PELVIC RING INJURIES AND ACETABULAR FRACTURES NORDIC … · 2016-05-23 · –Letournel acetabular...
Transcript of PELVIC RING INJURIES AND ACETABULAR FRACTURES NORDIC … · 2016-05-23 · –Letournel acetabular...
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PELVIC RING INJURIES AND
ACETABULAR FRACTURES
NORDIC TRAUMA 2016, AARHUS
Ken F. Linnau, MD, MS
Emergency Radiology
Harborview Medical Center – University of Washington
Seattle, WA
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Thanks to:
AJ Wilson, Spanaway, WA (formerly U of
Washington)
CC Blackmore, VMMC, Seattle, WA
RO Nathan, U of Washington, Seattle, WA
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http://en.wikipedia.org/wiki/File:2008_Wrangler_JK_Unlimited_Sahara.jpg
Jeep Wrangler JK Unlimited Sahara
1948 kg, 55 km/h (15m/s)
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http://en.wikipedia.org/wiki/File:2011_Ford_F-250_XLT_--_07-10-2010.jpg
Ford F250 Quad Cab
3715 kg, 65 km/h (18 m/s)
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SOMETIMES THEY CRASH
CRASH!!
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HOW BIG OF A BANG?
• E kin = ½ mv2
• E kin = ½ (3715 kg + 1948 kg)*
(18m/s +15 m/s)2
• E kin = 3 MJ
• ≈ two sticks of dynamite
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SOMETIMES THEY CRASH
CRASH!!
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EPIDEMIOLOGY: PELVIC RING
• Pelvic ring injury (19-37/100,000)
– About 2 % of all fractures
• Mortality rate: 9-19% (45% when open)
– Much higher than acetabular fx
• High-energy injury mechanism:
– MVC, MCC
– Car vs pedestrian
– Falls
• Associated injuries are very common
– Injury severity score (ISS) often > 15 (major trauma) Pohlemann-T et al. Injury 42 (2011): 997.
Gabbe-BJ et al. Injury 42 (2011): 985.
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EPIDEMIOLOGY: ACETABULUM
• Acetabular fractures are uncommon (3/100,000)
• Mortality rate: about 3%
– Much lower than pelvic ring disruption
• Most common mechanism:
– MVC (up to 80%)
– Falls (increasing)
– Car vs pedestrian
• Elderly: Mean age trending up (falls?)
• Elderly: Injury severity (ISS) trending down
Laird-A, Keating- JF, JBJS, 2005; 87-B: 969
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HOW DOES PELVIC RING INJURY KILL?
• Pelvic ring injuries bleed.
– Most bleeding is venous (> 80%)
– Arterial bleeding in less than 20%
– Arterial injury can be treated with embolization
• Level I recommendations for hemodynamically unstable patients
– Size of extraperitoneal hematoma predicts arterial injury and need for transfusion
– Pelvic angiography indicated in 3-10% of pelvic fractures
Blackmore-CC et al. Arch Surgery (2003); 138:504-9.
Cullinane-DC et al. J Trauma (2011) 71(6): 1850-68.
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HOW TO SELECT FOR ANGIO?
• No CT available, xray only:
• Clinical prediction rule
• With CT available:
• Absence of blush dismisses need for pelvic hemorrhage control in majority of cases
• Arterial contrast extravasation: angio Blackmore-CC et al. J Trauma (2006); 61(2): 346-52.
Verbeek-DOF et al. J Trauma (2014); 76(2): 374-79.
Cullinane-DC et al. J Trauma (2011); 71(6): 1850-68.
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PREDICTING MAJOR PELVIC
HEMORRHAGE
• Displaced obturator ring fracture (> 1cm)
• Diastatic symphysis (> 1cm)
• Hematocrit < 30%
• Pulse > 130 beats/min
None: less than 2% major pelvic hemorrhage
3 or 4: more than 60% major pelvic hemorrhage
Blackmore-CC et al. J Trauma (2006); 61(2): 346-52.
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Pulse 130
First Hct 19%
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IMAGING
–AP radiograph: overview
–Oblique pelvic views • Inlet and outlet views for pelvic ring injury
• Judet views for acetabulum (Obturator oblique/Iliac oblique)
–CT best for full assessment of injury • Consider 3D reformations
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HOW TO CLASSIFY PELVIC RING INJURY
• Use Young-Burgess or modified Tile (AO/OTA).
