical displacements

• Ex fix particularly useful in open injuries or pts requiring GI/GU procedures.

ORIF of Symphyseal disruptions

• Apply circumferential wrap at the level of the GT.

• Internally rotate the legs and tape them.• Ant approach to pubic symphysis.• Place reduction forceps anteriorly so that

plate can be put on the superior surface.

• Inlet view: judge the alignment of the plate;• Outlet view judge the length of screws;screws

should have a bicortical purchase.

Fractures of the Pubic ramus

• Fractures medial to insertion of inguinal ligament should be treated like symphyseal dislocations.

• Comminuted fractures: ORIF

• Minimal comminution: Ramus screw(ante vs retro)

Fractures of the Pubic ramus• Reduction techniqueSecure a precontoured plate in the supra-

acetabular bone.One tine of the reduction forceps on the medial

fragment and another on the most medial hole of the plate.

Posterior Pelvic Ring Injuries

• Indications for ORIF:-1. Displaced illiac wing fractures that enter and

exit both the crest and GSN/SIJ.2. Multiplanar instability(disruption of ligaments)3. Non impacted comminuted displaced sacral

fractures.4. Vertical or cephalad displacement.5. U shaped fractures with spino-pelvic

dissociation

Approaches to posterior pelvic ringPosterior approach to SIJ

• Pt is placed prone with logitunal traction.• In severely displaced fractures we can rigidly fix the

contralateral pelvis

Approaches to posterior pelvic ringPosterior approach to SIJ

Anterior Approach to the Sacroiliac Joint

• Make a curved incision over the iliac crest, beginning 7 cm posterior to the anterior superior iliac spine. Curve the incision anteriorly and medially along the line of the inguinal ligament for 5 cm.

• Subperiosteally dissect the illiacus muscle and retract medially to reach the anterior part of the SIJ.

• Care should be taken not to injure L5 nerve root.

Posterior approach to Sacrum

Sacroilliac Joint Dislocations

• Posterior approach----Only inferior joint visualised

• Anterior approach----Superior Ala visualized• Longitunal traction is the single most

important maneuvre.• Important to let the pelvis hang free as

pressure on ASIS will lead to ext rotation

• Two reduction forceps

Illio-Sacral screw Placement

• Inlet projection—screw towards anterior aspect of promontory

• Outlet ---screw is above the S1 foramen

• Screw to be directed anteriorly; superiorly and medially. Lateral Projection

Be aware of sacral dysmorphism

Illiac wing fractures and fracture dislocations( Crescent fractures)

• Illiac wing fractures exiting through the SIJ are crescent #.• Crescent fragment is the variable sized that contains the

PSIS and PIIS and remains attached to the sacrum.• Smaller the “CRESCENT” fragment > damage to posterior

structures

Crescent fractures

• Always approched posteriorly

SACRAL Fractures

• Can be regarded as a pelvic injury, spinal injury or both.

Indications for fixation:-Ant and post ring disruption with vertical sheer

sacrum fracture.Comminuted # with rotationSpinal-pelvic dissociationRarely in impacted # with Internal rotation

deformity

Illiosacral screw

Plate fixation

1. Spinal point of fixation- L5(usually)2. Illiac screw just inf to PSIS3. Illiac screw is connected to pedicle screw with appropriate

rods and screw-rod clamps

This bypasses the lines of force transmission from spine to illium through the construct instead of the sacrum

Spinal-Pelvic fixation

Post-Operative Care

• Mobized to chair 1st day post-op• Toe touch weight bearing upto 10 weeks

(unstable injuries)• Stable injuries immediate post-op FWB.• DVT prophylaxis.• Prophylaxis for hetereropic ossification.

Complictaions

• Intra-operative haemorrhage• Inability to achieve reduction• Wound infection.• Newly recognized post-op neurologic deficits• Loss of fixation and reduction• Sexual dysfunction

ACETABULAR FRACTURES

Introduction

• Generally caused by high energy trauma

• Such high energy injuries usually have a high incidence of major associated injuries

• The fracture or fracture dislocation produced depends on the magnitude and the direction of the injuring force as well as on the strength of the bone.

