The document discusses pelvic ring fractures and hip dislocations. It describes the anatomy of the pelvic ring and its ligaments. Common types of pelvic fractures include avulsion fractures, single bone fractures, complex fractures, and acetabulum fractures. Hip dislocations are also covered, including posterior, anterior, and central types. Treatment depends on the fracture or dislocation type. Complications of pelvic fractures can include bleeding, nerve injuries, and long term osteoarthritis. Complications of hip dislocations include arthritis, osteonecrosis, and nerve palsies.

1. ORTHOPEDIC SURGERY
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2. INJURIES TO THE LOWER LIMB ( 1 )
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5. PELVIC RING FRACTURES
 The pelvic ring is made of the two innominate bones
and the sacrum.
 Articulating in front at the symphysis pubis , posteriorly
articulating with sacroiliac joints.
 stability dependent on strong surrounding ligamentous
structures
 neurovascular structures intimately associated with
posterior pelvic ligaments
 high index of suspicion for injury of internal iliac vessels
or lumbosacral plexus
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6. PELVIC RING FRACTURES
 Ligaments
 anterior
 symphyseal ligaments
 pelvic floor
 sacrospinous ligaments
 sacrotuberous ligaments
 posterior sacroiliac complex (posterior tension band)
 strongest ligaments in the body
 more important than anterior structures for pelvic
ring stability
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8. PELVIC RING FRACTURES
 Mechanism typically high energy blunt trauma often from car
accidents
 Mortality rate 1-15% for closed fractures, as much as 50% for
open fractures
 Hemorrhage is leading cause of death overall
 Associated injuries
 orthopedics
 chest injury in up to 63%
 long bone fractures in 50%
 spine fractures in 25%
 non-orthopedic
 urogenital
 sexual dysfunction up to 50%
 head and abdominal injury in 40%
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9. PELVIC RING FRACTURES
 Patient may be severely shocked due to blood loss or visceral
injury.
 There may be swelling or bruising of the lower abdomen, the
thighs, the perineum, and the scrotum or the vulva.
 An inability to void and blood at the external meatus, are
the classic features of a ruptured urethra (NO
CATHETERIZATION).
 A ruptured bladder should be suspected in patients who do
not void or in whom a bladder is not palpable after adequate
fluid replacement.
 Abdominal tenderness and guarding suggests intraperitoneal
bleeding (ruptured liver or spleen) .
 Radiology :
 X-rays different plans , CT scan often needed
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10. PELVIC RING FRACTURES
 In general, fractures can be divided into:
 Avulsion.
 Single bone.
 Complex.
 Acetabulum
 Avulsion fractures
 Avulsion fractures of the origin of the hamstring (avulsion of the
ischial tuberosity), rectus femoris ( avulsion of anterior inferior iliac
spine) and sartorius muscles (avulsion of anterior superior iliac
spine) are seen in young fit athletes.
 Treatment
 The treatment is based on the severity of the injury and the degree
of displacement.
 At times, large fragments will need to be reduced and held with
internal fixation, i.e. a screw.
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12. PELVIC RING FRACTURES
 Single bone fracture
 These injuries are common in elderly patients with porotic bone or
where there has been a well localized area of trauma.
 Fractures include pubic rami and the wing of the ilium.
 Pubic rami fractures often occur in pairs and can be trivial in nature.
Occasionally, however, there can be associated injury to bladder or
urethra.
 Treatment
 Early mobilization in uncomplicated injuries is recommended. Patients will
be in severe pain for the first few days but should be mobile in about a
week.
 Wing of the ilium fracture
 The main function of the wing of the ilium is to provide a firm
foundation for muscle attachment and the protection of the pelvic
contents. A fracture is caused by a direct blow or a crush injury.
 Treatment.
 As there is excellent muscle attachment, the blood supply is good. These
fractures heal rapidly but may be very painful for the first few weeks
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Pubic rami fractures
Wing of the ilium fracture

14. PELVIC RING FRACTURES
 Complex fracture
 The pelvis can be considered to be a ring structure.
 It is uncommon to be able to break the true ring in a single
place, and fractures can therefore be multiple.
 There are three main fracture patterns, depending on the
mechanism of the injury. These are:
 Anterior/posterior compression (open book).
 Side compression.
 Vertical compression.
 Life threatening injuries need careful assessment by trauma
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Types of unstable pelvic fractures: (Left) Anterior-posterior
compression fracture. (Right) Lateral compression fracture.
In this fracture, the pelvis is pushed inward.
Vertical shear fracture. In this
fracture, one half of the pelvis
shifts upward.
open book fracture

