A lecture on Pelvic Fractures part 1.pptx

A presentation on Pelvic Fractures by Dr Agbley

1. PELVIC FRACTURES BY DR D.Y.D AGBLEY

2. OUTLINE INTRODUCTION ANATOMY OF THE PELVIS EPIDEMIOLOGY INITIAL ASSESSMENT DIAGNOSIS INVESTIGATION CLASSIFICATION MANAGEMENT COMPLICATIONS

3. INTRODUCTION Pelvic fractures are potentially life threatening injuries with an increased incidence due to high velocity RTAs. Survivors are at significant risk for morbidities like chronic pain,Leg Length Discrepancy, Sexual Dysfunction or nerve palsy 3-4 % of all fractures usually are associated with significant trauma.

4. INTRODUCTION Adult mortality 10- 15% Mortality is approx. 50% if hypotension on initial presentation Mortality is approx. 30% in open fractures Significant decrease in mortality and morbidity if prompt stabilization of an unstable fracture.

5. PELVIS ANATOMY

6. ANATOMY 1 Sacral Bone 2 Innominate Bones ( Pubis , Ilium , Ischium) * Symphysis Gap < 5mm

7. STABILIZING LIGAMENTS Anterior Sacroilliac Ligament (Resist external rotation) Posterior Sacroilliac Ligament (Posterior tension band ,Strongest) Sacrotuberous Ligament ( resist shear/flexion of SI joint) Sacrospinous Ligament (resist external rotation) Illiolumbar Ligament (resist rotation and augment posterior SI ligament) Interosseous Ligament (resist antero -posterior translation of pelvis) Symphisis

8. Possible Bleeders Sacral venous plexus* Iliolumbar a. Internal iliac a. Superior gluteal a.* Lateral sacral a. Pudendal a.*

9. NERVES

10. Visceral Anatomy Bladder/Urethra Rectum Prostate Vagina

11. ASSOCIATED INJURIES Chest Injury in up to 63% Long Bone Fractures in 50% Sexual Dysfunction up to 50% Head and abdominal injury in 40% Spine fractures in 25%

12. INITIAL ASSESSMENT HX : Ground level fall in elderly or with osteoporosis , high energy fall. MVC ,pedestrian vrs car SX/ Px : Varies based on severity; Pain , Inability to bear weight, Limb-Leg Discrepancy, Laceration and Bruising leg held in external rotation. The best initial step in the management is resuscitation as necessary.Pelvic fracture are associated venous injury and haemorrhage.large bore Ivs and fluid should be administered as necessary. Initial physical examination is of the utmost importance to promptly find any significant complication that need to be addressed

13. Primary survey A irway Maintenance with C-spine protection B reathing and Ventilation C irculation with hemorrhage control D isability: Neurologic status E xposure/Environment Control: Undress patient but prevent hypothermia

14. Associated signs: - Roux's sign:        - a decrease in the distance from the greater trochanter to the pubic crest on the affected side in lateral compression frx ;  - Earle's sign:        - a bony prominence or large hematoma as well as tenderness on rectal examination; 

15. Destot Sign Moral Lavale Lesion

16. Physical Examination Neurologic deficit involving lumbosacral plexus Pelvic/flank/ perineal contusions,ecchymoses,abrasions Blood at urethral meatus Blood in or around rectum Open wound of groin,buttock , or preineum Leg length inequality or external rotation of one extremity Abnormal pelvic motion on AP or lateral compression of anterior iliac spines and iliac crests

17. INITIAL PHYSICAL EXAMS General inspection: LLD, bruising,lacerations,ecchymosis( perianal,scrotal,labial ), Swelling,flank haematoma , presence of external rotation. Manual palpation: Gently palpate the bony structures of the hip for abnormality. Neurological :Lumbosacral plexus injury is common(most commonly L5 and S1) check for foot drop(L5) buttocks/perianal sensation(S1-S4), saddle anaesthesia (S3-S5) Urogenital: Prostate examination(men) , bimanual examination (women),be sure to check for ocult open fractures.

