PELVIS AND HIP

FRACTURES AND DISLOCATIONS

ANATOMY
 Pelvic ring is made up of two innominate bones and
the sacrum articulating in front at the symphysis pubis
and posteriorly at the sacroiliac joints.
 This basin-like structure transmits weight and
provides protection for the pelvic viscera, vessels and
nerves.
 The stability of the pelvic ring depends upon the
rigidity of the bony parts and the integrity of strong
ligaments.
 The most important ligaments are the sacroiliac and
iliolumbar ligaments, these are supplemented by the
sacrotuberous and sacrospinus ligaments and the
ligaments of the symphysis pubis.
ANATOMY
ANATOMY
 Branches of common iliac arteries with their
accompanying veins are particularly vulnerable in
fractures through the posterior part of the pelvic ring.
 The nerves of the lumbar and sacral plexuses are at
the same risk.
 The bladder lies behind the symphysis pubis, the
prostate lies between the bladder and the pelvic floor.
 The urethra is held by both pelvic floor muscles and
the pubourethral ligament, in females the urethra is
much more mobile and less prone to injury.
 The pelvic colon is a mobile structure, however the
rectum and anal canal are less mobile and therefore
vulnerable in pelvic fractures.
IN GENERAL
◦ FRACTURES
ISOLATED FRACTURES
FRACTURES WITH DISRUPTED PELVIC RING
FRACTURES OF ACETABULUM
◦ DISLOCATIONS
POSTERIOR +/_ FRACTURE
ANTERIOR
CENTRAL FRACTURE DISLOCATION
◦ FRACTURES OF PROXIMAL FEMUR
FRACTURES OF NECK
INTERTROCHANTERIC FRACTURES
SUBTROCHANTERIC FRACTURES
IN GENERAL
The basic principles of fracture treatment are

Appropriate reduction
Immobilization
Early rehabilitation
CLINICAL ASSESSMENT

 There may be a history of RTA, fall from a height or

crush injury.
 Usually complaining of:
 Severe pain.
 Swelling.
 Bruising.
 General examination.
 Chick for maximum point of tenderness.
 Abdomen should be examined.
 P/R examination.
CLINICAL ASSESSMENT
 In stable ring fractures, patient is not severely shocked
and tenderness is localized.
 In unstable ring fractures, patient is severely shocked, in
great pain, tenderness is widespread, can be associated
with visceral injury, intra-abdominal and retroperitoneal
haemorrhage, shock, sepsis and ARDS.
 Chick for bleeding at external meatus and extravasation
of urine.
* No attempt should be made to pass a catheter if
urethral injury is suspected.
 Neurological assessment is important to roll out
damage to lumbar or sacral plexuses.
 Mortality rate is considerable.
IMAGING OF THE PELVIS
 X-ray.
◦ AP view.
◦ Inlet view.
◦ Outlet view.
◦ Oblique views.
 U.S scan abdomen and pelvis.
 CT scan.
 I.V urogram.
 Urethrogram.
 Cystogram.
 Angiogram.
TYPES OF INJURY
Fractures of the pelvis account for < 5% of
all skeletal injuries.

1. Isolated fracture with intact pelvic injury.

2. Fracture with broken ring.
◦ Stable.
◦ Unstable.
3. Fracture of acetabulum.
4. Sacrococcygeal fracture.
ISOLATED FRACTURES
 Could be:
◦ Avulsion fractures as sartorius with ASIS, rectus
femoris with AIIS, adductor longus with a piece of
the pubis and the hamstrings with part of the
ischium, usually all treated conservatively except in
rare cases of the last one.
◦ Direct fractures as in a fracture of the ischium due
to fall from height, usually treated conservatively.
◦ Stress fractures as in fracture of the pubic rami or
fracture around the sacroiliac joint in severly
osteoporotic or osteomalacic patients and long
distance runners.
ISOLATED FRACTURES
FRACTURES OF THE PELVIC RING

 Anterior posterior compression (open

book).
 Lateral compression.
 Vertical shear.
 Combination injuries.
FRACTURES OF THE PELVIC RING

 Anterior posterior compression. (APC)

◦ APC ǀ : slight diastasis (< 2cm), may be invisible
on x-ray, ligaments strain, the pelvic ring is
stable.
◦ APC ǁ : diastasis is more marked, CT scan may
show slight separation of SIJ on one side, the
pelvic ring is stable.
◦ APC ǁǀ : severe injury, shift or separation of the
SIJ and symphysis pubis, the ring is unstable.
FRACTURES OF THE PELVIC RING
 Lateral compression. (LC)
◦ LC ǀ : simple, fracture pubic ramus anteriorly, the
ring is stable.
◦ LC ǀǀ : more severe, in addition to anterior fracture
there may be a fracture of the iliac wing, the ring
remains stable.
◦ LC ǀǀǀ : injury is worset, as in run over.

