pelvic fractures - belsurg

PELVIC FRACTURES

E. Audenaert, C. Pattyn

Dept Orthopedic Surgery and Tramatology

Ghent University Hospital

Presentation outline

• Acute management

• Immediate Hemorrhage control

• Pelvic ring fractures

– Classification pelvic ring fractures

– Surgical reconstruction

• Acetabulum fractures

– Classification acetabulum fractures

– Surgical reconstruction

ACUTE MANAGEMENT

On admission at the emergency unit…

Hemodynamicly stable or not?

only 10% of pelvic fractures33-50% mortality

early by exsanguinationlate by sequelae of prolonged shock and mass transfusion

coagulopathy, hypothermia, acidosis, MOF

A pelvic fracture bleeds to death

Hemodynamic stability?

• PREHOSPITALIZATION venous access

• Early identification of patients at risk

Blood Analysis (pre-hospital samples)

1.Hb (< 8 g/dl)

2.Base deficit

3.Low systolic blood pressure in tachycardpatient

http://ccforum.com/content/9/5/441/figure/F2?highres=y

Cause

• Abdominal trauma• Major splenic rupture

• Hepatic injuries

• Aortic bleeding

• Multiple

US/CT at emergency unit

• Unstable pelvic fracture

Clinical evaluation

DON’T FORGET X-RAYs OF THORAX AND PELVIS BEFORE ANY TRANSFER TO THE OR !!!

The patient is stable

Let the stressed people feel important

and relax…(after initial stabilization of pelvis for hemorrhage control)

The patient is unstable

• Abdominal cause Laparotomy at Operating Room

• Pelvic causeStabilize pelvis and thereby

haemorrhage at Emergency UnitConsider packing in massive bleeding

• Combined (liver/pelvis deadly duo)To Operating Room Extended laparotomy with pelvic

packing / StoppaFix abdominal bleedingStabilize pelvis

Angiography / Embolization

Angiographic embolization is both time-consuming and inhibitive to dynamic assessment and further surgical treatment

Bleeding usually diffuse from venous plexus. Arterial bleeding only in 10-20%

Surgery when considered should be simple, quick and well performed to be life-saving. Pelvic packing is therefore advised

Only in those who can be hemodynamically stabilized with volume replacement, but in whom ongoing pelvic hemorrhage is suspected (growing hematoma, 1–2 U PRBC transfusion per hour) can angiography be justified. The results in this population are promising, although mortality from these injuries remains high.

And further...• The polytraumatised patient

– check for open fractures• check skin, rectum and vagina

– perineal tear• Fix. Ext. and packing of bleeding

• colostomie mandatory + washing out distal colon

– urethral injury • incidence : 5% (posterior)

• check for high riding prostate

• Urethrography– Partial disruption : Foley catheter by urologist

– Total disruption : realignment (and SP tube? – cave : infection?)

Pelvic injury

• The polytraumatised patient

– RR stable after Ext. Fix. venous bleeding

– RR unstable after Ext. Fix. arterial bleeding angiography with embolisation (>A. Iliaca Int. involved)

– Ideal moment for ORIF, in order to avoid MOD

• 4-7 days posttraumatic– before : risk for MOD

– after : risk for infection

And finally…

• Plan your pelvic reconstructive surgery carefully and perform it

– Electively;

– by an experienced surgeon;

– with the appropriate tools;

– with the appropriate approach;

Immediate hemorrhage control

Common techniques

• Pelvic sling/belt+ Can be applied before hospital admission- Only temporary measure

• External fixation+ Fast and effective- Abdominal access impaired

• Pelvic packing+ Fast and effective- Preferentially in combination with posterior stabilization (C-clamp)

• C-clamp+ Fast and effective- Anatomy must be known, possible complications

Pelvic sling/ Sheet wrapping

• Easily and effectively

• 30 sec application time

• Pre-admission application

• Temporarily measure

• Potential disadvantages:

– Soft-tissue pressure

– Visceral injury

– Sacral nerve root compression

• Widely accepted• Helpful in acute phase• Can be performed at emergency unit• 1/3 have false route

3 Schanz screws in iliac crest

External fixation

Supra-acetabular Schanz screws

+ Strong fixation- Interference with hip flexion- Pin-infections

C- clamp • Fast, can be performed at emergeny unit

•Biomechanically superior to ex-fix

•No impairment of abdominal access or angiographic embolization

•Risk for nerve injury...

Pelvic packing

• Fast

• Effective

• Suprapubic vertical incision

• LIFE-SAVING procedure for the unstable patient

• Can be combined with abdominal access

pelvic ring fractures

Classification of pelvic ring fractures

According to stability of the posterior complex

Stable

Unstable

CONTINUUM

AO Classification

• Classification– A Stable

– B Partially stable• B1 open book

• B2 lateral compression

– C Unstable

Type C : 10 – 30% mortality; poor long-term outcome (50%) due to visceral laesions!

Type A & B : 65 – 70%

Anterior disruption?

Concommitant posterior disruption?Complete or incomplete?

