Spine (Vertebrae) Fracture And Spinal Cord

Injury

Dr. Hermansyah, SpOTBag. Bedah/ SMF Orthopedi

FK-Unand/ RSUP Dr. M. Djamil PadangRSUD Lubuk Basung

Normal Spinal AnatomyNormal Spinal Anatomy

Spinal ligamentSpinal ligament

• Intrasegmental• Ligamentum flavum• Intertransverse ligament• Interspinous ligament• Intersegmental• ALL• PLL• Supraspinous ligament

EpidemiologyEpidemiology

Incidence: 10,000 new cases/yearIncidence: 10,000 new cases/yearPrevalence: 191,000 cases and risingPrevalence: 191,000 cases and risingPrime occurrence: males, peak of their Prime occurrence: males, peak of their

productive livesproductive livesCost: $ 5.6 billion/year in the USCost: $ 5.6 billion/year in the USCost per person: directly related to the Cost per person: directly related to the

level level

of SCI and patient’s ageof SCI and patient’s age

Common MechanismsCommon Mechanisms

CompressionCompression FlexionFlexionExtensionExtensionRotationRotationLateral bendingLateral bendingDistractionDistractionPenetrationPenetration

Whiplash injuryWhiplash injury

Suspect spinal injury with...Suspect spinal injury with...

Sudden decelerations (MVCs, falls)Sudden decelerations (MVCs, falls) Compression injuries (diving, falls onto feet/buttocks)Compression injuries (diving, falls onto feet/buttocks) Significant blunt trauma (football, hockey snowboarding, Significant blunt trauma (football, hockey snowboarding,

jet skis)jet skis) Very violent mechanisms (explosions, cave-ins, lightning Very violent mechanisms (explosions, cave-ins, lightning

strike) strike) Unconscious patient Unconscious patient Neurological deficit Neurological deficit Spinal tendernessSpinal tenderness

NeurologicalNeurologicalassessment: Sensoryassessment: Sensory

Goal of spine trauma careGoal of spine trauma care

Protect further injury Protect further injury during evaluation during evaluation and managementand management

Identify spine injury Identify spine injury or document absence or document absence of spine injuryof spine injury

Optimize conditions for maximal Optimize conditions for maximal neurologic recoveryneurologic recovery

Goal of spine trauma careGoal of spine trauma care

Maintain or restore spinal alignmentMaintain or restore spinal alignment

Minimize loss of spinal mobilityMinimize loss of spinal mobility

Obtain healed & stable spineObtain healed & stable spine

Facilitate rehabilitationFacilitate rehabilitation

Pre-hospital managementPre-hospital management

Protect spine at all times during the Protect spine at all times during the management of patients with multiple management of patients with multiple injuriesinjuries

Up to 15% of spinal injuries have a Up to 15% of spinal injuries have a second (possibly non adjacent) fracture second (possibly non adjacent) fracture elsewhere in the spineelsewhere in the spine

Ideally, whole spine should be Ideally, whole spine should be immobilized in neutral position on a firm immobilized in neutral position on a firm surfacesurface

PROTECTION PROTECTION PRIORITY PRIORITYDetection Detection Secondary Secondary

““Log-rolling”Log-rolling”

Pre-hospital management Pre-hospital management

Cervical spine immobilizationCervical spine immobilization

Transportation of spinal cord-injured Transportation of spinal cord-injured patients patients

Cervical spine immobilizationCervical spine immobilization

““Safe assumptions”Safe assumptions”Head injury and unconsciousHead injury and unconsciousMultiple traumaMultiple traumaFall Fall Severely injured workerSeverely injured workerUnstable spinal columnUnstable spinal column

Hard backboard, rigid cervical collar and lateral support (sand bag)Hard backboard, rigid cervical collar and lateral support (sand bag)

Neutral positionNeutral position

Philadelphia hard collarPhiladelphia hard collar

Transportation of spinal cord-injured Transportation of spinal cord-injured patientspatients