 Vertical shear.
Hemi-pelvis is dispalced in a cranial direction and
often posteriorly, totally disconnected and the ring is
unstable.
FRACTURES OF THE PELVIC RING
FRACTURES OF THE PELVIC RING
MANAGEMENT

 Early management.
◦ A B C D E.
◦ Is there an intra-abdominal injury.?
◦ Is there a bladder or urethral injury.?
◦ Is the pelvic fracture stable or unstable.?
MANAGEMENT
 Unstable fractures : pelvic binder, lateral
compression or external fixator should be used, if
the bleeding persistent and there’s no intra-
abdominal injury, angiography can be performed.
 Treat urethral and bladder injuries.
 In most of the cases the external fixator may be the
definite treatment.
 In some cases an open reduction and internal
fixation for the symphysis pubis, the SIJ and the
pelvic bones.
EFFECT OF PELVIC BINDER
EFFECT OF PELVIC CLAMP
COMPLICATIONS
 Rupture of the bladder.
 Rupture of the urethra.
 Injury to rectum or vagina.
 Vascular injury as in iliac or one of its branches
 Injury to nerves.
 Persistent sacroiliac pain.
 Involvement of Acetabulum with subsequent OA
FRACTURE ACETABULUM

AO CLASSIFICATION

 Type A 1,2,3
One column only is involved.
 Type B 1,2,3
Main fracture line lies transversely,
part of acetabular roof always remains in continuity with the ilium.
 Type C 1,2,3
Both columns involved,
No part of acetabulum remains in continuity with the ilium
FRACTURE ACETABULUM
FRACTURE ACETABULUM
FRACTURE ACETABULUM
FX ACETABULUM WITH SUP GLUTEAL
ARTERY INJURY
FRACTURE ACETABULUM
FRACTURE ACETABULUM
FRACTURE ACETABULUM
??What to do
HIP JOINT DISLOCATION
The magnitude of force needed to dislocate the
hip, which is a well contained joint by bony and soft
tissue anatomy, is so great that the dislocation can
be even associated with fractures.

N.B Anatomical component:

1. Articular Capsule .
2. Acetabular labrum .
3. Ligaments:
 Iliofemoral .
 Pubofemoral .
 Ischiofemoral .
 Ligament of the head of the femur .
 Transverse ligament of the acetabulum .
HIP JOINT DISLOCATION

 Posterior dislocation+/_FR.
 Anterior dislocation.+/-FR
 Central Fracture dislocation .
HIP JOINT DISLOCATION
1. Posterior Hip Dislocation (90%) :
• Posterior dislocations occur when the knee and hip are flexed and
a posterior force is applied at the knee while the leg is in adducted
position.
• Posterior hip dislocations occur
typically during RTAs, when the
knees of the front-seat occupant
strike the dashboard.
Posterior Hip Dislocation
Signs & Symptoms of Posterior Hip Dislocation:
 Pain in the hip and buttock area.
 The affected limb is shortened, adducted, and
internally rotated, with the hip and knee held in slight
flexion.
 Patient unable to walk or adduct the leg.
 Signs of vascular or sciatic nerve injury may be present
 Pain in hip, buttock, and posterior leg.
 Loss of sensation in posterior leg and foot.
 Loss of dorsiflexion (peroneal branch) or plantar
flexion (tibial branch).
 Loss of DTRs at the ankle.
 Local hematoma in vascular injury.
Posterior Hip Dislocation
Posterior Hip Dislocation
Management

Under GA, place the patient in supine

position, While an assistant stabilizes the
pelvis with direct pressure, Flex the hip
and knee to 90° and pulls the thigh
vertically upward.

*irreducible.?
*unstable.?
Posterior Hip Dislocation

Complications

 Sciatic nerve injury.

 Vascular injury ( ? sup.
gluteal artery ).
 Damage to the femoral
head ( Pipkin ).
 Avascular necrosis.
 Osteoarthritis.
 Myositis ossificans.
HIP JOINT DISLOCATION

2. Anterior Hip Dislocation

Anterior dislocation of the hip

occurs from a direct blow to the
posterior aspect of the hip or
more commonly from a force
applied to an abducted leg that
displace the hip anteriorly out of
the acetabulum.
Anterior Hip Dislocation
Signs and symptoms of anterior hip dislocation:

 Pain in the hip area and inability to walk or adduct the leg.
 The leg is externally rotated, abducted and extended at the
hip.
 The femoral head may be palpated anterior to the pelvis.