A

Anterior fixation Posterior fixationAdditional anterior fixation

conservative

B Cstable Partially unstable Completely unstable

“The pelvic ring always ruptures on two places, because it is a ring!”when # ant. rami, always check SI joint !(CT)

According to mechanism of trauma

Young-Burgess

1. Anteroposterior compression2. Lateral compression3. Vertical shear4. Complex types

Provides insight in ligamenteousdisruption and stability

AP compression injuryType 1:- diastasis symphysis pelvis- Sacrospinous and sacrotuberous ligaments

are intact- No evidence of SI disruption

Type 2:- diastasis symphysis pelvis > 2.5cm- Sacrospinous and sacrotuberous ligaments are ruptured- Widening SI joint (intact posterior SI ligaments )

Type 3:- Displaced symphysis pelvis > 2.5cm- Sacrospinous and sacrotuberous ligaments are ruptured- Opening SI joint, (ruptured posterior SI ligaments

1

2

3

Vertical shear injury

• Requires traction before reduction !

Lateral compression injury

Horizontal fracture line ramiBoth compression and widening of SI joint (Pivot anterior SI)Inward displacement or rotation of hemipelvis of impact

TYPE I :rami fractures

TYPE II :posterior fracture

TYPE III :contralateral injury

Asymetric injury

Surgical reconstruction of pelvic ring fractures

Pelvic injury• Stability

– Symphysis– SI-complex : suspension bridge like– Pelvic floor

• SP and ST ligaments (rotational stability)• fascia

• Stiffness– 60% posterior– 40% anterior

“If you fix the back and not the front and let the patient ambulate,displacement is likely to happen (40%)!”

I. Symphysis #/disruption

– Bridging plate

– Dual plate superior to single plate

Homan

Approach

pfannenstielmediane laparotomie

associated intra-abdominal /urogenital lesionsacetabulum fracture

Reduction

Hard ware

4 hole DCP-plateReconstructie plaatNew plate (curved)One/double plating

3.5 mm Cortex Screws10 - 150 mm

Bicortical !

II. Pubic rami fractures

•ORIF

Extensieve dissectie van de inguinaleregion by

ilioinguinal appraoch

Modified Stoppa

•„intramedullar“ screw fixation

Methods

Intra-medullar• „Minimally invasive“

• 3-D orientation requires inlet and outlet views

• Possible penetration of hip joint and neurovascular lesions

• Retro-grade / Ante-grade

3.5 cortical screw or large cannlated screw, with washer

Rives-Stoppa• Fast

• Avoids extensive dissection of major vessels

• Can be extended by iliac crest window

• Same approach as for pelvic packing

Sagi et al. J Orthop Trauma 2010

Extension to lateral window

Ilioinguinal approach

– Ilioinguinal• Advantages

– Cosmetic

– Muscle recovery

• Disadvantages– No access post. Wall

– Injury N. Fem., N. Cut. Fem. Lat.

– Indirect reduction without visualisation of the joint

• CAVE :» Corona mortis aberrant connecting artery between

Obturator and Femoral artery, running across the ramuspubis superior

III. Posterior Fixation

• POSTERIOR APPROACHES– Posterior sacroiliac Joint/Sacrum

• Vertical skin incision (curved incision gives more problems)

• Advantage : possibility of decompression nerves

• Complete desinsertion of the Gluteus Maximus to prevent muscle necrosis

• CAVE : Morel-Lavalle laesion = contraindication– disruption subcutaneous blood supply

– > with contusions

Surgical approaches


– Lateral window as in ilioinguinal

Pelvic injury

• SI joint dissociation

– ant. plate or post. screw or both

– biomechanically no difference between srews or SI bars or plate

Pohlemann, Journal of Orthopaedic Trauma 1993

Pelvic injury

• Sacrum #• Zone 1,2,3

• 50% nerve injury!!

• Lateral compression injury : often stable– Indication for fixation

» Malalignment

» Leg length discrepancy

» Bony protrusion

– Ext fixation?

– Indication int. fixation : multiplanar instability

CAVE : zone 2 # nerve root damage when applying compression!!!

Percutaneous SI fixation

Plate fixation of SI joint from anterior true iliac window

Classification of Acetabulum Fractures

Acetabular fractures

• Classification

• Diagnosis

• Treatment

• Complications

• Results

Two columns (anterior and posterior column)

Qudrilateral plate (anterior and posterior wall)

Anterior and posterior approaches


• Classification

– AO (Tile) classification


• Classification

– Judet-Letournel

• Simple Fracture Patterns– 1. Posterior-wall

– 2. Posterior-column

– 3. Anterior-wall

– 4. Anterior-column

– 5. Transverse

Acetabular fractures• Classification

– Judet-Letournel

• Associated Fracture Patterns– 1. Posterior-column with posterior-wall

– 2. Transverse with posterior-wall

– 3. T-type

– 4. Anterior-column with posterior hemitransverse

– 5. Both-column

Acetabular fractures• Diagnosis

– RX : AP pelvis, Obturator and Iliac Oblique

– Evaluation of 5 lines :

• Iliopectineal (ant wall/column)

• Ilioischial (post column)

• Tear drop

• Acetabular dome

• Antero-posterior wall

Iliopectineal line intact

• If intact the anterior column/wall will be intact.

