pelvic trauma pelvic trauma
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PelvicTraumaPelvic
Trauma
William Herring, M.D. © 2002
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Pelvic FracturesStable Fractures (2/3)
Solitary ischial ramus fractureUnilateral fractures —both ramiIliac wing fracture (Duverny Fracture)Isolated sacral fracture
Pelvic Fractures Stable and Unstable
Stable fractures—single breaks in ring or peripheral fxs (66%)
Result of moderate trauma, e.g. falls
Unstable fractures—fxs of both anterior and posterior arches (33%)
Result of severe trauma, e.g. MVAs
Stable Pelvic FracturesSolitary Fractures of Ischial Ramus
Most common pelvic fracture (40% of all pelvic fxs)Most common stable fractureUsually seen in osteoporotic females
Stable Pelvic FracturesUnilateral Fractures of Both Rami
If distracted, look for other pelvic ring fractures
Stable Pelvic FracturesIliac Wing Fracture-Duverny Fracture
Due to direct lateral compressionOften associated with paralytic ileusCan perforate bowel and be open fracture
Stable Pelvic FracturesIsolated Sacral Fractures
Usually transversely orientedDifficult to detectLateral view may show angulation
Pelvic FracturesUnstable Fractures (1/3)
Malgaigne FractureStraddle FracturePelvic DislocationBucket Handle Fracture
Unstable FracturesMalgaigne Fracture
Most common unstable pelvic fracture (14% of all pelvic fxs)Vertical shearing involves both anterior & posterior archesResults in double vertical fracturesMost commonly through pubic rami and sacrum
Sacral Fractures Associated with Other Fxs
Usually vertically orientedCheck symmetry of sacral lines
Unstable FracturesStraddle Fracture
Bilateral fractures of all pubic ramiFracture fragments are usually elevatedAssociated with urethral and bladder injuries in 20%
Unstable FracturesPelvic Dislocation
Severe trauma“Sprung Pelvis” usually associated with GU injuryNormal SI=1-4mmNormal symphysis=5mm
Unstable FracturesBucket Handle Fracture
Fracture of anterior arch and contralateral posterior archRare
Pelvic TraumaUrethral Injury
Usually involves membranous or prostatic urethra Should be suspected in straddle fracture or pelvic dislocationRetrograde urethrogram should be performed prior to insertion of Foley
Pelvic TraumaRuptured Bladder
Should be suspected with straddle fractures and sprung pelvisMost common rupture is extraperitoneal (80%)Use retrograde cystogram to demonstrate rupture
Pelvic TraumaRuptured Bladder
Extraperitoneal ruptureContrast will remain adjacent to bladder
Intraperitoneal ruptureDome is torn and contrast flows freely
Pelvic TraumaSoft Tissue Clues
Displacement or obliteration of obturator internus fat planeSimilar findings with iliopsoas and gluteal fat planesPelvic hematomas may displace bladder or ureters
Iliopubic Line
Anterior ColumnAnterior aspect of acetabulum runs from ilium to pubis
Ilioischial Line
Posterior ColumnPosterior aspect of acetabulum runs from ilium to ischium
Roentgenographic “U” The Teardrop
“Teardrop” should not be located medial to ilioischial lineDisplacement of “teardrop” may be sign of occult acetabular fx
Pelvic TraumaAcetabular Fractures
20% of pelvic fractures involve acetabulumCT best way of evaluating acetabular fxs
Acetabular Fractures Classification
Posterior rim fractureTransverse acetabular fractureAnterior column fracturePosterior column fracture
Acetabular Fractures Posterior Rim Fractures
Most common acetabular fx (33%)Occurs with posterior dislocation of hipTypically in MVAs with forces through femoral shaft
Acetabular Fractures Transverse Acetabular Fractures
Separates innominate bone into two halvesLook for break in both iliopubic and ilioischial linesMay be associated with central dislocation of femoral head
Acetabular Fractures Anterior Column Fracture
Fracture through iliopubic lineMay be associated with central dislocation of femoral head
Acetabular Fractures Posterior Column Fracture-Walther Fx
Fracture through ilioischial lineMay be associated with central dislocation of femoral head
Pelvic TraumaAvulsion Fractures
Usually occur in athletic individualsIschial tuberosity (hamstrings)Anterior inferior iliac spine (rectus femoris)Anterior superior iliac spine (sartorious)Iliac crest (abdominal muscles)
Avulsion FracturesIschial Tuberosity
Occurs at insertion of hamstringsUsually seen in sprinters, hurdlers, gymnasts, long jumpersLooks enlarged when healed
Avulsion FracturesAnterior Inferior Iliac Spine
Occurs at insertion of rectus femoris
Avulsion FracturesAnterior Superior Iliac Spine
Occurs at insertion of sartorious
Avulsion FracturesIliac Crest Avulsion Fracture
Occurs at insertion of abdominal muscles
Pelvic TraumaComplications
HemorrhageUsually from laceration of hypogastric artery
Urinary tract injuryRuptured urethra or bladder
Pelvic TraumaComplications
Sacral plexus/sciatic nerve injuriesEspecially with fxs of posterior arch
InfectionRetroperitoneal abscess may form in open fxs
Ruptured UrethraClassical Triad
Blood on external meatusDistended bladderInability to void
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