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Pelvis fractures
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  • 1. Pelvis fracture by Dr hardik pawar
  • 2. • Introduction • Anatomy • Clinical evaluation • Investigation • Classification • Treatment
  • 3. Introduction • Pelvic injuries are a major cause of mortality and morbidity in multiple injured patients. • The close proximity of osteoligamentous structures to pelvic organs, neurovascular, hollow viscera, and urogenital structures may lead to wide range of severe complications and late sequel if not diagnosed and treated early • Fatalities are due to uncontrolled retroperitoneal hemorrhage.
  • 4. • Disabilities are due to anatomic disruption the pelvic ring. ( low back pain, leg-length discrepancies, dyspareunia, impotence, difficulties with child bearing). • Pelvic fractures can be particularly lethal when occur in combination with significant injuries to other major organ systems.
  • 5. Anatomy • bones, • ligaments, • muscles, • vessels, • nerves, • and viscera
  • 6. Joints of Pelvis
  • 7. • Pelvic ring formed by connection of the sacrum to innominate bones at sacroiliac joints and symphysis pubis.
  • 8. Divisions of Pelvis
  • 9. • The bony pelvis is divided into the so- called true and false pelvises, with the line of demarcation formed by the pelvic brim • The true pelvis contains the pelvic organs the bladder, urethra, and rectum, and the uterus and vagina in females, and the prostate gland in men whereas the false pelvis forms the lower part of the abdominal cavity.
  • 10. Ligaments • Transversely oriented ligaments resist transverse rotational instability. • These include: • iliolumbar, • short posterior SI, • anterior SI, • sacrospinous ligements. • Sumphysis pubis liga.
  • 11. • Vertically oriented ligaments resist vertical displacement of the pelvis. • These include: • long posterior SI, • sacrotuberous, • lateral lumbosacral ligaments. • (The strongest of these and the most important with regard to pelvic stability are the short and long posterior SI ligaments).
  • 12. • The Greater Sciatic Foramen • Seven Nerves Three Vessel Sets Sciatic nerve Superior gluteal artery/vein Superior gluteal nerve Inferior gluteal artery/vein Inferior gluteal nerve Internal pudendal artery/vein Internal pudendal nerve Posterior femoral cutaneous nerve One Muscle Nerve to quadratus femoris Piriformis Nerve to obturator externus
  • 13. •The obturator foramen: separating pubis from ischium, is covered by a membrane, deficient only on top to allow the obturator vessels and nerves to escape from the pelvis. At this point they are vulnerable and may be torn in pelvic trauma.
  • 14. Muscles
  • 15. Structures at risk in pelvis fractures • Soft tissue – perineum • Genitourinary • Gastro intestinal • Vascular • Nerves
  • 16. Perineum • Diamond shaped space b/w inf. Pubic rami And sacrotuberous liga. Anterior half is urogenital triangle Contains – deep perineal muscles • the urethral sphincter muscle, and (in women) the vaginal orifice. • Deep to this lie the muscles of the pelvic diaphragm, pubococcygeus, iliococcygeus, and ischiococcygeus • The anterior two, pubococcygeus and iliococcygeus, wrap around the rectum to form a kind of sling, and are termed levator ani. • posterior to the pelvic diaphragm muscles lie the obturator internus and piriformis
  • 17. Soft tissue
  • 18. Genitourinary • The bladder lies posterior to the pubis Its proximity to the rami puts it at risk for damage, because fractured rami may spear the bladder at the time of injury. • In males - the urethra the prostate The intrapelvic male sex organs, the seminal vesicles and ejaculatory and deferent ducts just above the prostate. • In females - the urethra vagina uterus lies between the bladder and rectum • fallopian tubes • ovaries, which are connected to the uterine body through the ovarian
  • 19. Gastroinestinal • final segment of the large intestine • rectum • anal canal • anus.
  • 20. Principal Sites of Hemorrhage after a Pelvic Fracture
  • 21. •The floor of the pelvis comprises the coccygeal and levator ani muscles. •The urethra, rectum and vagina transverse the floor of the pelvis & can be traumatized significantly during pelvic ring disruption.
  • 22. •Clinical assessment: •History: 1- Age: (Age affects bone structure) (Pelvic fracture occurs in elderly with less violent force, and associated with less soft tissue disruptions than young patients). 2- Gender: ( Males: more associated injuries to the urethra compared to females). ( Females: vaginal tear).
  • 23. 3- Mechanism of injury: Low energy - domestic falls , avulsion injury ,post menopausal , steroid induced, metabolic bone diz High energy - MVA, FALL from height , crush injury , sport injury , gun shots projectile ,industrial accidents 4- Associated injuries: ( Is important to determine the amount of trauma on the pelvis).
