Fracture of Pelvic complex and Rehabilitation Pre and Post operative

1. Review OF Literature
Presented by;
Dr. Rakhi Ratnam
MPT-II (Orthopedics)
7/24/2014

2. Pelvic Complex Fracture and its
Rehabilitation
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3. Contents:
 Introduction
 Epidemiology
 Mechanism Of Injury
 Clinical Evaluation
 Classification – Pelvic fracture
- Acetabulum fracture
- Jumper’s Fracture
- SI Joint disruption
- Coccyx Fracture
 Complications
 Emergency care and Management
 Rehabilitation
 Evidences
 References
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4. Introduction
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5. Epidemiology
 Incidence- 3-8%
 Mortality- 5-16%
 An Australian study of pelvic ring fractures
demonstrated an incidence of 23 per 100,000
persons per year.
 British study found the incidence of acetabular
fractures to be 3 per 100,000 persons per year.
(Pelvic trauma: Initial evaluation and management, Literature
review;2013) 7/24/20145

6.  German Chapter of the AO-International & German
Trauma Society have reported 21.3% of Pelvic
complex fracture.
 A new international report, The Asian Audit, by the
International Osteoporosis Foundation, says over the
past 30 years fractures have gone up threefold in
Asia, with India and China topping the charts. India
hobbles to second place in pelvic fractures with 4.4
lakh people falling prey every year.
 http://indiatoday.intoday.in/story/indias-bone
crisis/1/116534.html
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7. 7/24/20147

8. Anterior View Of the Symphysis Pubis
Suprapubic
ligament
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9. Blood Vessels
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10. Mechanism of injury
 Road traffic accidents (20-66%)
 Pedestrian collisions (14-59% )
 Motorcyclist collisions (5-9.3% )
 Fall from height
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658194/
Emergency Medicine Journal : EMJ
7/24/201410

11. Evaluation:
 Clinical Examination
 Radiological Examination
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12. Evidence
 In 1990, a level three prospective study first dealt
with concerns about examining the pelvis, looking
at 36 patients with blunt trauma (excluding
multiple injuries). The results found that springing
the pelvis had a specificity of 71% and a
sensitivity of 59%, suggesting that routine use of
this examination should be abandoned.
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13. Evidence
 Noakes et al, evaluated Pelvic stress fracture in 5
female marathoners because of intense training
sessions. Most patients experienced persistent groin
discomfort during any activity for the first 4 weeks
after injury, but all recovered completely after 8 to 12
weeks of rest. Authors confirmed the diagnosis if the
following three features are present in a long distance
runner presenting with groin pain: First, activity
causes such severe discomfort in the groin that
running is impossible. Second, the athlete develops
discomfort in the groin when standing unsupported on
the leg corresponding to the injured side (positive
standing test). In some cases the pain is so severe
that standing on one leg is impossible. Third, deep
palpation reveals extreme, exquisite nauseating
tenderness localized to the pubic ramus and not to
the overlying soft tissues
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14. 7/24/201414

15. 7/24/201415

16. Classification:
A. Tile’s Classification
TYPE A
Stable
• A1- Fractures of the pelvis not involving the ring
• A2- Stable, minimally displaced fractures of the ring
TYPE B
Rotationally
unstable ,
vertically
stable
• B1- Open book
• B2- Lateral compression: ipsilateral
• B3- Lateral compression: contralateral (bucket- handle)
TYPE C
Rotationally
and
vertically
unstable
• C1- Rotationally and vertically unstable
• C2- Bilateral
• C3- Associated with an acetabular fracture
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17. Evidence
 Study conducted to assess 3260 patients with
pelvic and acetabular fracture confirmed that
2551 patients had pelvic fracture and there
were concomitant 15.3% acetabular fracture. The
pelvic ring fracture was classified as stable in
54.8% (type A injury), as rotationally unstable in
24.7% (type B injury), and as unstable in
translation in 20.5% (type C injury).
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18. Type A
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19. Type B
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20. Type C
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21. B. Young and Burgess system
Lateral
Compression
(LC)
I- Sacral
compression on
impact side
II- Iliac wing
fracture on side
of impact
III-
Contralateral
open book
injury
Antero-
Posterior
Compression
(APC)
I- Slight
widening of
pubic
symphysis
II- Widened
interior
sacroiliac joint
III- Complete SI
joint disruption
Vertical Shear
(VS)
Vertical
displacement of
symphysis
diastasis
Combined
Mechanism
Injury (CM)
LC/VS most
common
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22. Evidence:
 Study conducted by Young in year 1990,
concluded that a classification system based on
the mechanism of injury and direction of injury
force allow correct and timely application of
external fixators, thus favouring to a more
favourable outcome.
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23. Lateral
Compression

