Download Injuries of the pelvis

Classification of pelvic
fractures, conservative and
operative treatment
Acetabular fractures
Traumatic hip dislocation
Ferenc Urbán
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Anatomy of the pelvis
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The pelvic ring is made up
of two innominate bones
and the sacrum, joined
posteriorly at the right and
left sacroiliac (SI) joints
and anteriorly at the
symphysis pubis. The
innominate bones are
formed at maturity by the
union of the ilium, ischium,
and pubis through the
triradiate cartilage
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The pelvic ring and it’s
positioning
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The most important ligaments
► Posterior
& anterior
sacroiliac ligaments!
► Sacrospinous ligament
► Sacrotuberous
ligament
► Symphysis
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Anatomical structures of the pelvis 1.
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The Greater Sciatic Foramen
SEVEN NERVES
THREE VESSEL SETS
Sciatic nerve (L4-S3)
Superior
gluteal
artery/vein
Superior gluteal nerve
Inferior gluteal nerve
Inferior
gluteal
artery/ vein
Internal pudendal nerve
Posterior femoral
Internal
cutaneous nerve
pudendal artery/ vein
Nerve to quadratus femoris
Nerve to obturator externus
ONE MUSCLE
Piriformis
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Anatomical structures of the
pelvis 2
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Functions of the pelvis
► Connects
the spine to the lower limbs
► Supports trunk
► Transmits forces applied to trunk on limbs
► Protects organs
► Provides passage for vessels, nerves, and
muscles
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Integrity and stability of pelvic
ring are essential
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High energy trauma
Dashboard injury
Motor vehicle accident
Falling from a height
It takes high energy to
create such damage...
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...so bone is not of primary
importance. Life is!
Therefore assessment in suspected pelvic ring fracture is according
to ATLS (advanced trauma life support)
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The pelvis is a shock organ!
Loss of blood
500-5000 ml
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Diagnostics
► Anamnesis
► Physical
examination*
► Native X-ray
► CT scan
► X-ray with contrast
material –
cystography, angiogr.
► Ultrasound
► Inspection
(wound,
suffusion, swelling,
shortening of the lower
limb)
► Palpation
Tenderness
Stability
Pathological movements
► Circulation &
innervation of the leg
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Primary assessment
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Primary assessment
►Inspection
and physical examination
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Primary assessment
►-
ray
Standard X-
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Reveals up
to 90% of
fractures
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X-ray of the pelvis
AP view
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Classification of the pelvic
fractures by Tile
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Tile A fractures
► Marginal
fractures
► Stable fractures of the pelvic ring
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Classification of the pelvic
fractures by Tile
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Sagittal forces
Lateral forces
Tile B fractures
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Classification of the pelvic
fractures by Tile
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Tile C fractures
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Müller AO Fracture Classification 61-
A type – stable pelvic ring
B type – horizontal
instability
C type – horizontal and
vertical instability
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If the pelvis is the
source, then its…
Massive blood loss
is:
►mostly venous
►due to posterior
disruption
►supported by
enlarged
compartment
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Emergency treatment
Reduce compartment
- Stabilize pelvis
pelvic clamp
external fixator
- Surgical tamponade
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Embolization
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MAST (military antishock trousers)
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Pelvic clamp or
external fixator
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Acute phase
► Pelvic
clamp
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External fixator for pelvic
injuries
► Shocktherapy!
► Bleedingcontrol
► Avoidance
of
continous traction
► Conversion
► Rarely definitive
method
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Fracture treatment
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Emergency treatment
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Stop bleeding otherwise
- Stabilize pelvis
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- Surgical tamponade laparotomy
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(dcs)
retroperitoneum
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- Embolization
- MAST
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Stable patient, closed
fracture
►There
is time for
additional
►diagnostics including:
►-
X-rays
►- Pelvic organs
►- Neurology
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Special X-ray views
► Pennal
inlet
Roentgen tube is
turned 45o in cranial
direction – brim
► Pennal outlet
Roentgen tube is
turned 45o in caudal
direction - sacrum
► Ala
view – 45o
contralateral –
posterior column and
ventral margin
► Obturator view – 45o
ipsilateral – anterior
column and posterior
margin
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Additional
radiology
INLET
OUTLET
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Additional radiology
CT scan
?
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3D reconstruction CT scan of the
pelvis
For planning!
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Accompanied injuries
- Urethra/prostate
- Rectum
- Vagina
- Sphincter/others
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Accompanied injuries
- Urethra/prostate
- Rectum
- Vagina
- Sphincter/others
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Ultrasound
Cystogram
Conservative treatment
► Functional
treatment
► Continous
traction
► Böhler-bed
Symphyseolysis < 2 cm
1/7 body weight in the level of
the bed in abduction
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Continous traction
•In the level of the bed – without Braun splint
•Abduction
•1/7 body weight
•If tibial tuberosity extension was started after 3 weeks it has to
be moved to the femoral condyle
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Operative treatment
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Operative treatment
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Operative treatment
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Operative treatment
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Treatment of accompanied
injuries and complications
► Urine
deviation – catheter and
epicystostomy
► Reconstruction of the bladder and urethra
► Treatment of the retroperitoneal
haematoma
► Treatment of vessel and nerve injuries
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Dislocations of the hip
Iliacal
Suprapubic
Ischiadic
Obturatorious
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Dislocations of the hip
Central
dislocation
Post.inf. – ischiadic
disl.
Sup. Ant. –
pubic
dislocation
Inf.ant. –
obturatorious disl.
Post. Sup. – iliac dislocation
The limb is inversed, the hip
extended
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X-ray of a hip dislocation
Iliacal
dislocation
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Treatment of dislocation
Closed reduction in
narcosis & relaxation
Emergency – AVN!!!
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Retention
In case of instability – continous
traction or ORIF in fracture
dislocations
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Fractures of the acetabulum
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Diagnostics of the acetabular fx
Ala-felvételview
Obturator-view
Foramen
obturatorium
Anterior columnlinea terminalis
Posterior margine
Acetabular roof
Ala
Posterior column – linea
ilioischiadica
Elülső vápapereAnterior
marginem
Bottom of the
acetabulum
Continous traction of acetabular fx
► In
central
dislocation
additional lateral
pulling is needed
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Operative treatment of
acetabular fractures
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Surgery
Posterior approach by Kocher-Langenbeck
Preparation of the schiatic nerve
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Stable OS – congruency!!!
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Fractures of the femur head
Pipkin IV.
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Epiphyseolysis of the femoral head
Pin fixation is prefered
in growing bone!!!
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Treatment principles in pelvic
injuries
► Resuscitate
patient
(ATLS)
► Evaluate pelvic organs
► Thorough examination
of fracture(s)
► Make a plan
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Treatment options
nonoperative/operative
Operation rarely needed
Anterior stabilization
Stabilization of entire
ring
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Operative treatment options
► External
fixation
► Internal fixation
screws
plates
► Combinations
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Conclusions
Due to high-energy trauma:
► First, save patient’s life
► More than just a bony injury
► Stabilization of paramount
importance
► Many might be treated
nonoperatively
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Take five or
continue?
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