  • 24. Associated injuries Neurologic impairment
  • 25. Visceral injuries
  • 26. Physical examination: • Evaluation should begin eith ABC • Initiate resucitation • Evaluate injuries to head , chest , abdomen and spine • * Unexplained hypotension may be the only initial indication of major pelvic disruption with instability in the posterior ligamentous complex
  • 27. •Inspection: ( The patient must be completely undressed). 1- Wounds: Open wounds , abrasions , ecchymosis Hematoma 2- Contusions: ( Position of contusions and abrasions may indicate direction of the injurious force).
  • 28. Cutaneous Manifestations of Pelvic Trauma
  • 29. 3- Bleeding genitalia: (In men, blood from urethra suggests a urethral rupture; in women, blood from urethra or vagina suggests an occult open fracture of the pelvis).
  • 30. 4- Displacement of pelvis or lower extremities: (If there is no other fracture in the leg, its degree of rotation and shortening suggest what type of pelvic fracture is present). ( Shortening appreciated as leg length discrepancy happens as a result of muscular pull on the unstable hemipelvis).
  • 31. - If the extremity is obviously shortened, internally rotated, and displaced at the posterior iliac spine, it is mostly a lateral compression injury with posterior impaction. - If the extremity is externally rotated and shortened, it indicates mostly a severe unstable vertical shear type
  • 32. •Palpation: ( Careful manual palpation of the pelvis may reveal crepitus or abnormal motion in the hemipelvis, either one indicative of instability). ( Repeated examination for pelvic instability should be avoided in unstable situations to prevent further induction of blood loss).
  • 33. •Palpation of posterior aspect may reveal large hematoma •Maneuvers: 1- Test for anterior defects: Direct palpation of symphysis pubis may reveal a gap or ecchymosis, indicating a symphysis disruption. 2- Test for rotational instability: Grasping the iliac crests and pushing the unstable hemipelvis inward and outward (compression – distraction maneuver).
  • 34. 3- Test for vertical instability: Can be appreciated when movement of the hemipelvis is detected as manual compression and traction are applied through an extended uninjured lower extremity. (Palpating the posterior iliac spine & tubercle while pushing and pulling the unstable pelvis)
  • 35. •Rectal & Vaginal examination: ( Both are essential for complete patient assessment). - Very often the fracture can be palpated by either of these routes to further assess the stability of the pelvic ring. - Presence or absence of vaginal or rectal lacerations. - High riding prostate gland.
  • 36. • Neurological examination - Injury to lumbosacral plexus, especially L5 root is common, therefore, a careful neurological examination is mandatory. - Nerve injuries of all types are much more common in shear type fractures.
  • 37. •Radiological examination: - AP pelvic view is mandatory and can provide a reliable working diagnosis in about 90% of the cases. - For 3 dimensional analysis, oblique views (inlet and outlet films) are included to evaluate anterior, posterior, cranicaudal and rotational displacement). - The inlet view is the best view for disclosing posterior displacement.
  • 38. Pelvis inlet
  • 39. • inlet view • X-ray beam angled ~45 degrees caudad • adequate image when S1 overlaps S2 body • ideal for visualizing: • anterior or posterior translation of the hemipelvis • internal or external rotation of the hemipelvis • widening of the SI joint • sacral ala impaction
  • 40. Pelvis outlet
  • 41. • outlet view • X-ray beam angled ~45 degrees cephalad • adequate image when pubic symphysis overlies S2 body • ideal for visualizing: • vertical translation of the hemipelvis • flexion/extension of the hemipelvis • disruption of sacral foramina and location of sacral fractures
  • 42. • radiographic signs of instability • > 5 mm displacement of posterior sacroiliac complex • presence of posterior sacral fracture gap • avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of 5th lumbar vertebrae)
  • 43. Other investigation • C T scan • routine part of pelvic ring injury evaluation • better characterization of posterior ring injuries • helps define comminution and fragment rotation • visualize position of fracture lines relative to sacral foramina • MRI • Fluroscopy • Angiography • Indications: • nonresponders who have been mechanically stabilized
  • 44. Classifications
  • 45. Classification • The Young-Burgess (1986; 1987) system is as follows: 1. APC injury • The hallmark of the AP compression injury is pubic diastasis with or without disruption of the SI joints. The location and degree of diastasis is correlated with the magnitude of force imparted to the pelvis and with the amount of resulting instability. The AP compression causes the pelvis to open: one or both hemipelves undergo external rotation. According to the Young-Burgess classification system, 3 degrees of AP compression injury are identified.
