Pelvis and hip

FRACTURES OF THE PELVIS

A) Isolated fractures(stable with
no disruption of the pelvic ring )
[1] Fracture of superior ischio-
pubic ramus
[2] Fracture of inferior ischio-
pubic ramus
[3] Fracture entering wall of
acetabulum
[4] Fracture of wing of ilium
[5] Avulsion fractures of anterior
inferior iliac spine, anterior
superior iliac spine, or ischial
tuberosity.
B) Fractures with disruption of
the pelvic ring (unstable)
[1] Combination of anterior
and posterior fractures of the
pelvic ring
[2] Disruption of pubic
symphysis and posterior
sacro-iliac joint
 DISLOCATIONS AND FRACTURE-DISLOCATIONS OF THE HIP

Only three types of dislocation and fracture-

dislocation of the hip need be considered:
1)Posterior dislocation or fracture-dislocation
2)Anterior dislocation
3)Central fracture-dislocation.
All these injuries are uncommon when
compared, for example, with dislocation of the
shoulder. Of the three types, the posterior
dislocation is the most common.
 Diagnosis

1-POSTERIOR DISLOCATION AND FRACTURE-DISLOCATION

The femoral head is forced out of the back of
the acetabulum by violence applied along the
shaft of the femur while the hip is flexed or semi
flexed (Fig. 14.4A). The injury often occurs as a
result of a motor accident in which the occupant
of a car involved in a collision is thrown forwards
and strikes the front of the flexed knee against a
part of the bodywork. Another common cause is a
motor cycle crash.
 In about half the cases of posterior dislocation
of the hip, the head of the femur carries with it a
small or large fragment of bone from the rim of
the acetabulum (fracture dislocation; see Fig.
14.6). It should be noted that the sciatic nerve is
almost directly in the path of displacement and
may easily be damaged.
 Clinical features
To remember the clinical deformity it is easiest
to think of the greater trochanter as being held
more or less in its normal position by the attached
muscles as if by guy ropes and forming the centre of
a new vertical axis about which the femoral head
may swing forwards or backwards (Fig. 14.5). Thus
in a posterior dislocation the femur and with it the
whole lower limb is rotated medially as well as
being displaced upwards (Fig. 14,5). There will be
true shortening of the limb, perhaps by 2 or 3 cm.
Radiographs will confirm the dislocation (Fig. 14.6)
and show whether or not there is an associated
fracture. Careful examination should always be
made for signs of injury to the sciatic nerve.
 Treatment
The dislocation should be reduced under
general anesthesia as soon as possible. Reduction
is usually effected without difficulty by pulling
longitudinally upon the femur while the hip is
flexed to a right angle and rotated laterally.
Technique. The patient is placed supine,
preferably on the floor or on a low table, and an
assistant grasps the pelvis firmly through the iliac
crests. The surgeon flexes the hip and knee to a
right angle so that the line of the femur points
vertically upwards, and then pulls the thigh
steadily upwards, at the same time gradually
rotating the femur laterally (Fig. 14.4B).
Fig. 14.5 The position of the limb in anterior dislocation and
posterior dislocation of the hip.

