Pelvic Fracture AnatomyAnatomy 2 innominate 1sacrum 2 innominate 1sacrum Innominate bone...

Pelvic FracturePelvic FracturePelvic FracturePelvic Fracture

AnatomyAnatomyAnatomyAnatomy

• 2 innominate 1sacrum2 innominate 1sacrum

• Innominate boneInnominate bone

ilium,ischium,pubis ilium,ischium,pubis

• Join by strong ligamentJoin by strong ligament

complex complex

1

Minor injuryMinor injury

• Minor fallMinor fall

• Stable vital signStable vital sign

• Non-displaced FxNon-displaced Fx

• Fx not involve ringFx not involve ring

• Treatment-bed restTreatment-bed rest

2

Minor injuryMinor injury

3

Major injuryMajor injuryMajor injuryMajor injury

• High energy traumaHigh energy trauma

• Unstable vital signUnstable vital sign

• High mortality,morbidityHigh mortality,morbidity

• Associated injuryAssociated injury

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Associated injuryAssociated injury

Rupture bladderRupture bladderRupture urethraRupture urethra

L-S plexus injuryL-S plexus injury

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Associated injuryAssociated injuryAssociated injuryAssociated injury

Hypovolemic shockHypovolemic shockHypovolemic shockHypovolemic shock

Retroperitonium hematomaRetroperitonium hematoma

bleeding bony surfacebleeding bony surface

venous plexus bleedingvenous plexus bleeding

vascular injury vascular injury

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Mechanism of injuryMechanism of injuryMechanism of injuryMechanism of injury

AP compression (open book)AP compression (open book)AP compression (open book)AP compression (open book)

SI joint wideningSI joint widening

Symphysis seperationSymphysis seperation

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Mechanism of injuryMechanism of injury

Lateral compression(internal rotation)Lateral compression(internal rotation)

Fx iliumFx ilium

Lock symphysisLock symphysis

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Vertical shear (Malgaigne Fx)Vertical shear (Malgaigne Fx)

SI dislocateSI dislocate

SymphysisSymphysisdislocatedislocate

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Major injury initial managementMajor injury initial management

•RecuscitationRecuscitation•Pelvic stabilizationPelvic stabilization

external fixator external fixator•Definite treatmentDefinite treatment

pelvic sling pelvic sling

ORIF ORIF

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Fracture of proximal femurFracture of proximal femur

Surgical anatomySurgical anatomy Vascular anatomyVascular anatomy

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Fracture neck of the femurFracture neck of the femur

• Intracapsular FxIntracapsular Fx• High rate of nonunion,High rate of nonunion,

avascular necrosis avascular necrosis• 2 aged groups2 aged groups

1.Young adult 1.Young adult

high energy high energy

2.Older with osteoporosis 2.Older with osteoporosis

minor fall minor fall

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Fracture neck of the femurFracture neck of the femur

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Fracture neck of the femurFracture neck of the femurFracture neck of the femurFracture neck of the femur

PE:PE:

• Limb slightly shorteningLimb slightly shortening

• Pain at groinPain at groin

• Tenderness at midinguinal pointTenderness at midinguinal point

Older patient ,minor injuryOlder patient ,minor injury

PleasePlease X ray both hip AP ,lat crosstable X ray both hip AP ,lat crosstable

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Young adult ,good bone qualityYoung adult ,good bone qualityReduction and multiple pinningReduction and multiple pinningYoung adult ,good bone qualityYoung adult ,good bone qualityReduction and multiple pinningReduction and multiple pinning

TreatmentTreatmentTreatmentTreatment

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TreatmentTreatmentTreatmentTreatmentOlder with osteoporosisOlder with osteoporosis

HemiarthroplastyHemiarthroplastyOlder with osteoporosisOlder with osteoporosis

HemiarthroplastyHemiarthroplasty

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• NonunionNonunion

• Avascular necrosisAvascular necrosis

• Venous thrombosisVenous thrombosis

• NonunionNonunion

• Avascular necrosisAvascular necrosis

• Venous thrombosisVenous thrombosis

ComplicationComplication

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Intertrochanteric FractureIntertrochanteric Fracture

• Fx line from greater to Fx line from greater to

lesser trochanter lesser trochanter

• More common in woman More common in woman

menopause menopause

• Extracapsular fractureExtracapsular fracture

• Older with osteoporosis -minor fallOlder with osteoporosis -minor fall

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PE:PE:

• Limb shortening,externalLimb shortening,external

rotation rotation

• Swelling ,ecchymosis at hipSwelling ,ecchymosis at hip

• Tenderness at greater Tenderness at greater

trochanter trochanter

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Treatment Treatment

Non operativeNon operative traction 6 wks. traction 6 wks. high complications high complications

Non operativeNon operative traction 6 wks. traction 6 wks. high complications high complications

Pressure sorePressure sorevenous thrombosisvenous thrombosisinfectioninfection

Pressure sorePressure sorevenous thrombosisvenous thrombosisinfectioninfection

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Operative treatment is preferableOperative treatment is preferable surgical risk, early ambulation surgical risk, early ambulation

