Basic principles of treatment of breaks of lower extremity and pelvis.

Basic principles of Basic principles of treatment of breaks of lower treatment of breaks of lower

extremity and pelvis.extremity and pelvis.

Reader: Kostiv S. Ya.Reader: Kostiv S. Ya.

Tibia Fractures, OpenTibia Fractures, Open

When an individual presents with an open When an individual presents with an open tibial fracture, the physician strives to save tibial fracture, the physician strives to save the life of the patient and the limb, to unite the life of the patient and the limb, to unite the fracture, and to prevent infection. the fracture, and to prevent infection. Maintaining a functional limb is the goal; Maintaining a functional limb is the goal; when that is not possible, the physician when that is not possible, the physician must consider amputation.must consider amputation.

FrequencyFrequency

Behrens et al reported an incidence of 2 Behrens et al reported an incidence of 2 open tibia fractures per 1000 injuries per open tibia fractures per 1000 injuries per year in a defined population group in an year in a defined population group in an industrialized western society; this is 0.2% industrialized western society; this is 0.2% of all injuries (Behrens, 1982; Behrens, of all injuries (Behrens, 1982; Behrens, 1986). The incidence and severity may be 1986). The incidence and severity may be even higher in the developing worleven higher in the developing worl

EtiologyEtiology

Motor vehicle accidents, skiing accidents, and Motor vehicle accidents, skiing accidents, and high-energy falls are the common causes. The high-energy falls are the common causes. The mechanism of injury determines the fracture mechanism of injury determines the fracture configuration (eg, skiing injuries typically cause configuration (eg, skiing injuries typically cause spiral fractures). Most fractures are comminuted. spiral fractures). Most fractures are comminuted. Pedestrians who are hit in the upper and middle Pedestrians who are hit in the upper and middle one third of the tibia sustain bumper injuries. one third of the tibia sustain bumper injuries. Distal tibial and plafond fractures are commonly Distal tibial and plafond fractures are commonly a result of a fall from a significant height.a result of a fall from a significant height.

PresentationPresentation

All persons who have undergone high-energy trauma All persons who have undergone high-energy trauma should be examined in accordance with the principles should be examined in accordance with the principles defined by the Road Trauma Committee of the Royal defined by the Road Trauma Committee of the Royal Australasian College of Surgeons/Emergency Australasian College of Surgeons/Emergency Management of Severe Trauma (Geller, 1997; Shuler, Management of Severe Trauma (Geller, 1997; Shuler, 1996). The primary survey includes the ABCs (ie, airway, 1996). The primary survey includes the ABCs (ie, airway, breathing, circulation). A Glasgow Coma Scale score breathing, circulation). A Glasgow Coma Scale score indicates the severity of any head injury component. The indicates the severity of any head injury component. The secondary survey should include the chest, abdomen, secondary survey should include the chest, abdomen, and pelvis for associated injuries, as well as the upper and pelvis for associated injuries, as well as the upper limbs and the contralateral lower limb. The ipsilateral limbs and the contralateral lower limb. The ipsilateral limb also may have other fractures, such as a femur limb also may have other fractures, such as a femur fracture, leading to a floating knee, or joint injuries such fracture, leading to a floating knee, or joint injuries such as knee dislocations.as knee dislocations.

ClassificationClassificationTable TypeTable Type Wound DescriptionWound Description Other CriteriaOther CriteriaII <1 cm (so-called puncture wounds)<1 cm (so-called puncture wounds) IIII 1-10 cm1-10 cm IIIAIIIA >10 cm, coverage available>10 cm, coverage available Segmental fractures, farm injuries,Segmental fractures, farm injuries,or any injury occurring in a highly contaminated environmentor any injury occurring in a highly contaminated environmentHigh-velocity gunshot injuriesHigh-velocity gunshot injuriesIIIBIIIB 10 cm, requiring soft tissue coverage procedure10 cm, requiring soft tissue coverage procedure Periosteal strippingPeriosteal strippingIIICIIIC With vascular injury requiring repairWith vascular injury requiring repairTypeType Wound DescriptionWound Description Other CriteriaOther CriteriaII <1 cm (so-called puncture wounds)<1 cm (so-called puncture wounds) IIII 1-10 cm1-10 cm IIIAIIIA >10 cm, coverage available>10 cm, coverage available Segmental fractures, farm injuries,Segmental fractures, farm injuries,or any injury occurring in a highly contaminated environmentor any injury occurring in a highly contaminated environmentHigh-velocity gunshot injuriesHigh-velocity gunshot injuriesIIIBIIIB 10 cm, requiring soft tissue coverage procedure10 cm, requiring soft tissue coverage procedure Periosteal strippingPeriosteal strippingIIICIIIC With vascular injury requiring repairWith vascular injury requiring repair

Gustilo-Anderson Classification of Gustilo-Anderson Classification of Open FracturesOpen Fractures

Tscherne Classification of Soft Tscherne Classification of Soft Tissue InjuriesTissue Injuries

IndicationsIndicationsThe various limb salvage scoring systems, such as the MESS (Mangled The various limb salvage scoring systems, such as the MESS (Mangled Extremity Severity Score), are good indicators for salvage but poor Extremity Severity Score), are good indicators for salvage but poor indicators for amputation; thus, a limb with a good MESS usually should be indicators for amputation; thus, a limb with a good MESS usually should be salvaged, but a limb with a poor MESS does not necessarily require salvaged, but a limb with a poor MESS does not necessarily require amputation.amputation.

Regarding nailing versus external fixation, Bhandari et al reported from a Regarding nailing versus external fixation, Bhandari et al reported from a meta-analysis that compared with external fixation, the use of unreamed meta-analysis that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in nails decreased the risk of reoperation, superficial infection, and malunion in persons with open tibial fractures (Bhandari, 2001; Bhandari, 2000). They persons with open tibial fractures (Bhandari, 2001; Bhandari, 2000). They also found a reduced risk of reoperation with using reamed nails compared also found a reduced risk of reoperation with using reamed nails compared with unreamed nails. This appears to support some authors who have with unreamed nails. This appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail. Plate fixation was exchange nailing with a larger-diameter reamed nail. Plate fixation was found to be uniformly the worst of all methods of internal fixation. Although it found to be uniformly the worst of all methods of internal fixation. Although it may be tempting to use plate fixation for a fracture that is exposed (ie, may be tempting to use plate fixation for a fracture that is exposed (ie, because of the open nature of injury), the risk of nonunion, malunion, and because of the open nature of injury), the risk of nonunion, malunion, and deep infection is too high to justify the action (Bhandari, 2001).deep infection is too high to justify the action (Bhandari, 2001).

ContraindicationsContraindications

Absolute contraindications to limb salvage Absolute contraindications to limb salvage are a completely mangled limb, the are a completely mangled limb, the presence of warm ischemia for longer than presence of warm ischemia for longer than 6 hours, and poor facilities for salvage.6 hours, and poor facilities for salvage.

Absolute contraindications to nailing an Absolute contraindications to nailing an open fracture are untreated compartment open fracture are untreated compartment syndrome and types IIIB and IIIC open syndrome and types IIIB and IIIC open fractures.fractures.