Anterior dislocation: -limb

rotated laterally

New axis of rotation

Posterior dislocation:-limb
rotated medially
 After the dislocation has been reduced the limb is
supported by traction, for 3-6 weeks. Mean while
mobilizing exercises for the hip and knee are begun
after a few days and are gradually intensified.
Complications
These are:
(1) Injury to the sciatic nerve,
(2) Damage to the femoral head,
(3) Avascular necrosis of the femoral head,
(4) Post-traumatic ossification and
(5) Osteoarthritis.
 2) ANTERIOR DISLOCATION
Anterior dislocation of the hip is much less common
than posterior dislocation. Indeed, it is a very uncommon
injury. It is caused by forced abduction and lateral rotation
of the limb, usually in a violent injury such as a motor
accident or aircraft crash. There is not usually an associated
fracture of the acetabular margin.
Clinically, the limb rests in marked lateral rotation (Fig. 14.5).
Treatment
Reduction under anesthesia is effected by strong
traction upon the limb combined with medial rotation.
Thereafter, treatment is the same as for posterior
dislocation.
Complications
There is not the same risk of damage to the sciatic nerve
as there is in posterior dislocations, but the femoral nerve
and artery may be compressed, and the risk of
osteoarthritis from avascular necrosis is the same
 3) CENTRAL FRACTURE-DISLOCATION
In central fracture—dislocation of the hip the
femoral head is driven through the medial wall, or
'floor', of the acetabulum towards the pelvic cavity. It
differs from anterior and posterior dislocations in that
the capsule remains intact, but there is inevitably a
fracture of the acetabulum, usually with much
comminution.
Central fracture-dislocation is caused by a heavy
lateral blow upon the femur, as in a fell from a height
onto the side or a crushing injury, or it may be caused
by a longitudinal force acting upon the femur (as from
a blow upon the flexed knee) while the hip is
abducted. The degree of displacement varies with the
severity of the violence
Fig. 14.8 Fracture of the acetabulum with slight medial displacement of the femoral
head and acetabular floor. The main part of the weight-bearing surface of the
acetabulum is intact. With traction, or failing that by operation, a reasonably
smooth acetabular surface may be restored, but there is nevertheless a serious risk
that osteoarthritis will develop later.
 Treatment
Severe shock may demand energetic resuscitation, and
the possibility of major internal bleeding should be
borne in mind.
Treatment of the skeletal injury depends largely upon
the degree of comminution and displacement of the
acetabular fragments, and upon whether or not it is
possible to restore the articular surface to its normal
shape. In practice the cases thus fall into two groups:
(1) those in which the main part of the weight bearing
surface of the acetabulum can be restored to its
normal position, congruous with the femoral head;
and (2) those in which this is impossible on account of
severe comminution of the weight-bearing surface.
W here restoration of the articular surface is
possible, non-surgical treatment by skeletal
traction through a femoral Steinmann pin will
sometimes pull down the displaced fragment of
the acetabulum, which should then remain
congruent with the femoral head when traction is
removed. Traction should, however, be
maintained for 4-6 weeks until bony stability has
developed. Surgical treatment is indicated
when an anterior or posterior fracture
dislocation (Fig. 14.9) cannot be reduced by
traction.
Fig. 14.9 Severe central fracture-dislocation of the hip (arrows). There
is no possibility of restoring a smooth acetabular surface .
Fig. 14.10 CT scans in two planes to show
displaced fragments in severe central
fracture-dislocation of the hip.
Traction may be continued for symptomatic relief for 2
or 3 days while the fracture is fully evaluated and the
most appropriate surgical treatment planned. Ideally
patients with these difficult fractures should be
transferred to a unit that specializes in their
treatment, but this should not be delayed for more
than 7-10 days. The incision chosen for treatment
depends on the location of the fracture and may
require an anterior ilio-inguinal approach, an
extended iliofemoral approach, or some­times a
combined anterior and posterior approach. Following
open reduction, fixation of the fragments may be
achieved by a combination of multiple screws and
contoured plates.
In many instances it is necessary to use additional
bone grafts to reconstitute skeletal defects
resulting from fracture impaction.
Surgical complications are frequent, particularly
infection and thrombo-embolism and appropriate
prophylactic treatment is required. Following
surgery, light traction should be continued until
wound healing has occurred and weight-bearing is
deferred for at least 6 weeks.
• It should be borne in mind that many patients with
central dislocation of the hip will eventually need
total replacement arthroplasty on account of
secondary degenerative changes, and one of the
objectives of the primary treatment should be to
restore the hip sufficiently closely to its normal
position to ensure that conditions are favorable
for arthroplasty, should it be required.
 Complications
As in other fractures of the pelvis there may be
severe haemorrhage from damage to a major
blood vessel, but the common complication is