– Most widely used by orthopedic surgeons
– Both aim to aid in treatment decision making
• Modified Tile (AO/OTA):
– Emphasizes stability and mechanism of injury
• Young-Burgess:
– Based primarily on mechanism of injury
– Higher reliability over all (optimal) Koo-H et al. J Orthop Trauma (2008) 22 (6):379-84.
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Young Burgess:
Combined Mechanism (CM)
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ACETABULUM: SURGEONS WANT TO
KNOW…
– Type of fracture
– Alignment and displacement
– Stability
– Type of surgical exposure
– Letournel acetabular classification
• Helps to select appropriate exposure
• May predict outcome
ML Routt, Jr.: “Surgical treatment of acetabular fractures” in Skeletal
Trauma, 4th Ed, Saunders 2009
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38 YOM, 6 FT FALL
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Logroll
patient 45°
in each
direction
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LETOURNEL AND JUDET COLUMN
CONCEPT
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ANTERIOR COLUMN OF THE
ACETABULUM
– Anterior border of the iliac wing
– Pelvic brim: the bony ridge in the cavity of the pelvis that marks the boundary between the false pelvis and the true pelvis
– Superior pubic ramus
– Anterior wall of acetabulum
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POSTERIOR COLUMN OF THE
ACETABULUM
• Posterior column – Greater and lesser
sciatic notch
– Ischial tuberosity
– Posterior wall of acetabulum
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LETOURNEL AND JUDET FRACTURE
CLASSIFICATION
Simple
fractures
Posterior wall Posterior
column
Anterior wall Anterior
column
Transverse
Complex
fractures
Posterior
column and
Posterior wall
Transverse
and posterior
wall
T- type
transverse
Anterior column
and posterior
hemitransverse
Both column
30%
70%
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LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse Ant column Anterior wall
Transv/ post wall Post column Post wall
T-type AC/ post hemitransv Transverse / post wall
PC/ post wall Post col/ post wall
Both column
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LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse Ant column Anterior wall
Transv/ post wall Post column Post wall
T-type AC/ post hemitransv Transverse / post wall
PC/ post wall Post col/ post wall
Both column
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Transverse Column Wall
Sagittal Coronal Peripheral
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MORE EPIDEMIOLOGY
Ferguson TA, et al. JBJS-Br 2010: 92-B, 2: 250
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LETOURNEL AND JUDET CLASSIFICATION –
RESHUFFLED BY PREVALENCE
Transverse Column Wall
Transverse/ post wall
Both column Post wall
T-type AC/ post hemitransverse Anterior wall
Transverse
Ant column
PC/ post wall
Post column
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LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse/ post wall Both column Post wall
T-type
Transverse
80-90% of all acetabular fxs
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22 YOM MVC
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22 YOM MVC
Posterior wall fracure
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47 YOM BICYCLE CRASH
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LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse/ post wall Both column Post wall
T-type
Transverse
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85 YOF FALL
Sagittal
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85 YOF FALL
Transverse
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29 YOF MVC
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29 YOF MVC
Sagittal
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29 YOF MVC
Superior
Inferior
Transverse T-
type
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22 YOM MVC
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22 YOM MVC
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22YOM MVC
Both
column
Anterior
Posterior
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22YOM MVC
Johnson TS. Radiology 2005; 235(3): 1023
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43 YOM MCC
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43 YOM MCC
Sagittal Peripheral
Transverse with associated posterior wall fracture
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43 YOM MCC
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SUMMARY
• Pelvic ring injuries may require angio-embolization
– Consider using clinical prediction rule
– Retroperitoneal hematoma size
– Blush on CT
• Posterior wall, both column and transverse variants account for 80-90% of acetabular fractures
• Column == Coronal at the tectum
• Transverse == Sagittal at tectum, no iliac wing extension
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SURGICAL APPRAOCH
Surgical approach Fracture type
Kocher - Langenbeck Posterior wall
Posterior column
Transverse
Transverse –Posterior wall
Some T-type
Ilioinguinal Anterior column
Anterior wall
Anterior column posterior
hemitranverse
Transverse
Both column
Some T-type
Extended Iliofemoral, Stoppa,
trochanteric flip
Variable
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Copyright © 2006 by the American Roentgen Ray Society
Durkee, N. J. et al. Am. J. Roentgenol. 2006;187:915-925
--Normal pelvic bone anatomy