Emergency Medical Systems (EMS)Emergency Medical Systems (EMS)Paramedical staffParamedical staffPrimary trauma centerPrimary trauma centerSpinal injury centerSpinal injury center

Clinical assessmentClinical assessment

Advance Trauma Life Support (ATLS) Advance Trauma Life Support (ATLS) guidelinesguidelines

Primary and secondary surveys Primary and secondary surveys Adequate airway and ventilation are the Adequate airway and ventilation are the

most important factorsmost important factorsSupplemental oxygenationSupplemental oxygenationEarly intubation is critical to limit Early intubation is critical to limit

secondary injury from hypoxiasecondary injury from hypoxia

Physical examinationPhysical examination Inspection and palpation Inspection and palpation

Occiput to CoccyxOcciput to CoccyxSoft tissue swelling and bruisingSoft tissue swelling and bruisingPoint of spinal tendernessPoint of spinal tendernessGap or Step-offGap or Step-offSpasm of associated musclesSpasm of associated muscles

Neurological assessmentNeurological assessmentMotor, sensation and reflexesMotor, sensation and reflexesPRPR

Do not forget the cranial nerve (C0-C1 injury)Do not forget the cranial nerve (C0-C1 injury)

Neurogenic ShockNeurogenic ShockTemporary loss of autonomic function of the Temporary loss of autonomic function of the

cord at the level of injurycord at the level of injury results from cervical or high thoracic injuryresults from cervical or high thoracic injury

PresentationPresentationFlaccid paralysis distal to injury siteFlaccid paralysis distal to injury siteLoss of autonomic functionLoss of autonomic function

• hypotensionhypotension

• vasodilatationvasodilatation

• loss of bladder and bowel controlloss of bladder and bowel control

• loss of thermoregulationloss of thermoregulation

• warm, pink, dry below injury sitewarm, pink, dry below injury site

• bradycardiabradycardia

20

Neurogenic Hypovolemic

Etiology Loss of sympathetic outflow

Loss of blood volume

Blood pressure

Hypotension Hypotension

Heart rate Bradycardia Tachycardia

Skin temperature

Warm Cold

Urine output

Normal Low

Comparison of neurogenic and hypovolemic shock

Neurologic assessmentNeurologic assessment

Spinal shockSpinal shockBulbocavernosus reflexBulbocavernosus reflex

Complete VS incomplete cord injuryComplete VS incomplete cord injury ต้�องพ้�นภาวะ ต้�องพ้�นภาวะ spinal shock spinal shock ไปก่�อนไปก่�อนSacral sparingSacral sparing

• Voluntary anal sphincter controlVoluntary anal sphincter control• Toe flexorToe flexor• Perianal sensationPerianal sensation• Anal wink reflexAnal wink reflex

Neurologic assessmentNeurologic assessment

American Spinal Injury Association gradeAmerican Spinal Injury Association gradeGrade A – EGrade A – E

American Spinal Injury Association scoreAmerican Spinal Injury Association scoreMotor score (total = 100 points)Motor score (total = 100 points)

• Key muscles : 10 musclesKey muscles : 10 musclesSensory score (total = 112 points)Sensory score (total = 112 points)

• Key sensory points : 28 dermatomesKey sensory points : 28 dermatomes

Incomplete cord injuryIncomplete cord injury

Anterior cord syndromeAnterior cord syndromeBrown-Sequard syndromeBrown-Sequard syndromeCentral cord syndromeCentral cord syndrome

Anterior cord syndromeAnterior cord syndrome

Loss of motor, pain Loss of motor, pain and temperatureand temperature

Preserved Preserved propioception and propioception and deep touch deep touch

Brown-Sequard syndromeBrown-Sequard syndrome

Loss of ipsilateral Loss of ipsilateral motor and motor and propioceptionpropioception

Loss of contralateral Loss of contralateral pain and pain and temperaturetemperature

Central cord syndromeCentral cord syndrome

Weakness : Weakness : upper > lower upper > lower

Variable sensory Variable sensory lossloss

Sacral sparingSacral sparing

IMAGINGIMAGING

Numerous large prospective studies haveNumerous large prospective studies have

described the large cost and low yield ofdescribed the large cost and low yield of

the indiscriminate use of c-spine radiologythe indiscriminate use of c-spine radiology

in trauma patients.in trauma patients.