  • 46. Classification • APC- I injuries: Less than 2.5 cm of the pubic diastasis is noted, either at the symphysis or through vertically oriented rami fractures. The SI joints and posterior ligaments remain intact, and stability is maintained.
  • 47. Classification • APC- II injuries: The amount of anterior diastasis exceeds 2.5 cm. In addition, diastasis occurs in 1 or both of the SI joints. This incomplete posterior arch disruption results in rotational instability. The posterior ligaments are not injured; therefore, vertical stability is preserved.
  • 48. Classification • APC- III injuries: These injuries extend to the posterior SI ligaments, which are disrupted. Consequently, the pelvis is vertically and rotationally unstable.
  • 49. Classification 2. Lateral compression (LC) injury • Lateral compression injury results in internal rotation of the affected hemipelvis. This internal rotation decreases rather than increases the pelvic volume. Consequently, pelvic vascular injuries and resulting hemorrhage are less common with this injury than with other injuries. Lateral compression injuries are associated with brain and intra-abdominal injuries.
  • 50. Classification • The hallmarks of a lateral compression injury include sacral buckle fractures and horizontal pubic rami fractures. The Young-Burgess classification system describes 3 types of injuries.
  • 51. Classification • LC- I injuries: These involve a force directed posteriorly to the lateral aspect of the hemipelvis, which results in an ipsilateral sacral buckle fractures; ipsilateral horizontal pubic rami fractures; or, less commonly, disruption of the pubic symphysis with overlap of the pubic bones. The posterior ligaments remain intact; therefore, the pelvis is stable.
  • 52. Classification • LC- II injuries: These involve more internal rotation of the hemipelvis. As in type I injuries, ipsilateral sacral buckle fractures and horizontal pubic rami fractures are associated with fracture of the ipsilateral iliac wing or disruption of the ipsilateral posterior SI joint. The pelvis is rotationally unstable, but its vertical stability is maintained.
  • 53. Classification • LC- III injuries: The force continues from the ipsilateral side across the midline to affect the contralateral hemipelvis. The ipsilateral hemipelvis sustains either a type I or type II injury with associated internal rotation. The contralateral pelvis undergoes external rotation. Contralateral vertical pubic rami fractures or disruption of the ligaments may occur. As in type II injuries, the pelvis is rotationally unstable but vertically stable.
  • 54. Classification 3. Vertical shear injury • A vertically oriented force applied to a hemipelvis, usually by the femur, results in a vertical shear injury. At the anterior aspect, vertically oriented fractures of the pubic rami occur. Posteriorly, the ipsilateral SI joint (or occasionally the contralateral SI joint) and its associated ligaments are disrupted.
  • 55. Classification • The affected hemipelvis is displaced in a cranial direction. Complete disruption of the posterior ligaments yields a rotationally and vertically unstable pelvis. • Associated injuries seen in the vertical shear pattern are similar to those encountered in type III AP compression injuries.
  • 56. Combined mechanism
  • 57. Miscellaneous fractures • Straddle fracture • Malgaigne fracture • Jumper’s fracture
  • 58. Denis classification of sacral fractures
  • 59. Denis zone 3 H U Lamda T
  • 60. Management 1. Early management • Treatment should not await for full and detailed diagnosis. • Doctor should move according to the priority of life saving measures with the already available information. • ATLS PROTOCOL • ABCDE • Airway , breathing , circulation , disability , exposure
  • 61. • The system is based on a three-stage approach: • 1. Primary survey and simultaneous resuscitation – a rapid assessment and treatment of life-threatening injuries. • 2. Secondary survey – a detailed, head-to- to evaluation to identify all other injuries. • 3. Definitive care – specialist treatment of identified injuries.
  • 62. Management of severe bleeding 1. resuscitation Treatment of shock. 2. Pelvic binder 3. External fixation to close the book. Management of genito urinary injury Management of GI injuries
  • 63. •Reduction and stabilization of the pelvis can be achieved by a variety of mechanical means: - Bind the pelvis by a rolled sheet. - Apply pneumatic antishock garments (PASGs). - Pelvic c – clamps. - External fixator. Stabilization
  • 64. • pelvic binder/sheet • risk of over-rotation of hemipelvis and hollow viscus injury (bladder) in pelvic fractures with internal rotation component (LC) • technique • centered over greater trochanters to effect indirect reduction • do not place over iliac crest/abdomen • prolonged pressure from binder or sheet may cause skin necrosis
  • 65. •Pneumatic antishock garments (PASGs). (It functions by compressing the pelvis, and if applied it should not be deflated until the patient is actively being resuscitated in the trauma room). Advantages: reduce displacement of APC INJURY - Easy to use, applicable in the field, & reusable. Disadvantage: Increase displacement of LC INJURY - It blocks access to the patient and restricts excursion of the diaphragm. - Gluteal & thigh compartment syndromes after its extended use in hypotensive patients.
