Download Pelvic injuries, femoral fractures

Pelvis injuries
Fractures of the femur
(proximal,shaft)
Dr Tamás Bodzay
Pelvis anatomy
Pelvis function
- axial load bearing
- protection: abdominal, pelvic structures
Pelvic injury mechanism
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Falling from altitude
Compression
Motor vehicle accident
High energy trauma
Associated injuries
• Blood loss:1500 – 2000 ml (shock)
- fracture site: 70 %
- venous plexus: 20 %
- arterial bleeding: 10%
• Associated injuries:
- urethra
- urinary bladder (extra- intraperitoneal)
- rectum
Classification
- localisation of the injury
- instability (Tile-AO)
- direction of the force (Young-Burgess)
Type A
(stable)
Young patients: sport injuries / muscle attachment/
Elderly patients: falls
Type B
(rotational instability)
Type B 1.( open book)
Symphysis opens up /3-6 cm/
Posterior internal ligaments ruptured,
Posterior external ligaments intact
Type B 2.
Symphysis squashed
Posterior internal ligaments intact,
Posterior external ligaments
ruptured
Typ. C
(rotational + vertical instability)
• AP compression
(B1)
• Lateral compression
(B2)
• Vertical shear
(C)
Pelvic injuries
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3 % of the all injuries
25% by the politrauma patients
Mortality:16%
Mortality by hemodinamical unstable
patients: 30%
• Mortality by open injuries:55%
Diagnostics-physical examination
1x!!
Diagnostics- X ray
Diagnostics- CT
Treatment
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Stable injury= non-operative treatment
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Unstable injury= operative treatment
Instability:
- (bio)mechanical
- HEMODINAMICAL !!
(Blood loss:1500 – 2000 ml ;shock)
Hemodinamically unstable
patient:emergency fixation
Definitive treatmentsymphyseolysis: plate fixation
Definitive treatment- transiliacal fx.:
plate fixation
Definitive treatment- SI-lysis: plate
fixation or iliosacral screw fixation
Definitive treatment- sacrum fx:
Classification
• I- posterior type:wall,
collumn, wall+
collumn,
• II- anterior type:wall,
collumn, wall+
collumn,
• III- transverse type:
transverse, T, both
collumn
Diagnostics- X ray
• AP view
• Ala view
• Obturator view
AP view
Ala view
Obturator view
Diagnostics- CT
Operativ treatment- approaches
Operativ treatment- screw fixation
Operativ treatment- plate fixation
Dashboard injury ?
Dashboard injury
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acetabular fx.
femoral head fx.
femoral neck fx.
femur diaphyseal fx.
femur distal fx.
patellar fx.
PCL tear.
tibial head fx.
Pipkin’s classification of femoral
head fractures.
• Type I: Fracture inferior to
fovea centralis.
• Type II: Fracture superior
to fovea centralis.
• Type III: Type 1 or 2 +
femoral neck fracture.
• Type IV: Type 1, 2 or 3 +
acetabular fracture
Treatment of femoral head
fractures
• Type I: excision or
fixation.
• Type II: ORIF with screws
in youngs; joint
replacement in elderly.
• Type III: same as Type II
• Type IV: same as in Type
III + acetabular fracture
fixation.
Clinical symptoms of the hip
fractures
• abduction
• external rotation
• shortening
The blood supply of the femoral head
Capsule
Obturator artery
Ligamentum teres
Foveal artery
Medial femoral
circumflex artery
Lateral femoral
circumflex artery
Femoral artery
Extracapsular arterial ring
Ascending cervical arteries
Profunda femoris artery
Retinacular arteries
Ascending cervical arteries
Extracapsular arterial ring
Subsynovial intracapsular
arterial ring
Müller (AO), Garden and Pauwels classification of femoral neck fractures
B1 Neck fracture, subcapital,
with slight displacement
1 impacted in valgus > or =
15°
2 impacted in valgus < 15°
3 non impacted
G1 : incomplete, impacted
displacement
B2 Neck fracture,
transcervical
1 basicervical
2 midcervical adduction
3 midcervical shear
G2 : non-displaced
Pauwels classification refers
to the angle of the fracture line
compared to the horizontal
B3 Neck fracture, subcapital, non
impacted, displaced
1 moderate displacement in varus and
external rotation
2 moderate displacement with vertical
translation and external rotation
3 marked displacement
G3 : incomplete displacement
G4 : complete
Grade 1: 30°
Grade 2: 50°
Grade 3: 70°
Treatment of the femoral neck
fractures- screw fixation
• Treatment of stable femoral neck fractures (Type
Garden-I and –II) : two cannulated screws
• Treatment of unstable femoral neck fractures (Type
Garden-III and –IV): two cannulated screws+a two-hole
tension plate
Three-point-buttressing
Screw fixation of the Garden I.
fracture
Screw fixation of the Garden III.
fracture
Treatment of the femoral neck
fractures- arthroplasty
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Type Garden-IV;subcapital fracture
Time between injury and surgery > 48 hour
Impossible reduction
Pathologic femoral neck fracture
Arthroplasty
hemiarthroplasty : age > 80
years
total hip arthroplasty: age <
80 years
Classification of the trochanteric
fractures
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A-1 Trochanteric, simple
A-1.1 Cervicotrochanteric
A-1.2 Pertrochanteric
A-1.3 Trochanterodiaphyseal
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A-2 Pertrochanteric,
multifragmentary
A-2.1 One intermediate
fragment
A-2.2 Two intermediate
fragments
A-2.3 More than two
intermediate fragments
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A-3 Intertrochanteric
A-3.2 Intertrochanteric
A-3.2 Reversed, simple
A-3.3 With additional fracture of
medial cortex
Implants for the fixation the
pertochanteric fractures
Fixation of fracture type AO 31A1(stable pertochanteric fracture):
DHS
Stabilization of fracture type AO
31-A2: Fi-nail
Stabilization of fracture type AO
31-A2: PFNA-nail
Fixation of fracture type AO 31A3: DCS
Stabilization of fracture type AO
31-A3: Fi-nail
Classification of the femoral shaft
fractures
A1
A2
A3
B1
B2
B3
C1
C2
C3
Non-operative treatment
Operative treatment
• Intramedullary nailing
• Plate synthesis
• External fixator
Intramedullary nailing
• Biomechanical
• Biological
Intramedullary nailing
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Closed technique
Early mobilisation
Good weight-bearing capacity
Low grade septic complication
Rapid bony consolidation
Reaming
• Metal-bone contact:
relative stable
• Reaming: improved
metal-bone contact =
increased stability
Indications: fx. in the 3-45/7
Interlocking
• Interlocking: increased
rotational stability
Indications: fx. in the 2-34-5-6/7
Unreamed interlocking nailing
• Reaming: intramedullary
pressure elevation
(1969 Lilienström)
• Bone marrow
embolisation
(1989 Wenda)
• Destroyed lung function
(1997 Pape)
Indications: thorax/head
injury+fx. in the 3-4-5/7
Plate fixation
• Intraarticular and
diaphysis fx.
• Compartment
syndrome
• Vascular injury
• Previously inserted
implants
External fixator
• Open femoral shaft fractures (Type III.)
• Septic complications
• Femoral shaft fractures + polytrauma
(ISS > 40)
Implant choice
• Mono/multitrauma: reamed nailing with
interlocking
• Polytrauma: ISS < 40 - unreamed locking
nailing, ISS > 40 or head/thorax injury- FE.
• Intraarticular and diaphysis fx,
compartment syndrome, vascular injury,
previously inserted implants-plates