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Dr SHAMMAS B M Dept of Orthopedics Calicut Medical College
• Fractures of the adult pelvis,
generally are either • (1) stable fractures resulting from low-energy trauma, such as falls in elderly patients or • (2) fractures caused by high-energy trauma that result in significant morbidity and mortality
• The potential complications include
injuries to the major vessels and nerves of the pelvis and the major viscera, such as the intestines, the bladder, and the urethra • Immediately after injury, mortality can result from severe intrapelvic hemorrhage. • Hemorrhage frequently results from fracture surfaces and small vessels in
• ANATOMY • The pelvis is composed anteriorly of the
ring of the pubic and ischial rami connected with the symphysis pubis. • A fibrocartilaginous disc separates the two pubic bodies. • The sacrum and the two innominate bones are joined at the sacroiliac joint by the
• interosseous sacroiliac ligaments • the sacrotuberous ligaments • the anterior and posterior sacroiliac
ligaments, • the sacrospinous ligaments, • iliolumbar ligaments • This ligamentous complex provides stability to the posterior sacroiliac complex because the sacroiliac joint itself has no inherent bony stability
• Pelvic stability is determined by
ligamentous structures in various planes. • The primary restraints to external rotation of the hemipelvis are the ligaments of the symphysis, the sacrospinous ligament, and the anterior sacroiliac ligament. • Rotation in the sagittal plane is
• Vertical displacement of the
hemipelvis is controlled by all the mentioned ligamentous structures, • but if other ligaments are absent, it may be controlled by intact interosseous sacroiliac and posterior sacroiliac ligaments, along with the iliolumbar ligament.
• Pennal et al. developed a
mechanistic classification in which pelvic fractures are described as • anteroposterior compression injuries, • lateral compression injuries, • vertical shear injuries.
• Tile modified the Pennal system to
make it an alphanumeric system involving three groups based on the concept of pelvic stability
– A (stable), – B (rotationally unstable but vertically stable), – C (rotationally and vertically unstable).
• Type B1 fractures include "open book"
fractures or anterior compression injuries in which the anterior pelvis opens through a diastasis of the symphysis • or through a fracture of the anterior pelvic ring. The posterior sacroiliac and interosseous ligaments remain intact. • In the first stage, the symphysis separation is less than 2.5 cm, and the sacrospinous ligament remains intact.
• In the second stage, the diastasis is more
than 2.5 cm with rupture of the sacrospinous ligament and the anterior sacroiliac ligament.. • In the third stage, the lesions are bilateral, creating a B3 injury • Young and Burgess proposed a different modification of the original Pennal classification, adding a new category for combined mechanical injuries
• Sacral fractures have been classified separately • • • •
classification used is by Denis, Davis, and Comfort type 1 fractures occur lateral to the neural foramina through the sacral ala; type 2 fractures are transforaminal; type 3 fractures occur medial or central to the neural foramina. Transverse fractures of the sacrum are classified as type 3 injuries because they involve the spinal canal.
• The standard roentgenographic
projections required for evaluation of pelvic fractures are an • anteroposterior view of the pelvis and • 40-degree caudad inlet and • 40-degree cephalad outlet views described by Pennal et al..
• The inlet view demonstrates
rotational deformity or anteroposterior displacement of the hemipelvis. • The outlet view demonstrates vertical displacement of the hemipelvis, sacral fractures, and widening or fracture of the anterior pelvis
• Computed tomography is an
essential part of the evaluation of any significant pelvic injury, allowing evaluation of the posterior portion of the pelvic ring that may be poorly seen on standard roentgenographs.
• Widening of the symphysis of more than 2.5 cm
has been correlated with rupture of the sacrospinous ligament and a rotationally unstable pelvis. Avulsion fractures of the lateral sacrum and ischial spine also are signs of rotational instability. Widening of the anterior pelvis causes rupture of the anterior sacroiliac ligament, making the sacroiliac joint appear widened on the anteroposterior view.
• However, as demonstrated by axial CT
images, the posterior ligaments of the sacroiliac joint may remain intact, maintaining the vertical stability of the pelvis. • Impacted fractures of the anterior cortex of the sacrum are common with lateral compression injuries and generally are stable, • but a sacral fracture with a gap usually indicates vertical instability.