WHO NEEDS AN X-RAY???WHO NEEDS AN X-RAY???

NEXUSNEXUSCriteria were as follows…..Criteria were as follows…..

1.1. Absence of tenderness in the posterior Absence of tenderness in the posterior midlinemidline

2.2. Absence of a neurological deficitAbsence of a neurological deficit

3.3. Normal level of alertness (GCS15)Normal level of alertness (GCS15)

4.4. No evidence of intoxicationNo evidence of intoxication

5.5. No distracting pain elsewhereNo distracting pain elsewhere

NEXUSNEXUS

1.1. Any patient who fulfilled all 5 of the Any patient who fulfilled all 5 of the aforementioned criteria were considered aforementioned criteria were considered low risk for C-spine injury and as such low risk for C-spine injury and as such did not receive C-spine radiographydid not receive C-spine radiography

2.2. For patients who had any of the 5 For patients who had any of the 5 criteria,radiographic imaging was criteria,radiographic imaging was indicated in the form of AP, lateral, and indicated in the form of AP, lateral, and odontoid C-spine viewsodontoid C-spine views

Canadian C-Spine RulesCanadian C-Spine Rules

Plain Film RadiologyPlain Film Radiology

The standard 3 view plain film series is the lateral, The standard 3 view plain film series is the lateral, antero-posterior, and open-mouth view antero-posterior, and open-mouth view

The lateral cervical spine film must include the base of The lateral cervical spine film must include the base of the occiput and the top of the first thoracic vertebrathe occiput and the top of the first thoracic vertebra

The lateral view alone is inadequate and will miss up The lateral view alone is inadequate and will miss up to 15% of cervical spine injuries.to 15% of cervical spine injuries.

X-ray Guidelines (cervical)X-ray Guidelines (cervical)Adequacy, dequacy, AlignmentlignmentBBone abnormality, one abnormality, BBase of skullase of skullCCartilage, artilage, CContoursontoursDDisc spaceisc spaceSSoft tissueoft tissue

Interpreting Lateral Plain Interpreting Lateral Plain FilmFilm

AAdequacydequacyShould see C7-T1 Should see C7-T1

junctionjunctionIf not get If not get

swimmerswimmer’’s view or s view or CTCT

Swimmer’s View

Interpreting lateral Plain FilmInterpreting lateral Plain Film

AAlignmentlignmentAnterior vertebral lineAnterior vertebral line

• Formed by anterior borders of vertebral bodiesFormed by anterior borders of vertebral bodies

Posterior vertebral linePosterior vertebral line• Formed by posterior borders of vertebral bodiesFormed by posterior borders of vertebral bodies

Spino-laminar LineSpino-laminar Line• Formed by the junction of the spinous processes and the Formed by the junction of the spinous processes and the

laminaelaminae

Posterior Spinous LinePosterior Spinous Line• Formed by posterior aspect of the spinous processesFormed by posterior aspect of the spinous processes

AlignmentAlignment

BonesBones

CartilageCartilage Predental Space Predental Space

should be no more should be no more than 3 mm in adults than 3 mm in adults and 5 mm in and 5 mm in childrenchildren

Increased distance Increased distance may indicate may indicate fracture of odontoid fracture of odontoid or transverse or transverse ligament injuryligament injury

Cartilage Cont.Cartilage Cont. Disc SpacesDisc Spaces

Should be uniform Should be uniform

Assess spaces Assess spaces between the between the spinous processesspinous processes

Soft tissueSoft tissue

Nasopharyngeal Nasopharyngeal space (C1) - 10 mm space (C1) - 10 mm (adult)(adult)

Retropharyngeal Retropharyngeal space (C2-C4) - 5-7 space (C2-C4) - 5-7 mmmm

Retrotracheal space Retrotracheal space (C5-C7) - 14 mm (C5-C7) - 14 mm (children), 22 mm (children), 22 mm (adults)(adults)

Extremely variable Extremely variable and nonspecificand nonspecific

Measurements anterior to the mid-cervical spine up to 7 mm are common. > 7 mm,-a fracture is likely and the neck should be immobilized.

