Pelvic Fracture AnatomyAnatomy 2 innominate 1sacrum 2 innominate 1sacrum Innominate bone...

Pelvic FracturePelvic FracturePelvic FracturePelvic Fracture

AnatomyAnatomyAnatomyAnatomy

• 2 innominate 1sacrum2 innominate 1sacrum

• Innominate boneInnominate bone

ilium,ischium,pubis ilium,ischium,pubis

• Join by strong ligamentJoin by strong ligament

complex complex

Minor injuryMinor injury

• Minor fallMinor fall

• Stable vital signStable vital sign

• Non-displaced FxNon-displaced Fx

• Fx not involve ringFx not involve ring

• Treatment-bed restTreatment-bed rest

Minor injuryMinor injury

Major injuryMajor injuryMajor injuryMajor injury

• High energy traumaHigh energy trauma

• Unstable vital signUnstable vital sign

• High mortality,morbidityHigh mortality,morbidity

• Associated injuryAssociated injury

Associated injuryAssociated injury

Rupture bladderRupture bladderRupture urethraRupture urethra

L-S plexus injuryL-S plexus injury

Associated injuryAssociated injuryAssociated injuryAssociated injury

Hypovolemic shockHypovolemic shockHypovolemic shockHypovolemic shock

Retroperitonium hematomaRetroperitonium hematoma

bleeding bony surfacebleeding bony surface

venous plexus bleedingvenous plexus bleeding

vascular injury vascular injury

Mechanism of injuryMechanism of injuryMechanism of injuryMechanism of injury

AP compression (open book)AP compression (open book)AP compression (open book)AP compression (open book)

SI joint wideningSI joint widening

Symphysis seperationSymphysis seperation

Mechanism of injuryMechanism of injury

Lateral compression(internal rotation)Lateral compression(internal rotation)

Fx iliumFx ilium

Lock symphysisLock symphysis

Vertical shear (Malgaigne Fx)Vertical shear (Malgaigne Fx)

SI dislocateSI dislocate

SymphysisSymphysisdislocatedislocate

Major injury initial managementMajor injury initial management

•RecuscitationRecuscitation•Pelvic stabilizationPelvic stabilization

external fixator external fixator•Definite treatmentDefinite treatment

pelvic sling pelvic sling

ORIF ORIF

Fracture of proximal femurFracture of proximal femur

Surgical anatomySurgical anatomy Vascular anatomyVascular anatomy

Fracture neck of the femurFracture neck of the femur

• Intracapsular FxIntracapsular Fx• High rate of nonunion,High rate of nonunion,

avascular necrosis avascular necrosis• 2 aged groups2 aged groups

1.Young adult 1.Young adult

high energy high energy

2.Older with osteoporosis 2.Older with osteoporosis

minor fall minor fall

Fracture neck of the femurFracture neck of the femur

Fracture neck of the femurFracture neck of the femurFracture neck of the femurFracture neck of the femur

PE:PE:

• Limb slightly shorteningLimb slightly shortening

• Pain at groinPain at groin

• Tenderness at midinguinal pointTenderness at midinguinal point

Older patient ,minor injuryOlder patient ,minor injury

PleasePlease X ray both hip AP ,lat crosstable X ray both hip AP ,lat crosstable

Young adult ,good bone qualityYoung adult ,good bone qualityReduction and multiple pinningReduction and multiple pinningYoung adult ,good bone qualityYoung adult ,good bone qualityReduction and multiple pinningReduction and multiple pinning

TreatmentTreatmentTreatmentTreatment

TreatmentTreatmentTreatmentTreatmentOlder with osteoporosisOlder with osteoporosis

HemiarthroplastyHemiarthroplastyOlder with osteoporosisOlder with osteoporosis

HemiarthroplastyHemiarthroplasty

• NonunionNonunion

• Avascular necrosisAvascular necrosis

• Venous thrombosisVenous thrombosis

• NonunionNonunion

• Avascular necrosisAvascular necrosis

• Venous thrombosisVenous thrombosis

ComplicationComplication

Intertrochanteric FractureIntertrochanteric Fracture

• Fx line from greater to Fx line from greater to

lesser trochanter lesser trochanter

• More common in woman More common in woman

menopause menopause

• Extracapsular fractureExtracapsular fracture

• Older with osteoporosis -minor fallOlder with osteoporosis -minor fall

PE:PE:

• Limb shortening,externalLimb shortening,external

rotation rotation

• Swelling ,ecchymosis at hipSwelling ,ecchymosis at hip

• Tenderness at greater Tenderness at greater

trochanter trochanter

Treatment Treatment

Non operativeNon operative traction 6 wks. traction 6 wks. high complications high complications