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17. PELVIC RING FRACTURES
 Acetabulum fracture
 Fractures of the acetabulum disrupt the hip joint.
 Major disruption will often lead to osteoarthritic degeneration
in the long term.
 The major goal of treatment is to limit the chance of this and to
retain early active movement of the hip joint.
 Plain radiographs do not give sufficient detail of the acetabulum
to classify the type of fracture or the degree of displacement of
the fracture fragments., CT scan is required
 Treatment
 In undisplaced fractures , patients can be treated in bed for the
first few days to allow the pain to settle, then they should be
mobilized with a non-weight-bearing regimen for a minimum of
6 weeks
 Displaced fracture treated by skeletal traction +/- open
reduction internal fixation (ORIF)
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19. PELVIC RING FRACTURES
 Complications
 Urogenital Injuries
 present in 12-20% of patients with pelvic fractures
 higher incidence in males (21%)
 posterior urethral tear : most common urogenital injury with
pelvic ring fracture
 bladder rupture : may see extravasation around the pubic
symphysis
 Neurologic injury
 Deep vein thrombosis (DVT)and Pulmonary embolism (PE)
 DVT in ~ 60%, PE in ~ 27% , fatal PE in 2%
 prophylaxis essential
 Chronic instability
 Sacroiliac pain.
 Distortion of pelvic canal.
 Osteoarthritis.
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20. HIP DISLOCATION
 Traumatic dislocations of the hip are an
orthopedic emergency
 rare, but high incidence of associated injuries
 mechanism is usually young patients with high
energy trauma
 Classification
 Simple vs. Complex
 simple
 pure dislocation without associated
fracture
 complex
 dislocation associated with fracture of
acetabulum or proximal femur
 Anatomic classification
 Posterior dislocation (90%)
 Anterior dislocation
 Central dislocation
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21. HIP DISLOCATION
 Posterior dislocation (90%) (most common)
 Occur with axial load on femur, typically with hip flexed and
adducted
 Axial load through flexed knee (dashboard injury)
 Associated with posterior wall and anterior femoral head
fracture
 Presentation
 Hip and leg in slight flexion, adduction, and internal rotation
 Detailed neurovascular exam (10-20% sciatic nerve injury)
 Examine knee for associated injury or instability
 Associated with
 osteonecrosis
 posterior wall acetabular fracture
 femoral head fractures
 sciatic nerve injuries
 ipsilateral knee injuries (up to 25%)
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22. HIP DISLOCATION
 Radiographs in posterior
dislocation
 femoral head appears smaller
than contralateral femoral
head
 femoral head superimposes
roof of acetabulum
 decreased visualization of
lesser trochanter due to
internal rotation of femur
 CT scan
 helps to determine direction of
dislocation, loose bodies, and
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24. HIP DISLOCATION
 Anterior dislocation
 Associated with femoral head impaction or chondral injury
 Occurs with the hip in abduction and external rotation
 Presentation
 Hip and leg in slight flexion , abduction, and external rotation
 Radiograph :
 anterior dislocation
 femoral head appears larger than contralateral femoral head
 femoral head is medial or inferior to acetabulum
 Ct scan
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26. HIP DISLOCATION
 Central dislocation of the hip
 fall on the side or blow over the greater trochanter may force the
femoral head medially through the floor of the acetabulum .
 Although it is called central dislocation of the hip , it is really a
fracture of the floor of the acetabulum
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27. HIP DISLOCATION
 Treatment
 Nonoperative
 emergent closed reduction within 6 hours
 Indications : acute anterior and posterior dislocations
 Contraindications :ipsilateral displaced or non-displaced femoral
neck fracture
 Operative
 Open reduction and/or removal of incarcerated fragments
 Indications
 irreducible dislocation
 radiographic evidence of incarcerated fragment
 delayed presentation
 non-concentric reduction
 should be performed on urgent bas
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Post reduction CT must be performed for all traumatic hip dislocations

28. HIP DISLOCATION
 Complications
 Post-traumatic arthritis : up to 20% for simple dislocation,
markedly increased for complex dislocation
 Femoral head osteonecrosis :5-40% incidence
 Increased risk with increased time to reduction
 Sciatic nerve injury : 8-20% incidence
 associated with longer time to reduction
 Recurrent dislocations : less than 2%
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