AP C-spine FilmsAP C-spine Films

Spinous processes Spinous processes should line up should line up

Disc space Disc space should be should be uniformuniform

Vertebral body Vertebral body height height should be uniform. should be uniform. Check for oblique Check for oblique fractures.fractures.

Open mouth viewOpen mouth view

AdequacyAdequacy: all of : all of the dens and the dens and lateral borders of lateral borders of C1 & C2C1 & C2

AlignmentAlignment: lateral : lateral masses of C1 and masses of C1 and C2C2

BoneBone: Inspect : Inspect dens for lucent dens for lucent fracture linesfracture lines

CT ScanCT Scan

Thin cut CT scan Thin cut CT scan should be used to should be used to evaluate abnormal, evaluate abnormal, suspicious or poorly suspicious or poorly visualized areas on visualized areas on plain filmplain film

The combination of The combination of plain film and directed plain film and directed CT scan provides a CT scan provides a false negative rate of false negative rate of less than 0.1%less than 0.1%

MRIMRI

Ideally all patients Ideally all patients with abnormal with abnormal neurological neurological examination should examination should be evaluated with be evaluated with MRI scanMRI scan

Management of SCIManagement of SCIPrimary GoalPrimary Goal

Prevent secondary injuryPrevent secondary injury

Immobilization of the spine begins in the Immobilization of the spine begins in the initial assessmentinitial assessmentTreat the spine as a long boneTreat the spine as a long bone

• Secure joint above and belowSecure joint above and below

Caution with “partial” spine splintingCaution with “partial” spine splinting

Management of SCIManagement of SCISpinal motion restriction: immobilization devicesSpinal motion restriction: immobilization devicesABCsABCs

Increase FiOIncrease FiO22

Assist ventilations as needed with c-spine controlAssist ventilations as needed with c-spine control Indications for intubation :Indications for intubation :

• Acute respiratory failureAcute respiratory failure• GCS <9GCS <9• Increased RR with hypoxiaIncreased RR with hypoxia• PCO2 > 50 PCO2 > 50 • VC < 10 mL/kg VC < 10 mL/kg

IV Access & fluids titrated to BP ~ 90-100 mmHgIV Access & fluids titrated to BP ~ 90-100 mmHg

Management of SCIManagement of SCILook for other injuries: “Life over Limb”Look for other injuries: “Life over Limb”Transport to appropriate SCI center once Transport to appropriate SCI center once

stabilizedstabilizedConsider high dose methylprednisoloneConsider high dose methylprednisolone

ControversialControversial as recent evidence questions benefit as recent evidence questions benefitMust be started < 8 hours of injuryMust be started < 8 hours of injuryDo not use for penetrating traumaDo not use for penetrating trauma30 mg/kg bolus over 15 minute 30 mg/kg bolus over 15 minute After bolus: infusion 5.4mg/kg IV for 23 hoursAfter bolus: infusion 5.4mg/kg IV for 23 hours

Principle of treatmentPrinciple of treatment

Spinal alignmentSpinal alignmentdeformity/subluxation/dislocation deformity/subluxation/dislocation

reductionreduction

Spinal column stabilitySpinal column stabilityunstable unstable stabilization stabilization

Neurological statusNeurological statusneurological deficit neurological deficit decompression decompression

CompleteComplete - Absence of sensory and - Absence of sensory and motor functions in the lowest sacral motor functions in the lowest sacral segments segments

