Pelvic and Acetabular Fractures



General

Classification (Tile)

Type A: Stable

A1
Fracture not involving the ring
avulsion fracture of ASIS,AIIS or ischium
fracture of iliac wing
A2
Stable minimally displaced ring fractures

Type B:

Rotationally unstable / Vertically stable
B1
Open book
B2
Lateral compression (ipsilateral post and ant fractures)
Stage
  1. separation of the symphysis less than 2.5 cm
    -implies no post lesion
  2. separation of symphysis more than 2.5 cm, unilat
  3. more than 2.5 cm, bilat
-implies disruption of sacrospinous + ant sacroiliac ligs
B3
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;
  1. Four poster
  2. Open book
  3. 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:

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

4. Sacral / coccygeal fractures

Investigations:

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

X-Rays

® 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

Treatment:

Resuscitation

fluid replacement
antishock garment
embolisation
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

A
symptomatic, mobilisation
B1
Stage 1 no stabilisation
2+3 stabilise with Ex fix or ant plate
B2+3
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
C
Options
  1. Ant frame+ skeletal traction (supracondylar femoral pin)
    -safe
    -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
  2. ORIF
    - risks: bleeding - loss of tamponade, coagulopathy
    infection
    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

Type
B1
definitive treatment of stage 2+3
B2+3
to aid and maintain reduction
C
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

Complications:

  1. 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
  2. Infection increased incidence associated with open bowel injury ® drain wounds
  3. 6% incidence and increased with ilio-inguinal approach ® avoid operations in febrile patients ® use prophylactic antibiotics
  4. Nerve palsy (usually peroneal component) of sciatic nerve in 11.2% (17.4% of posterior fractures)
  5. Ectopic bone formation in ~ 20% ® indomethicin useful ? carcinogenic effect of radiation in young people
  6. 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)
  7. 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
  8. Impotence evident in ~ 40%
  9. Post traumatic osteoarthritis in 4 - 15% dependant on quality of reduction

Prognosis:

Mortality 5 - 20% and up to 42% for open fractures
Increasing age ® increased mortality
Age more than 70 years ® 50% mortality
Pedestrians ® 50% mortality
Pregnancy ® 33% foetal loss
20 - 40% of females subsequently need caesarean section

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Acetabular Fractures

Classification AO

Type A

one column fractured, the other intact
  1. post wall
  2. post column
  3. ant wall and/or ant column

Type B

transverse types with portion of roof attached to intact ilium
  1. transverse +/- post wall
  2. T types
  3. anterior type with post hemitransverse

Type C

both columns are fractured and all articular segments , including the roof are detached from the remaining segment of the intact ilium, = the floating acetabulum
  1. ant column fracture extends to the iliac crest
  2. ant column fracture extends to ant border of ilium
  3. fracture enters the SI jt

Investigation

standard AP/lat/ inlet/outlet views

On AP view

iliopectineal line- showing ant column
ilioischial line- showing post column
med wall of acetabulum
ant + post lip of acetabulum

Judet views

obturator oblique
roll pt in 45 deg
see entire obturator foramen
see ant column + post wall
iliac oblique
roll pt 45 deg externally
see entire iliac crest
see post column + ant wall
CT +/- 3D

Management

assess both fracture and pt factors
Is surgery indicated or not?
Nonop: indications
  1. displacement less than 2-5 cm in dome, depending on location of fracture and pt factors
  2. low ant column fractures
  3. low transverse fractures
  4. assoc both column fracture with secondary congruence
Roof angle- a measurement of how much dome is intact
on the AP draw line vertically from acet roof to centre of femoral head, draw second line from edge of fracture to centre of head
the roof angle is bw these lines
if roof angle more than 45 deg rarely need operative treatment
Operative: indicated for the incongruous or unstable jt

Prognosis

Judet and Letournel JBJS 46A: 1615-1647, 1964
if anatomic reduction was achieved 90% pts have good results
Factors in injury pattern affecting prognosis:
  • high energy vs low
  • location of fracture
  • degree of comminution or displacement
  • presence of jt dislocation

Complications

AVN of femoral head or acetabular fragments
~ 6% femoral head AVN - most in post fractures and high energy
metal in jt
nerve injury
sciatic n ~ 20%
femoral n - rarely injured
superior gluteal n- vulnerable in greater sciatic notch
pudendal n can be injured by compression on traction table
Lat cut n of thigh often cut in approaches
vessel injury
Heterotopic ossification
varies from 3-69%
Increase in approaches that reflect muscle from side wall of ilium
Male
use indocid

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Dislocations and Fracture Dislocations of the Hip