Medical TherapyMedical Therapy

ntravenous antibiotics are administered promptly. First-generation ntravenous antibiotics are administered promptly. First-generation cephalosporins (gram-positive coverage) such as cephalothin (1-2 g cephalosporins (gram-positive coverage) such as cephalothin (1-2 g q6-8h) suffice for Gustilo-Anderson type I fractures. An q6-8h) suffice for Gustilo-Anderson type I fractures. An aminoglycoside (gram-negative coverage) such as gentamycin (120 aminoglycoside (gram-negative coverage) such as gentamycin (120 mg q12h; 240 mg/d) is added for types II and III injuries. mg q12h; 240 mg/d) is added for types II and III injuries. Additionally, metronidazole (500 mg q12h) or penicillin (1.2 g q6h) Additionally, metronidazole (500 mg q12h) or penicillin (1.2 g q6h) can be added for coverage against anaerobes. Tetanus prophylaxis can be added for coverage against anaerobes. Tetanus prophylaxis should be instituted. Antibiotics generally are continued for 72 hours should be instituted. Antibiotics generally are continued for 72 hours following wound closure.following wound closure.

After initial assessment, the wound is irrigated in the emergency After initial assessment, the wound is irrigated in the emergency department. A sterile dressing is applied, and the limb is splinted. department. A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room as soon as Debridement should be performed in the operating room as soon as feasible. Debridement within 6 hours is necessary to keep the rate feasible. Debridement within 6 hours is necessary to keep the rate of infection low (Kindsfater, 1995). A key factor in infection of infection low (Kindsfater, 1995). A key factor in infection prevention is early, rigid stabilization of the fracture.prevention is early, rigid stabilization of the fracture.

Surgical TherapySurgical Therapy

Fracture repairFracture repair

AmputationAmputation

ComplicationsComplications

Open tibial fractures have higher rates of Open tibial fractures have higher rates of nonunion, infection, and CPS.nonunion, infection, and CPS.

Osteomyelitis may occur and can be acute, Osteomyelitis may occur and can be acute, subacute, or chronic. It may surface many subacute, or chronic. It may surface many months or years after injury.months or years after injury.

Pin site infections are common with external Pin site infections are common with external fixator treatment. Chronic osteomyelitis in the pin fixator treatment. Chronic osteomyelitis in the pin sites is relatively common.sites is relatively common.

Femoral Neck Stress and Femoral Neck Stress and Insufficiency FracturesInsufficiency Fractures

IntroductionIntroduction

Femoral neck stress fractures are a common Femoral neck stress fractures are a common cause of hip pain in select populations. Chronic, cause of hip pain in select populations. Chronic, repetitive activity that is common to runners and repetitive activity that is common to runners and military recruits predisposes these populations to military recruits predisposes these populations to femoral neck stress fractures. These injuries femoral neck stress fractures. These injuries must be differentiated from insufficiency must be differentiated from insufficiency fractures, which, although similar in appearance fractures, which, although similar in appearance and presentation, result from an entirely different and presentation, result from an entirely different pathophysiology and occur in a different pathophysiology and occur in a different population.population.

ProblemProblem

The femoral neck area is subjected to large The femoral neck area is subjected to large compressive and sheer forces associated with compressive and sheer forces associated with ambulation. Even in the most sedentary ambulation. Even in the most sedentary individual, the daily cyclic loading of the hip and individual, the daily cyclic loading of the hip and femoral neck produces high stresses on the femoral neck produces high stresses on the bony trabeculae in this anatomic region. In long-bony trabeculae in this anatomic region. In long-distance runners and other high-performance distance runners and other high-performance athletes, the forces across the femoral neck are athletes, the forces across the femoral neck are multiplied exponentially because the athletes' multiplied exponentially because the athletes' training regimens place tremendous physical training regimens place tremendous physical burdens on this relatively small bridge of bone, burdens on this relatively small bridge of bone, which connects the femoral head to the which connects the femoral head to the diaphysis.diaphysis.

FrequencyFrequencyFemoral neck stress fractures occur most commonly in 2 subsets of the Femoral neck stress fractures occur most commonly in 2 subsets of the population. Elite distance runners, military recruits, and dancers constitute population. Elite distance runners, military recruits, and dancers constitute the first group. The true prevalence of fractures in this group is difficult to the first group. The true prevalence of fractures in this group is difficult to pinpoint because such patients with hip pain and femoral neck stress pinpoint because such patients with hip pain and femoral neck stress fractures who never present to a physician and whose fractures go on to fractures who never present to a physician and whose fractures go on to heal spontaneously are never identified. Data from several military hip heal spontaneously are never identified. Data from several military hip fracture studies by Stoneham and Morgan, in Britain, and Volpin and fracture studies by Stoneham and Morgan, in Britain, and Volpin and colleagues, in Israel, place the prevalence at 0.2-4.7% in patients without a colleagues, in Israel, place the prevalence at 0.2-4.7% in patients without a history of a single traumatic episode.3, 4 The prevalence of stress fractures history of a single traumatic episode.3, 4 The prevalence of stress fractures in the general population may be surmised to be far less than that in the general population may be surmised to be far less than that demonstrated in these 2 groups.demonstrated in these 2 groups.

The second group comprises hypoestrogenic (postmenopausal) women and The second group comprises hypoestrogenic (postmenopausal) women and individuals with pathologic entities resulting in osteopenia (eg, osteoporosis, individuals with pathologic entities resulting in osteopenia (eg, osteoporosis, Paget disease, hyperparathyroidism). Fractures in this group are termed Paget disease, hyperparathyroidism). Fractures in this group are termed insufficiency fractures, because bone quality is insufficient to support the insufficiency fractures, because bone quality is insufficient to support the diurnal physiologic demands placed on it.diurnal physiologic demands placed on it.

EtiologyEtiologyFemoral neck stress fractures in young, otherwise healthy individuals are Femoral neck stress fractures in young, otherwise healthy individuals are related to the inability of bony trabeculae weakened by osteoporosis to related to the inability of bony trabeculae weakened by osteoporosis to withstand physical stresses. Unusually high physical demands on normal withstand physical stresses. Unusually high physical demands on normal bone over the long term can lead to mechanical failure of the bone bone over the long term can lead to mechanical failure of the bone trabeculae. The phenomenon is seen with exercise beyond the point of trabeculae. The phenomenon is seen with exercise beyond the point of muscle fatigue, alterations of ground reactive forces that yield abnormal muscle fatigue, alterations of ground reactive forces that yield abnormal stress patterns in bone, and increased muscular contractions. Contrast this stress patterns in bone, and increased muscular contractions. Contrast this with insufficiency fractures of the femoral neck, which are the result of with insufficiency fractures of the femoral neck, which are the result of normal stresses of everyday activity placed on structurally compromised normal stresses of everyday activity placed on structurally compromised bone. Thus, insufficiency fractures occur in individuals who have bone. Thus, insufficiency fractures occur in individuals who have concomitant metabolic derangements, such as hyperparathyroidism and concomitant metabolic derangements, such as hyperparathyroidism and renal failure, or menopause.renal failure, or menopause.

At least 1 example of a crossover group exists: amenorrheic female At least 1 example of a crossover group exists: amenorrheic female athletes. Due to their lack of body fat, female distance runners often athletes. Due to their lack of body fat, female distance runners often temporarily halt their menstrual cycle. As a result, they become temporarily halt their menstrual cycle. As a result, they become hypoestrogenic and, therefore, physiologically similar to postmenopausal hypoestrogenic and, therefore, physiologically similar to postmenopausal females.females.