PW / PC+PW / PC fracture

• PW fragment?

PW fracture

• Ilioischial disrupted?

PC fracture

Iliopectineal line disruptedIlioischial line intact

• If both intact

AC/AW fracture

• Fracture inferior pubic ramus?

AC fracture

Iliopectineal line disruptedIlioischial line disrupted

Inferior pubic ramus intact

• Transverse fracture

• If PW fragment

Tr + PW

Iliopectineal line disruptedIlioischial line disrupted

Inferior pubic ramus disrupted

• T-type fracture

• Both column

• Anterior-column with posterior hemitransverse CT scan /3D reconstruction


• Diagnosis

– 2D and 3D CT-scan

• Additional information

• Loose bodies

• Evaluation secondary congruency

• 3D CT used to confirm diagnosis and approach

Surgical reconstruction

Acetabular fractures• Non-operative management

– Patient factors• Age

• Systemic illness and associated medical problems

• Local and systemic infection

• Soft tissue and visceral injuries

• Severe osteoporosis

– Minimally displaced fractures• Secondary congruence in both-column fractures; the anterior and posterior columns

“collapse” around the femoral head, giving a somewhat congruent hip joint.

• Intact 10 mm CT subchondral arc

• Intact 45 degree roof arc measurements on plain radiographs

• At least 50 percent of the articular surface of the posterior wall intact on all CT-sections

• Femoral head congruent with acetabular roof on AP, obturator and iliac oblique

• Fluoroscopic stress views recommended to augment criteria

– Displaced fractures• Some fractures where a large portion of the femoral head remains congruent with the major

dome fragment; as is some infratectal transverse fractures

Acetabular fractures• Operative management

– Most displaced acetabular fractures• Displacement defined as greater than 2 mm in the weight bearing

dome• Loss of congruence (subluxation) of the femoral head with the

acetabulum on any of the three radiographic view• Posterior wall fracture with associated hip instability• Incarcerated osteochondral fragment with a non-concentric

reduction

– Surgical approaches• Cfr supra

– Should choose the approach which allow the entire reduction and stabilisation through that single approach

Acetabular fractures• Factors affecting outcome of acetabular

fractures

– Condition of the weight-bearing dome

– Condition of the femoral head

– Joint stability (frank dislocation)

– Proper relationship of femoral head and superior acetabulum (loss of congruence)


MATTA

Reductions Good & Excellent(plain film) Clinical Results

0-1 mm 71% 83%2-3 mm 20% 68%>3 mm 7% 50%

Acetabular fractures• Complications

– Infection

– Thromboembolism

– Iatrogenic Sciatic Nerve Injury

– Other Iatrogenic Neurovascular Injury

– Gluteal weakness

– Heterotopic Ossification

– Avascular Necrosis

– Post-traumatic Arthritis

11th Toronto Pelvic and Acetabular Fracture Management Course


• Results

– Clinical outcome factors• Comorbidities

• Bone quality

• Fracture pattern

• Injury to cartilage surface of the acetabulum and femoral head

• Vascularity of the head

• Neurologic impairment

• Accuracy of final reduction of the roof of the acetabulum

• Hip stability

• Surgical complication

Approaches

• Anterior

– Stoppa

– Ilioinguinal

• Posterior

– Kocher-Langenbeck

Surgical approaches

• POSTERIOR APPROACHES– Kocher Langenbeck + Trochanteric Osteotomy

• Prone position preferable – Controlled traction

– Femoral head in reduced position

– Access to quadrilateral surface

– Controlled flexion of knee

– Neurologic monitoring

– Fluoroscopy

• Lateral position possible reduction more difficult due to gravitational forces

– Easier to get anterior to the head

Surgical approaches

• POSTERIOR APPROACHES– Kocher Langenbeck + Trochanteric Osteotomy

• Complications– 2-18% injury sciatic nerve

» CAVE abnormal anatomy

» 12% separate peron. and tibial split by portion of piriformis

» 3% peron. posterior to piriformis while tibial is anterior

» 1% one nerve trough piriformis

– 5-8% heterotopic ossification

– 2-5% infection

– 5-10% gluteal weakness

Surgical approaches• POSTERIOR APPROACHES

– Kocher Langenbeck + Trochanteric Osteotomy

Surgical approaches


• Vertical skin incision (curved incision gives more problems)

• Advantage : possibility of decompression nerves

• Complete desinsertion of the Gluteus Maximus to prevent muscle necrosis

• CAVE : Morel-Lavalle laesion = contraindication– disruption subcutaneous blood supply

– > with contusions

Protrusions

Lardinois fixator

“GOOD JUDGEMENT COMES FROMEXPERIENCE …

… EXPERIENCE COMES FROM BAD JUDGEMENT”

Thank You

Acknowledgements to

- Prof Dr R Verdonk, Dr J Vanhaecke, Ugent- Prof Dr C Pattyn, UGent- Dr G Putzeys, AZ Groeninge- Prof Dr Rommens, Mainz

pelvic fractures - belsurg

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