Friday, November 12, 2010

Pelvic and Acetabular Fractures


Classification (Tile)

Type A: Stable

Fracture not involving the ring
avulsion fracture of ASIS,AIIS or ischium
fracture of iliac wing

Stable minimally displaced ring fractures

Type B:

Rotationally unstable / Vertically stable

Open book

Lateral compression (ipsilateral post and ant fractures)
separation of the symphysis less than 2.5 cm
-implies no post lesion
separation of symphysis more than 2.5 cm, unilat
more than 2.5 cm, bilat
-implies disruption of sacrospinous + ant sacroiliac ligs

Lateral compression (contra-lateral post and ant fractures= bucket handle)
- the rotation of the bucket handle can cause gross pelvic deformity or significant LLD
External fixation ® definitive treatment, to aid or maintain reduction

Type C:

Rotationally and vertically unstable
C1: Unilateral
C2: Bilateral
C3: Associated with acetabular fractures
External fixation ® partial stability ® reduce bleeding, relieve pain and aid in nursing the patient
Posterior stabilisation may also be required
ref : Tile " pelvic ring fractures :should they be fixed" JBJS 70B:1-12, 1988

Classification (Apley)

1. Avulsions:

Due to violent muscle action
Sartorius from ASIS
Rectus femoris from AIIS
Adductor longus from pubis
Hamstrings form ischial tuberosity
Treatment ® rest and reassurance

2. Ring fractures:

Stable fractures ® symptomatic treatment
Disruption of posterior structures ® 4 - 6 weeks RIB
Unstable fractures;

Four poster
Open book
Malgaine type

Direct fractures of the iliac wing ® bed rest
Stress fractures of the pubis / pubic rami are not uncommon in osteoporotic patients

3. Acetabular fractures:

Anterior pillar (not WB part of joint)
Posterior pillar (often associated with dislocation of hip and involves WB part of joint ® ORIF)
Comminuted both column type (difficult to reduce and degenerative changes common)

4. Sacral / coccygeal fractures


Clinical examination

® associated injuries (bladder, urethra, spine, femurs etc)
signs hip ROM
obvious instability on compression/ springing
Destots sign- blood above inguinal lig or in scrotum
Roux's sign- decrease distance from gt troch to pubic tubercle
Earle's sign- tender swelling on PR


® standard AP
inlet view (tilt X-Ray beam 40o caudad) -shows post displacement
outlet view- ( 40o cranial beam)-shows superior migration or rotation
2 Judet views
CT scan and reconstructions ® plan surgical approach
Angiography and embolisation of bleeding vessels may be life saving



fluid replacement
antishock garment
direct surgical intervention
application of Ex Fix can reduce venous and bony bleeding signif

Provisional stabilisation

for fractures that increase pelvic volume ie open book (B1) or vertical shear (C3)
apply ex fix or pelvic clamp percutaneously in emerg room
Ex fix- 2 pins placed percut in Ileum- 1 at ASIS, 1 at iliac tubercle, at ~ 45 deg to each other- complate frame as anterior rectangle

By Type

symptomatic, mobilisation

Stage 1 no stabilisation
2+3 stabilise with Ex fix or ant plate

most need no stabilisation

B3 - displaced bucket handle
if LLD less than 1.5 cm- accept
if LLD more than 1.5 cm or pelvic deformity excessive- reduction by ER of hemipelvis with pins in the iliac crest, maintained with anterior frame

Ant frame+ skeletal traction (supracondylar femoral pin)
-indicated if - adequate reduction of post sacroiliac complex
when post injury a iliac fracture rather than an S-I dislocation or a sacral fracture
-disadvantages traction for 8-12 wks
- risks: bleeding - loss of tamponade, coagulopathy
wound necrosis esp in post wounds
nerve damage
-indication: inadequate reduction of post injury(esp SI disloc)
open post wound
in assoc with acetabular fracture

Indications for Ex Fix


definitive treatment of stage 2+3

to aid and maintain reduction

to produce partial stability to decrease bleeding, decrease pain, aid nursing
If ORIF to be performed should be delayed until patient stable, all investigations completed and operation planned but should not exceed 7 days


Non-union / malunion ® high incidence of nerve, bladder etc complications at revision surgery (high incidence in Malgaine type 90%, and usually symptomatic)
ORIF delayed more than 3/52 ® callus formation which would limit reduction accuracy
Infection increased incidence associated with open bowel injury ® drain wounds
6% incidence and increased with ilio-inguinal approach ® avoid operations in febrile patients ® use prophylactic antibiotics
Nerve palsy (usually peroneal component) of sciatic nerve in 11.2% (17.4% of posterior fractures)
Ectopic bone formation in ~ 20% ® indomethicin useful ? carcinogenic effect of radiation in young people
Thrombo-embolic problems in ® anticoagulate for 6 - 8 weeks after open operation
RAH 3500 units heparin tds starting at 72 hours post injury or surgery and adjusted according to APTT (aim for APTT 31-36) ® warfarinise after one week post injury or operation ® therapeutic range (INR 2 - 2.5)
About 1/3 of unstable fractures (13% overall) have an associated urethral injury ® retrograde urethrogram prior to IDC ® cystogram ® IVP if indicated
Bladder rupture usually extra-peritoneal and may ® vesico colic, vesical fistulas
Impotence evident in ~ 40%
Post traumatic ost

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