Ortho seminar

1. INJURIES OF PELVIS
- By Roll No : 41,42

2. Pelvic Fractures:
• Caused due to High velocity trauma which can be:
• Road traffic accidents(RTA)
• Due to fall from height
• Common in young adults
• The relative incidences are as follows:
• RTA—80.7 percent.
• Fall—16.1 percent.
• Compression fracture—rest.

3. RELEVANT ANATOMY

4. MECHANISM OF INJURY:
• 4 mechanisms by which pelvic fractures can be produced:
 Antero-posterior compression(Common in RTA)
 Lateral compression(Common in RTA)
 Vertical shear forces
 Inferior forces(fall on buttocks)
ANTERO-POSTERIOR
COMPRESSION
LATERAL
COMPRESSION
INFERIOR FORCES

5. CLASSICATION:
• BROADLY into two type:
• Fractures not Affecting the Integrity of the Pelvic Ring.
Direct blow fractures, which are commonly seen in iliac bone and
avulsion fractures frequently encountered in the young, come
under this group. Avulsion fractures are commonly seen in
anterosuperior and inferior iliac spines and ischial tuberosity.
• Fractures Affecting the Integrity of the Pelvic Ring.
These are single or double break fractures in the pelvic ring and
could be stable or unstable. A stable fracture is one, which resists
displacing forces. Obviously, fractures, which cannot resist usual
forces, are called unstable fractures and these pose a major
therapeutic challenge.

7. KEY AND CONWELL’S CLASSIFCATION:
• Fracture of individual bones without break in Pelvic Ring
• Avulsion fractures of-
• ANTERIOR SUPERIOR ILIAC SPINE
• ANTEROINFERIOR ILIAC SPINE
• ISCHIAL TUBEROSITY
• Fracture of pubis
• Fracture of iliac wing(DUVERNEY)
• Fracture Sacrum
• Fracture Coccyx
• Single break in Pelvic Ring
• Fracture of both ipsilateral rami
• Fracture near or subluxation of symphysis pubis.
• Fracture near or subluxation of sacroiliac joints.
• Double breaks in Pelvic Ring
• Straddle’s Fracture
• Malgaigne’s Fracture
• Bucket handle fracture
• Acetabulum Fracturs
• Undisplaced
• Displaced
TYPE A-DUVERNEY
FRACTURE(of iliac wing)

8. Lateral compression fracture:
• Malgaigne’s Fracture:
Ipsilateral sacro-iliac disruption and ipsilateral superior and inferior pubic
ramus fracture.
• Bucket Handle Fracture:
Sacro-iliac disruption and contralateral superior and inferior pubic ramus
fracture.Hemi-pelvis rotates superiorly
Complex Fracture:
Involve both AP compression,Latreal compression and Vertical compression
• Straddle’ Fracture :
Bilateral superior and inferior pubic ramus fracture.

10. Classification:
• Marvis Tiles classified fracture into three types:
a. TYPE A(Stable, minimally displaced fractures)
b. TYPE B(Unstable fractures - rotationally unstable but vertically stable)
c. TYPE C(Unstable - rotationally and vertically)

12. CLINICAL FEATURES:
• Symptoms:
• Gives history of high velocity trauma
• Presents in Hyovolaemic shock
• Features of Intrabdominal Injuries &
• Genitourinary Injuries
• Clinical Signs:
BY Milch

13. CLINICAL TESTS:
• Pelvic Compression Test:
When a compressive force is applied through the two iliac crests of the patient's
pelvis towards each other, the patient complains of pain in pelvic fracture or
springy feeling is an indicator of pelvic fracture(TO BE DONE IN SUPINE POSITION)
• Distraction Test:
When distraction force is applied to the two iliac bones at the anterosuperior iliac
spine, the patient complains of pain
• Direct Pressure Test:
Direct pressure over the symphysis pubis elicits pain

15. INVESTIGATIONS:
• Radiography
Different Views are to be done to study fracture configuration
• Plain AP view.
• Oblique view—45° oblique projections.
• Internal and external rotation view.
• Inlet view—40° caudad view.
• Outlet view—40° cephalad view.
• CT Scan:
Gold Standard for pelvic fractures.

17. MANAGENT OF PELVIC FRACTURES:
• Patient should be stabilized first by ATLS to prevent cardiac arrest in
patients with injury as the patient is already in hypovolaemic shock.
• Airway(Cervical Spine stabilization)
• Breathing
• Circulation(Stop bleeding complication by applying tamponade)
• Disability
• Exposure and environmental control
• After this X-ray is to be done and further treatment is to be done
which depends on the type of fracture and assosciated complications.

