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23.pelvis & lower limbs

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 23 The pelvis and lower limb  CHRISTOPHER J.K. BULSTRODE Fractures of the pelvis Fractures of the pelvis are relatively common in osteoporotic elderly patients. In this age group they are low-energy injuries and may, in fact, be pathological fractures. A careful check should be made for abnormalities which might suggest a benign lyric lesion or a metastatic tumour. In young patients, a pelvic fracture is associated with very high-energy accidents and carry a mortality of up to 2 per cent. !his is because of the associated injuries. !he pelvis is a stable ring, made up of bones and ligaments. If there is a displaced fracture of the pelvis then it must be broken in at least two  places, and the ring is likely to be unstable. "nstable pelvic fractures carry a very  poor prognosis because they are associated with torrential retroperitoneal bleeding from the pelvic veins. Immediate temporary stabilisation of the pelvic ring may be life-saving by helping the pelvic veins to clot off through tamponade, and by reducing the chance of movement displacing the clot. #elvic fractures are also associated with damage to the rectum, the vagina and the urethra $especially in the male%. A careful e&amination of all these structures should be performed in any patient with a significant pelvic fracture. 'lassification of pelvic fractures  Fractures outside the ring !hese fractures do not disrupt the structure of the ring and occur either following a direct blow or as a traction injury of an epiphysis. In fractures of the sacrum a careful check should be made for nerve damage as the sacral nerves are likely to be involved. Fractures of the coccy& can occur when the patient falls on to their backside. !he fracture is very painful but usually settles after a few weeks. If it does not, then treatment is very difficult as coccydynia $pain in the coccy&% seems to be associated with a neurotic personality. (either injection of the fracture site with local anaesthetic and steroids nor e&cision of the coccy& reliably relieves the pain. !raction injuries !he origin of rectus femoris can be avulsed when, for e&ample, a patient kicks a heavy wet football. )imilarly, in Fig. 2*.+ the adductor tubercle can be avulsed if the leg is forcibly abducted. oth of these fractures settle with rest. Fracture of the iliac wing !he iliac wing can be broken following direct trauma, or indeed when harvesting bone graft $Fig. 2*.+%. (o active treatment is necessary. )ingle fractures of the ring !hese fractures are by definition undisplaced and commonly occur either through the  pubic or ischial ramus $Fig. 2*.2%. !hey are common in the elderly following a fall and may be pathological, through a metastasis or even a lytic lesion created by hyperparathyroidism $rown tumour%. Fractures in or around the acetabulum A fall from a great height on to the feet or a direct blow to the greater trochanter can fracture the pelvis around the acetabulum. !he femoral head can be driven centrally through the floor of the acetabulum into the pelvis $the central acetabular fracture% $Fig. 2*.*%. Alternatively, either the front wall $the anterior pillar% or the back wall $the posterior pillar% of the acetabulum can be fractured. In e&treme cases a

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