Lower Limb Trauma: Fracture Pelvis PDF

3/15/2022 LOWER LIMB TRAUMA Fracture Pelvis DR. MUTHANNA HASHIM HAMMOSHI ORTHOPEDIC SPECIALIST NINEVAH MEDICAL COLLEGE 5TH STAGE LECTURE Objectives 1-Pelvis (anatomy ,,imaging study,,fracture classification,,intial and definitive treatment,,complications) 2-Acetabulum injuries (causes, si...

3/15/2022 LOWER LIMB TRAUMA Fracture Pelvis DR. MUTHANNA HASHIM HAMMOSHI ORTHOPEDIC SPECIALIST NINEVAH MEDICAL COLLEGE 5TH STAGE LECTURE Objectives 1-Pelvis (anatomy ,,imaging study,,fracture classification,,intial and definitive treatment,,complications) 2-Acetabulum injuries (causes, significance and tratment) 3-Coccyx fracture (epidemiology and treatmrnt) 1  3/15/2022 Injuries of the pelvis Importance: associate with blood loss, shock, sepsis, ARDS, and visceral injuries. Mortality rate is up to 10% Usually follow RTA (pedestrians) or FFH. Surgical Anatomy Pelvic ring: 2 innominate bones (ilium, ischium and pubis) and sacrum. Articulate anteriorly by symphysis pubis and posteriorly at sacroiliac jt. Transmit weight and protects viscera: Posterioly: iliac vessels and their branches, lumbar and sacral plexuses. Anteriorly: bladder. Urethra, uterus and vagina. Also: rectum and anal canal. 2 3/15/2022 3  3/15/2022 FRACTURE PELVIS needs high energy to create such damage IMPORTANCE OF PRLVIC FRACTURE Mortality rate 15-25% for closed fractures, as much as 50% for open fractures o hemorrhage is leading cause of death overall increased mortality associated with 1-systolic BP less than 90 mmgh 2-age more than 60 years 3- need for transfusion > 4 units 4  3/15/2022 Associated injuries chest injury in up to 63% long bone fractures in 50% head and abdominal injury in 40% spine fractures in 25% urogenital injuries in 12-20% clinical assessment Priority is always for correction of general condition, blood loss, and resuscitation. Suspected!!! Every RTA, FFH, or crush injury. Abdominal and lower limb injuries. Swelling bruising of abdomen, thighs, perinium, scrotum or vulva. Tenderness over symphysis pubis or sacroiliac region. Clinical examination Symptoms pain & inability to bear weight Physical examination : test stability by placing gentle rotational force on each iliac crest low sensitivity for detecting instability perform only once look for abnormal lower extremity positioning external rotation of one or both extremities limb-length discrepancy 5  3/15/2022 Physical examination 1-skin examination scrotal, labial or perineal hematoma swelling or ecchymosis o flank hematoma lacerations of perineum 2-neurologic exam o rule out lumbosacral plexus injuries (L5 and S1 are most common) rectal exam to evaluate sphincter tone and perirectal sensation 3- urogenital exam o most common finding is gross hematuria more common in males (21% in males, 8% in females) NB: never attempt urethral catheter which may convert partial urethral injury to complete. 4-vaginal and rectal examinations mandatory to rule out occult open fracture Imaging studies X-rays in every suspected case. C-T scan with 3D reconstruction image for complex fracture patterns. IVU, urethrography or cystography for suspected urethral or bladder injuries. Imaging study standered anteriopost erior view 6  3/15/2022 Posterior sacral fracture appear by ct scan Types of fractures Isolated # with intact pelvic ring; eg. Iliac blade #, stress # of pubic rami, avulsion # of anterior superior iliac spine…. Treatment is usually reassurance, rest and analgesia. #s of the pelvic ring; stable or unstable. Acetabular fractures. A (50–70%)Single fracture Intact ring -Stable 7  3/15/2022 Iliac blade # Avulsion of ASIS 8  3/15/2022 Fractures of pelvic ring Mechanisms of injury 1- AnteroPosterior Compression: Frontal collision between pedestrian and a car. Anteriorly; Pubic rami # or diastasis of symphysis pubis. Posteriorly: sacroiliac joint separation or # ilium or sacrum. Also known as open book #. Open book # 9  3/15/2022 2- lateral compression: Side-on impact in RTA or FFH. Anteriorly: pubic rami on one or both sides #ed. Posteriorly: SIJ strain or # ilium (same or opposite side). Linked to abdominal, chest or head injuries. Lateral compression fracture Lateral compression # 10  3/15/2022 3- Vertical shear: Usually after FFH. Pubic rami # and SIJ disruption. Innominate bone displaced vertically. Pelvis unstable. Gross soft tissue tearing and retropretoneal hemorrhage. Clinical features Stable injuries: Not severely shocked, pain on attempting to walk. Tender points. Seldom visceral injury. 11  3/15/2022 Unstable injuries Severe shock, pain, and unable to stand. Widespread tenderness. Visceral injuries are common. Early management ATLS protocol should be applied. Pelvic binder is mandatory at the accident scene for every suspected pelvic fracture. Clear airways and maintain breathing. Set IV line, assess and compensate for blood loss. Diagnose and treat internal or external bleeding. GCS and manage head injury. Treat associated abdominal injuries. Treat bladder and urethral injuries. 12  3/15/2022 Treatment of the fracture Isolated fractures and minimally displced fractures (stable pelvic fractures) : Bed rest for 4-6 wks with or without traction. Then walking on crutches. Open book injuries Anterior gap men. Bruising, pain on sitting, local tenderness and painful P-R exam. Treatment: reduction by finger in the rectum. Sitting on a rubber ring cushion. Persistent pain treated by local steroid injection or excision of the coccyx. Reference 17