Pelvis injuriesFractures of the femur

(proximal,shaft)

Dr Tamás Bodzay

Pelvis anatomy

Pelvis function

- axial load bearing

- protection: abdominal, pelvic structures

Pelvic injury mechanism

• 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 squashedPosterior internal ligaments intact,Posterior external ligamentsruptured

Typ. C (rotational + vertical instability)

• AP compression(B1)

• Lateral compression(B2)

• Vertical shear(C)

Pelvic injuries

• 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 examination1x!!

Diagnostics- X ray

Diagnostics- CT

Treatment- Stable injury= non-operative treatment

- Unstable injury= operative treatment

Instability:

- (bio)mechanical- HEMODINAMICAL !!

(Blood loss:1500 – 2000 ml ;shock)

Hemodinamically unstablepatient:emergency fixation

Definitive treatment-symphyseolysis: plate fixation

Definitive treatment- transiliacal fx.: plate fixation

Definitive treatment- SI-lysis: platefixation 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, bothcollumn

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

• 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 femoralhead fractures.

• Type I: Fracture inferior tofovea centralis.

• Type II: Fracture superiorto fovea centralis.

• Type III: Type 1 or 2 + femoral neck fracture.

• Type IV: Type 1, 2 or 3 + acetabular fracture

Treatment of femoral headfractures

• Type I: excision orfixation.

• Type II: ORIF with screwsin youngs; jointreplacement in elderly.

• Type III: same as Type II• Type IV: same as in Type

III + acetabular fracturefixation.

Clinical symptoms of the hipfractures

• abduction

• external rotation• shortening

ObturatorObturatorarteryartery

FovealFovealarteryartery

FemoralFemoralarteryartery

ExtracapsularExtracapsulararterialarterialringring

AscendingAscendingcervicalcervicalarteriesarteries

RetinacularRetinaculararteriesarteries

SubsynovialSubsynovialintracapsularintracapsulararterialarterialringring

The bloodsupply of the femoral head

Capsule

Ligamentum teres

Medial femoralcircumflex artery

Lateral femoralcircumflex artery

Profunda femoris artery

Ascending cervical arteries

Extracapsular arterial ring

B2 Neck fracture, transcervical1 basicervical

2 midcervical adduction3 midcervical shear

B1 Neck fracture, subcapital, with slight displacement

1 impacted in valgus > or = 15°

2 impacted in valgus < 15°3 non impacted

B3 Neck fracture, subcapital, non impacted, displaced

1 moderate displacement in varus and external rotation

2 moderate displacement with verticaltranslation and external rotation

3 marked displacement

Müller (AO), Garden and Pauwels classification of femoral neck fractures

G1 : incomplete, impacted G2 : non-displaced G3 : incomplete displacement G4 : completedisplacement

Pauwels classification refersto the angle of the fracture line

compared to the horizontal

Grade 1: 30°Grade 2: 50°Grade 3: 70°

Treatment of the femoral neckfractures- screw fixation

• Treatment of stable femoral neck fractures (TypeGarden-I and –II) : two cannulated screws

• Treatment of unstable femoral neck fractures (TypeGarden-III and –IV): two cannulated screws+a two-holetension plate

Three-point-buttressing

Screw fixation of the Garden I. fracture

Screw fixation of the Garden III. fracture

Treatment of the femoral neckfractures- arthroplasty

• 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 trochantericfractures

• A-1 Trochanteric, simple• A-1.1 Cervicotrochanteric• A-1.2 Pertrochanteric• A-1.3 Trochanterodiaphyseal

• A-2 Pertrochanteric, multifragmentary

• A-2.1 One intermediate• fragment• A-2.2 Two intermediate• fragments• A-2.3 More than two• intermediate fragments

• 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 thepertochanteric fractures

Fixation of fracture type AO 31-A1(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 31-A3: DCS

Stabilization of fracture type AO 31-A3: Fi-nail

Classification of the femoral shaftfractures

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

• Closed technique• Early mobilisation• Good weight-bearing capacity• Low grade septic complication• Rapid bony consolidation

Reaming

• Metal-bone contact: relative stable

• Reaming: improvedmetal-bone contact = increased stability

Indications: fx. in the 3-4-5/7

Interlocking

• Interlocking: increasedrotational stability

Indications: fx. in the 2-3-4-5-6/7

Unreamed interlocking nailing

• Reaming: intramedullarypressure elevation(1969 Lilienström)

• Bone marrowembolisation

(1989 Wenda)• Destroyed lung function

(1997 Pape)

Indications: thorax/headinjury+fx. in the 3-4-5/7

Plate fixation

• Intraarticular and diaphysis fx.

• Compartmentsyndrome

• 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 withinterlocking

• Polytrauma: ISS < 40 - unreamed lockingnailing, ISS > 40 or head/thorax injury- FE.

• Intraarticular and diaphysis fx, compartment syndrome, vascular injury, previously inserted implants-plates