PathophysiologyPathophysiology

A closer look at the genesis of a stress fracture in the femoral neck A closer look at the genesis of a stress fracture in the femoral neck reveals that the damage manifested on the physical level derives reveals that the damage manifested on the physical level derives not from a traumatic event per se but rather from a metabolic not from a traumatic event per se but rather from a metabolic derangement. Bone initially responds to increased mechanical derangement. Bone initially responds to increased mechanical loading by increasing resorption. Resorption is normally loading by increasing resorption. Resorption is normally counterbalanced by an equal but opposite, osteoblast-mediated counterbalanced by an equal but opposite, osteoblast-mediated metabolic repair. Under situations of extraordinarily high levels of metabolic repair. Under situations of extraordinarily high levels of training, such as those faced by military personnel and elite training, such as those faced by military personnel and elite athletes, bone resorption begins to exceed the bone's capacity to athletes, bone resorption begins to exceed the bone's capacity to remodel. Additionally, pharmacologic (glucocorticoids), nutritional remodel. Additionally, pharmacologic (glucocorticoids), nutritional (vitamin D and calcium deficiency), and other (postmenopausal, (vitamin D and calcium deficiency), and other (postmenopausal, hyperparathyroid) states can adversely affect osteoblasts' ability to hyperparathyroid) states can adversely affect osteoblasts' ability to keep pace with osteoclastic resorption. If this metabolic imbalance keep pace with osteoclastic resorption. If this metabolic imbalance persists, microfractures develop that eventually weaken bone to the persists, microfractures develop that eventually weaken bone to the point of a complete fracture.point of a complete fracture.

Presentation and examinationPresentation and examinationAlthough femoral neck stress fractures are relatively uncommon in the Although femoral neck stress fractures are relatively uncommon in the general population, they must be part of any thorough physician's differential general population, they must be part of any thorough physician's differential diagnosis for an athlete presenting with anterior hip or groin pain. A history diagnosis for an athlete presenting with anterior hip or groin pain. A history of insidious hip or groin pain that is directly related to an increase in the of insidious hip or groin pain that is directly related to an increase in the level or duration of athletic activity and that is relieved by rest is typical. level or duration of athletic activity and that is relieved by rest is typical. Early diagnosis is often difficult because of the lack of an identifiable Early diagnosis is often difficult because of the lack of an identifiable traumatic event, which tends to dissuade primary care physicians from traumatic event, which tends to dissuade primary care physicians from obtaining radiographs. Even the astute physician ordering hip films upon obtaining radiographs. Even the astute physician ordering hip films upon first presentation may overlook this diagnosis because fracture callus is not first presentation may overlook this diagnosis because fracture callus is not evident early in the process. A bone scan may be helpful in cases in which evident early in the process. A bone scan may be helpful in cases in which suspicion is high but radiographic findings are equivocal. The higher degree suspicion is high but radiographic findings are equivocal. The higher degree of sensitivity of bone scanning is useful in detecting stress fractures and of sensitivity of bone scanning is useful in detecting stress fractures and other forms of periosteal injury without complete fracture.other forms of periosteal injury without complete fracture.

In patients presenting with hip pain and negative findings during the initial In patients presenting with hip pain and negative findings during the initial workup, obtaining plain radiographs of the ipsilateral knee also should be workup, obtaining plain radiographs of the ipsilateral knee also should be considered. Referred pain along the course of the anterior branch of the considered. Referred pain along the course of the anterior branch of the obturator nerve may manifest as ipsilateral hip pain and should be in the obturator nerve may manifest as ipsilateral hip pain and should be in the clinician's differential diagnosis, especially in younger patients.clinician's differential diagnosis, especially in younger patients.

IndicationsIndications

Surgical treatment is warranted for all stress fractures that have Surgical treatment is warranted for all stress fractures that have progressed to a transverse fracture of the femoral neck. The progressed to a transverse fracture of the femoral neck. The question then becomes which treatment procedure is more question then becomes which treatment procedure is more beneficial to the patient. The orthopedist may choose either internal beneficial to the patient. The orthopedist may choose either internal fixation or arthroplasty. The decision-making process should include fixation or arthroplasty. The decision-making process should include consideration of the patient's bone quality, life expectancy, consideration of the patient's bone quality, life expectancy, physiologic status, and overall activity level. However, the main physiologic status, and overall activity level. However, the main factor in deciding which type of repair to undertake should be the factor in deciding which type of repair to undertake should be the likelihood of revision surgery being needed in the future for a failed likelihood of revision surgery being needed in the future for a failed arthroplasty. For most younger individuals in otherwise good health, arthroplasty. For most younger individuals in otherwise good health, this means internal fixation of the fracture is warranted.this means internal fixation of the fracture is warranted.

Indications for hemiarthroplasty include such factors as pathologic Indications for hemiarthroplasty include such factors as pathologic bone, rheumatoid arthritis, renal failure or other chronic illness, and bone, rheumatoid arthritis, renal failure or other chronic illness, and limited lifespan.limited lifespan.

ContraindicationsContraindications

In general, nondisplaced, compression-type femoral neck fractures In general, nondisplaced, compression-type femoral neck fractures are relative contraindications to surgery. In contrast, tension-type are relative contraindications to surgery. In contrast, tension-type stress fractures demand surgical treatment because they have a stress fractures demand surgical treatment because they have a high propensity for fracture displacement. Contraindications to high propensity for fracture displacement. Contraindications to surgical fixation of a tension-type femoral neck fracture are few surgical fixation of a tension-type femoral neck fracture are few because this is one of the few true orthopedic surgical emergencies. because this is one of the few true orthopedic surgical emergencies. If a displaced femoral neck fracture occurs, the very real possibility If a displaced femoral neck fracture occurs, the very real possibility of disruption of blood supply to the femoral head makes surgery of disruption of blood supply to the femoral head makes surgery necessary. Absolute contraindications include a medically unstable necessary. Absolute contraindications include a medically unstable patient who would be unable to tolerate the stress of surgery and patient who would be unable to tolerate the stress of surgery and anesthesia. If initial operative fixation is not obtained and anesthesia. If initial operative fixation is not obtained and osteonecrosis ensues, the patient, when stabilized, will require a osteonecrosis ensues, the patient, when stabilized, will require a hemiarthroplasty as definitive treatment.hemiarthroplasty as definitive treatment.

Laboratory StudiesLaboratory Studies

No particular laboratory studies aid in the diagnosis of No particular laboratory studies aid in the diagnosis of this disorder; however, a prudent part of the preoperative this disorder; however, a prudent part of the preoperative workup is the ordering of standard laboratory tests (eg, workup is the ordering of standard laboratory tests (eg, blood chemistries, hemoglobin and hematocrit values, blood chemistries, hemoglobin and hematocrit values, and coagulation profile). When an insufficiency fracture and coagulation profile). When an insufficiency fracture is suspected, the medical workup should include a is suspected, the medical workup should include a search for metabolic abnormalities, including abnormal search for metabolic abnormalities, including abnormal calcium, phosphate, and alkaline phosphatase values.calcium, phosphate, and alkaline phosphatase values.If septic arthritis of the hip is suspected, a C-reactive If septic arthritis of the hip is suspected, a C-reactive protein level, erythrocyte sedimentation rate, and WBC protein level, erythrocyte sedimentation rate, and WBC count with differential should help rule out an infectious count with differential should help rule out an infectious process.process.