24. APC-I
•Slight widening of the
pubic symphysis .
•Intact sacrotuberous and
sacrospinous ligaments
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25. APC- II
• Widened anterior SI
Joint
•Disrupted
sacrotuberous and
sacrospinous ligaments
• Intact posterior SI
Ligaments
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26. APC-III
•Complete SI Joint
disruption with lateral
displacement
• disrupted sacrotuberous
and sacrospinous
ligaments
•Disrupted posterior SI
ligaments
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27. Vertical Shear
• Vertical displacement of
symphyseal diastasis
usually through SI joint.
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28. Combined
Mechanical Injury
•Combination of
other injury patterns,
usually LC/VS
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29. Denis Classification Of
Sacral Fractures
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30. Sacral insufficiency fracture
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31. Acetabulum Fracture Classification
Of Letournel and Judet:
Posterior
wall
fracture
Posterior
column
fracture
Anterior
wall
fracture
Anterior
column
fracture
Transverse
fracture
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32. 7/24/201432

33. Complications:
 Hemorrhage
 Venous thromboembolism
 Gastrointestinal Injury
 Genitourinary Injury
 Neurologic Injury
 Open Fractures
 Malunion, Nonunion
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34. Evidences:
 Study conducted on 48 men and 8 women in year
2011 at PGI Chandigarh to evaluate the venous
thromboembolism(VTE) in postoperative period of
pelvic fracture and concluded that 16 patients
developed VTE. 12 patients developed proximal
DVT, 2 cases distal DVT and 10 cases pulmonary
embolism. Pulmonary angiography and indirect
computed tomographic venography were used as
a diagnostic tool.
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35.  Retrospective study conducted at KLEU(Dr.
Prabhakar kore hospital)from April 2000 to Dec
2010. During the 10 year period 11 females (age 8-
49 yrs) presented with urethral injury in conjunction
with pelvic fracture. Nine of these females had
avulsion of the urethra and the remaining two had
avulsion with longitudinal tears of the bladder
continuing to the proximal urethra with pelvic
fracture.
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36.  Nerve injury is a common complication of major
pelvic injuries. Study conducted on 73 patients who
suffered major pelvic injuries, 24 (33%) had resultant
neurologic deficits. The extent of nerve injury is
proportionate to the severity of the posterior pelvic
bone injury.
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37. Management:
 Emergency Care management
 Surgical management
 Rehabilitation
 Long term follow up
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38. Conservative management
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39. Surgical management
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40. 7/24/201440

41. 7/24/201441

42. APC II fracture
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43. 7/24/201443

44. X- ray of the patient,after 3 months of treatment. Posterior wall fracture line
required a trochanteric osteotomy to protect the abductors.
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45. Rehabilitation
Evidence
Study conducted in year 2002 on post
operative management of acetabular fracture
has summed up the mobilization protocol after
Surgical management.
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46. Evidences
 Study conducted on elderly population in year
2006 concluded early initiation of
Physiotherapy, walker assisted ambulation
with toe touch, Range of motion at the hip and
strengthening exercises for Quadriceps.
Fracture treatment must be highly
individualized because of high degree of
diversity.
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47.  According to American Academy Of Orthopedic
Surgeons (AAOS), pelvic binder, pelvic clamp, or a
sheet wrap MUST be used to immobilize the injury.
 Pelvic binding devices provide a simple alternative to
surgical fixators. These devices can be applied in the
prehospital environment, potentially allowing control
of unseen major haemorrhage.
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48. Phase 1.
Goals are- reduce swelling and pain
PT Rx Starts immediately after the surgery
Phase 2.
Goals are- ROM, Strength, Flexibility
PT Rx is given for several weeks
Rehabilitation