Pathoanatomy

• Fractures depend on the position of the femoral head at the moment of impact

Fracture locationPosition of femoral head

Posterior column # IR

Anterior column # ER

Superior dome # Adduction

Inferior aspect of the dome # Abduction

Acetabulum - Anatomy• Incomplete hemispherical

socket with an – inverted horse-shoe shaped

articular surface– non articulating cotyloid

fossa. • The articular surface is

composed of and supported by two columns of bone (described by Letournel and Judet) as an inverted ‘Y’

Acetabulum – Anatomy‘The Column Concept’

• Used in the classification of the fractures• The anterior column

– Iliac crest, iliac spines, the anterior half of the acetabulum and the pubis.

• The posterior column – Ischium, ischial spine, posterior half of the acetabulum and

the dense bone forming the sciatic notch• The shorter posterior column ends at its intersection

with the anterior column at the top of the sciatic notch

Acetabulum - Anatomy

• The dome or roof is the weight bearing portion of the articular surface that supports the femoral head

• The quadrilateral surface is the flat plate of bone forming the lateral border of the pelvic cavity

• The iliopectineal eminence is the prominence in the anterior column that lies directly over the femoral head.

Acetabulum – AnatomyNeurovascular structures

• The sciatic nerve• The superior gluteal Artery and Nerve • Corona mortis

Classification (Letournel and Judet)

• Simple fractures– fractures of the posterior wall, posterior column,

anterior wall, anterior column and transverse fractures.

• Associated fractures– T-shaped fractures, fractures of the posterior

column and posterior wall, transverse + posterior wall fracture, anterior fracture + hemitransverse posterior fracture and both column fracture.

Signs and symptoms

• Apart from local examination– Look out for associated life threatening injuries

(intra-abdominal injuries)– A, B, C first before the rest– Older patients

• Arrhythmia, transient ischemic attacks may have led to the fall

– SDH can occur when older patients fall.

Radiographic Evaluation

• Requires– A CT scan– 3 plain radiographic views

• Antero-posterior view of the hip• 45° iliac oblique view• 45° obturator oblique view

Judet view 45° oblique view

Plain Radiographs1 - AP View

• Start evaluation with this view• Iliopectineal line – represents the anterior column;

Ilioischial line – represents the posterior column; Posterior lip – represents the posterior wall; Anterior lip – represents the anterior wall; Dome; Tear-drop

Plain Radiographs2 - The obturator oblique view

• Anterior column fracture displacements

• Posterior wall fragments and their displacement

Plain Radiographs3 - The iliac oblique view

• Posterior column #• Anterior wall #

CT Scan• 3 mm interval axial cuts• Include the entire pelvis to

avoid missing a portion of the fracture

• Compare with opposite hip

Watch forAnterior and posterior wall fragments, marginal impaction, retained bone fragments in the joint, comminution, presence or absence of a dislocations and any sacroiliac joint pathology.

Management

• Initial treatment – follow ATLS protocols• Operative treatment of acetabular fractures

are usually not performed as an emergency• Normally, a closed reduction Skeletal

traction

Operative Surgical anatomy

• Posterior wall fragments– vary in the size and degree of comminution– Well appreciated in a CT scan. – Unrecognized fracture lines maybe detected at

surgery– So the posterior wall fracture should never be

fixed with lag screw alone. – The posterior wall fragment receives its blood

supply from the capsule avoid detaching the capsule from its blood supply.

Operative Surgical anatomy

• Posterior Column fractures– Can occur anywhere along the posterior column

from the ischial spine to the sciatic notch.– Typically, the column fragment rotates. – It is necessary to derotate the fragment and check

the reduction.

Operative Surgical anatomy

• Anterior Column fractures– Occur at various levels along the anterior column. – Although the pubic ramus is part of the anterior

column, ramus fracture usually indicates the presence of a pelvic fracture rather than an acetabular fracture.

Operative Surgical anatomy

• Transverse fractures– Run across the acetabulum. – transtectal: fracture courses through the weight-bearing

dome (WBD);– juxtatectal: fracture courses above the cotyloid fossa, so

that a significant portion of the wt bearing dome is left intact;

– infratectal: fracture courses below the wt bearing dome.

• T-type fractures– Transverse fracture with a fracture line seperating the

anterior column from the posterior column

Operative Surgical anatomy

• Anterior and posterior hemi-transverse fractures– This is an anterior column fracture with and

additional fracture line that runs transversely across the posterior column.

– Here, the displacement is usually anterior and the posterior column not significantly disturbed.

– Thus reducing the anterior column usually reduces the posterior column.