Imaging StudiesImaging Studies

Plain radiography remains the initial imaging examination in the Plain radiography remains the initial imaging examination in the evaluation of suspected hip disease. A standard hip radiographic evaluation of suspected hip disease. A standard hip radiographic series includes an AP view of the pelvis and coned-down AP and series includes an AP view of the pelvis and coned-down AP and frog-lateral views of the affected hip.frog-lateral views of the affected hip.

The AP view of the pelvis allows evaluation of the contralateral hip for The AP view of the pelvis allows evaluation of the contralateral hip for concomitant disease and can be used to exclude osseous or articular concomitant disease and can be used to exclude osseous or articular abnormalities of the pelvis (eg, sacroiliitis, sacral stress fractures, pubic abnormalities of the pelvis (eg, sacroiliitis, sacral stress fractures, pubic ring fractures) that could present clinically as hip pain. The AP views of ring fractures) that could present clinically as hip pain. The AP views of the pelvis and hip are obtained with the feet internally rotated.the pelvis and hip are obtained with the feet internally rotated.

The frog-lateral view of a hip is obtained with the radiographic beam The frog-lateral view of a hip is obtained with the radiographic beam oriented in the AP direction, with the hip abducted. A groin lateral view oriented in the AP direction, with the hip abducted. A groin lateral view of the hip, instead of the frog-lateral view, can be used in cases of an of the hip, instead of the frog-lateral view, can be used in cases of an acute femoral neck fracture or displaced fracture, because the affected acute femoral neck fracture or displaced fracture, because the affected hip remains in a neutral position. In this examination, the opposite leg is hip remains in a neutral position. In this examination, the opposite leg is abducted and elevated and the radiographic beam is oriented parallel to abducted and elevated and the radiographic beam is oriented parallel to the table, with 20° cephalad angulation.the table, with 20° cephalad angulation.

Imaging StudiesImaging StudiesIn the case of a compression-type fracture, the inferior aspect of the femoral In the case of a compression-type fracture, the inferior aspect of the femoral neck demonstrates cortical thickening with a hazy, radiolucent center. This neck demonstrates cortical thickening with a hazy, radiolucent center. This radiographic picture may be easily confused with osteoid osteoma if an radiographic picture may be easily confused with osteoid osteoma if an adequate history is not obtained from the patient. Transverse-type fractures adequate history is not obtained from the patient. Transverse-type fractures appear much differently on radiography, the first sign being a faint line of appear much differently on radiography, the first sign being a faint line of sclerosis across the femoral neck. If left untreated, these transverse sclerosis across the femoral neck. If left untreated, these transverse fractures may easily progress to complete neck fractures, with significant fractures may easily progress to complete neck fractures, with significant displacement and varus angulation.displacement and varus angulation.Because of its sensitivity in detecting periosteal injury, bone scanning has Because of its sensitivity in detecting periosteal injury, bone scanning has been very helpful in the absence of conventional radiographic findings. In been very helpful in the absence of conventional radiographic findings. In the presence of stress fractures, bone scanning demonstrates focal the presence of stress fractures, bone scanning demonstrates focal increased uptake of the radiotracer, at the fracture site. This represents an increased uptake of the radiotracer, at the fracture site. This represents an area of increased bone turnover. One drawback to this modality, however, is area of increased bone turnover. One drawback to this modality, however, is that findings on scintography are often negative during the first 24 hours that findings on scintography are often negative during the first 24 hours after stress fracture. The positive predictive value of radionuclide imaging in after stress fracture. The positive predictive value of radionuclide imaging in diagnosing femoral neck stress pathology approaches 68%.diagnosing femoral neck stress pathology approaches 68%.


Having similar sensitivity and the added advantage of greater Having similar sensitivity and the added advantage of greater specificity for stress fractures, MRI has become the new modality of specificity for stress fractures, MRI has become the new modality of choice for detecting stress pathology. In several studies, both the choice for detecting stress pathology. In several studies, both the sensitivity and specificity of MRI in detecting femoral neck stress sensitivity and specificity of MRI in detecting femoral neck stress fractures was 100%. However, with this increased specificity comes fractures was 100%. However, with this increased specificity comes increased price for the testing modality. In addition to being less increased price for the testing modality. In addition to being less invasive than bone scanning (no radiotracer needs to be injected), invasive than bone scanning (no radiotracer needs to be injected), MRI provides much more information about the surrounding soft MRI provides much more information about the surrounding soft tissues. MRI has been shown to be effective in differentiating stress tissues. MRI has been shown to be effective in differentiating stress fracture from malignancy or infection.fracture from malignancy or infection.A diagnostic MRI of a femoral neck stress fracture depicts A diagnostic MRI of a femoral neck stress fracture depicts decreased signal intensity on T1-weighted images and increased decreased signal intensity on T1-weighted images and increased signal intensity on T2, as well as short TI inversion recovery (STIR) signal intensity on T2, as well as short TI inversion recovery (STIR) images with or without a low signal fracture line.images with or without a low signal fracture line.

Outcome and PrognosisOutcome and Prognosis

he prognosis for femoral neck stress fractures depends largely on he prognosis for femoral neck stress fractures depends largely on the classification of the fracture. Compression-type injuries the classification of the fracture. Compression-type injuries historically fare very well, with the patient recovering full preinjury historically fare very well, with the patient recovering full preinjury function after diligent adherence to a physician-prescribed plan of function after diligent adherence to a physician-prescribed plan of limited weightbearing and walking with an aid. Transverse-type limited weightbearing and walking with an aid. Transverse-type fractures, when identified early and with the only radiographic fractures, when identified early and with the only radiographic abnormality being sclerotic changes, tend to recover well after abnormality being sclerotic changes, tend to recover well after internal fixation. Potential lasting effects of surgical management internal fixation. Potential lasting effects of surgical management include hip pain and nonunion or malunion of the fracture. The worst include hip pain and nonunion or malunion of the fracture. The worst prognosis exists for transverse fractures that are inherently unstable prognosis exists for transverse fractures that are inherently unstable because of mechanical reasons and that can progress to complete because of mechanical reasons and that can progress to complete displaced fractures. The rate of nonunion and AVN in these cases is displaced fractures. The rate of nonunion and AVN in these cases is as high as 35%, according to some authors.as high as 35%, according to some authors.

Future and ControversiesFuture and Controversies

Debate currently exists over the surgical treatment of transverse-Debate currently exists over the surgical treatment of transverse-type femoral neck stress fractures in older patients. Given that most type femoral neck stress fractures in older patients. Given that most individuals who sustain true stress fractures (as distinguished from individuals who sustain true stress fractures (as distinguished from insufficiency fractures) are young and healthy, only a small number insufficiency fractures) are young and healthy, only a small number of individuals are affected by this controversy.of individuals are affected by this controversy.

