pelvic ring injuries and acetabular fractures nordic … · 2016-05-23 · –letournel acetabular...

PELVIC RING INJURIES AND

ACETABULAR FRACTURES

NORDIC TRAUMA 2016, AARHUS

Ken F. Linnau, MD, MS

Emergency Radiology

Harborview Medical Center – University of Washington

Seattle, WA

Thanks to:

AJ Wilson, Spanaway, WA (formerly U of

Washington)

CC Blackmore, VMMC, Seattle, WA

RO Nathan, U of Washington, Seattle, WA

http://en.wikipedia.org/wiki/File:2008_Wrangler_JK_Unlimited_Sahara.jpg

Jeep Wrangler JK Unlimited Sahara

1948 kg, 55 km/h (15m/s)

http://en.wikipedia.org/wiki/File:2011_Ford_F-250_XLT_--_07-10-2010.jpg

Ford F250 Quad Cab

3715 kg, 65 km/h (18 m/s)

SOMETIMES THEY CRASH

CRASH!!

HOW BIG OF A BANG?

• E kin = ½ mv2

• E kin = ½ (3715 kg + 1948 kg)*

(18m/s +15 m/s)2

• E kin = 3 MJ

• ≈ two sticks of dynamite

SOMETIMES THEY CRASH

CRASH!!

EPIDEMIOLOGY: PELVIC RING

• Pelvic ring injury (19-37/100,000)

– About 2 % of all fractures

• Mortality rate: 9-19% (45% when open)

– Much higher than acetabular fx

• High-energy injury mechanism:

– MVC, MCC

– Car vs pedestrian

– Falls

• Associated injuries are very common

– Injury severity score (ISS) often > 15 (major trauma) Pohlemann-T et al. Injury 42 (2011): 997.

Gabbe-BJ et al. Injury 42 (2011): 985.

EPIDEMIOLOGY: ACETABULUM

• Acetabular fractures are uncommon (3/100,000)

• Mortality rate: about 3%

– Much lower than pelvic ring disruption

• Most common mechanism:

– MVC (up to 80%)

– Falls (increasing)

– Car vs pedestrian

• Elderly: Mean age trending up (falls?)

• Elderly: Injury severity (ISS) trending down

Laird-A, Keating- JF, JBJS, 2005; 87-B: 969

HOW DOES PELVIC RING INJURY KILL?

• Pelvic ring injuries bleed.

– Most bleeding is venous (> 80%)

– Arterial bleeding in less than 20%

– Arterial injury can be treated with embolization

• Level I recommendations for hemodynamically unstable patients

– Size of extraperitoneal hematoma predicts arterial injury and need for transfusion

– Pelvic angiography indicated in 3-10% of pelvic fractures

Blackmore-CC et al. Arch Surgery (2003); 138:504-9.

Cullinane-DC et al. J Trauma (2011) 71(6): 1850-68.

HOW TO SELECT FOR ANGIO?

• No CT available, xray only:

• Clinical prediction rule

• With CT available:

• Absence of blush dismisses need for pelvic hemorrhage control in majority of cases

• Arterial contrast extravasation: angio Blackmore-CC et al. J Trauma (2006); 61(2): 346-52.

Verbeek-DOF et al. J Trauma (2014); 76(2): 374-79.

Cullinane-DC et al. J Trauma (2011); 71(6): 1850-68.

PREDICTING MAJOR PELVIC

HEMORRHAGE

• Displaced obturator ring fracture (> 1cm)

• Diastatic symphysis (> 1cm)

• Hematocrit < 30%

• Pulse > 130 beats/min

None: less than 2% major pelvic hemorrhage

3 or 4: more than 60% major pelvic hemorrhage

Blackmore-CC et al. J Trauma (2006); 61(2): 346-52.

Pulse 130

First Hct 19%

IMAGING

–AP radiograph: overview

–Oblique pelvic views • Inlet and outlet views for pelvic ring injury

• Judet views for acetabulum (Obturator oblique/Iliac oblique)

–CT best for full assessment of injury • Consider 3D reformations

HOW TO CLASSIFY PELVIC RING INJURY

• Use Young-Burgess or modified Tile (AO/OTA).