18. Neurological exam Rectal exam for tone Bulbocavernosus reflex Myotomes of lower extremity L1-2 : hip flexor L3-4 : Quadriceps/knee extension L4-5 : Ankle and toe dorsiflexion S1 : ankle plantarflexion S2-3 : toe plantarflexion

19. Stabilization Methods Sheet around pelvis Pelvic binder

20. External fixator Return blood from lower ext. to central vascular system Ability to close open-book-type injury, reducing pelvic volume Stabilize pelvic ring permitting clot formation

21. Angiography Advantage Useful in assessing and embolization of arterial injury - Unexplained blood loss after stabilization and aggressive resuscitation , Pulseless extremity Disadvantage : Source of arterial bleeding is identified in only 10-15% of patients with severe pelvic disruption Does not address venous bleeding

22. Indications for Angiography Unexplained blood loss after stabilization AND aggressive resuscitation Pulseless extremity

23. Angiography Complication : Lead to necrosis of buttock after occlusion of entire internal iliac artery Sciatic or femoral paresis Bladder wall necrosis Emboli to normal vessels Associated with high mortality rate

24. IMAGING PELVIC FRACTURES Plain Radiographs AP view

25. Plain AP view Pubic Rami fracture Symphyseal Displacement SIJ and Sacrum Illiac Fracture L5 transverse process Asso Acet /proximal femur

26. Plain Radiograph – Inlet View

27. Anterior/Posterior Displacement of sacrum,SIJ,Illium,Symphysis Rotational Deformities of illium Impacted Sacral fractures

28. Plain Radiography Outlet view Adequate image when pubic symphysis overlies S2 body

29. Imaging CT Scan Gold standard for pelvic fractures.Detailed information about anterior and posterior ring. MRI Limited role GU and Vascular strutures

30. CLASSIFICATION OF PELVIC FRACTURES Young and Burgess Classification - Most common classification used - Based on the mechanism of injury Tiles Classification - Based on stability

31. TILE/AO Classification

32. Tile/AO Classification Type A: STABLE

33. Tile/AO Classification Type B: Rotationally unstable, Vertically stable

34. Tile/AO Classification Type C: Rotation and vertically unstable

35. Sacral Fracture-Denis Classification

36. Principles of Initial Management Suspect if high velocity RTA(car vs pedestrian; Motorcycle) or a fall from height(usually >15feet) Pelvis has no inherent stability and relies on ligamentous supports. Vascular structures are intimately associated with ligaments and are often injured.

37. Non-Operative Management Lateral impaction type injuries with minimal (< 1.5 cm) displacement Pubic rami fractures with no posterior displacement Minimal gapping of pubic symphysis Without associated SI injury 2.5 cm or less, assuming no motion with stress or mobilization This number is not absolute, so other evidence of instability (like SI injury) must be ruled out

38. Non-Operative Management X-rays are static picture of dynamic situation It may be that the deformity is worse than seen on X-rays taken Stress radiographs may be helpful Other evidence of instability should be sought Lumbar transverse process fractures Avulsions of sacrotuberous / sacrospinous ligaments

39. Non-Operative Treatment Tile A (stable) injuries can generally bear weight as tolerated Walker/crutches/cane often helpful in early mobilization Serial radiographs followed during healing Displacement requires reassessment of stability and consideration given to operative treatment

40. Non-Operative Treatment Tile B (partially stable) injuries can be treated non-operatively if deformity is minimal Weight bearing should be restricted (toe-touch only) on side of posterior ring injury Serial radiographs followed during healing Displacement requires reassessment of stability and consideration given to operative treatment

41. Principles of Operative Treatment Posterior ring structure is important Goal is restoration of anatomy and enough stability to maintain reduction during healing Most injuries involve multiple sites of injury In general, more points of fixation lead to greater stability This does NOT mean that all sites of injury need fixation

42. Principles of Operative Treatment Anterior ring fixation may provide structural protection of posterior fixation If combined open and percutaneus techniques are used, the open portion is often done first to aid in reduction of the percutaneusly treated injury LETOURNEL’s Golden rule: Posterior stabilization to be done before anterior as posterior is the main weight bearing part.