The 2 current methods of fixation include internal fixation and The 2 current methods of fixation include internal fixation and prosthetic replacement. Multiple studies comparing the 2 modalities prosthetic replacement. Multiple studies comparing the 2 modalities of fracture fixation for these types of injuries have demonstrated of fracture fixation for these types of injuries have demonstrated widely varying results. Infection rates, morbidity, mortality, and widely varying results. Infection rates, morbidity, mortality, and patient satisfaction have been examined without a definitive answer patient satisfaction have been examined without a definitive answer gleaned. Additionally, the prosthetic opponents point out that the gleaned. Additionally, the prosthetic opponents point out that the cost and potential complications of the components are not cost and potential complications of the components are not justifiable for individuals whose remaining life expectancy might be justifiable for individuals whose remaining life expectancy might be half that of the implant.half that of the implant.

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

Pelvic FracturesPelvic Fractures

ProblemProblemUnstable pelvic fractures typically occur as a result of high-energy injuries. Unstable pelvic fractures typically occur as a result of high-energy injuries. Associated organ system injuries are observed commonly with pelvic Associated organ system injuries are observed commonly with pelvic fractures due to the energy imparted to the patient. Head, chest, and fractures due to the energy imparted to the patient. Head, chest, and abdominal injuries frequently occur in association with pelvic fractures. abdominal injuries frequently occur in association with pelvic fractures. Fractures of the extremities and spinal column also can occur in patients Fractures of the extremities and spinal column also can occur in patients with pelvic fractures.with pelvic fractures.

Hemorrhage may accompany pelvic fractures. Most hemorrhage associated Hemorrhage may accompany pelvic fractures. Most hemorrhage associated with pelvic fractures occurs as a result of bleeding from exposed fractures, with pelvic fractures occurs as a result of bleeding from exposed fractures, soft tissue injury, and local venous bleeding (Huittinen, 1973). Arterial soft tissue injury, and local venous bleeding (Huittinen, 1973). Arterial injuries also may contribute to hemorrhage with pelvic fractures albeit less injuries also may contribute to hemorrhage with pelvic fractures albeit less commonly than venous bleeding (Schield, 1991).commonly than venous bleeding (Schield, 1991).

Unstable and displaced pelvic ring disruptions cause significant deformity, Unstable and displaced pelvic ring disruptions cause significant deformity, pain, and disability. Deformities resulting from pelvic ring injuries include any pain, and disability. Deformities resulting from pelvic ring injuries include any combination of rotational and translational deformities. Significant combination of rotational and translational deformities. Significant permanent (sustained) pelvic deformities have been identified in poorer permanent (sustained) pelvic deformities have been identified in poorer patient outcomes and decreased activity levels (Failinger, 1992; McLaren, patient outcomes and decreased activity levels (Failinger, 1992; McLaren, 1990; Pohlemann, 1994).1990; Pohlemann, 1994).

FrequencyFrequency

The incidence of pelvic fractures in the United The incidence of pelvic fractures in the United States has been estimated to be 37 cases per States has been estimated to be 37 cases per 100,000 person-years. The incidence of pelvic 100,000 person-years. The incidence of pelvic fractures is greatest in people aged 15-28 years. fractures is greatest in people aged 15-28 years. In persons younger than 35 years, males sustain In persons younger than 35 years, males sustain more pelvic fractures than females; whereas in more pelvic fractures than females; whereas in persons older than 35 years, women sustain persons older than 35 years, women sustain more pelvic fractures than men (Melton, 1981). more pelvic fractures than men (Melton, 1981). Most pelvic fractures that occur in younger Most pelvic fractures that occur in younger patients result from high-energy mechanisms, patients result from high-energy mechanisms, whereas pelvic fractures sustained in the elderly whereas pelvic fractures sustained in the elderly population occur from minimal trauma, such as a population occur from minimal trauma, such as a low fall (Melton, 1981).low fall (Melton, 1981).

EtiologyEtiology

Pelvic fractures occur after both low-energy and high-energy events. Pelvic fractures occur after both low-energy and high-energy events. Low-energy pelvic fractures occur commonly in 2 distinct age Low-energy pelvic fractures occur commonly in 2 distinct age groups: adolescents and the elderly. Adolescents typically present groups: adolescents and the elderly. Adolescents typically present with avulsion fractures of the superior or inferior iliac spines or with avulsion fractures of the superior or inferior iliac spines or apophyseal avulsion fractures of the iliac wing or ischial tuberosity apophyseal avulsion fractures of the iliac wing or ischial tuberosity resulting from an athletic injury. Low-energy pelvic fractures in the resulting from an athletic injury. Low-energy pelvic fractures in the elderly frequently result from falls while ambulating, which are elderly frequently result from falls while ambulating, which are highlighted by stable fractures of the pelvic ring. Elderly patients highlighted by stable fractures of the pelvic ring. Elderly patients also may present with insufficiency fractures, typically of the sacrum also may present with insufficiency fractures, typically of the sacrum and anterior pelvic ring (Gotis-Graham, 1994).and anterior pelvic ring (Gotis-Graham, 1994).

High-energy pelvic fractures most commonly occur after motor High-energy pelvic fractures most commonly occur after motor vehicle crashes. Other mechanisms of high-energy pelvic fractures vehicle crashes. Other mechanisms of high-energy pelvic fractures include motorcycle crashes, motor vehicles striking pedestrians, and include motorcycle crashes, motor vehicles striking pedestrians, and falls.falls.

IndicationsIndicationsManagement of pelvic fractures in the immediate setting is centered on Management of pelvic fractures in the immediate setting is centered on controlling life-threatening injuries, particularly severe hemorrhage. Several controlling life-threatening injuries, particularly severe hemorrhage. Several techniques have been used to control hemorrhage; these techniques are techniques have been used to control hemorrhage; these techniques are based on decreasing the volume of the pelvis, thereby limiting the amount of based on decreasing the volume of the pelvis, thereby limiting the amount of blood that can escape into the pelvic cavity.blood that can escape into the pelvic cavity.

Perhaps the simplest method to decrease pelvic volume is securely Perhaps the simplest method to decrease pelvic volume is securely wrapping a sheet around the patient's pelvis. External fixators and other wrapping a sheet around the patient's pelvis. External fixators and other external pelvic clamps have been advocated to control pelvic volume, with external pelvic clamps have been advocated to control pelvic volume, with the added benefit of providing bony stability, thereby preventing fracture the added benefit of providing bony stability, thereby preventing fracture movement and dislodgment of clots (Tile, 1988). Pneumatic antishock movement and dislodgment of clots (Tile, 1988). Pneumatic antishock garments also have been used to control hemorrhage associated with pelvic garments also have been used to control hemorrhage associated with pelvic fractures. Care must be taken when using pneumatic antishock garments as fractures. Care must be taken when using pneumatic antishock garments as they increase intramuscular and intrathoracic pressure, potentially leading to they increase intramuscular and intrathoracic pressure, potentially leading to compartmental syndrome and respiratory compromise distress. Pneumatic compartmental syndrome and respiratory compromise distress. Pneumatic antishock garments are contradicted in patients with pulmonary edema antishock garments are contradicted in patients with pulmonary edema and/or diaphragmatic rupture (American College of Surgeon's Committee on and/or diaphragmatic rupture (American College of Surgeon's Committee on Trauma, 1993).Trauma, 1993).

