Common adult fracturesAxial skeleton (Pelvis)

Waleed M. Awwad, MD. FRCSCAssistant professor and Consultant

Orthopedic Surgery department

Pelvic fracturesPelvic fractures

EpidemiologyEpidemiology

• 37 cases per 100,000 / year at USA.• Age:– Young: high energy mechanisms.– Elderly: minimal trauma.

• Male are more commonly affected before the age of 35.

• 37 cases per 100,000 / year at USA.• Age:– Young: high energy mechanisms.– Elderly: minimal trauma.

• Male are more commonly affected before the age of 35.

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

Pelvic stabilityPelvic stability

• Rotational or vertical.– Sacroiliac displacement 5mm.– Posterior fracture gap.– Symphysis diastasis.

• Specific injury pattern (direction of force):– AP external rotation of hemipelvis, spring

open.– LC (T-bone):

• Posterior half of ilium.• Anterior half of iliac wing.• Greater trochanteric region.• External rotation and abduction, shear forces.

Pelvic fracture patterns.Pelvic fracture patterns.

AssessmentAssessment

• ABCDE’s must be assessed first and treated appropriately.• Patients should be examined with spinal collar until spinal

pathology is excluded.• Careful log rolling keeping the head, neck and pelvis in line should

be done to examine the spine properly.• Pelvic stability test (AP-LC only once).• Massive flank or buttock contusion.• Palpation of posterior aspect, symphysis and perineum.• Digital rectal and vaginal exam in any pelvic ring fractures.

• ABCDE’s must be assessed first and treated appropriately.• Patients should be examined with spinal collar until spinal

pathology is excluded.• Careful log rolling keeping the head, neck and pelvis in line should

be done to examine the spine properly.• Pelvic stability test (AP-LC only once).• Massive flank or buttock contusion.• Palpation of posterior aspect, symphysis and perineum.• Digital rectal and vaginal exam in any pelvic ring fractures.

AssessmentAssessment

• Hemodynamic status:

– Usual cause of retroperitoneal hemorrhage is venous.– Arterial bleeding:

• Small vessels: embolization• Large vessels: immediate surgical exploration.

• At emergency: open book pelvic fracture.– Pelvic wrapping at the level of GT.

• Hemodynamic status:

– Usual cause of retroperitoneal hemorrhage is venous.– Arterial bleeding:

• Small vessels: embolization• Large vessels: immediate surgical exploration.

• At emergency: open book pelvic fracture.– Pelvic wrapping at the level of GT.

AssessmentAssessment

AssessmentAssessment

Associated injuriesAssociated injuries

• Neurological: Lumbosacral plexus and nerve root.

• Genitourinary:– Bladder: 20% incidence.

• Extraperitoneal: foley if unable to pass.• Intraperitoneal: surgical repair.

– Urethral:10% incidence. male > females.• Blood at meatus or catheterization, high ridding

prostate.• Any clinical suspicion retrograde urethrogram.

• Bowel: perforation (open injury), rarely entrapment.

• Diverting colostomy.

Radiographic evaluationRadiographic evaluation

• AP pelvic view.• Inlet and outlet views.• Obturator and iliac oblique views if acetabular

fracture.• Computed tomography.• MRI (limited clinical utility).

Radiographic evaluationRadiographic evaluation

ManagementManagement

• Depend on severity and stability.

ManagementManagement

• Depend on severity and stability.• If stabile: protected weight bearing and serial

X-rays.• If unstable:– External fixation.– Internal fixation.

• Absolute surgical indication:– Open pelvic fractures.– Open book pelvic fracture or vertical unstable.

Acetabulum Acetabulum

• 3 per 100,000 population / year.• Neurological injury up to 30% (peroneal

division more than tibial).• Components:– Anterior and posterior column.– Acetabular dome (weight bearing area).

RadiologicalRadiological

• Obturator and iliac oblique views:

– Iliac oblique: posterior column, iliac wing and anterior wall of the acetabulum.

– Obturator oblique: anterior column and posterior wall of the acetabulum.

RadiologicalRadiological

ClassificationClassification

ManagementManagement

• Goal of treatment is anatomic restoration of articular surface to prevent post traumatic arthritis.

• Non operative treatment:– Non displaced fracture or less than 2mm displacement.– Less than 20% posterior wall fracture.

• Surgical treatment:– Displacement >2mm.– Large posterior wall fragment. – Intra-articular fragment.– Irreducible fracture dislocation. – Posterior instability.

QuestionsQuestions