Operative Surgical anatomy

• Both column fractures– Entire acetabulum is separated from the axial skeleton. – Sometimes, it is called as a floating acetabulum. – Since the entire acetabulum is separated from the ilium,

the actual joint can appear congruent. – This radiographic appearance is called the secondary

congruence.– Spur sign

Spur sign

• Pathognomonic of both column fratures. see in obturator oblique view

Surgical Approaches

• Iliofemoral• Ilioinguinal• Kocher Langenbeck• Triradiate transtrochanteric• Extended iliofemoral• Combined anterior and posterior approach

Kocher – Langenbeck approach

• The Kocher-Langenbeck approach is a nonextensile approach to the posterior acetabular column

Outline all bony landmarks with a sterile marking pen:(1) posterior superior iliac spine(2) greater trochanter(3) shaft of femur

incise the subcutaneous tissues alongthe gluteus maximus muscle (using scissors)the tractus iliotibialis (using a scalpel)

Isolate the piriformis tendon and the conjoined tendons of the obturator internus and superior and inferior gemelli muscles.

They are tagged and incised 1 cm lateral from their femoral insertions.

Illio-Inguinal Approach

The ilioinguinal approach was developed by Emile Letournel based on cadaveric dissections to provide anterior access for fractures of the acetabulum.

Illio-Inguinal Approach

Make a curved incision beginning posterior to the ASIS and extend past the midline 2 cm proximal to the symphysis.

the external oblique aponeurosis is incised from the ASIS to the lateral border of the rectus sheath, passing cranial to the external inguinal ring.

Illio-Inguinal Approach

Mobilize the spermatic cord or round ligament in a sling. The posterior wall of the inguinal canal is now exposed

Divide the rectus abdominal muscle 1 cm proximal to its insertion into the symphysis pubis. Divide the muscles forming the posterior wall of the inguinal canal

Ligate and divide the inferior epigastric vessels.

Illio-Inguinal Approach

Using a swab, push the peritoneum upwards to reveal the femoral vessels. Mobilize the iliacus muscle from the inner aspect of the ilium.

Isolate the femoral vessels together in the femoral sheath and protect them with a rubber sling. Pass a second sling around the tendon of iliopsoas with the femoral nerve lying on top of it

• The first window encompasses the entire internal iliac fossa from the sacroiliac joint posteriorly to the iliopectineal eminence anteriorly.

• The second window provides access to the pelvic brim and quadrilateral surface from the sacroiliac joint to the lateral third of the superior pubic ramus.

• Through the third window the entire medial portion of the superior ramus and symphysis can be visualized

Extended Iliofemoral approach• It gives excellent visualization of the ilium, the superior

dome and the posterior column. The anterior column can be seen up to the iliopectineal eminence. This exposure is similar to that provided by the triradiate approach with the additional benefit of access to the bone above the sciatic notch.

Triradiate transtrochanteric approach

• It is ideal for fractures with both column injuries where in the entire outer table of the pelvis from the anterior superior iliac spine to the top of the sciatic notch can be seen.

Combined anterior and posterior approaches

• Patient is in lateral position with no fixed support. It allows for the surgeon to roll the patient prone or supine if necessary.

Approaches for specific fractures

Approaches for specific fractures

Indications for non-operative treatment

• Non displaced and minimally displaced fratures.

• Fractures that traverse the wt bearing dome, but with less than 2 mm displacement – managed by non wt bearing and or skeletal traction for 8 weeks.

Indications for non-operative treatment

• Fractures with significant displacement but, in which the region of the joint involved is judged to be unimportant prognostically.

• This can be determined by the roof arc measurement described by Matta and Olson as 45 degrees for each roof arc, medial, anterior and posterior.

• Most authors agree that displaced fractures through the weight bearing dome should be treated with ORIF, regardless of how they ‘line up’ in traction.

Roof arc measurement

Medical contraindications to surgery

• Multisystem injury• An open wound in the anticipated surgical

field The Morel – Lavallée lesion• Presence of a suprapubic catheter is a

contraindication for ilioinguinal approach.• Elderly patients with osteoporotic bone –

where ORIF may not be feasible.

Indications for operative treatment

• In fracture incongruity due to– Posterior column or wall injuries– Displaced fractures of the superior dome– Retained bony fragments

• In the limb– Sciatic nerve injury– Fracture of the ipsilateral femur– Injury to the ipsilateral knee

• In the patient – polytraumatised patient

Treatment of specific fracture patterns

• Posterior wall fractures – Posterior Langenbeck approach with the patient

positioned either prone or lateral using lag screw and a reconstruction plate placed from the ischium over the retro acetabular surface onto the lateral ileum. (If the fracture extends superiorly into the dome, a trochanteric osteotomy may be performed to allow additional exposure)

– To avoid AVN of the posterior wall, the posterior wall fragments must not be detached from the posterior capsule. The knee must be kept flexed throughout the procedure to avoid injury to the sciatic nerve.

