Fractures of the - PowerPoint Presentation

Slide1

Fractures of the Pelvis and sacrum

By Sarah Hansen SPTASlide2

Objectives

Be able to list and differentiate between the different classification systems for pelvic fractures.

Demonstrate knowledge of the classification systems for sacral fractures.

Be able to apply the terms and information from this in-service to everyday chart reviews, documentation, and pt treatments. Slide3

Bones of the pelvis:

Ilium

Ischium

Pubis

Tri-radiate

cartliage

AcetabulumSlide4

Cont…

The

acetabulum

is formed around the cartilaginous junction of the three pelvic bones, the

ilium

,

ischium, and pubis.This junction is called the tri-radiate cartilage, it is a Y-shaped synchondrosis centered on the acetabulum.

Complete fusion of the

innominate

bone occurs in the late teens.Slide5

Pelvic Fx classification

There are two commonly used classification systems for pelvic fractures:

-

Letournel

and

Judet -Young BurgessSlide6

Letournel and Judet

:

Columns

Anterior column

(aka

iliopubic

column)

Posterior column

(aka

ilioischial

column)Slide7

Columns of the pelvis:

From the

lateral view, the

tri-radiate cartilage junction resembles a Y

with the

longer limb

forming the anterior column and the shorter, the posterior column of the acetabulum. These columns transfer forces from the lower extremities through the hip and sacroiliac joint into

the axial skeleton.

Slide8

Letournel and Judet

:

Ant./Post. Injuries

Injuries to the anterior column usually occur when forces are applied to the hip in external rotation.

Injuries to the posterior column usually occur when forces are applied to the hip in internal rotation.Slide9

Letournel and Judet

:

Pelvic

fx

classification

Description: Treatment:

Anterior column

May compromise any May require screws and

portion of ant column. Plates to

stabalize

fx

.

Anterior wall

Involves central portion of Reduction/internal fixation

ant column.

Anterior column

Involves ant wall

fx

Reduction/internal fixation

posterior transverse

and post. Transverse

fxSlide10

Letournel and Judet:

Pelvic

fx

classification

Description: Treatment:

Posterior column

Often result of MVA, Internal fixation

usually dashboard impact.

Sciatic nerve commonly inj.

Posterior wall

Most common pelvic

fx

ORIF

Involves central part of

posterior

c

olumn.

Posterior column

Multiple

fxs

in posterior Internal fixation,

Posterior wall

column of pelvis. Immediate surgerySlide11

Letournel and Judet:

Pelvic

fx

classification

Description: Treatment:

Transverse

Both ant/post columns Screws/plates, ORIF

are broken.

Both column

both ant/post columns ORIF

are broken in a more

vertical orientation.

Transverse

Usually caused by a blow

Posterior wall

directly upon the gr.

t

rochanter

.

T-shape

Poorest clinical results.Slide12

Young Burgess: Anterior Posterior Compression (APC)

Description:

Treatment: APC I Symphysis

widening < 2.5

cm. Non

-operative.

Protected WB

APC

II

Symphysis

widening > 2.5 cm

. Anterior

symphyseal

Anterior

SI joint

diastasis

. plate or ext

fixator

.

Posterior SI ligaments intact.

APC

III

Disruption of

ant/post Anterior

symphyseal

plate or

SI

ligaments

(SI dislocation). external

fixator

. posterior

  Associated

with vascular injury. stabilization with SI screws.   Slide13

Young Burgess: Lateral Compression (LC)

Description: Treatment:

LC I

Oblique

ramus

fracture and Non-operative. ipsilateral anterior sacral Protected WB. compression fracture.  LC II

Ramii

fracture and

ipsilateral

Open reduction and

posterior

ilium

fracture dislocation internal fixation of

ilium

.

(Crescent fracture).   

LC III

Ipsilateral

lateral compression and Posterior stabilization with

contralateral

APC (windswept pelvis).   plate or SI screws

Common mechanism: rollover MVA or as needed.

pedestrian

vs

auto.  Slide14

Young Burgess:Vertical Shear (VS)

Description:

Treatment:

Vertical shear (VS) Posterior and superior directed force.  Posterior stabilization with Associated with the highest risk of plate or SI screws hypovolemic shock (63%); mortality as needed. rate up to 25%. Slide15

Other terms:

Single fractures of the pelvic ring.

Pure

acetabular

fx

, straddle fx, chip/avulsion fx.Pelvic ring is disrupted in more than one location.Posterior pelvis, sacrum, or sacroiliac complex is disrupted.Malgaigne fxBucket handle

fx

Open book

fx

Stable

UnstableSlide16

Other terms:

Straddle

fx

:

Bilateral superior and inferior

rami

fractures. -Originally described in horseback riders.Chip/Avulsion fx: injury at a tendon/ligament

attatchment

. Where the

tendon or ligament pulls off a piece of the bone

.