• An avulsion fracture of the tip of the L5
transverse process at the attachment of the iliolumbar ligament is another indication of vertical instability • Vertical instability usually is defined as 1 cm or more of cephalad migration of one hemipelvis. • if vertical stability is questionable, stress testing can be beneficial.
• Bucholz recommended a push-pull
test in which, under roentgenographic control, the examiner pushes up on one extremity while pulling down on the other.
TREATMENT: RESUSCITATION PHASE
• During acute resuscitation, management
of patients with pelvic fractures should follow one of the existing trauma protocols • The MAST suit (military antishock trousers) has proved beneficial during patient transport but is not used routinely in the evaluation/resuscitation phase • A deflatable bean bag has been suggested to stabilize the pelvis temporarily in the initial resuscitation phase.
• In patients with an unstable pelvic fracture
who demonstrate hemodynamic instability after an initial fluid bolus, emergency external fixation should be performed early in the resuscitation effort. • Reported benefits are • (1) a tamponade effect on the retroperitoneal hematoma, effected by reducing the retroperitoneal volume; • (2) less motion of the fracture surfaces, which allows more effective clot formation; and
• (3) greater patient mobility during
transport and for CT scanning and other evaluations • Moreno et al., Burgess et al., and others noted a reduction in the transfusion requirements of patients with unstable pelvic fractures who were treated with immediate external fixation compared with those who did not undergo immediate fixation.
• Many variations of pelvic external
fixators are available. • simple anterior frame with two 5mm pins in each iliac wing is used commonly. • Vertically unstable fractures usually also are treated with ipsilateral distal femoral skeletal traction until definitive internal fixation can be done.
• In the emergent application of a pelvic
external fixator, the following basic technical principles must be observed: • adequate soft tissue protection via guide sleeves for drilling and pin insertion; • skin incisions at 90 degrees to the iliac crest and large enough to accommodate guide sleeves; • 5 mm or larger blunt half-pins, • 180 mm in length or longer
• 2 or 3 pin clusters per hemipelvis;. • converging pin placement into the
anterior third of the iliac wing; • a frame construct that provides clearance from and access to the abdomen; • and dual frame construct to allow independent free manipulation without loss of pelvic reduction.
• Pins can be placed • percutaneously or • via an open technique. • If the pins are placed percutaneously, • Pin is placed 2 cm posterior to the
anterosuperior iliac spine. aiming the pin toward the greater trochanter and allowing it to find its way between the tables of the hemipelvis.
• Frame Construction and Fracture
Reduction/Stabilization. • Apply two upright bars to each pin cluster and connect them to cross bars, thereby creating a dual Slatis-type rectangular frame construct. • Each independent frame can be loosened subsequently and manipulated, thereby allowing access to the abdomen.
• Once the pins are in position and the
frame is constructed, before tightening, reduce the displaced pelvic ring injury. • Open book types require "closure of the book;" • lateral compression injuries require "opening the book." • Tile C injuries are unstable posteriorly, and simple "book-closing" maneuvers can further displace the disrupted posterior pelvic anatomy. Therefore, apply bilateral compressive forces to the pelvic ring posteriorly.
• If used for the definitive treatment of the
pelvic fracture, the frame is left in place for 8 to 12 weeks, depending on the fracture type and reduction. • Pin site care must be meticulous, with peroxide swabs used twice daily to clean away the crusted transudate that often forms.
• Because in vertically unstable fractures an
anteriorly applied external fixator does not control motion in the posterior sacroiliac complex, • the Ganz C-clamp and • the pelvic stabilizer developed by Browner and associates. • Used only as a temporary stabilizing device that should be removed within 5 days if possible.
TREATMENT: RECONSTRUCTIVE PHASE
• Stable, nondisplaced pelvic fractures (Tile
type A) do not require operative stabilization and can be adequately managed with early mobilization and analgesics. • Operative reduction and stabilization have been advocated for rotationally unstable but vertically stable (Tile type B) fractures with a • pubic symphysis diastasis of more than 2.5 cm, • pubic rami fractures with more than 2 cm displacement, or
• other rotationally unstable pelvic
injuries with significant limb-length discrepancy of more than 1.5 cm or • unacceptable pelvic rotational deformity.