Treatment of specific fracture patterns

• Posterior column fracture– Though uncommon if significantly displaced, requires ORIF

(Kocher Langenbeck approach).– Typical fixation is with a lag screw combined with a

contoured reconstruction plate along the posterior column.

– Rotational deformity must be corrected by placing a Shanz screw in the ischium to control rotation while the fracture is reduced with a reduction clamp

Treatment of specific fracture patterns

• Anterior wall and anterior column fracture– Isolated anterior wall fractures are uncommon. – Sometimes, they are associated with anterior hip

dislocation.– Fractures requiring surgery are fixed with a buttress plate

applied through an ilioinguinal or iliofemoral approach.– Anterior column fractures are approach similarly with

fixation by a contoured plate along with a pelvic brim.

Treatment of specific fracture patterns

• Transverse fractures– Transtectal fractures have the worst prognosis and

accurate reduction is essential.– Juxtatectal fractures also usually require reduction.– Typical reduction is through a posterior approach using a

Farabeuf clamp to reduce the fractures while rotation is controlled by a Shanz screw in the ischium.

– Posterior fixation typically is with a buttress plate along the posterior column and anterior fixation using a lag screw placed into the anterior column from a position above the acetabulum.

Treatment of specific fracture patterns

• Posterior Column fracture with associated posterior wall fracture– A Kocher-Langenbeck approach is used with or with out a

trochanteric osteotomy. – The column fracture is reduced first. – A short reconstruction plate is placed posteriorly along the

posterior edge of the column. A separate plate is used for the wall fragment.

– T screws through the plate secure rotational reduction on the posterior column fragment.

Treatment of specific fracture patterns

• Transverse fracture with associated posterior wall fracture– The common fracture can be difficult to reduce.– The posterior wall component requires a posterior

exposure, but reduction of the anterior part of the transverse fracture can be difficult through a Kocher-Langenbeck approach and extensile or combined approach is frequently necessary.

Treatment of specific fracture patterns

• T-type and anterior column-posterior Hemi-transverse fracture– They are treated through an ilioinguinal approach with a

contoured plate placed along the pelvic brim and lag screws extending into the posterior column.

– For a T-type fracture with severe posterior displacement but minimal anterior displacement, posterior approach alone may be sufficient with placement of anterior column lag screw.

– If both the anterior and posterior components of the fracture are significantly displaced, an extensive or combined approach are required.

Treatment of specific fracture patterns

• Both column fractures– These have varying degrees of comminution and can be

extremely complex and difficult to treat. – Many both column fractures can be treated through an

anterior ilioinguinal approach. – But a posterior or extensile exposure is required for

involvement of the sacroiliac joint, significant posterior wall fracture, or intraarticular comminution.

– Reduction is begun from the most proximal portion of the fracture and proceed towards the joint.

Implants for acetabular fractures

Post-operative care

• Closed suction drain• Antibiotic for 48 – 72 hours• Passive motion of the hip on the 2nd or 3rd day.• Touch down ambulation & crutches on 2nd to 4th

day.• The minimal weight bearing status is continued for 8

weeks in patients with simple fractures and 12 weeks in most others.

• Rehabilitation of the abductor muscle group is needed.

Complications

• General– Thromboembolic disease– Infection

• Specific

Specific Complications

• Sciatic nerve injury– Thirty percentage of acetabular fractures have associated

sciatic nerve injury. – In 2 – 6 % of patients, it occurs as a result of surgery and is

more often associated with posterior fracture pattern treated through a Kocher-Langenbeck and extensile exposures.

– The peroneal component of sciatic nerve is more often involved than the tibial component.

– Complete peroneal palsies have the worst prognosis. Tibial component has greater chances of recovery.

Specific Complications

• Other nerves– Femoral nerve injury – though rare, care to be taken

during the anterior ilioinguinal approach.– Superior Gluteal nerve injury is vulnerable in the greater

sciatic notch, resulting in abductor paralysis.– Pudendal nerve injury– Injury to the lateral femoral cutaneous nerve causes

sensory loss in the lateral aspect of the thigh.

Specific Complications

• Post-traumatic arthritis• Heterotopic ossification• Chondrolysis• AVN

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