– Most widely used by orthopedic surgeons

– Both aim to aid in treatment decision making

• Modified Tile (AO/OTA):

– Emphasizes stability and mechanism of injury

• Young-Burgess:

– Based primarily on mechanism of injury

– Higher reliability over all (optimal) Koo-H et al. J Orthop Trauma (2008) 22 (6):379-84.

Young Burgess:

Combined Mechanism (CM)

ACETABULUM: SURGEONS WANT TO

KNOW…

– Type of fracture

– Alignment and displacement

– Stability

– Type of surgical exposure

– Letournel acetabular classification

• Helps to select appropriate exposure

• May predict outcome

ML Routt, Jr.: “Surgical treatment of acetabular fractures” in Skeletal

Trauma, 4th Ed, Saunders 2009

38 YOM, 6 FT FALL

Logroll

patient 45°

in each

direction

LETOURNEL AND JUDET COLUMN

CONCEPT

ANTERIOR COLUMN OF THE

ACETABULUM

– Anterior border of the iliac wing

– Pelvic brim: the bony ridge in the cavity of the pelvis that marks the boundary between the false pelvis and the true pelvis

– Superior pubic ramus

– Anterior wall of acetabulum

POSTERIOR COLUMN OF THE

ACETABULUM

• Posterior column – Greater and lesser

sciatic notch

– Ischial tuberosity

– Posterior wall of acetabulum

LETOURNEL AND JUDET FRACTURE

CLASSIFICATION

Simple

fractures

Posterior wall Posterior

column

Anterior wall Anterior

column

Transverse

Complex

fractures

Posterior

column and

Posterior wall

Transverse

and posterior

wall

T- type

transverse

Anterior column

and posterior

hemitransverse

Both column

30%

70%

LETOURNEL AND JUDET

CLASSIFICATION -- RESHUFFLED

Transverse Column Wall

Transverse Ant column Anterior wall

Transv/ post wall Post column Post wall

T-type AC/ post hemitransv Transverse / post wall

PC/ post wall Post col/ post wall

Both column


Sagittal Coronal Peripheral

MORE EPIDEMIOLOGY

Ferguson TA, et al. JBJS-Br 2010: 92-B, 2: 250

LETOURNEL AND JUDET CLASSIFICATION –

RESHUFFLED BY PREVALENCE


Transverse/ post wall

Both column Post wall

T-type AC/ post hemitransverse Anterior wall

Transverse

Ant column

PC/ post wall

Post column

LETOURNEL AND JUDET



Transverse/ post wall Both column Post wall

T-type

Transverse

80-90% of all acetabular fxs

22 YOM MVC

22 YOM MVC

Posterior wall fracure

47 YOM BICYCLE CRASH

LETOURNEL AND JUDET



Transverse/ post wall Both column Post wall

T-type

Transverse

85 YOF FALL

Sagittal

85 YOF FALL

Transverse

29 YOF MVC

29 YOF MVC

Sagittal

29 YOF MVC

Superior

Inferior

Transverse T-

type

22 YOM MVC

22YOM MVC

Both

column

Anterior

Posterior

22YOM MVC

Johnson TS. Radiology 2005; 235(3): 1023

43 YOM MCC

43 YOM MCC

Sagittal Peripheral

Transverse with associated posterior wall fracture

43 YOM MCC

SUMMARY

• Pelvic ring injuries may require angio-embolization

– Consider using clinical prediction rule

– Retroperitoneal hematoma size

– Blush on CT

• Posterior wall, both column and transverse variants account for 80-90% of acetabular fractures

• Column == Coronal at the tectum

• Transverse == Sagittal at tectum, no iliac wing extension

Thank you!

[email protected]

http://uwmsk.org/acet

abularfx/index.html

SURGICAL APPRAOCH

Surgical approach Fracture type

Kocher - Langenbeck Posterior wall

Posterior column

Transverse

Transverse –Posterior wall

Some T-type

Ilioinguinal Anterior column

Anterior wall

Anterior column posterior

hemitranverse

Transverse

Both column

Some T-type

Extended Iliofemoral, Stoppa,

trochanteric flip

Variable

pelvic ring injuries and acetabular fractures nordic … · 2016-05-23 · –letournel acetabular...

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