18. Treatment:
A pelvic fracture may fall into one of the following three categories from the treatment
viewpoint:
An injury with minimal or no displacement:
The patient is advised absolute bed rest for 3-4 weeks. Once the fracture becomes ‘sticky’ and the
pain subsides, gradual mobilization and weight bearing is permitted. It takes from 6-8 weeks for the
patient to be up and about.
An injury with anterior opening of the pelvis (open-book injury):
A minimal opening up (less than 2.5 cm) does not need any special treatment.Reduction is needed
if the opening is more than 2.5 cm. This is done by manual pressure on the two iliac wings so as to
‘close’ the pelvic ring. The reduction thus achieved is maintained by one of the following methods:
• External Fixator-This is a reliable and comfortable method. Two or three pins threaded at
the tip (Schanz pin) are inserted in the anterior part of the wing of the iliac bone on each
side. After reduction of the displacement by manual pressure, the pins are clamped to a
metal rod or frame placed transversely over the front of the pelvis.
• Internal Fixation-The pubic symphysis disruption may be reduced and internally fixed with
a plate
• Hammock sling traction

20. CONT.
Injuries with vertical displacement:
These are the most difficult pelvic injuries to treat. These are treated
by bilateral upper tibial skeletal traction. A heavy weight (upto 20 kg)
may be required to achieve reduction. After 3 weeks, the weight is
reduced to about 10 kg to maintain the position. The traction is
removed after 6-8 weeks, and the patient mobilised.

22. COMPLICATIONS:
Rupture of urethra:
This is commonly associated in cases where wide disruption of symphysis pubis and pubic
rami fractures is present. The urethra in males is more commonly injured – membranous
urethra being the commonest site. The rupture may be complete or incomplete, partial
thickness or full thickness. Diagnosis may be made by three cardinal signs of urethral injury
i.e., blood per urethra, perineal haematoma and distended bladder.
Treatment:
It may be possible to pass a catheter gently in a case with partial and incomplete urethral
tear. In case this fails, the help of a uro-surgeon should be sought. Principles of treatment
are:
(i) drainage of the bladder by suprapubic cystostomy. Treatment plan for pelvic ring
disruption injuries
(ii) micturating cysto-urethrogram after 6 weeks to assess the severity of urethral stricture,
and treatment accordingly

23. Rupture of bladder:
:The bladder is ruptured in pubic symphysis disruption or pubic rami fractures.
In case the bladder is full at the time of injury, the rupture is usually extra-
peritoneal, and urine extravasates into perivesical space. Diagnosis may be
suspected if a patient has not passed urine for a long time after the fracture.
Catheterisation may be successful but only a few drops of bloodstained urine
come out. A cysto-urethrogram will distinguish between a bladder and a
urethral rupture
Treatment:
An urgent operation is required, preferably by a urologist. The principles of
treatment are:
(i) to repair the rent in the bladder
(ii) drainage of the bladder by an indwelling catheter,
(iii) to drain the urine in the prevesical space

24. Injury to rectum or vagina:
There may be disruption of the perineum with damage to the rectum or
vagina.
Injury to major vessels:
This is a rare but serious complication of a pelvic fracture. The common
iliac artery or one of its branches may be damaged by a spike of bone.
Aggressive management is crucial. If facilities are available, embolisation of
the bleeding vessel under X-ray control is a good procedure. In other cases,
the vessel is explored surgically and ligated or repaired

25. Injury to nerves:
In case of major disruption of the pelvic ring with marked vertical displacement of
half of the pelvis, it is common for the nerves of the lumbo-sacral plexus to be injured.
The damage may be caused by a fragment pressing on the nerves, or by stretching.
Treatment is conservative. Recovery occurs in some cases, but in most the injury is
irreversible and the consequent paralysis permanent.
Rupture of the diaphragm:
A traumatic rupture of the diaphragm sometimes occurs in cases with severely
displaced pelvic fractures. It is worthwhile getting an X-ray of the chest in case a
patient with pelvic fracture complains of breathing trouble or pain in the upper
abdomen.
Treatment is by surgical repair.

26. OTHERS INJURIES:
Acetabulum :
Judet Classification:
• Anterior Wall Fracture
• Posterior Wall Fracture
• Anterior Columnar Fracture
• Posterior Columnar Fracture
• Bi-Columnar Fracture
X-Ray View-Judet View
Spur Sign: Seen in Bi-Columnar Fracture.
Laterally shape ileum gives shape of the spur.

27. Sacrum Fracture:
• Jumpers Fracture(Lover’s fracture):
 Fracture of Sacrum due to fall from height.
Usually due to jumping out of window or roof due to fear from police
or jealous husband

28. Coccyx Injuries:
• Mechanism of injury:
It is due to a direct fall on the buttocks. It can also result from seat injuries while driving
two wheelers or four wheelers. Of late constant pressure due to prolonged sitting as in the
case of computer professionals can give rise to coccydynia.
• Clinical Features:
• Pain in Buttocks
• Unable to sit comfortably
• Due to coccydynia pain become chronic
• Difficulty in travelling
• Investigation:
Plain X-ray of the coccyx especially the lateral view helps to make the diagnosis .It is
difficult to position the patient for the X-rays. MRI of the sacrococcygeal region is a better
option.

30. TREATMENT:
• Conservative measures by bed rest and symptomatic treatment for pain and
inflammation.
• Physiotherapy Management:
• Injection Therapy:
to relieve pain if not treated by above methods , injection therapy consisting of a mixture of
local steroids (Depomedorol, Kenacort, etc.) and xylocaine gives excellent relief of pain.
• Surgical Excision of Coccyx on extreme conditions.
Sitz bath-—this consists of sitting in a
shallow tub of warm water. Commonly
advocated in Piles patients after surgery