IncompleteIncomplete - Preservation of sensory - Preservation of sensory or motor function below the level of or motor function below the level of injury, including the lowest sacral injury, including the lowest sacral segmentssegments

Frankel scaleFrankel scale

A complete paralysis A complete paralysis B sensory function only below the injury B sensory function only below the injury

level level C incomplete motor function below C incomplete motor function below

injury level injury level D fair to good motor function below D fair to good motor function below

injury level E normal function injury level E normal function

Treatment Treatment

SuportifSuportifNon OperativeNon OperativeSurgerySurgery

Steroid Protocol: for Spinal Steroid Protocol: for Spinal Cord InjuryCord Injury

Methylprednisolone given as bolus of 30 Methylprednisolone given as bolus of 30 mg / kg body wt - followed by infusion at mg / kg body wt - followed by infusion at 5.4 mg / kg / hour for 23 hours; 5.4 mg / kg / hour for 23 hours;

Excluded pts: - patients who are more Excluded pts: - patients who are more than 8 hours from injury (these patients than 8 hours from injury (these patients may actually do worse w/ steroids); may actually do worse w/ steroids);

Note: up to 40% of spine injured patients Note: up to 40% of spine injured patients who receive steroids can be expected to who receive steroids can be expected to develop some Gastrointenstinal bleedingdevelop some Gastrointenstinal bleeding

Non – Operative Treatment Non – Operative Treatment OptionsOptions

No treatmentNo treatment

advice / restrict activityadvice / restrict activity

Spinal ‘immobilisation’Spinal ‘immobilisation’

Bed restBed rest

Lumbar pillow / Log rollingLumbar pillow / Log rolling

TractionTraction

Casting / BracingCasting / Bracing

Combination treatmentCombination treatment

Guilford braceGuilford brace

Stable A3 FractureStable A3 Fracture

Bed Rest until Normal Trunk ControlBed Rest until Normal Trunk ControlStanding X RaysStanding X Rays? Use extension Brace or Cast? Use extension Brace or Cast

Indications for surgeryIndications for surgery

1.The spinal cord appears to be compressed 1.The spinal cord appears to be compressed 2.An progressive neurological deterioration. 2.An progressive neurological deterioration. 3.Dislocation with facet joint locking3.Dislocation with facet joint locking4.Unstable fracture of spine 4.Unstable fracture of spine

OccipitoatlantoaxiOccipitoatlantoaxial fusion with the al fusion with the Luque rectangleLuque rectangle

C Type Fracture L2C Type Fracture L2

USS2 Fracture Set – USS2 Fracture Set – Fixation of A3 FractureFixation of A3 Fracture

Complications Complications

A Infection of urinary and genital A Infection of urinary and genital tract tract

B. Pressure Sores : Prevention is B. Pressure Sores : Prevention is the most important treatment. the most important treatment.

C. Respiratory Complications : C. Respiratory Complications : respiratory infection respiratory infection

D. Disorder of D. Disorder of thermoregulation

PELVIC RING FRACTUREPELVIC RING FRACTURE

HermansyahHermansyah

Bag Bedah/ SMF Orthopedi Bag Bedah/ SMF Orthopedi

FK-Unand/ RSUP Dr. M.Djamil PadangFK-Unand/ RSUP Dr. M.Djamil Padang

PELVIC FRACTURES: CLASSIFICATION & PELVIC FRACTURES: CLASSIFICATION & MANAGEMENTMANAGEMENT

Pelvic fractures are caused by high energy blunt Pelvic fractures are caused by high energy blunt traumatrauma

Significant mortality and morbiditySignificant mortality and morbidity

Mortality 30% in unstable fracturesMortality 30% in unstable fractures

10 to 12% due to haemorrhage10 to 12% due to haemorrhage

ANATOMYANATOMY Sacrum and 2 Sacrum and 2

innominate bonesinnominate bones Innominate bones Innominate bones

articulate anteriorly articulate anteriorly at symphysis pubisat symphysis pubis

Sacrum articulates Sacrum articulates with the ilium with the ilium posteriorly through posteriorly through sacroiliac joints sacroiliac joints

ANATOMYANATOMYPelvic ring stability is Pelvic ring stability is

provided by:provided by: Iliolumbar ligs.Iliolumbar ligs. Dorsal sacroiliac Dorsal sacroiliac

ligamentsligaments Sacrotuberous ligsSacrotuberous ligs Ventral sacroiliac ligs.Ventral sacroiliac ligs. Sacrospinous ligsSacrospinous ligs Posterosuperior Posterosuperior

interosseous ligs.interosseous ligs.