Tile classification scheme for pelvic Tile classification scheme for pelvic fractures is as follows (Tile, 1995):fractures is as follows (Tile, 1995):

Type A - Rotationally and vertically stableType A - Rotationally and vertically stableA1 - Avulsion fracturesA1 - Avulsion fracturesA2 - Stable iliac wing fractures or minimally displaced pelvic ring A2 - Stable iliac wing fractures or minimally displaced pelvic ring fracturesfracturesA3 - Transverse sacral or coccyx fracturesA3 - Transverse sacral or coccyx fracturesType B - Rotationally unstable and vertically stableType B - Rotationally unstable and vertically stableB1 - Open-book injuriesB1 - Open-book injuriesB2 - LC injuriesB2 - LC injuriesB3 - Bilateral type B injuriesB3 - Bilateral type B injuriesType C - Rotationally unstable and vertically unstableType C - Rotationally unstable and vertically unstableC1 - Unilateral injuryC1 - Unilateral injuryC2 - Bilateral injuries in which one side is a type B injury and the C2 - Bilateral injuries in which one side is a type B injury and the contralateral side is a type C injurycontralateral side is a type C injuryC3 - Bilateral injury in which both sides are type C injuriesC3 - Bilateral injury in which both sides are type C injuries

Laboratory StudiesLaboratory Studies

A complete blood cell count, renal panel, A complete blood cell count, renal panel, coagulation profile, and toxicology screens coagulation profile, and toxicology screens usually are obtained in the emergency usually are obtained in the emergency department upon patient presentation. department upon patient presentation. Serial hematocrits are helpful in the acute Serial hematocrits are helpful in the acute setting to monitor resuscitation efforts.setting to monitor resuscitation efforts.


Anteroposterior pelvic radiographAnteroposterior pelvic radiograph Obtained as component of the initial trauma evaluationObtained as component of the initial trauma evaluation Highlights most major pelvic disruptions (Young, 1987)Highlights most major pelvic disruptions (Young, 1987)

Inlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980)Inlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980) X-ray tube angled 45° caudad and centered on the umbilicusX-ray tube angled 45° caudad and centered on the umbilicus Highlights AP and mediolateral translations, and internal and external Highlights AP and mediolateral translations, and internal and external

rotatory deformitiesrotatory deformitiesOutlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980)Outlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980)

X-ray tube angled 45° cephalad and centered on the symphysis pubisX-ray tube angled 45° cephalad and centered on the symphysis pubis Highlights superior and inferior translations abduction and/or adduction, Highlights superior and inferior translations abduction and/or adduction,

and flexion and/or extension rotational deformitiesand flexion and/or extension rotational deformitiesLateral sacral radiograph (Nork, 2001; Roy-Camille, 1985)Lateral sacral radiograph (Nork, 2001; Roy-Camille, 1985)

Indicated in injuries sustained from falls and when bilateral sacral Indicated in injuries sustained from falls and when bilateral sacral fractures are noted on plain radiographs or CT scansfractures are noted on plain radiographs or CT scans

Demonstrates transverse fracture of sacral body and /or kyphosis of Demonstrates transverse fracture of sacral body and /or kyphosis of sacrumsacrum

Imaging StudiesImaging StudiesPelvic CT scansPelvic CT scans

Useful to confirm plain film findings and more to document sacral morphology Useful to confirm plain film findings and more to document sacral morphology when planning percutaneous iliosacral screw placement (Routt, 2000)when planning percutaneous iliosacral screw placement (Routt, 2000)

Often can be included with abdominal CT scansOften can be included with abdominal CT scans Five-millimeter axial images from iliac crests to acetabular dome, then 3-mm Five-millimeter axial images from iliac crests to acetabular dome, then 3-mm

axial images including all acetabular articular segments, then 5-mm slices axial images including all acetabular articular segments, then 5-mm slices through remainder of caudal pelvis (Routt, Orthop Clin North Am, 1997)through remainder of caudal pelvis (Routt, Orthop Clin North Am, 1997)

Three-dimensional reformatted pelvic CT scans also may be beneficial to Three-dimensional reformatted pelvic CT scans also may be beneficial to highlight pelvic ring injuries and associated deformity patterns.highlight pelvic ring injuries and associated deformity patterns.

Pelvic angiogramsPelvic angiograms Indicated in patients with ongoing hemorrhage after adequate intravenous fluid Indicated in patients with ongoing hemorrhage after adequate intravenous fluid

resuscitation and provisional pelvic ring stabilizationresuscitation and provisional pelvic ring stabilization Useful in patients who have pelvic ring or acetabular injuries involving the greater Useful in patients who have pelvic ring or acetabular injuries involving the greater

sciatic notch to detect obvious or occult injury to the superior gluteal arterysciatic notch to detect obvious or occult injury to the superior gluteal artery Embolization of lacerated arterial vessels may be performed at the same setting, Embolization of lacerated arterial vessels may be performed at the same setting,

as can manipulative reductions using the angiography fluoroscopic imaging as can manipulative reductions using the angiography fluoroscopic imaging systemsystem


Retrograde urethrogramRetrograde urethrogram Indicated in patients suspected of having Indicated in patients suspected of having

urethral tearsurethral tears Recommended to be performed under the Recommended to be performed under the

direction of a urologistdirection of a urologist

CystogramCystogram Indicated in patients suspected of having a Indicated in patients suspected of having a

urinary bladder injuryurinary bladder injury Recommended to be performed under the Recommended to be performed under the

direction of a urologistdirection of a urologist

Medical TherapyMedical TherapyInitial therapy in the acutely injured patient centers on the ABCs as Initial therapy in the acutely injured patient centers on the ABCs as recommended by ATLS protocols published by the American College of recommended by ATLS protocols published by the American College of Surgeons (American College of Surgeon's Committee on Trauma, 1993). Surgeons (American College of Surgeon's Committee on Trauma, 1993). The following mnemonic defines the specific, ordered, prioritized The following mnemonic defines the specific, ordered, prioritized evaluations and interventions that should be followed in injured patients evaluations and interventions that should be followed in injured patients (American College of Surgeon's Committee on Trauma, 1993):(American College of Surgeon's Committee on Trauma, 1993):

A = Airway with cervical spine controlA = Airway with cervical spine controlB = BreathingB = BreathingC = CirculationC = CirculationD = Disability or neurologic statusD = Disability or neurologic statusE = Exposure (undress) with temperature controlE = Exposure (undress) with temperature control

After initial resuscitation and stabilization, other non–life-threatening injuries After initial resuscitation and stabilization, other non–life-threatening injuries are evaluated and managed appropriately. Following these guidelines, are evaluated and managed appropriately. Following these guidelines, under the direction of a trauma surgeon or general surgeon, patient under the direction of a trauma surgeon or general surgeon, patient treatment is optimized.treatment is optimized.

