pelvic fracture anatomyanatomy 2 innominate 1sacrum 2 innominate 1sacrum innominate bone...
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Pelvic FracturePelvic FracturePelvic FracturePelvic Fracture
AnatomyAnatomyAnatomyAnatomy
• 2 innominate 1sacrum2 innominate 1sacrum
• Innominate boneInnominate bone
ilium,ischium,pubis ilium,ischium,pubis
• Join by strong ligamentJoin by strong ligament
complex complex
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Minor injuryMinor injury
• Minor fallMinor fall
• Stable vital signStable vital sign
• Non-displaced FxNon-displaced Fx
• Fx not involve ringFx not involve ring
• Treatment-bed restTreatment-bed rest
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Minor injuryMinor injury
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Major injuryMajor injuryMajor injuryMajor injury
• High energy traumaHigh energy trauma
• Unstable vital signUnstable vital sign
• High mortality,morbidityHigh mortality,morbidity
• Associated injuryAssociated injury
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Associated injuryAssociated injury
Rupture bladderRupture bladderRupture urethraRupture urethra
L-S plexus injuryL-S plexus injury
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Associated injuryAssociated injuryAssociated injuryAssociated injury
Hypovolemic shockHypovolemic shockHypovolemic shockHypovolemic shock
Retroperitonium hematomaRetroperitonium hematoma
bleeding bony surfacebleeding bony surface
venous plexus bleedingvenous plexus bleeding
vascular injury vascular injury
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Mechanism of injuryMechanism of injuryMechanism of injuryMechanism of injury
AP compression (open book)AP compression (open book)AP compression (open book)AP compression (open book)
SI joint wideningSI joint widening
Symphysis seperationSymphysis seperation
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Mechanism of injuryMechanism of injury
Lateral compression(internal rotation)Lateral compression(internal rotation)
Fx iliumFx ilium
Lock symphysisLock symphysis
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Mechanism of injuryMechanism of injury
Vertical shear (Malgaigne Fx)Vertical shear (Malgaigne Fx)
SI dislocateSI dislocate
SymphysisSymphysisdislocatedislocate
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Major injury initial managementMajor injury initial management
•RecuscitationRecuscitation•Pelvic stabilizationPelvic stabilization
external fixator external fixator•Definite treatmentDefinite treatment
pelvic sling pelvic sling
ORIF ORIF
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Fracture of proximal femurFracture of proximal femur
Surgical anatomySurgical anatomy Vascular anatomyVascular anatomy
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Fracture neck of the femurFracture neck of the femur
• Intracapsular FxIntracapsular Fx• High rate of nonunion,High rate of nonunion,
avascular necrosis avascular necrosis• 2 aged groups2 aged groups
1.Young adult 1.Young adult
high energy high energy
2.Older with osteoporosis 2.Older with osteoporosis
minor fall minor fall
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Fracture neck of the femurFracture neck of the femur
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Fracture neck of the femurFracture neck of the femurFracture neck of the femurFracture neck of the femur
PE:PE:
• Limb slightly shorteningLimb slightly shortening
• Pain at groinPain at groin
• Tenderness at midinguinal pointTenderness at midinguinal point
Older patient ,minor injuryOlder patient ,minor injury
PleasePlease X ray both hip AP ,lat crosstable X ray both hip AP ,lat crosstable
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Young adult ,good bone qualityYoung adult ,good bone qualityReduction and multiple pinningReduction and multiple pinningYoung adult ,good bone qualityYoung adult ,good bone qualityReduction and multiple pinningReduction and multiple pinning
TreatmentTreatmentTreatmentTreatment
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TreatmentTreatmentTreatmentTreatmentOlder with osteoporosisOlder with osteoporosis
HemiarthroplastyHemiarthroplastyOlder with osteoporosisOlder with osteoporosis
HemiarthroplastyHemiarthroplasty
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• NonunionNonunion
• Avascular necrosisAvascular necrosis
• Venous thrombosisVenous thrombosis
• NonunionNonunion
• Avascular necrosisAvascular necrosis
• Venous thrombosisVenous thrombosis
ComplicationComplication
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Intertrochanteric FractureIntertrochanteric Fracture
• Fx line from greater to Fx line from greater to
lesser trochanter lesser trochanter
• More common in woman More common in woman
menopause menopause
• Extracapsular fractureExtracapsular fracture
• Older with osteoporosis -minor fallOlder with osteoporosis -minor fall
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PE:PE:
• Limb shortening,externalLimb shortening,external
rotation rotation
• Swelling ,ecchymosis at hipSwelling ,ecchymosis at hip
• Tenderness at greater Tenderness at greater
trochanter trochanter
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Treatment Treatment
Non operativeNon operative traction 6 wks. traction 6 wks. high complications high complications
Non operativeNon operative traction 6 wks. traction 6 wks. high complications high complications
Pressure sorePressure sorevenous thrombosisvenous thrombosisinfectioninfection
Pressure sorePressure sorevenous thrombosisvenous thrombosisinfectioninfection