Pressure sorePressure sorevenous thrombosisvenous thrombosisinfectioninfection

Operative treatment is preferableOperative treatment is preferable surgical risk, early ambulation surgical risk, early ambulation

Subtrochanteric FractureSubtrochanteric FractureSubtrochanteric FractureSubtrochanteric Fracture

• Fx at level of lesser trochanter Fx at level of lesser trochanter

and a point 5 cm. Distally and a point 5 cm. Distally

• thick cortical bonethick cortical bone

• high mechanic stresshigh mechanic stress

• high energy traumahigh energy trauma

Treatment Treatment

Operative treatment is preferableOperative treatment is preferable

• Posterior dislocation 80%

most common

• Anterior dislocation 5%

• Central dislocation 15%

Hip DislocationHip Dislocation

Dashboard injuryDashboard injury

Blow to femur inadduction internalrotation of the hip

Posterior dislocationPosterior dislocation

PE:PE:

• hip flexion,internal rotate

and adduct

• ass.knee ligament injuries

• assess sciatic nerve

X-rayX-ray

• Head out of acetabulum

• smaller femoral head

• femur adduct, internal

rotate(disappear lesser

trochanter)

TreatmentTreatment

• Early diagnosis• prompt closed reduction• Allis’s maneuver• failed closed reduction-

open reduction

Allis’s maneuverAllis’s maneuver

• Stabilized pelvis

• longitudinal traction

• 90 degree hip flexion

• upward traction

Allis’s maneuverAllis’s maneuver

Management after reductionManagement after reduction

• Test for stability• X-ray both hip AP evaluate joint space• Stable reduction skin traction- pain subside ambulation with crutches• Unstable reduction ORIF

Fragment entrap in jointFragment entrap in jointJoint space widening Joint space widening

Anterior dislocationAnterior dislocation

Blow to femur in abduction,externalrotate of hip joint

• Early diagnosis• prompt closed reduction• Allis’s maneuver• failed closed reduction-

open reduction

TreatmentTreatment

• General anesthesia

• Traction along axis

• Internal rotation

• Lateral traction

Reduction techniqueReduction technique

Clinical manifestationClinical manifestation X rayX ray

Traction along axisTraction along axis

Internal rotationInternal rotationStabilized pelvisStabilized pelvis

Lateral tractionLateral traction37

Post reductionPost reduction

• X ray pelvis AP

• Skin traction until

pain subside(5-7 d)

• Ambulation with crutches

Fracture shaft of the femurFracture shaft of the femur

• High energy injury

• Bleeding 1- 2.5 L.

• Ass. femoral neck Fx.

• Ass. hip dislocation

• High energy injury

• Bleeding 1- 2.5 L.

• Ass. femoral neck Fx.

• Ass. hip dislocation

• Deformity of thigh

angulation shortening

• PE.of hip and knee

•Vascular assessment

dorsalis pedis a.

posterior tibial a.

• Deformity of thigh

angulation shortening

• PE.of hip and knee

•Vascular assessment

dorsalis pedis a.

posterior tibial a.

Physical examinationPhysical examination

• Splinting - Thomas’s splint

• Film femur include hip-knee

detect neck Fx-dislocate hip

• Temporary stabilization with

proximal tibial traction

• Splinting - Thomas’s splint

• Film femur include hip-knee

detect neck Fx-dislocate hip

• Temporary stabilization with

proximal tibial traction

ManagementManagement

• Non-operative treatment

Traction 6-8 wks.

Femoral castbrace 10-12wks.

• Operative treatment

ORIF with plate-screw

Intramedullary nailing

• Non-operative treatment

Traction 6-8 wks.

Femoral castbrace 10-12wks.

• Operative treatment

ORIF with plate-screw

Intramedullary nailing

Transverse Fx midshaft femurTransverse Fx midshaft femur ORIF with plate-screwORIF with plate-screw43

Comminuted Fx midshaft femurComminuted Fx midshaft femur Intramedullary nailIntramedullary nail44

• Fx distal femoral metaphysis

9 cm. above joint line

• Posterior displacement of

the distal fragment

• High rate of stiffed knee

• Fx distal femoral metaphysis

9 cm. above joint line

• Posterior displacement of

the distal fragment

• High rate of stiffed knee

Supracondylar fractureSupracondylar fracture

How to described Fx?How to described Fx?