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Subtrochanteric FractureSubtrochanteric FractureSubtrochanteric FractureSubtrochanteric Fracture

• Fx at level of lesser trochanter Fx at level of lesser trochanter

and a point 5 cm. Distally and a point 5 cm. Distally

• thick cortical bonethick cortical bone

• high mechanic stresshigh mechanic stress

• high energy traumahigh energy trauma

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Treatment Treatment

Operative treatment is preferableOperative treatment is preferable

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• Posterior dislocation 80%

most common

• Anterior dislocation 5%

• Central dislocation 15%

Hip DislocationHip Dislocation

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Dashboard injuryDashboard injury

Blow to femur inadduction internalrotation of the hip

Blow to femur inadduction internalrotation of the hip

Posterior dislocationPosterior dislocation

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PE:PE:

• hip flexion,internal rotate

and adduct

• ass.knee ligament injuries

• assess sciatic nerve

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X-rayX-ray

• Head out of acetabulum

• smaller femoral head

• femur adduct, internal

rotate(disappear lesser

trochanter)

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TreatmentTreatment

• Early diagnosis• prompt closed reduction• Allis’s maneuver• failed closed reduction-

open reduction

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Allis’s maneuverAllis’s maneuver

• Stabilized pelvis

• longitudinal traction

• 90 degree hip flexion

• upward traction

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Allis’s maneuverAllis’s maneuver

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Management after reductionManagement after reduction

• Test for stability• X-ray both hip AP evaluate joint space• Stable reduction skin traction- pain subside ambulation with crutches• Unstable reduction ORIF

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Fragment entrap in jointFragment entrap in jointJoint space widening Joint space widening

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Anterior dislocationAnterior dislocation

Blow to femur in abduction,externalrotate of hip joint

Blow to femur in abduction,externalrotate of hip joint

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• Early diagnosis• prompt closed reduction• Allis’s maneuver• failed closed reduction-

open reduction

TreatmentTreatment

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• General anesthesia

• Traction along axis

• Internal rotation

• Lateral traction


Reduction techniqueReduction technique

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Clinical manifestationClinical manifestation X rayX ray

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Traction along axisTraction along axis

Internal rotationInternal rotationStabilized pelvisStabilized pelvis

Lateral tractionLateral traction37


Post reductionPost reduction

• X ray pelvis AP

• Skin traction until

pain subside(5-7 d)

• Ambulation with crutches

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Fracture shaft of the femurFracture shaft of the femur

• High energy injury

• Bleeding 1- 2.5 L.

• Ass. femoral neck Fx.

• Ass. hip dislocation

• High energy injury

• Bleeding 1- 2.5 L.

• Ass. femoral neck Fx.

• Ass. hip dislocation

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• Deformity of thigh

angulation shortening

• PE.of hip and knee

•Vascular assessment

dorsalis pedis a.

posterior tibial a.

• Deformity of thigh

angulation shortening

• PE.of hip and knee

•Vascular assessment

dorsalis pedis a.

posterior tibial a.

Physical examinationPhysical examination

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• Splinting - Thomas’s splint

• Film femur include hip-knee

detect neck Fx-dislocate hip

• Temporary stabilization with

proximal tibial traction

• Splinting - Thomas’s splint

• Film femur include hip-knee

detect neck Fx-dislocate hip

• Temporary stabilization with

proximal tibial traction

ManagementManagement

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ManagementManagement

• Non-operative treatment

Traction 6-8 wks.

Femoral castbrace 10-12wks.

• Operative treatment

ORIF with plate-screw

Intramedullary nailing

• Non-operative treatment

Traction 6-8 wks.

Femoral castbrace 10-12wks.

• Operative treatment

ORIF with plate-screw

Intramedullary nailing

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Transverse Fx midshaft femurTransverse Fx midshaft femur ORIF with plate-screwORIF with plate-screw43

Comminuted Fx midshaft femurComminuted Fx midshaft femur Intramedullary nailIntramedullary nail44

• Fx distal femoral metaphysis

9 cm. above joint line

• Posterior displacement of

the distal fragment

• High rate of stiffed knee

• Fx distal femoral metaphysis

9 cm. above joint line

• Posterior displacement of

the distal fragment

• High rate of stiffed knee

Supracondylar fractureSupracondylar fracture

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How to described Fx?How to described Fx?