49. Phase 3: six to eight weeks
Goals are- restore your preinjury activity and
performance level
balance, stretching and strength training.
Phase4:
Goals are- Strength, balance, flexibility
Prevent post traumatic arthritis
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50. Long term outcomes:
 Study conducted in year 2010 to assess the long-
term outcome of pelvic ring injuries in 24 patients
on follow up of average 33 months. The
clinicoradiological assessment was done using
Pelvic scoring system adapted by cole etal and
concluded that pain and limp were present in 13
patients and residual working disability was found
in 9 patients.
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51. Evidence: Pregnancy related
outcome
Study conducted on 16 pregnant females
concluded that Uncomplicated pregnancies and
deliveries are possible after pelvic fracture. The
new cesarean delivery rate among these women
is significantly increased with over half related to
patient and obstetrical preferences.
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52. References:
1. Rockwood and Green’s Fracture in Adults. Lippincott publication. Volume
2;VI Edition; Page numbers-1583-1665
2. Campbell’s Operative Orthopedics. Elsevier publication. Volume 3; XI Edition;
Page numbers-3237-3309
3. Ramesh kumar sen, Amit kumar, Sameer Aggarwal. Risk factors of Venous
thromboembolism in Indian patients with Pelvic-Acetabular trauma; Journal of
orthopedic surgery 2011;19(1):18-29
4. Nerli RB, Sujata Jali, M. B. Hiremath. Female Urethral injuries related to Pelvic
Fractures. Journal of trauma and treatment;April 05, 2012
5. Majeed et al. Neurologic deficits in major pelvic injuries. Clinical orthopedics
and clinical research; 1992 Sep;(282):222-8.
6. O.Johnell et al. An estimate of the worldwide prevalence and disability
associated with osteoporotic fractures. Osteoporosis
International;2006:17;1726-33
7. Damayanti Dutta. India’s Bone Crisis; India Today (16th October 2010)
7/24/201452

53. 8. Caroline lee, Keith Porter. The prehospital management of Pelvic fractures.
Emergency Medical journal;2007 February; 24(2): 130–133.
9. Ellen f. Binder, Marybeth brown et al. Effects of extended outpatient rehabilitation
after pelvic frature. JAMA, August 18,2004 –vol 292,no-7.
10. Eric Pagenkopf, MD, Andrew Grose et al. Acetabular Fractures in the Elderly:
Treatment Recommendations. Musculoskeletal journal of hospital for special
surgery.2006;2(2):161-171.
11. Pohlemann T , Tscherne H, Baumgärtel F. Pelvic fractures: epidemiology, therapy
and long-term outcome. Overview of the multicenter study of the Pelvis Study
Group. 1996 Mar;99(3):160-7.
12. Jeremy w.r young. Fracture of the pelvis: current concepts of rehabilitation. Review
article;AJR,1990:1169-1175.
13. Ramesh k sen. Outcome analysis of pelvic ring fractures. Indian journal of
orthopedics; 2010 Jan-Mar; 44(1): 79–83.
14. Gansselen A, Pohlemann T, Paul C. Epidemiology of pelvic ring injuries. US
National Library of Medicine National Institutes of Health. 1996;27 Suppl 1:S-A13-
20.
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54. 15. M. Thaker. Post operative management of acetabular fracture. Indian J Orthop
2002;36:29-30
16. Noakes,Smith,Linderberg. Pelvic stress fractures in long distance runners.
American journal of sports medicine. 1985 Mar-Apr;13(2):120-123.
17. Chesser TJ, Cross AM, Ward AJ. The use of pelvic binders in the emergent
management of potential pelvic trauma. Injury 2012;43:667–9.
18. Stanley Hoppenfield.Treatment and Rehabilitation of Fractures. Lippincott
Publication. Page no. – 31-49
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