43. Anterior Pelvic Ring Injuries Indications for ORIF Symphyseal dislocation >2.5cm(static or dynamic) To augment posterior fixation in vertically dislaced fractures. Locked symphysis .

44. Surgical Approach to the Anterior Pelvic Ring Pfannenstiel Approach Supine Position 8 cm incision A Foley catheter and nasogastric tube are inserted

45. The cut edges of the rectus abdominal muscles superiorly to reveal the symphysis and pubic crest. If access to the back of the symphysis is required, use the fingers to push the bladder gently off the back of the bone

46. Symphyseal Dislocations Ant Ex Fix = Internal Fixation for controlling rotation but Internal fixation >>> for resisting vertical displacements Ex fix particularly useful in open injuries or pts requiring GI/GU procedures.

47. ORIF of Symphyseal disruptions Apply circumferential wrap at the level of the GT. Internally rotate the legs and tape them. Ant approach to pubic symphysis . Place reduction forceps anteriorly so that plate can be put on the superior surface.

48. Inlet view: judge the alignment of the plate; Outlet view judge the length of screws;screws should have a bicortical purchase.

49. Fractures of the Pubic ramus Fractures medial to insertion of inguinal ligament should be treated like symphyseal dislocations. Comminuted fractures: ORIF Minimal comminution : Ramus screw(ante vs retro)

50. Fractures of the Pubic ramus Reduction technique Secure a precontoured plate in the supra- acetabular bone. One third of the reduction forceps on the medial fragment and another on the most medial hole of the plate.

51. Posterior Pelvic Ring Injuries Indications for ORIF:- Displaced illiac wing fractures that enter and exit both the crest and GSN/SIJ. Multiplanar instability(disruption of ligaments) Non impacted comminuted displaced sacral fractures. Vertical or cephalad displacement. U shaped fractures with spino -pelvic dissociation

52. Approaches to posterior pelvic ring Posterior approach to SIJ

53. Anterior Approach to the Sacroiliac Joint Make a curved incision over the iliac crest, beginning 7 cm posterior to the anterior superior iliac spine. Curve the incision anteriorly and medially along the line of the inguinal ligament for 5 cm .

54. Sacroilliac Joint Dislocations Posterior approach----Only inferior joint visualised Anterior approach----Superior Ala visualized Longitunal traction is the single most important maneuvre . Important to let the pelvis hang free as pressure on ASIS will lead to ext rotation

55. Two reduction forceps

56. Illio -Sacral screw Placement Inlet projection—screw towards anterior aspect of promontory Outlet ---screw is above the S1 foramen Screw to be directed anteriorly ; superiorly and medially. Lateral Projection

57. Be aware of sacral dysmorphism

58. Illiac wing fractures and fracture dislocations( Crescent fractures) Illiac wing fractures exiting through the SIJ are crescent #. Crescent fragment is the variable sized that contains the PSIS and PIIS and remains attached to the sacrum. Smaller the “CRESCENT” fragment > damage to posterior structures Crescent fracture always approached posteriorly

59. SACRAL Fractures Can be regarded as a pelvic injury, spinal injury or both. Indications for fixation:- Ant and post ring disruption with vertical sheer sacrum fracture. Comminuted # with rotation Spinal-pelvic dissociation Rarely in impacted # with Internal rotation deformity

60. Illiosacral screw Plate fixation

61. Spinal point of fixation- L5(usually) Illiac screw just inf to PSIS Illiac screw is connected to pedicle screw with appropriate rods and screw-rod clamps This bypasses the lines of force transmission from spine to illium through the construct instead of the sacrum Spinal-Pelvic fixation

62. Post-Operative Care Mobilized to chair 1 st day post-op Toe touch weight bearing upto 10 weeks (unstable injuries) Stable injuries immediate post-op FWB. DVT prophylaxis. Prophylaxis for hetereropic ossification.

63. Complictaions Intra-operative haemorrhage Inability to achieve reduction Wound infection. Newly recognized post-op neurologic deficits Loss of fixation and reduction Sexual dysfunction

64. THANK YOU