Surgical TherapySurgical Therapy

Symphysis pubis disruptionsSymphysis pubis disruptions Letournel recommended operative stabilization of Letournel recommended operative stabilization of

symphyseal disruptions when the pubic diastasis symphyseal disruptions when the pubic diastasis measured greater than 1.5 cm (Letournel, 1978). measured greater than 1.5 cm (Letournel, 1978). Routt et al also noted that children and people of Routt et al also noted that children and people of smaller stature may demonstrate rotational pelvic smaller stature may demonstrate rotational pelvic instability with pubic diastases less than 2.5 cm instability with pubic diastases less than 2.5 cm (Routt, Orthop Clin North Am, 1997). It has been (Routt, Orthop Clin North Am, 1997). It has been observed that a symphysis pubis diastasis may observed that a symphysis pubis diastasis may increase after administration of general anesthesia, increase after administration of general anesthesia, implying that plain radiographs may underestimate implying that plain radiographs may underestimate the actual deformity due to associated muscle spasm.the actual deformity due to associated muscle spasm.

Pubic ramus fracturesPubic ramus fracturesPubic ramus fractures occur as parasymphysial fractures, midramus fractures, and pubic root Pubic ramus fractures occur as parasymphysial fractures, midramus fractures, and pubic root fractures in association with distraction and compression injuries of the pelvis (Routt, Orthop Clin fractures in association with distraction and compression injuries of the pelvis (Routt, Orthop Clin North Am, 1997). Displacement of pubic rami fractures may cause impingement or laceration of North Am, 1997). Displacement of pubic rami fractures may cause impingement or laceration of the bladder, vagina, and perineum, and, for these reasons, operative management may be the bladder, vagina, and perineum, and, for these reasons, operative management may be considered. Operative treatment of pubic rami fractures is indicated to provide additional pelvic considered. Operative treatment of pubic rami fractures is indicated to provide additional pelvic ring stability in association with posterior pelvic ring fixation. Stabilization of pubic rami fractures ring stability in association with posterior pelvic ring fixation. Stabilization of pubic rami fractures also may be considered in fractures involving the obturator neurovascular canal with also may be considered in fractures involving the obturator neurovascular canal with accompanying neurologic injury.accompanying neurologic injury.

Treatment options for pubic rami fractures include external fixation, percutaneous screw fixation, Treatment options for pubic rami fractures include external fixation, percutaneous screw fixation, and open reduction and internal fixation. External fixation with either multiple pins (Kellam, 1989) and open reduction and internal fixation. External fixation with either multiple pins (Kellam, 1989) or single pins in each hemipelvis (Tucker, 2001) may be used successfully in conjunction with or single pins in each hemipelvis (Tucker, 2001) may be used successfully in conjunction with stabilization of posterior ring injuries to impart additional stability to the pelvic fixation construct. stabilization of posterior ring injuries to impart additional stability to the pelvic fixation construct. External fixation for pubic ramus fractures is indicated to impart additional stability after posterior External fixation for pubic ramus fractures is indicated to impart additional stability after posterior pelvic ring repair and also when percutaneous or open treatment is contraindicated.pelvic ring repair and also when percutaneous or open treatment is contraindicated.

Intramedullary fixation of pubic ramus fractures has been described for treatment of pubic rami Intramedullary fixation of pubic ramus fractures has been described for treatment of pubic rami fractures (Simonian, J Orthop Trauma 1994;8(6):476-82; Tile, 1995). Intramedullary pubic ramus fractures (Simonian, J Orthop Trauma 1994;8(6):476-82; Tile, 1995). Intramedullary pubic ramus fixation with a 4.5-mm cortical screw has demonstrated fixation strength equivalent to plate fixation with a 4.5-mm cortical screw has demonstrated fixation strength equivalent to plate fixation and has demonstrated good results in clinical settings (Routt, 2000; Simonian, J Orthop fixation and has demonstrated good results in clinical settings (Routt, 2000; Simonian, J Orthop Trauma 1994;8(6):483-9). Intramedullary stabilization of ramus fractures may be performed with Trauma 1994;8(6):483-9). Intramedullary stabilization of ramus fractures may be performed with either a percutaneous or open technique with either antegrade or retrograde screw placement in either a percutaneous or open technique with either antegrade or retrograde screw placement in the pubic ramus. Extramedullary plate fixation is another option to stabilize pubic rami fractures the pubic ramus. Extramedullary plate fixation is another option to stabilize pubic rami fractures after open reduction and usually is achieved with 3.5-mm pelvic reconstruction plates.after open reduction and usually is achieved with 3.5-mm pelvic reconstruction plates.

Iliac wing fracturesIliac wing fracturesliac wing fractures are caused by forces applied directly to the iliac wing. Simple liac wing fractures are caused by forces applied directly to the iliac wing. Simple fracture patterns without associated pelvic ring instability are managed with fracture patterns without associated pelvic ring instability are managed with nonoperative measures. Comminuted iliac wing fractures are caused by high-energy nonoperative measures. Comminuted iliac wing fractures are caused by high-energy injuries, and severe soft tissue injury, including open wounds, frequently accompany injuries, and severe soft tissue injury, including open wounds, frequently accompany these injuries (Switzer, 2000).these injuries (Switzer, 2000).

Indications for operative management of iliac wing fractures include associated skin Indications for operative management of iliac wing fractures include associated skin abnormalities, significant closed degloving injuries, and open wounds. Severely abnormalities, significant closed degloving injuries, and open wounds. Severely displaced or comminuted iliac wing fractures, unstable iliac fractures that preclude displaced or comminuted iliac wing fractures, unstable iliac fractures that preclude adequate pulmonary function secondary to pain, bowel herniation or incarceration adequate pulmonary function secondary to pain, bowel herniation or incarceration within the fracture, and fractures associated with unstable pelvic ring injuries are within the fracture, and fractures associated with unstable pelvic ring injuries are other indications for open reduction and internal fixation (Routt, Orthop Clin North Am, other indications for open reduction and internal fixation (Routt, Orthop Clin North Am, 1997; Switzer, 2000). Preoperative pelvic angiograms are recommended for fractures 1997; Switzer, 2000). Preoperative pelvic angiograms are recommended for fractures involving the greater sciatic notch.involving the greater sciatic notch.

The lateral window of the ilioinguinal surgical exposure is used to access iliac wing The lateral window of the ilioinguinal surgical exposure is used to access iliac wing fractures. After fracture exposure, tenaculum clamps, Farabeuf clamps, and Schanz fractures. After fracture exposure, tenaculum clamps, Farabeuf clamps, and Schanz pins used as joysticks are used to obtain fracture reduction. Fracture reduction is pins used as joysticks are used to obtain fracture reduction. Fracture reduction is maintained with medullary lag screws in combination with pelvic reconstruction plates maintained with medullary lag screws in combination with pelvic reconstruction plates for definitive stabilization. For patients with open iliac fractures, the fixation construct for definitive stabilization. For patients with open iliac fractures, the fixation construct should rely on medullary screws in order to seclude the implants from contamination.should rely on medullary screws in order to seclude the implants from contamination.

Crescent fracturesCrescent fractures

Treatment of crescent fractures with the patient in the Treatment of crescent fractures with the patient in the supine position allows for direct reduction of the SI joint supine position allows for direct reduction of the SI joint and indirect reduction of the iliac fracture (Lange, 1990). and indirect reduction of the iliac fracture (Lange, 1990). The lateral window of the ilioinguinal surgical exposure is The lateral window of the ilioinguinal surgical exposure is used to access the SI joint. After the SI joint is visualized used to access the SI joint. After the SI joint is visualized and debrided, reduction is performed under direct and debrided, reduction is performed under direct visualization using a combination of clamps, external visualization using a combination of clamps, external fixators, and, occasionally, a femoral distractor used in fixators, and, occasionally, a femoral distractor used in compression. The SI joint is stabilized with iliosacral compression. The SI joint is stabilized with iliosacral screws, 3.5-mm reconstruction plates placed screws, 3.5-mm reconstruction plates placed perpendicular to one another, or both used in perpendicular to one another, or both used in combination (Routt, Orthop Clin North Am, 1997).combination (Routt, Orthop Clin North Am, 1997).