ANATOMYANATOMYHighly vascularHighly vascular

Iliac vessels run Iliac vessels run along the inner along the inner wall of the pelviswall of the pelvis

Trauma MechanismTrauma Mechanism

YOUNG and BURGESSYOUNG and BURGESS

CLASSIFICATIONCLASSIFICATION

Tile’s classification Tile’s classification system uses radiographic system uses radiographic images to ascertain images to ascertain the degree of stability the degree of stability of the of the pelvis , and hence determine which pelvic injuries pelvis , and hence determine which pelvic injuries require stabilization and which can be managed require stabilization and which can be managed nonoperatively. nonoperatively. 

Hence the classification by Tile is more relevant for Hence the classification by Tile is more relevant for formulating treatment, but does not give significant formulating treatment, but does not give significant information regarding the degree of damageinformation regarding the degree of damage

CLASSIFICATIONCLASSIFICATIONType A: Stable (Posterior Arch Intact)Type A: Stable (Posterior Arch Intact)

A1:Avulsion injuryA1:Avulsion injury

A2:Iliac wing or anterior arch fracture caused by A2:Iliac wing or anterior arch fracture caused by a direct blowa direct blow

A3: Transverse sacrococcygeal fractureA3: Transverse sacrococcygeal fracture

Type B: Partially Stable (Incomplete Type B: Partially Stable (Incomplete Disruption of Posterior Arch)Disruption of Posterior Arch)

B1:Open book injury (external rotation)B1:Open book injury (external rotation)

B2:Lateral compression injury (internal rotation)B2:Lateral compression injury (internal rotation)

B2-1:Ipsilateral anterior and posterior injuriesB2-1:Ipsilateral anterior and posterior injuries

B2-2:Contralateral (bucket-handle) injuriesB2-2:Contralateral (bucket-handle) injuries

B3:BilateralB3:Bilateral

Type C: Unstable (Complete Disruption of Type C: Unstable (Complete Disruption of Posterior Arch)Posterior Arch)

C1:UnilateralC1:Unilateral

C1-1:Iliac fractureC1-1:Iliac fracture

C1-2:Sacroiliac fracture-dislocationC1-2:Sacroiliac fracture-dislocation

C1-3:Sacral fractureC1-3:Sacral fracture

C2:Bilateral, with one side type B, one side type C2:Bilateral, with one side type B, one side type CC

C3:BilateralC3:Bilateral

TREATMENTTREATMENT

INITIAL MANAGEMENT:INITIAL MANAGEMENT:ATLS protocol: Primary surveyATLS protocol: Primary survey

IV fluids and blood transfusion with wide bore canulaIV fluids and blood transfusion with wide bore canula

A/P Xray of pelvis, L/S spine, Chest, Cervical spine (lat A/P Xray of pelvis, L/S spine, Chest, Cervical spine (lat view)view)

If blood is seen on external urethral meatus, suprapubic If blood is seen on external urethral meatus, suprapubic cystostomy is preferable to catheterization.cystostomy is preferable to catheterization.