Malgaigne

fx

:

Two

vertical fractures involving one side of the pelvic

ring.

-One

anterior

to

acetabulum

and one posterior.Slide17

Cont…

Bucket Handle

fx

:

Fracture of anterior arch and

contralateral

posterior arch. Usually caused by direct blow to pelvis, may cause rotary deformity of the hemipelvis that was effected as well as leg length discrepancy.Open Book

fx

:

Separation of pubic

symphysisSlide18

Sacral fractures:Denis Et Al

Zone I

- Fractures occur lateral to the sacral foramina

.

-The

most common, accounting for 50% of the fractures in the series of Denis et al.

-Zone

-I fractures mainly involve the sacral

ala

, with possible extension into the sacroiliac joint

.

Neurological injury

occurs in approximately 6% of patients and typically involves the

L4

and

L5

nerve roots.

Zone

II

- Vertical

transforaminal

fracture without involvement of the sacral spinal

canal

.

-Second

most common pattern, accounting for 34% of

sacral injuries. 

-Neurological

injury is found in 28% of patients, and most frequently affects

the

L5, S1, or S2 nerve root.

Malunions

in this area are associated with very poor functional

outcomes. Vertical shear injuries are considered to be highly unstable zone-II fractures.

Zone-III -

Any sacral fracture involving the spinal canal

.

-Least

frequently encountered

fracture

pattern, only 16

%.

-Zone

III injuries

are

associated with the highest prevalence and severity of neurological

injury,

about 57%.Slide19

Other sacral fx classification

Sacral

Insufficiency

Fracture:

A

stress fracture of the sacrum that is most

common cause is postmenopausal osteoporosis, presents with groin, low back, and buttock pain. Transverse Fractures:

-Upper

(S1-S3

):

higher

incidence of bladder

dysfunction.

-Lower (

S4-S5

):

very unstable, require

surgery to stabilize

from sacrum

to lower lumbar

spine

.

U

-shaped sacral

fracture:

-Results

from axial

loading and is associated with 

spino

-pelvic

dissociation.

-Formed

by bilateral

transforaminal

sacral fractures connected by a transverse fracture (usually between 2nd and 3rd segments

). -High incidence of neurologic

complications, usually involves a disruption of cauda

equina

at level of transverse

fx

.Slide20

Something to keep in mind…

“Once reconstruction occurs, the next challenge is rehabilitation of the injured patient. Surgeons have become increasingly aware that outcome is not simply an x-ray finding, or even a score on a validated scale. Outcome for the patient with pelvic and

acetabular

injuries is a complex analysis that comes down to the basics of life for many patients. Posttraumatic

arthrosis

chronic pain, nerve damage and bowel, bladder, and sexual dysfunction, intertwined with psychological distress are the real challenges to the patient. No matter how heroic the initial work and salvage of the patient’s life, ultimately the quality of life becomes the sine qua non of a “good” result. While many centers are working diligently to improve the acute outcome of pelvic fracture patients and fixation techniques for the pelvis and

acetabulum, the time has come to apply the same energy toward improvements in post-injury rehabilitation. The interface of the patient, the surgeon, the rehabilitation specialist, and society may be the next frontier in the management of pelvic and

acetabular

injuries.”

http://www.scribd.com/doc/46866708/Fractures-of-the-Pelvis-and-AcetabulumSlide21

Bibliography:

Denis, Francis M.D.; Davis, Steven B.S.; Comfort, Thomas M.D. Current

Orthopaedic

Practice. Sacral Fractures: An Important Problem Retrospective Analysis of 236 Cases. February 1988. Available

at

http

://journals.lww.com/corr/abstract/1988/02000/sacral_fractures__an_important_problem.10.aspx. Accessed 9/26/12Phieffer LS, Lundberg WP Templeman DC. PubMed

.

Instability of the posterior pelvic ring associated with disruption of the pubic

symphysis

.

October 2004. Available at

http://www.ncbi.nlm.nih.gov.dbprox.slcc.edu/pubmed/15363918

. Accessed 9/12/2012.

Routt ML

Jr

,

Simonian

PT.

PubMed

.

Internal fixation of pelvic ring disruptions.

1996. Available at

http://www.ncbi.nlm.nih.gov.dbprox.slcc.edu/pubmed/8915199

. Accessed 9/12/2012

Scheterer

MJ,

Osterhoff

G,

Wehrle

S,

Wanner

GA,

Simmen

HP,Werner

CM.

PubMed

. Detection of posterior pelvic injuries in fractures of the pubic rami

, June 6, 2012. Available at

http://www.ncbi.nlm.nih.gov.dbprox.slcc.edu/pubmed/22682148?dopt=AbstractPlus. Accessed 9/12/2012

Young JW,

Resnik

CS.

PubMed

.

Fracture of the pelvis: Current concepts of classification.

December 1990. Available at

http://www.ajronline.org/content/155/6/1169.long

. Accessed 9/12/2012.