  • 66. •Pelvic C- clamps: (recently developed devices that can be rapidly applied to reduce and provisionally stabilize the pelvis in the emergency department). - The design allows for compression of the pelvis through percutaneously inserted pins applied to the outer surface of the ilium. Care must be taken because serious complications can result from misplacement of the pins.
  • 67. Definitive Pelvic Fracture Management objectives
  • 68. Treatment • General guidelines • MINIMALLY DISPLACED LC 1 AND APC 1 – PROTCATED WEIGHT BEARING AND SYMPTOMATIC TREATMENT • • DICRUPTION OF ANT. RING WITHOUT COMPELETE POST. RING DISRUPTION APC 2 , LC 1 WITH DISPLACEMENT – REDUCTION AND STABILIZATION • COMPLETE DISRUPTION OF POST RING LC 2 , LC 3 , APC 3 , VS - STABILIZATION OF BOTH ANT AND POST PELVIC RING
  • 69. Non operative treatment • Indication • Pubic rami fractures with no post. Displacement • Gapping of pubic symphysis < 2.5 cm • Lateral impaction type with minimal displacement Options : Tractions , Protected weight bearing Pelvic binders
  • 70. Operative treatment INDICATIONS : • Open pelvic fractures associated with visceral injuries • Open book and verticaly unstable fractures • Symphyseal diastasis > 2.5 cm • SI joint displacement > 1 cm • Leg length discrepancy > 1.5 cm • Rotational deformity • Sacral fracture displacement > 1 cm
  • 71. Surgical techniques • External fixation – ant. Ex fix • Ganz fixation • ORIF of pubic symphysis with plates • Posterior ring fixation with plates or screws • Posterior SI "tension" plating • Percutaneous iliosacral screw fixation for sacroiliac disruptions • Percutaneous fixation of sup. Pubic rami • Transiliac rod fixation of sacral fractures
  • 72. •Management of open pelvic fractures: - Isolated iliac wing fractures are managed like open fractures in other areas of the body with aggressive debridement & stabilization of fractured components. - Aggressive debridement and packing of the wound to prevent continuous bleeding and possible sepsis.
  • 73. - Perineal lacerations and wounds that communicate with the rectum or colon require early diverting colostomy (preferably at transverse colon to provide uncontaminated skin around the pelvis). - Early detection and repair of vaginal lacerations to minimize subsequent pelvic abscesses. • Other advisable damage control procedures at an early stage include suprapubic urine catheter drainage, insertion of a transurethral catheter, and suture of the bladder after urological injuries.
  • 74. •Anterior external fixator: ( The standard method for controlling pelvic hemorrhage). - Proper application should provide stability to the pelvis and hematoma, while allowing access to the abdomen for surgical procedures. - Although it can be applied in the emergency department, it is frequently deferred until O.T.
  • 75. APC TYPE 2
  • 76. LATERAL COMPRESSION TYPE 2
  • 77. APC TYPE 3
  • 78. LATERAL COMPRESSION TYPE 3
  • 79. Right VS injury
  • 80. APC 2 INJURY
  • 81. Pr e o p e r a t i v e ( A ) a n d p o st o p e r a t i v e ( B) x - r a y s d e m o n st r a t i n g o p e n r e d u c t i o n a n d i n t e r n a l f i x a t i o n o f t h e a n t e r i o r r i n g o f t h e p e l v i s.
  • 82. Ri g h t i l i a c w i n g f r a ct u r e . B. Ma n a g e d co n se r v a t i v e l y . Fr a ct u r e ca l l u s i s p r e se n t a t 6 WEEKS
  • 83. St a b i l i za t i o n t e ch n i q u e i n ce n t r a l a n d / o r b i l a t e r a l sa cr u m f r a ct u r e s:
  • 84. JUMPER ‘S FRACTURE
  • 85. Teatment
  • 86. Pelvic Surgical Approaches
  • 87. COMPLICATIONS • EARLY : • Heammorhage • GI tract injury • GU injury • Neurologic injury • Vascular injury • Infection • Thromboembolism
  • 88. • LATE • Fixation failure • Mal union • Chronic persistent pain • Non union • Sexual dysfunction
  • 89. THANK YOU