Multidisciplinary approachMultidisciplinary approach

PrioritisingPrioritising

HEAD

PELVIS

ABDOMEN

CHEST

How to stabilise the PelvisHow to stabilise the Pelvis

Rotational instability – Binding – III – 3Rotational instability – Binding – III – 3Vertical instability – skeletal traction –Vertical instability – skeletal traction – III – 3 III – 3Non invasive external stabilisation devices Non invasive external stabilisation devices

or a bed sheet but allow access to or a bed sheet but allow access to laparotomy and femoral access for laparotomy and femoral access for angiographyangiography – IV – IV

If Non invasive fails invasive anterior If Non invasive fails invasive anterior external fixationexternal fixation - IV - IV

ITIM

Circumferential SheetingCircumferential Sheeting

SupineSupine

2 “Wrappers”2 “Wrappers”

PlacementPlacement

ApplyApply

““Clamper”Clamper”

30 Seconds30 Seconds

1

2

34

Routt et al, JOT, 2002

SAM SLINGSAM SLING

TREATMENTTREATMENT

HAEMODYNAMICALLY STABLEHAEMODYNAMICALLY STABLE::

Complete secondary surveyComplete secondary survey

Inlet and outlet views, Pelvic CT scanInlet and outlet views, Pelvic CT scan

Pelvic binder for unstable fracturesPelvic binder for unstable fractures

Definitive fixationDefinitive fixation

TREATMENTTREATMENT

HAEMODYNAMICALLY UNSTABLEHAEMODYNAMICALLY UNSTABLE

TREATMENTTREATMENT

TREATMENTTREATMENT

LAPAROTOMYLAPAROTOMY

PELVIC EXTERNAL FIXATOR PELVIC EXTERNAL FIXATOR Damage control Damage control

surgery, Minimally surgery, Minimally invasiveinvasive

Stabilizes rotationally Stabilizes rotationally unstable pelvis, in unstable pelvis, in patients with shockpatients with shock

Before laparotomy Before laparotomy

Immediate External FixationImmediate External FixationPelvic Pelvic ““clampsclamps””

Percutaneous fixationPercutaneous fixation Exposure not a Exposure not a

problemproblem Low complication rateLow complication rate Bio mechanically Bio mechanically

idealideal

Detailed anatomical Detailed anatomical knowledge requiredknowledge required

Technically Technically demandingdemanding

DEFINITIVE FRACTURE FIXATIONDEFINITIVE FRACTURE FIXATION

INDICATIONS:INDICATIONS:1.1.Symphyseal diastasis > 2cmSymphyseal diastasis > 2cm2.2.Contralateral bucket handle injury causing >1.5cm Contralateral bucket handle injury causing >1.5cm

limb length discrepancylimb length discrepancy3.3.Rotationally and vertically unstable fractures (Tiles Rotationally and vertically unstable fractures (Tiles

Type C)Type C)

TIMINGTIMING When patient is stabilized, and fit enough to When patient is stabilized, and fit enough to

undergo the definitive procedureundergo the definitive procedure

DEFINITIVE FRACTURE DEFINITIVE FRACTURE FIXATIONFIXATION

Lag screw, Lag screw, Neutralization platesNeutralization plates for for Iliac wing fracturesIliac wing fractures

Plate fixation Plate fixation for for Symphyseal diastasisSymphyseal diastasis

DEFINITIVE FRACTURE DEFINITIVE FRACTURE FIXATIONFIXATION

Plate fixation, Plate fixation, sacroiliac screw sacroiliac screw fixationfixation for Sacral for Sacral fracturesfractures

Cancellous screwCancellous screw or or Sacroiliac plate Sacroiliac plate fixation fixation for for Sacroiliac disruptionSacroiliac disruption

ANGIOGRAPHYANGIOGRAPHY

SUMMARYSUMMARY

Stabilization of a haemodynamically unstable patient Stabilization of a haemodynamically unstable patient is of paramount importance.is of paramount importance.

Unstable pelvic fractures should be stabilized Unstable pelvic fractures should be stabilized externally as soon as possible.externally as soon as possible.

For unresponsive patients, urgent laparotomy with For unresponsive patients, urgent laparotomy with angiography on stand by.angiography on stand by.

Not all pelvic fractures requires fixation.Not all pelvic fractures requires fixation.