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Pelvis & Hip Fractures & Dislocations Moritz Haager October 24, 2002 Objectives: Epidemiology & relevance Anatomical review Classification Systems Examples Management Pelvic Fractures: Epidemiology ~3% of all fractures in ED 50-60% secondary to MVA Motorcycle crashes ~15% Car vs. pedestrian ~15% Falls 10-30% Crush injuries ~5% Mortality 6-10%; Inc’s to ~50% in unstable pt Tend to occur in setting of multi-system injury therefore often serious other injuries Complications: Hemorrhage, neurological injury, deformity, GU injury, GI injury Pelvic Anatomy Pelvis = sacrum + 2 inominate bones Inominate bones = ilium, ischium, pubis Strength from ligamentous + muscular supports Pelvic Anatomy Anterior Support: ~40% of strength Symphysis pubis Fibrocartilaginous joint covered by ant & post symphyseal ligaments Pubic rami Posterior Support: ~60% of strength Sacroiliac complex Sacroiliac ligaments Iliolumbar ligaments Pelvic floor Sacrospinous ligament Sacrotuberous ligament Pelvic diaphragm Acetabulum Divided into 3 columns: Anterior superior column (= ilium) Anterior inferior column (= pubis) Posterior Column (= ischium) Vascular Anatomy Vessels lie closely adherent to posterior pelvic walls Most common cause of bleeding is venous Most commonly injured arteries are superior gluteal and internal pudendal aa. History & Physical ABC’s & initial stabilization AMPLE Hx Destot’s sign: Hematoma above inguinal ligament or scrotum Grey-Turner’s sign Earle’s sign: Most important feature is mechanism Presence of bony prominence, palpable hematoma, or tender # line on DRE Blood at urethral meatus / vaginal introitus Examine pelvis only once Sensitivity of exam 93% vs. 87% for AP pelvis Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5 Imaging Plain films AP Inlet view / Outlet view Judet view (oblique) AP alone ~90% sensitive; combined w/ inlet / outlet views ~94% sensitive Limited in ability to clearly delineate posterior injuries Pelvic films are NOT necessary in pts with normal physical exam + GCS >13 At least one study shows clinical exam reliable in EtOH Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5 CT scans Evaluates extent of posterior injury better Superior imaging of sacrum and acetabulum More detailed info about associated injuries Inlet & Outlet Views Inlet view X-ray beam at 60o to plate directed towards feet Used to look for vertical & horizontal fracture displacement, and SI widening Outlet view Beam aimed 30o towards head Used to look at sacral fractures & SI disruption Imaging What you really want to know is if there has been damage to the posterior structures Clues on X-rays: L5 transverse process avulsion (iliolumbar ligament) Ischial spine avulsion (sacrospinous ligament) Unable to clearly make out sacral foramina Assymmetry of sacral foramina Significant displacement of anterior arch fracture Sacral avulsion (sacrotuberous ligament) Classification Systems: 2 most common are Tile and Young systems Tile Classification system: Advantages Disadvantages Comprehensive Predicts need for operative intervention Does NOT predict morbidity or mortality Young Classification System: Advantages Based on mechanism of injury predicts ass’d injury Estimates mortality Disadvantages Excludes more minor injuries Tile Classification System Type A: Stable pelvis: post structures intact A1: avulsion injury A2: iliac wing or ant arch # A3: Transverse sacrococcygeal # Tile Classification System Type B: Partially stable pelvis: incomplete posterior structure disruption B1: open-book injury B2: lateral compression injury B3: contralateral / bucket handle injuries Tile Classification System Type C: Unstable pelvis: complete disruption of posterior structures C1: unilateral C2: bilateral w/ one side Type B, one side Type C C3: bilateral Type C Young Classification System: Lateral Compression (50%) – transverse # of pubic rami, ipsilateral or contralateral to posterior injury LC I – sacral compression on side of impact LC II – iliac wing # on side of impact LC III – LC-I or LC-II on side of impact w/ contralateral APC injury Young Classification System: AP Compression (25%) Symphyseal and / or Longitudinal Rami Fractures APC I – slight widening of the pubic symphysis and/or anterior SI joint APC II – disrupted anterior SI joint, sacrotuberous, and sacrospinous ligaments APC III – complete SI joint disruption w/ lateral displacement and disruption of sacrotuberous and sacrospinous ligaments Young Classification System: Vertical Shear (5%) Symphyseal diastasis or vertical displacement andteriorly and posteriorly Combined Mechanism – combination of injury patterns Young: Morbidity & Mortality Fracture Type LC - I Severe Bladder Bleeding Rupture 0.5% 4% Urethral Injury 2% Mortality LC – II 36% 7% 0% 6% LC – III 60% 20% 20% 13% APC – I 1% 8% 12% 7% APC – II 28% 11% 23% 7% APC – III 53% 14% 36% 25% VS 75% 15% 25% 25% CM 58% 16% 21% 17% 6% Tile B1 / Young APC II Tile C1/ Young VS Tile A1 Management Stable vs Unstable patient Stable pt: Conservative Tx (bed rest slow wt bearing) Tile: A1, A2, A3 (coccyx #’s only) Young: APC – I, LC – I, some LC – II Unstable pt: Tile B & C / Young APC & VS = high energy injuries Require surgical management Timing & methods for stabilization controversial Management: Unstable Patient ABC’s, resuscitation Evaluate for site(s) of blood loss Options for pts not requiring laparotomy: DPL, FAST, CT Laparotomy if indicated Sheet around pelvis / MAST pants External fixator Early ORIF Angiographic embolization Early antibiotics for open # (cefazolin & gent) Hemodynamically Unstable Pelvic Fracture Initial Resuscitation DPL Gross + blood Laparotomy + Cell Count CT Abdomen / Pelvis - Cell Count ?Candidate for External Fixator Yes Persistent Hemodynamic Instability External Fixator Angio + Embolization No Unstable Stable Management: Unstable Patient Does our approach work? No prospective RCT’s Allen et al. Management Guidelines for hypotensive pelvic fracture patients. Am Surg 2000; 66: 735-38 Retrospective analysis of 75 pts BP<90 & complex pelvic fracture Utilized external fixator, early ORIF, and embolization Overall mortality 14.7% Predictors of mortality: BE < -5 BP < 90 after initial resuscitation Higher ISS Avulsion Fractures Common pelvic #’s Mechanism: Most common types: Forced contraction of muscle avulsing bony fragment (soccer & gymnastics) Ischial tuberosity hamstring ASIS avulsion sartorius AIIS rectus femoris Tx: PRICE, crutches, f/u with ortho in 1-2 weeks Sacral Fractures Mechanism: Presentation: Perianal or buttock pain +/- ecchymosis ~22% have neuro sx Dx: Direct trauma or forced flexion AP pelvis, CT Tx: No neuro deficits PRICE & ortho in 1 week + neuro deficits urgent ortho consult Sacral Fractures Classification: Type A: ~90% vertical transforaminal # line – usually ass’d pelvic #’s Neuro deficits less common Type B: Transverse # line below S2 Neuro deficits less common Type C: Transverse # line above S2 High incidence of neuro deficit Least common sacral # Coccyx Fractures Mechanism: Presentation: Pain w/ sitting, standing, or defecating Local tenderness Dx: Direct trauma (falls) Clinical Tx: STD (Stool softeners, Tylenol, Donut cushion) Coccygectomy if persistent chronic pain Duverney’s (Iliac Wing) Fractures: Mechanism: Presentation: Localized pain, swelling, tenderness Trendelenburg gait Ileus, abdominal tenderness Dx: Direct trauma 30% have ass’d acetabulaR # AP pelvis Tx: No abd findings PRICE, ortho f/u in 1 week Abd rigidity / ileus r/o intraabdominal injury Acetabular Fractures 20% of pelvic fractures Sciatic nerve injury in 13% MVA most common mechanism 4 types: Posterior rim Transverse Iliopubic column Ilioischial column Acetabular #: Posterior Rim Most common Mechanism: Dx: Knee-on-dashboard Post hip dislocation common AP pelvis +/- CT Tx: Admit, Ortho consult Reduce post dislocation w/in 6 hrs if present Document neurovascular status Post Reduction: Allis Method Post Reduction: Stimson Method Transverse Fractures Mechanism: Dx: Lateral medial force on greater trochanter with hip flexed (T bone MVA) May have ass’d central hip dislocation AP pelvis: disruption of teardrop CT Tx: Admit, ortho consult Iliopubic Column Fractures Mechanism: Dx: Lateral medial force to greater trochanter with hip in flexion & external rotation (laying down the bike) May get central or anterior femur dislocation AP pelvis: disruption of arcuate line + ant rim, tear drop medially displaced CT Tx: Admit, ortho consult Ilioischial Column Fractures Mechanism: Dx: Ant post force to knee w/ thigh in abduction & flexion Sciatic nerve injury in 25-30% AP pelvis: ilioischial line disruption +/- medial displacement of femoral head CT Tx: Admit, ortho consult Proximal Femur Injuries Fractures: Dislocations: Femoral neck, intertrochanteric, femoral head, greater & lesser trochanter, subtrochanteric Anterior, posterior, central hip dislocations Rising incidence due to aging population & MVA’s Young pts high energy trauma Elderly pts minor mechanisms – need high index of suspicion Anatomy Ward’s triangle Weakest part of proximal femur Vascular anatomy Distal blood supply AVN / non-union in 10% of non-displaced, & 3040% displaced #’s Blood supply: Retinacular (epiphyseal) aa. Foveal a. Metapyseal a. Neuroanatomy Femoral n. Injury causes weak knee extension and sensory deficit superior & medial to patella Main sensory to hip joint femoral nerve block Sciatic n. Injury causes weak lower leg & hamstring mm. and sensory deficit of post thigh and below knee Hip Dislocations Etiology Types: Adults: high energy mechanism (MVA) Elderly, prosthetic joints, kids < 6yo: minor mech Posterior >> anterior > central Orthopedic emergencies: Urgent reduction after ABC’s / stabilization Significant neurovascular complications Often multiple associated injuries Mandate CT post-reduction Dislocations: presentation Posterior Anterior PID – Posterior (shortened), Internally rotated, adducted Knee-on-dashboard mechanism 10% sciatic nerve injury Superior: extension & external rotation Inferior: abduction, external rotation, flexion Central Shortening, severe pain w/ any ROM High energy lateral blow Risk for serious bleeding from acetabulum / sciatic nerve Imaging Plain Films: ant vs. post dislocations Femoral head size Posterior dislocation femoral head smaller Lesser trochanter visibility Post dislocation adduction & internal rotation, lesser trochanter not seen Ant dislocation external rotation; lesser trochanter clearly visible CT Indicated for more detailed evaluation of femoral neck, intra-articular #’s, and acetabulm Dislocations: Tx Urgent: Simple ant & post dislocations should be reduced using Allis or Stimson method Should be done w/in 6 hrs of injury unless ass’d femur # Ortho consult for others Femoral Head Fractures Usually occur 2o to hip dislocation Pipkin classification Dx: Anterior: 22-77% ass’d FH # Posterior: 10-16% ass’d FH # Post-reduction AP pelvis Often subtle Tx: Surgical Femoral Neck Fractures Mechanism: Presentation: Elderly –Osteoporosis: minor falls & min ass’d injuries Young – high energy mech multi-trauma Non-displaced – can present w/ minimal Sx Displaced – BESS (aBducted, Externally rotated, Shortened, Severe pain w/ ROM) Dx: AP + lateral films of hip often difficult to see non-displaced #’s MRI, Bone Scan Femoral Neck Fractures Garden Classification Rosen: displaced vs. non-displaced Non-displaced (1520%) X-ray clues: Increased sub-capital density Kinked S and reverse S curves Discontinuous cortical lines Displaced Femoral Neck Fractures Tx: Analgesia Why did this pt fall? Narcotics, Femoral nerve block R/o cardiac, neuro, infectious etc Non-displaced: Displaced: Impacted stable, early mobilization (96% heal) Not impacted ORIF ORIF / arthroplasty Complications: AVN, non-union, DVT/PE, loss of fixation Intertrochanteric Fractures: Similar to femoral neck #’s in mechanism, presentation, Dx, and Tx Elderly pts, minor mech Non-displaced #’s can be difficult to see Tend to bleed more (up to 1.5L) – rate of AVN < 1% Mortality 10-30% in 1st year Tend to be more externally rotated Ortho consult mostly surgical Tx Subtrochanteric Fractures: #’s b/w lesser trochanter & point 5 cm distal Similar to intertrochanteric #’s in patient population, mechanism, Sx, and Dx Common site for pathologic #’s: Paget’s, renal osteodystrophy, osteogenesis imperfecta, metastatic CA (esp breast) Also can bleed significantly Tx is controversial – need ortho consult Cortical bone slow healing & non-union Tend to be comminuted difficult to reduce Greater Trochanter Fractures Mechanism: Presentation: Limping, pain / tenderness, hip flexed Dx: 7-17 yo: avulsion from muscle contraction Adults: direct blow communition AP + lat plain films Tx: Controversial; PRICE vs. ORIF Ortho consult Lesser Trochanter Fractures Mechanism: Presentation: Groin pain, inability to lift leg when seated (iliopsoas insufficiency) Dx: 85% occur in <20 yo Avulsion injury (iliopsoas) – resisted hip flexion AP + Lateral films Tx: Good prognosis -- bed rest, early mobilization Femoral Neck Stress Fractures Mechanism: Presentation: Vague groin, hip, or knee pain & above Hx Slow onset, worse w/ activity, better w/ rest Antalgic gait, local tenderness, pain on ROM Dx: Repetitive loading fatigue (runners) Difficult – often missed may displace Plain films – often –ve in 1st 2 weeks CT, bone scan, MRI Tx: Conservative: NWB x 6 weeks - avoid activity x 1 month Femoral Nerve Block Analgesia to shaft & proximal femur Avoids hypotension & respiratory depression Recent Cochrane Review unable to confirm or deny benefit of using local blocks Parker et al. Nerve blocks for hip fractures. Coch Data Sys Rev. 2002 Technique: Clean & prep Palpate femoral a. freeze skin laterally 10 – 20 ml 0.5% bupivicaine lateral to femoral a. in 2-3 cm fan-like distribution Onset: 15 min; Duration: up to 8 hrs