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Operative treatment is preferableOperative treatment is preferable surgical risk, early ambulation surgical risk, early ambulation
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Subtrochanteric FractureSubtrochanteric FractureSubtrochanteric FractureSubtrochanteric Fracture
• Fx at level of lesser trochanter Fx at level of lesser trochanter
and a point 5 cm. Distally and a point 5 cm. Distally
• thick cortical bonethick cortical bone
• high mechanic stresshigh mechanic stress
• high energy traumahigh energy trauma
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Treatment Treatment
Operative treatment is preferableOperative treatment is preferable
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• Posterior dislocation 80%
most common
• Anterior dislocation 5%
• Central dislocation 15%
Hip DislocationHip Dislocation
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Dashboard injuryDashboard injury
Blow to femur inadduction internalrotation of the hip
Blow to femur inadduction internalrotation of the hip
Posterior dislocationPosterior dislocation
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Posterior dislocationPosterior dislocation
PE:PE:
• hip flexion,internal rotate
and adduct
• ass.knee ligament injuries
• assess sciatic nerve
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X-rayX-ray
• Head out of acetabulum
• smaller femoral head
• femur adduct, internal
rotate(disappear lesser
trochanter)
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TreatmentTreatment
• Early diagnosis• prompt closed reduction• Allis’s maneuver• failed closed reduction-
open reduction
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Posterior dislocationPosterior dislocation
Allis’s maneuverAllis’s maneuver
• Stabilized pelvis
• longitudinal traction
• 90 degree hip flexion
• upward traction
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Posterior dislocationPosterior dislocation
Allis’s maneuverAllis’s maneuver
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Management after reductionManagement after reduction
• Test for stability• X-ray both hip AP evaluate joint space• Stable reduction skin traction- pain subside ambulation with crutches• Unstable reduction ORIF
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Posterior dislocationPosterior dislocation
Fragment entrap in jointFragment entrap in jointJoint space widening Joint space widening
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Anterior dislocationAnterior dislocation
Blow to femur in abduction,externalrotate of hip joint
Blow to femur in abduction,externalrotate of hip joint
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• Early diagnosis• prompt closed reduction• Allis’s maneuver• failed closed reduction-
open reduction
TreatmentTreatment
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• General anesthesia
• Traction along axis
• Internal rotation
• Lateral traction
Anterior dislocationAnterior dislocation
Reduction techniqueReduction technique
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Anterior dislocationAnterior dislocation
Clinical manifestationClinical manifestation X rayX ray
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Anterior dislocationAnterior dislocation
Traction along axisTraction along axis
Internal rotationInternal rotationStabilized pelvisStabilized pelvis
Lateral tractionLateral traction37
Anterior dislocationAnterior dislocation
Post reductionPost reduction
• X ray pelvis AP
• Skin traction until
pain subside(5-7 d)
• Ambulation with crutches
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Fracture shaft of the femurFracture shaft of the femur
• High energy injury
• Bleeding 1- 2.5 L.
• Ass. femoral neck Fx.
• Ass. hip dislocation
• High energy injury
• Bleeding 1- 2.5 L.
• Ass. femoral neck Fx.
• Ass. hip dislocation
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• Deformity of thigh
angulation shortening
• PE.of hip and knee
•Vascular assessment
dorsalis pedis a.
posterior tibial a.
• Deformity of thigh
angulation shortening
• PE.of hip and knee
•Vascular assessment
dorsalis pedis a.
posterior tibial a.
Physical examinationPhysical examination
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• Splinting - Thomas’s splint
• Film femur include hip-knee
detect neck Fx-dislocate hip
• Temporary stabilization with
proximal tibial traction
• Splinting - Thomas’s splint
• Film femur include hip-knee
detect neck Fx-dislocate hip
• Temporary stabilization with
proximal tibial traction
ManagementManagement
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ManagementManagement
• Non-operative treatment
Traction 6-8 wks.
Femoral castbrace 10-12wks.
• Operative treatment
ORIF with plate-screw
Intramedullary nailing
• Non-operative treatment
Traction 6-8 wks.
Femoral castbrace 10-12wks.
• Operative treatment
ORIF with plate-screw
Intramedullary nailing
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Transverse Fx midshaft femurTransverse Fx midshaft femur ORIF with plate-screwORIF with plate-screw43
Comminuted Fx midshaft femurComminuted Fx midshaft femur Intramedullary nailIntramedullary nail44
• Fx distal femoral metaphysis
9 cm. above joint line
• Posterior displacement of
the distal fragment
• High rate of stiffed knee
• Fx distal femoral metaphysis
9 cm. above joint line
• Posterior displacement of
the distal fragment
• High rate of stiffed knee
Supracondylar fractureSupracondylar fracture
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How to described Fx?How to described Fx?