◦ Signs of injury to the femoral nerve or artery may be

present:
 femoral nerve :
*Paresis of lower extremity.
*Weak or absent DTRs at knee.
*Paresthesias of lower extremity.
 femoral artery:
*dull aching pain, pallor, paresthesias and coldness.
Anterior Hip Dislocation
Anterior Hip Dislocation
Management
Reduction :assistant stabilize the pelvis, then
correct abduction& ext rotation so convert ant.
Dislocation into post. Dislocation..then to be
reduced as post dislocation .

Complications
 Avascular necrosis.
 Femoral nerve injury.
 Femoral artery injury.
 Others..??
Anterior Hip Dislocation
HIP JOINT DISLOCATION
3. Central Fracture-Dislocation Hip

In which the femoral head is driven through the

floor of the acetabulum towards the pelvic cavity, it
differs from other dislocations in that the capsule
remains intact.
It caused by heavy lateral blow upon the femur,
the degree of displacement varies with the severity
of the violence.
the extent of the damage of the acetabulum may
be difficult to assess without CT scan.
CENTERAL FRACTURE-DISLOCATION HIP
CENTERAL FRACTURE-DISLOCATION HIP

Management
It can be treated conservatively if the
acetabulum can be restored to its normal
position on traction otherwise open reduction
and internal fixation, even THR may be
needed.
Complications
As in the other fractures of the pelvis either
locally or generally, according to degree of
damage.
FEMORAL HEAD FRACTURES
Pipkin
classification
 In general the indications for open reduction
are:

◦ Irreducible dislocation.
◦ Persistent instability of the joint following
reduction (e.g fracture-dislocation of the posterior
acetabulum).
◦ Fracture of the femoral head, neck or shaft.
◦ Neurovascular deficits that occur after closed
reduction.
FRACTURES OF PROXIMAL FEMUR
FRACTURE OF THE NECK OF THE
FEMUR

 More in persons >60 yrs.

 More in women.
 Mortality rate is up to 10% at thirty days post injury
and reaches 30% after one year.
 They are classified into basal, transcervical and
subcapital.
 It can be displaced or impacted with different clinical
features in both.
 X-rays AP/Lat. views may be enough, but CT scan and
MRI scan may be needed.
FFRACTURE OF THE NECK OF THE EMUR

Blood supply of head and neck

is a complex network result as
 Anastomosis of medial and lateral circumflex

areteries starting distally and run proximally

adherent to capsule and synovial membrane.
 Epiphyseal vessels emerge from the

intracapsular ring.
 The epiphyseal arteries anastomose with the

artery through the ligamentum teres.

FRACTURE OF THE NECK OF THE FEMUR
FRACTURE OF THE NECK OF THE FEMUR

Clinical features :
 Displaced fractures: A typical history is that the
patient -usually an old woman- tripped and fell
and unable to get up again.
 O/E Lateral rotation & shortening. .
 Impacted fractures: The patient may have been
able to pick herself up and she may even have
walk a few steps, no gross deformity.
Pauwels’
Classification

Garden’s
Classification
FRACTURE OF THE NECK OF THE FEMUR
FRACTURE OF THE NECK OF FEMUR
Choice of implant :
 Type of fixation is not standard, depends on the
age, general and local conditions, type and site of
fracture, available facilities and experience of the
surgeon.
 Implants :
◦ Screws.
◦ Plate and screws.
◦ DHS.
◦ PFN.
◦ Arthroplasty.
FRACTURE OF THE NECK OF THE
FEMUR
Complications :
 Avascular necrosis.
 Non-union.
 Osteoarthritis.
INTER-TROCHANTRIC FRACTURE
 It’s much more benign than a fracture of neck of
femur, it’s usually units readily and it’s almost
immune to avascular necrosis and non-union.
 Clinical features and radiological examinations are
almost the same as fractures of the neck of femur.
 Treatment, every case must be evaluated separately
and choice of the implant can be changed with every
case.
◦ Screws.
◦ Plate and screws.
◦ DHS.
◦ PFN.
◦ Molded plate and screws.
Evans’
Classification
INTER-TROCHANTRIC FRACTURE

Complications
 Failure of fixation

device.
 Malunion.
THANK YOU
DR. SALAH GHAITH