degenerative arthritis from damage to the
articular surface of the acetabulum. This may
develop early (within a few months) or after a
period of years.
If the disability from arthritis becomes severe
the only effective treatment is by operation. The
choice usually lies between arthrodesis and total
replacement arthroplasty.
FRACTURES OF THE PROXIMAL FEMUR
 Classification
[1] Fracture of the neck of
the femur
[2] Fracture of the
trochanteric region
 FRACTURE OF THE NECK OF THE FEMUR
Fracture of the neck of the femur is common in
persons over the age of 60 years and is one of the
so-called 'fatigue fractures . Women are especially
at risk, because of a tendency for their bone to
become increasingly fragile after the menopause
in consequence of generalised osteoporosis.
The causative injury is often slight usually a fall or
stumble. In most cases the fracture is probably
caused by a rotational force. In about 95% of
cases, there is marked displacement, the shaft
fragment being rotated laterally and displaced
upwards, often with comminution of the posterior
cortex (Fig. 14.11).
 Clinical features
A-Displaced fracture. A typical history is that the patient
usually an elderly woman tripped and fell, and was unable
to get up again unaided. She was subsequently unable to
take weight on the injured limb. On examination the most
striking feature is the marked lateral rotation of the limb.
This is often as much as 90°, so that the patella and the foot
point laterally. The limb is shortened by about 2-3 cm. Any
movement of the hip causes severe pain.
B-Impacted abduction fracture In the exceptional case in
which the fracture is impacted, the history and signs are
different. The patient may have been able to pick herself up
after falling, and she may even have walked a few steps
afterwards, perhaps with assistance. Indeed, some patients
have remained mobile despite pain, and have not sought
medical advice immediately. On examination there is no
detectable shortening and no rotational deformity. The
patient is able to move the hip through a moderate range
without severe pain.
 Treatment
Displaced fractures and impacted abduction
fractures must be considered separately.
Displaced fractures. A displaced fracture of the neck
of the femur is one of the few fractures that needs
rigid immobilization if it is to have any chance of
uniting. The alternative treatment, in which the
femoral head is excised and replaced by a metal
prosthesis, is more commonly used, especially
when there is comminution of either fragment,
severe displacement, and when the patient is
elderly or debilitated.
Fig. 14.12 A) Compression
screw-plate (dynamic hip
screw) used for some
fractures of the femoral
neck and for trochanteric
fractures. The lag screw(s)
gripping the head
fragment is drawn into the
barrel by tightening the
end screw, thus
compressing the
fragments together. B)
Same fracture fixed with
parallel long screws.
After operation the patient is nursed free in bed and
active hip movements are encouraged. Most
surgeons encourage early walking with the aid of
crutches or a frame within the first week after the
operation on the grounds that in these elderly
patients the advantages to the general health of
being up and about far outweigh the theoretical
advantages to the fracture of rest.
Alternative methods for selected fractures in the
elderly. Because of the uncertain results of fixing
these fractures by internal devices, especially in
the elderly, most surgeons now advise immediate
excision of the femoral head and its replacement
by a metal prosthesis (replacement arthroplasty,
see Fig. 14.17A).
Treatment in children. Femoral neck fracture is
uncommon in children, but when it occurs most
surgeons advise operative fixation, usually by two or
three threaded pins, because bone healing is more
reliable and complications fewer.
Impacted abduction fractures. It must be emphasized
that a diagnosis of impacted abduction fracture
should not be made unless both the clinical and
radiological criteria of impaction are satisfied (Fig.
14.14). In the absence of such strict criteria, firm
impaction of the fracture cannot be assumed, and
there is a serious risk that the fragments will fall
apart. Despite the feasibility of conservative
treatment, there is an increasing trend towards
routine internal fixation of impacted abduction
fractures, because of a fear that displacement may
occur.
 Complications
Fractures of the neck of the femur are more
prone to serious complications than is any other
fracture. The important complications are
avascular necrosis, non­union, and late
osteoarthritis. All these complications affect
fractures with displacement rather than impacted
abduction fractures.
Fig. 14.16 Ununited fracture of the neck of the femur with extrusion of the
screw that was used for fixation, and redisplacement of the fragments.
Fig. 14.20 Avascular necrosis of a large segment of the femoral head
2 years after fracture of the femoral neck. Although the fracture
appears to have united, the ischaemic changes adjacent to the joint
margin, with considerable collapse of the bona, are causing
osteoarthritis.
Fig. 14.23 Comminuted trochanteric fracture with sub-
trochanteric extension. (U Trochanteric fracture after fixation
with Gamma nail.
Fig. 14.24 Failure of fixation in a comminuted trochanteric fracture.
The screw has cut out from the femoral head.