Dr Suresh Pandey

1. Suresh Pandey
MBBS, MS Ortho
Fellowship Arthroplasty and Arthroscopy
Consultant Orthopedic surgeon
Chitwan Hospital
Manakamana Hospital and Trauma Centre
Bharatpur, Nepal

2. Introduction
 Complex area of Orthopedics
 Needs experience
 Good reduction is the most important determinant

6. Column Concept

8. Mechanism
 high energy trauma in younger patients (e.g., motor
vehicle accidents)
 low energy trauma in elderly patients (e.g., fall from
standing height)

9. Position of Limb

10. Associated Injury

11. Neurovascular structure
 Ext iliac vessels
 Sciatic, femoral and LCN
 Superior gluteal n and vessels
 Corona Mortis

13.  Letournel and Judet classification: Most common
 AO classfication

14. Classification
 Simple fracture
 Associated fracture

21. Management Approach
 ATLS protocol
 High energy trauma: so look for and manage
associated injury
 Rarely need emergency operation

22. Investigation
 Blood
 X ray
 CT
 USG

23. X ray

30. Roof arc measurement
 Tells fracture line exits (whether inside the dome or
outside)
 Stable if >45 deg
 Not applicable in post wall or both column fracture

31. CT Scan
 To know exact fracture
lines, wall and column
fracture, complex
fracture, incarcerated
fragment and plan
treatment
 2D and 3D cut provides
better morphology

34. Conservative

38. Traction
 Controversial
 Initial management to reduce or maintain reduction
and to manage other injury and soft tissue to heal

39. Operative

40. Timing of Surgery
 Ideal 5-7 days
 >3 weeks too late

41. Approach

42. Reduction instruments

43. Reduction techniques

44. Post wall
 Avoid devascularization of
the fragment
 Remove I/A frgment if any

45. Post Column
 Less common
 Post KL approach
 Screw and recon plate
along post column

46. Anterior wall and column
 Isolated Ant wall
uncommon
 Ant Ilioing/Iliofemoral
approach
 Contoured plate along
pelvic brim

47. Transverse fracture
 Presents spectrum of
difficulty
 Transtectal have worst
prognosis
 Infratectal can be treated
conservatively
 Approach?

48. Both column fracture
 Most difficult
 T type fracture with
transv component above
the dome
 Reduction begins at
most proximal and then
towards joint

49. Post Op care
 Antibiotics
 Pain M/M
 DVT prophylaxis
 Drain
 Ambulation

50. Complications
 Neurovascular injury
 Infection: 4%
 DVT
 AVN: 7.5%
 Post traumatic OA: 10-35%
 HO: 14-50% without prophylaxis
 Mortality: 2.5%

51. Conclusion
 Prognosis depends on
 Patient factor
 Surgeons’ factors
Accurate reduction is key to success
Associated with many complications