Classification

Anterior

Type 1: superior dislocations ( includes pubic and subspinous dislocations)
  1. no assoc fracture
  2. assoc fracture of head +/- neck of femur
  3. assoc fracture of acetabulum
Type 2: Inferior disloc (includes obturator, thyroid, perineal dislocations)
  1. no assoc fracture
  2. assoc fracture of head +/- neck of femur
  3. assoc fracture of acetabulum

Posterior

Thompson and Epstein "Traumatic dislocations of the hip"
JBJS 33A: 746-778, 1951
Type
  1. with or without minor fracture (minor fracture = less than 20% of wall)
  2. with a large single fracture of the post acetabular rim
  3. with comminution of the acet rim with or without a major fragment
  4. with fracture of the acetabular floor
  5. with fracture of femoral head
type 5 has been further subclassified by Pipkin
"Treatment of Grade 4 fracture-dislocation of the hip"JBJS 39:1027-1042, 1957
Type
  1. with fracture of head caudad to fovea
  2. with fracture of head cephalad to fovea
  3. type 1 or 2 with assoc fracture of femoral neck
  4. type 1, 2 or 3 with assoc fracture of acetabulum

Central Fractures and Fracture Dislocations

can be classified by reference to the acetabular fracture (ie the AO type above) and the degree of displacement

Anterior


10-15% of all dislocations
due to
MVA when knee strikes dash with hip abducted
fall from ht
blow to back of squatting pt

Treatment

evaluation esp neurovasc
early reduction
Closed reduction multiple attempts at CR not advisable
Technique
Allis's maneuvre pt supine, knee flexed,assistant stabilises pelvis and applies lat traction force to inner thigh. Longitudinal traction, hip slightly flexed,adducted and internally rotated to reduce
If CR unsuccessful® open via anterior type approach
After reduction
traction (time until has limb control) , gentle controlled ROM
mobilise FWB

Complications

NV compromise- direct pressure on femoral artery, vein or nerve
irreducibility by CR
Post traumatic arthritis develops in ~ 1/3
Increase in assoc fracture of head or acet, AVN
AVN less than in post dislocation ~ 8% of cases

Posterior

80% of hip dislocations are posterior
due to force applied to flexed knee with hip in varying degrees of flexion
- if hip in neutral adduction/ abduction simple disloc only results.
- if in slight abduction get fracture post acet wall

Treatment

limb short, IR + adducted
NV assess- sciatic n injury in 10-14%
early reduction
Type 1
Closed reduction
Allis's maneuvre pt supine, pelvis stabilised by assistant
Traction in line of deformity followed by flexion to 90 deg
Hip gently rotated in and out with traction to reduce
If CR unsucessful - open via post approach
Post reduction traction until good limb control, controlled ROM exs
FWB when out of traction
Types 2-4
( fracture- dislocations)
one attempt at CR -if unsuccessful- open
Epstein "Traumatic dislocation of the hip" Williams and Wilkins, Baltimore 1980
recommends primary open reduction of all post fracture-dislocations of the hip to
  1. remove fragments of bone etc from jt- ( found in 90%)
  2. to restore jt stability and congruity by ORIF of large frags
  3. to ensure accurate reduction
type 2: ORIF post fragment
type 3: ORIF if comminuted fragments render the jt unstable or incongruous
type 4: treat as for acetabular fracture
Post reduction traction - 6-8 wks
Type 5
Pipkin 1 aim for CR - no need to ORIF fragment if not anatomical
fragment can be excised without problem
Pipkin 2 aim for CR if not anatomical - ORIF
Pipkin 3 ORIF neck fracture - then treat head fracture
Pipkin 4 treat the acetabular fracture , then the femoral head fracture

Complications

early
sciatic n palsy 10-14%
irrducibility by CR
assoc knee lig injuries esp PCL, posterolat complex
recurrence in traction
late
recurrent dislocation- rare
myositis osssificans 2%
AVN related to the time hip dislocated
reduction within 6 hrs less risk of AVN
may manifest up to several yrs post injury
protected WB has no benefit on the occurrence of late collapse
Post traumatic OA:
- increases with severity of injury
~ 30% with types 2-5
? reduced in open reduction with R/O fragments

Central Fracture- dislocations

treat as for acetabular fracture

Options

traction with or without CR
ORIF
primary arthroplasty or arthrodesis

Complications

early
sciatic n palsy
superior gluteal artery injury
bowel obstruction
DVT
AVN
infection pin tract esp in lat traction pins or screws
recurrent central dislocation- if time in traction too short
late
post traumatic OA- related to extent of trauma
AVN
nonunion of acetabular fracture - rare -

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