• Operative treatment of rotationally
unstable pelvic fractures can be accomplished by • an anterior external fixator used for definitive treatment or • open reduction and internal fixation with anterior plating. • Retrograde pubic ramus screws placed percutaneously or with an open technique also have been described
• External fixator ay be especially useful in
patients with associated genitourinary or gastrointestinal injuries with significant contamination or other soft tissue problems that might preclude anterior open reduction and internal fixation. • Some authorsadvocate the use of a single four- or six-hole 3.5-mm reconstruction plate.
Anterior Internal Fixation of Tile Types B and C Pelvic Fractures
• Approach the symphysis through a
Pfannenstiel incision • for reduction of the symphysis, place a Weber clamp anterior to the rectus muscles onto the body of the pubis bilaterally. • a curved, 3.5-mm reconstruction plate on the superior surface of the symphysis is used for fixation
• Double plating is used only in type C
injuries when it is not certain that posterior fixation is possible during the initial procedure, as in a patient undergoing emergency laparotomy • If internal fixation of a pubic ramus fracture is indicated in a type B or C pelvic fracture, it is performed through an ilioinguinal incision .
• Tile type C pelvic injuries require
posterior fixation to regain vertical stability. • External fixation alone is not recommended as definitive treatment for vertically unstable pelvic fractures, • because the posterior instability cannot be controlled by this
• For Tile type C fractures the anterior ring can be • •
fixed with either an external fixator or an anterior plate as described above. Posterior treatment generally is determined by the portion of the posterior ring disrupted. For sacral fractures and sacroiliac joint disruptions some authors have described image intensifier–directed screw fixation from the ilium posteriorly into the sacral body . This technique risks damage to the L5 nerve root and iliac vessels anterior to the body of the sacrum and to the sacral nerve roots within its bony confines
• Because neurological injury occurs with 30% of • •
transforaminal sacral fractures (Denis zone II fractures), some authors advocate open reduction and internal fixation of such fractures with decompression of the involved neural foramina. Transiliac rod fixation has been reported for sacral disruptions, although there is a risk of neurological injury with compression of the sacrum . Tension band plating also can be used between the two posterior iliac crests
• Simpson et al. reported excellent results
with the use of the anterior retroperitoneal approach for anterior plating of the sacroiliac joint because it allowed direct observation of the joint . • If this approach to the sacroiliac joint is used, the superior gluteal artery, L4 nerve root, and lumbosacral trunk must be carefully protected, especially in the inferior third of the joint.
• For iliac wing fractures, open
reduction and pelvic reconstruction plate fixation techniques are used. • For fracture-dislocations of the sacroiliac joint (the so-called crescent fracture), the fracture can be reduced and fixed anteriorly or posteriorly, with or without hardware transfixing the sacroiliac joint.
• Internal Fixation: Posterior Screw Fixation
of Sacral Fractures and Sacroiliac Dislocations (Prone) • Use a standard posterior vertical incision, 2 cm lateral to the posterior superior spine, for sacroiliac dislocations, fracturedislocations, or sacral fractures. • Reflect the posterior portion of the gluteal muscles from the posterior iliac wing and the gluteus maximus origin from the sacrum. Expose the greater sciatic notch to evaluate reduction.
• Under image intensifier control,
insert screws perpendicular to the iliac wing across the sacroiliac joint into the sacral ala, directing the screws toward the S1 vertebral body.
• Percutaneous Iliosacral Screw Fixation of
Sacroiliac Disruptionsand Sacral Fractures (Supine) • the normal sacral ala has an inclined anterosuperior surface, the sacral alar slope, that extends from proximalposterior to distal-anterior . • Anterior to the sacral ala in this region run the L5 nerve route and the iliac vessels.
• The cortex of the alar slope forms the
anterior boundary of the "safe zone" for passage of iliosacral screws into the body of S1. The posterior boundary of the safe zone is formed by the foramen of the S1 nerve root. • Screws used to fix sacroiliac joint disruptions are placed perpendicular to the joint, whereas • screws used to fix sacral fractures are placed more transversely to allow passage of the screw into the contralateral ala.
• Anterior Approach and Stabilization
of Sacroiliac Joint • Upper half of a Smith-Petersen incision along the anterior iliac crest is used • initially used staples but now uses dynamic compression plates, reconstruction plates, or four-hole plates.
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