Sacroiliac joint disruptionsSacroiliac joint disruptionsStabilization is achieved with either 3.5- or 4.5-mm pelvic reconstruction plates placed Stabilization is achieved with either 3.5- or 4.5-mm pelvic reconstruction plates placed perpendicular to one another across the SI joint. Plates should be contoured carefully perpendicular to one another across the SI joint. Plates should be contoured carefully to avoid distraction at the inferior portion of the SI joint (Routt, 1997). The S1 nerve to avoid distraction at the inferior portion of the SI joint (Routt, 1997). The S1 nerve root is at risk when drilling and inserting a screw within the sacral ala, and root is at risk when drilling and inserting a screw within the sacral ala, and fluoroscopic guidance is recommended.fluoroscopic guidance is recommended.

Stabilization of SI disruptions from the prone position uses a vertical paramedian Stabilization of SI disruptions from the prone position uses a vertical paramedian dorsal surgical exposure; however, one must be wary of significant wound problems dorsal surgical exposure; however, one must be wary of significant wound problems that may develop using posterior exposures in a compromised soft tissue envelope that may develop using posterior exposures in a compromised soft tissue envelope (Goldstein, 1986; Kellam, 1989). Unlike anterior surgical exposures, reduction of the (Goldstein, 1986; Kellam, 1989). Unlike anterior surgical exposures, reduction of the SI joint is performed indirectly because visualization is compromised as the joint is SI joint is performed indirectly because visualization is compromised as the joint is brought into reduction. Reduction is verified manually by palpation of the anterior brought into reduction. Reduction is verified manually by palpation of the anterior aspect of the SI joint through the greater sciatic notch and radiographically with aspect of the SI joint through the greater sciatic notch and radiographically with intraoperative fluoroscopic imaging. Reduction of the dislocated ilium to the sacrum intraoperative fluoroscopic imaging. Reduction of the dislocated ilium to the sacrum may be assisted with clamps placed through the greater sciatic notch clamping the may be assisted with clamps placed through the greater sciatic notch clamping the posterior iliac wing to the sacral ala (Matta, 1989; Moed, 1998). Stabilization is posterior iliac wing to the sacral ala (Matta, 1989; Moed, 1998). Stabilization is obtained with combinations of transiliac plates using either pelvic reconstruction or obtained with combinations of transiliac plates using either pelvic reconstruction or dynamic compression plates, transiliac screws, and iliosacral screws.dynamic compression plates, transiliac screws, and iliosacral screws.

Sacral fracturesSacral fractures

Sacral fractures usually are treated by indirect reduction Sacral fractures usually are treated by indirect reduction techniques unless a need for foraminal decompression is techniques unless a need for foraminal decompression is present or an acceptable reduction cannot be obtained present or an acceptable reduction cannot be obtained by closed manipulative means. Open treatment is by closed manipulative means. Open treatment is performed in the prone position using a vertical performed in the prone position using a vertical paramedian dorsal surgical exposure. Direct access to paramedian dorsal surgical exposure. Direct access to the posterior sacrum is achieved by elevating the the posterior sacrum is achieved by elevating the paraspinal muscles from the sacrum, whereby paraspinal muscles from the sacrum, whereby decompression of sacral foramina may be accomplished. decompression of sacral foramina may be accomplished. After fracture reduction, stabilization is obtained with After fracture reduction, stabilization is obtained with transiliac bars, transiliac screws, transiliac plates, or transiliac bars, transiliac screws, transiliac plates, or iliosacral screws. Despite the implant, care must be iliosacral screws. Despite the implant, care must be taken not to over compress the sacral fractures and taken not to over compress the sacral fractures and potentially create an iatrogenic sacral nerve root injury.potentially create an iatrogenic sacral nerve root injury.

ComplicationsComplications

Muscle ruptures and herniasMuscle ruptures and hernias

Neurologic injuryNeurologic injury

Postoperative wound infectionPostoperative wound infection

Proximal DVTsProximal DVTs

GenitourinaryGenitourinary

Outcome and PrognosisOutcome and PrognosisEarly stabilization of pelvic ring injuries has demonstrated improved outcomes in Early stabilization of pelvic ring injuries has demonstrated improved outcomes in patients with pelvic fractures. Stabilization of pelvic fractures immobilizes bleeding patients with pelvic fractures. Stabilization of pelvic fractures immobilizes bleeding cancellous surfaces, thereby decreasing overall blood loss (Huittinen, 1973). cancellous surfaces, thereby decreasing overall blood loss (Huittinen, 1973). Goldstein et al noted decreased operative time, blood transfusions, and hospital stays Goldstein et al noted decreased operative time, blood transfusions, and hospital stays for patients who were treated within 24 hours of hospital admission (Goldstein, 1986). for patients who were treated within 24 hours of hospital admission (Goldstein, 1986). Similarly, Latenser et al noted decreased complications, blood loss, hospital stays, Similarly, Latenser et al noted decreased complications, blood loss, hospital stays, long-term disability, and better survival for patients treated within 8 hours of hospital long-term disability, and better survival for patients treated within 8 hours of hospital admission (Latenser, 1991).admission (Latenser, 1991).

Injury pattern and reduction of fracture-related displacements have been correlated Injury pattern and reduction of fracture-related displacements have been correlated with outcome results. Injuries involving the SI joint are associated with poorer results with outcome results. Injuries involving the SI joint are associated with poorer results when compared to patients with either sacral fractures or iliac wing fractures when compared to patients with either sacral fractures or iliac wing fractures (Holdsworth, 1948; Schield, 1991; Tilem, 1988). Posterior pelvic displacement of 5 (Holdsworth, 1948; Schield, 1991; Tilem, 1988). Posterior pelvic displacement of 5 mm has been identified as leading to poorer patient outcomes (Pohlemann, 1994). mm has been identified as leading to poorer patient outcomes (Pohlemann, 1994). Another study noted that pelvic displacement greater than 1 cm in any plane led to Another study noted that pelvic displacement greater than 1 cm in any plane led to increased levels of pain when compared to patients with less than 1 cm of increased levels of pain when compared to patients with less than 1 cm of displacement. Limb length discrepancy greater than 2.5 cm also has been implicated displacement. Limb length discrepancy greater than 2.5 cm also has been implicated in poor results (Tilem, 1988).in poor results (Tilem, 1988).

Anterior-posterior (AP) compression pelvic fracture.

Vertical shear (VS) fracture pattern.

Denis zone II sacral fracture

Crescent fracture on CT sca

Anterior-posterior compression pelvic fracture with an associated Denis zone II sacral fracture. (The symphysis was plated with a 3.5-mm reconstruction plate, and the sacrum was fixed with iliosacral screws.)

Basic principles of treatment of breaks of lower extremity and pelvis.

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Transcript of Basic principles of treatment of breaks of lower extremity and pelvis.