T or Y Fx(combined)T or Y Fx(combined)

Intercondylar Fx(intra-articular)Intercondylar Fx(intra-articular)

Supracondylar Fx(extra-articular)Supracondylar Fx(extra-articular)

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• Conservative Traction stiffed knee

• Conservative Traction stiffed knee

• Operative Early function Early knee motion

• Operative Early function Early knee motion

TreatmentTreatment

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T Fracture of distal femurORIF with plate and screwT Fracture of distal femurORIF with plate and screw

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• Largest sesamoid

• Function

-lever arm for knee

extension

-protect condyle

• Largest sesamoid

• Function

-lever arm for knee

extension

-protect condyle

Fracture of the patellaFracture of the patella

49


•Avulsion(traction) Quads. pull up Knee flexion

•Avulsion(traction) Quads. pull up Knee flexion

•Direct injury•Direct injury

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Sign & symtomSign & symtom

• Swelling,effusion

• Palpable defect

• Unable to extend

knee actively

• Swelling,effusion

• Palpable defect

• Unable to extend

knee actively

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Non displaced FxNon displaced Fx Cylinder castprevent knee flexion

Cylinder castprevent knee flexion

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Displaced transverse FxDisplaced transverse Fx ORIF ORIF

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• Most common long bone Fx

• medial surface palpable

• Open Fx common

• frequent complication

• Most common long bone Fx

• medial surface palpable

• Open Fx common

• frequent complication

Fracture of the tibiaFracture of the tibia

54

• Swelling ,deformity• Ascess vascular

dorsalis pedis a.

posterior tibial a.• marked swelling

compartment syn.

• Swelling ,deformity• Ascess vascular

dorsalis pedis a.

posterior tibial a.• marked swelling

compartment syn.

Symtom & SignSymtom & Sign

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TreatmentTreatmentConservativeConservative Closed reduction

apply long leg castClosed reduction

apply long leg cast

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X ray post reduction

X ray post reduction Criteria for accept alignmentCriteria for accept alignment

• Varus,vulgus < 5 degree

• AP angulation <10 degree

• Malrotation <10 degree

• Shortening < 1cm.

• Contact surface >50%

• Varus,vulgus < 5 degree

• AP angulation <10 degree

• Malrotation <10 degree

• Shortening < 1cm.

• Contact surface >50%

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After long leg cast4-6 weeks

After long leg cast4-6 weeks

Change to PTB cast 8-12 wks.

Until Fx consolidation

Change to PTB cast 8-12 wks.

Until Fx consolidation Patella Tendon BearingPTB cast

Patella Tendon BearingPTB cast

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TreatmentTreatment

Operative Operative

• Failed closed reduction

• Unacceptable alignment

• Multiple fractures

• open fracture

• Failed closed reduction

• Unacceptable alignment

• Multiple fractures

• open fracture

Intramedullary nailIntramedullary nail

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External fixatorExternal fixatorORIF plate & secrewORIF plate & secrew

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ComplicationComplication

Compartment syndrome

Compartment syndrome

• Early detection

• Release pressure

remove cast,splint

fasciotomy

• Early detection

• Release pressure

remove cast,splint

fasciotomy

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MalunionMalunionVascular injuryVascular injury InfectionInfection62

A man 23 yr. MCA 10 min . Single injuryPain at Rt. ankle, can’t palpable dorsalis pedisand posterior tibial artery

A man 23 yr. MCA 10 min . Single injuryPain at Rt. ankle, can’t palpable dorsalis pedisand posterior tibial artery

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X ray ankle AP, LatX ray ankle AP, Lat

Fx of distal fibularFx of distal fibular

Diastasis of syndesmosisDiastasis of syndesmosis

Fx of medial mall.Fx of medial mall.

Ankle subluxationAnkle subluxation

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How do you managethis case?

How do you managethis case?

Vascular injury?Joint subluxationVascular injury?Joint subluxation

•4 R•R egcognition•R eduction•R etention•R ehabiliation

•4 R•R egcognition•R eduction•R etention•R ehabiliation

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AP viewAP view Mortise viewMortise view Lateral viewLateral view66

head

body

neck

Fracture of the talusFracture of the talus

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• Talar neck Fx most common

• Caused by hyperdorsiflexion

• 3/5 cover by cartilage

• Vascular enter at talar neck

• Talar neck Fx most common

• Caused by hyperdorsiflexion

• 3/5 cover by cartilage

• Vascular enter at talar neck

Fracture of the talusFracture of the talus

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Subtalar jt. dislocation

Talar neck Fx

Ankle dislocation

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ORIF talar neck with screwORIF talar neck with screw

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Fracture of the CalcaneusFracture of the Calcaneus

• Most common tarsal bone Fx

• Extra-articular Fx

Direct injury

• Intra-articular Fx(Subtalar Jt.)

Fall from height

• Most common tarsal bone Fx

• Extra-articular Fx

Direct injury

• Intra-articular Fx(Subtalar Jt.)

Fall from height

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Physical ExaminationPhysical Examination

•Heel widening,short

•Ecchymosis

•Tenderness at heel

•Squeeze test

•T-L spine exam

•Heel widening,short

•Ecchymosis

•Tenderness at heel

•Squeeze test

•T-L spine exam

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X rayX ray

•Calcaneus lateral•Axial view•Calcaneus lateral•Axial view

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TreatmentTreatment

•Non displaced Fx

Short leg cast 6 wks.•Displaced Fx

ORIF

•Non displaced Fx

Short leg cast 6 wks.•Displaced Fx

ORIF

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Pelvic Fracture AnatomyAnatomy 2 innominate 1sacrum 2 innominate 1sacrum Innominate bone...

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