T or Y Fx(combined)T or Y Fx(combined)
Intercondylar Fx(intra-articular)Intercondylar Fx(intra-articular)
Supracondylar Fx(extra-articular)Supracondylar Fx(extra-articular)
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• Conservative Traction stiffed knee
• Conservative Traction stiffed knee
• Operative Early function Early knee motion
• Operative Early function Early knee motion
TreatmentTreatment
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T Fracture of distal femurORIF with plate and screwT Fracture of distal femurORIF with plate and screw
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• Largest sesamoid
• Function
-lever arm for knee
extension
-protect condyle
• Largest sesamoid
• Function
-lever arm for knee
extension
-protect condyle
Fracture of the patellaFracture of the patella
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Mechanism of injuryMechanism of injury
•Avulsion(traction) Quads. pull up Knee flexion
•Avulsion(traction) Quads. pull up Knee flexion
•Direct injury•Direct injury
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Sign & symtomSign & symtom
• Swelling,effusion
• Palpable defect
• Unable to extend
knee actively
• Swelling,effusion
• Palpable defect
• Unable to extend
knee actively
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Non displaced FxNon displaced Fx Cylinder castprevent knee flexion
Cylinder castprevent knee flexion
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Displaced transverse FxDisplaced transverse Fx ORIF ORIF
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• Most common long bone Fx
• medial surface palpable
• Open Fx common
• frequent complication
• Most common long bone Fx
• medial surface palpable
• Open Fx common
• frequent complication
Fracture of the tibiaFracture of the tibia
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• Swelling ,deformity• Ascess vascular
dorsalis pedis a.
posterior tibial a.• marked swelling
compartment syn.
• Swelling ,deformity• Ascess vascular
dorsalis pedis a.
posterior tibial a.• marked swelling
compartment syn.
Symtom & SignSymtom & Sign
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TreatmentTreatmentConservativeConservative Closed reduction
apply long leg castClosed reduction
apply long leg cast
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X ray post reduction
X ray post reduction Criteria for accept alignmentCriteria for accept alignment
• Varus,vulgus < 5 degree
• AP angulation <10 degree
• Malrotation <10 degree
• Shortening < 1cm.
• Contact surface >50%
• Varus,vulgus < 5 degree
• AP angulation <10 degree
• Malrotation <10 degree
• Shortening < 1cm.
• Contact surface >50%
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After long leg cast4-6 weeks
After long leg cast4-6 weeks
Change to PTB cast 8-12 wks.
Until Fx consolidation
Change to PTB cast 8-12 wks.
Until Fx consolidation Patella Tendon BearingPTB cast
Patella Tendon BearingPTB cast
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TreatmentTreatment
Operative Operative
• Failed closed reduction
• Unacceptable alignment
• Multiple fractures
• open fracture
• Failed closed reduction
• Unacceptable alignment
• Multiple fractures
• open fracture
Intramedullary nailIntramedullary nail
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External fixatorExternal fixatorORIF plate & secrewORIF plate & secrew
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ComplicationComplication
Compartment syndrome
Compartment syndrome
• Early detection
• Release pressure
remove cast,splint
fasciotomy
• Early detection
• Release pressure
remove cast,splint
fasciotomy
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MalunionMalunionVascular injuryVascular injury InfectionInfection62
A man 23 yr. MCA 10 min . Single injuryPain at Rt. ankle, can’t palpable dorsalis pedisand posterior tibial artery
A man 23 yr. MCA 10 min . Single injuryPain at Rt. ankle, can’t palpable dorsalis pedisand posterior tibial artery
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X ray ankle AP, LatX ray ankle AP, Lat
Fx of distal fibularFx of distal fibular
Diastasis of syndesmosisDiastasis of syndesmosis
Fx of medial mall.Fx of medial mall.
Ankle subluxationAnkle subluxation
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How do you managethis case?
How do you managethis case?
Vascular injury?Joint subluxationVascular injury?Joint subluxation
•4 R•R egcognition•R eduction•R etention•R ehabiliation
•4 R•R egcognition•R eduction•R etention•R ehabiliation
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AP viewAP view Mortise viewMortise view Lateral viewLateral view66
head
body
neck
Fracture of the talusFracture of the talus
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• Talar neck Fx most common
• Caused by hyperdorsiflexion
• 3/5 cover by cartilage
• Vascular enter at talar neck
• Talar neck Fx most common
• Caused by hyperdorsiflexion
• 3/5 cover by cartilage
• Vascular enter at talar neck
Fracture of the talusFracture of the talus
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Subtalar jt. dislocation
Talar neck Fx
Ankle dislocation
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ORIF talar neck with screwORIF talar neck with screw
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Fracture of the CalcaneusFracture of the Calcaneus
• Most common tarsal bone Fx
• Extra-articular Fx
Direct injury
• Intra-articular Fx(Subtalar Jt.)
Fall from height
• Most common tarsal bone Fx
• Extra-articular Fx
Direct injury
• Intra-articular Fx(Subtalar Jt.)
Fall from height
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Physical ExaminationPhysical Examination
•Heel widening,short
•Ecchymosis
•Tenderness at heel
•Squeeze test
•T-L spine exam
•Heel widening,short
•Ecchymosis
•Tenderness at heel
•Squeeze test
•T-L spine exam
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X rayX ray
•Calcaneus lateral•Axial view•Calcaneus lateral•Axial view
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TreatmentTreatment
•Non displaced Fx
Short leg cast 6 wks.•Displaced Fx
ORIF
•Non displaced Fx
Short leg cast 6 wks.•Displaced Fx
ORIF
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