pelvic injuries

Objectives : by the end of this lecture you should be able to classify pelvic injuries discuss pelvic ring fracture discuss acetabular fracture discuss traumatic hip dislocation appreciate the importance of early steps of management in pelvic injuries

The importance of the pelvic bones Weight transmission to both limbs. Protection of pelvic viscera. Types pelvic ring fractures. acetabular frctures. isolated fractures (intact pelvic ring). sacrococcygeal fractures.

1-pelvic ring fractures. Being a rigid bony structure, any break in a point within the ring is associated with injury at another point of the ring except:- fractures in children. Direct trauma.

The stability of this ring is maintained by the integrity of 2 innominate hip bones, symphysis pubis, and sacroiliac ligaments (anterior and posterior sacroiliac ligaments) the posterior sacroiliac ligament is the most important structure.

Mechanisms of injury 1- AP compression: frontal collision (RTA) open book fracture. 2- Lateral compression: side on impact, roll over accidents closed book fractures. 3- Vertical shear: FFH (standing) severely unstable fracture. 4- Complex injuries: more than one mechanism. Open book Closed book Vertical shear

Clinical features History of major trauma. Multiple injured patient. Shock. Associated pelvic visceral injury. Local signs (ecchymosis, tenderness, inability to stand, swelling).

Imaging X- ray:- show the pattern of injury and crude estimation for the displacement. CT scan:- show the exact picture of the fracture. Show the sacroiliac ligament injury.

Classification A- Stable:- in all directions (planes): minor or direct trauma, associated with less soft tissue damage and less blood loss (good prognosis). B- Unstable:- in one plane (cross section plane): at least the posterior sacroiliac ligament is intact preventing vertical displacement but the pelvic ring move like the hinge of a door. i.e. external rotation (open book) due to AP compression. Or internal rotation (closed book) due to lateral compression. C- Unstable:- in all planes (cross sectional and vertical):

TREATMENT (ABC) then Type A\\ conservative (only). Type B\\ 1- open book <2cm conservative 2- open book >2cm MUA + external fix. 3- closed book undisplaced conservative 4- closed book displaced MUA + external fix. Type C\\ MUA + external fix. MUA= Manipulation under anesthesia.

N.B The early steps of treatment are simple but life saving. External fixation reduce blood loss. If fixation is needed the first choice is external fixation except in 1- failure of external fixation. 2- if the pt. need lapratomy in both cases do internal fixation.

Complications Early Late 1-shock (bleeding) 1- limping (shortening) 2- pelvic visceral injury 3- neurovascular injury 4- DVT 5- pulmonary embolism. Late 1- limping (shortening) 2- persistent sacroiliac pain 3- birth canal problems.

Acetabular fractures Mechanism of injury: Acetabulum is the region where the 3 hip bones meet together. Mechanism of injury: lateral trauma over the greater trochanter or dash board injury.

Classification: (Tile's) 1- anterior column fracture 2- posterior column fracture 3- transverse fracture 4- complex fracture

Classification of fractures of the acetabulum according to Letournel Classification of fractures of the acetabulum according to Letournel. (A) Posterior wall fracture. (B) Posterior column fracture. (C) Anterior wall fracture. (D) Anterior column fracture. (E) Transverse fracture.

Clinical features Imaging 1- X-ray 2- CT-scan history of major trauma. Shock (vascular injury). Features of sciatic or femoral nerve injury. Inability to move the hip, local tenderness, ecchymosis, edema. Imaging 1- X-ray 2- CT-scan

iliopectineal line ilioischeal line CT Scan

Treatment The early steps are the same of that of pelvic ring fractures (ABC) THEN. 1- conservative: by skeletal traction 6-8 wks then 6-8 wks on crutches. Indicated in - elderly - unfit for surgery - Undisplaced fracture - non weight bearing area. 2- surgical (ORIF): indicated in - young - weight bearing area - major fracture.

conservative operative

Alternatively, use a Judet fracture table Alternatively, use a Judet fracture table. This table permits skeletal traction, which is applied to the distal femur. The knee must be kept flexed, with an appropriate foot support, to relax the sciatic nerve. Skeletal traction assists with reduction of the femoral head and acetabular fracture.

Complications Early : 1- shock 2- DVT 3- Sciatic nerve injury. Late : 1- myositis ossificance 2- avascular necrosis of femoral head 3- Osteoarthritis.

Traumatic hip dislocation 1- central 2- posterior 3- anterior

1-Central = acetabular fracture

2-Posterior dislocation: Most common type 80% Mechanism of injury:- dashboard injury

1-History of trauma. 2-Deformity 3-Inability to move the hip. Clinical features: 1-History of trauma. 2-Deformity 3-Inability to move the hip. Imaging:- 1-x-ray. 2-CT scan.

Treatment: Complications:- Indications of open reduction Immediate close reduction (under GA) + skin traction for 3-6 wks. Indications of open reduction 1- failure of close reduction. 2- associated fracture acetabulum. 3- old dislocation. Complications:- Early: 1- sciatic nerve injury (usually neuropraxia). 2- vascular injury. 3- associated fracture femur. Late: avascular necrosis. Myositis ossificance. Unreduced dislocation. Osteoarthritis.

3- Anterior hip dislocation: less common. Mechanism of injury:- FFH, RTA Features:- trauma -Deformity -Inability to move the hip. X-ray:- Treatment:- Immediate close reduction (under GA) + traction for 3 wks. Complications: Early: 1-neurovascular injury (femoral). Late:The same of posterior dislocation.

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