T or Y Fx(combined)T or Y Fx(combined)

Intercondylar Fx(intra-articular)Intercondylar Fx(intra-articular)

Supracondylar Fx(extra-articular)Supracondylar Fx(extra-articular)

• Conservative Traction stiffed knee

• Operative Early function Early knee motion

TreatmentTreatment

T Fracture of distal femurORIF with plate and screwT Fracture of distal femurORIF with plate and screw

• Largest sesamoid

• Function

-lever arm for knee

extension

-protect condyle

• Largest sesamoid

• Function

-lever arm for knee

extension

-protect condyle

Fracture of the patellaFracture of the patella

•Avulsion(traction) Quads. pull up Knee flexion

•Direct injury•Direct injury

Sign & symtomSign & symtom

• Swelling,effusion

• Palpable defect

• Unable to extend

knee actively

• Swelling,effusion

• Palpable defect

• Unable to extend

knee actively

Non displaced FxNon displaced Fx Cylinder castprevent knee flexion

Cylinder castprevent knee flexion

Displaced transverse FxDisplaced transverse Fx ORIF ORIF

• Most common long bone Fx

• medial surface palpable

• Open Fx common

• frequent complication

• Most common long bone Fx

• medial surface palpable

• Open Fx common

• frequent complication

Fracture of the tibiaFracture of the tibia

• Swelling ,deformity• Ascess vascular

dorsalis pedis a.

posterior tibial a.• marked swelling

compartment syn.

• Swelling ,deformity• Ascess vascular

dorsalis pedis a.

posterior tibial a.• marked swelling

compartment syn.

Symtom & SignSymtom & Sign

TreatmentTreatmentConservativeConservative Closed reduction

apply long leg castClosed reduction

apply long leg cast

X ray post reduction

X ray post reduction Criteria for accept alignmentCriteria for accept alignment

• Varus,vulgus < 5 degree

• AP angulation <10 degree

• Malrotation <10 degree

• Shortening < 1cm.

• Contact surface >50%

• Varus,vulgus < 5 degree

• AP angulation <10 degree

• Malrotation <10 degree

• Shortening < 1cm.

• Contact surface >50%

After long leg cast4-6 weeks

Change to PTB cast 8-12 wks.

Until Fx consolidation

Change to PTB cast 8-12 wks.

Until Fx consolidation Patella Tendon BearingPTB cast

Patella Tendon BearingPTB cast

TreatmentTreatment

Operative Operative

• Failed closed reduction

• Unacceptable alignment

• Multiple fractures

• open fracture

• Failed closed reduction

• Unacceptable alignment

• Multiple fractures

• open fracture

Intramedullary nailIntramedullary nail

External fixatorExternal fixatorORIF plate & secrewORIF plate & secrew

ComplicationComplication

Compartment syndrome

• Early detection

• Release pressure

remove cast,splint

fasciotomy

• Early detection

• Release pressure

remove cast,splint

fasciotomy

MalunionMalunionVascular injuryVascular injury InfectionInfection62

A man 23 yr. MCA 10 min . Single injuryPain at Rt. ankle, can’t palpable dorsalis pedisand posterior tibial artery

X ray ankle AP, LatX ray ankle AP, Lat

Fx of distal fibularFx of distal fibular

Diastasis of syndesmosisDiastasis of syndesmosis

Fx of medial mall.Fx of medial mall.

Ankle subluxationAnkle subluxation

How do you managethis case?

Vascular injury?Joint subluxationVascular injury?Joint subluxation

•4 R•R egcognition•R eduction•R etention•R ehabiliation

AP viewAP view Mortise viewMortise view Lateral viewLateral view66

Fracture of the talusFracture of the talus

• Talar neck Fx most common

• Caused by hyperdorsiflexion

• 3/5 cover by cartilage

• Vascular enter at talar neck

• Talar neck Fx most common

• Caused by hyperdorsiflexion

• 3/5 cover by cartilage

• Vascular enter at talar neck

Fracture of the talusFracture of the talus

Subtalar jt. dislocation

Talar neck Fx

Ankle dislocation

ORIF talar neck with screwORIF talar neck with screw

Fracture of the CalcaneusFracture of the Calcaneus

• Most common tarsal bone Fx

• Extra-articular Fx

Direct injury

• Intra-articular Fx(Subtalar Jt.)

Fall from height

• Most common tarsal bone Fx

• Extra-articular Fx

Direct injury

• Intra-articular Fx(Subtalar Jt.)

Fall from height

Physical ExaminationPhysical Examination

•Heel widening,short

•Ecchymosis

•Tenderness at heel

•Squeeze test

•T-L spine exam

•Heel widening,short

•Ecchymosis

•Tenderness at heel

•Squeeze test

•T-L spine exam

X rayX ray

•Calcaneus lateral•Axial view•Calcaneus lateral•Axial view

TreatmentTreatment

•Non displaced Fx

Short leg cast 6 wks.•Displaced Fx

•Non displaced Fx

Short leg cast 6 wks.•Displaced Fx

Pelvic Fracture AnatomyAnatomy 2 innominate 1sacrum 2 innominate 1sacrum Innominate bone...

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