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Orthopaedic Evaluation of Pelvic Ring

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Orthopaedic Evaluation of Pelvic Ring & Acetabulum Fractures Department of Orthopaedics Garden City Hospital James M. Steinberg, D.O. Clinical Evaluation Immediate ... – PowerPoint PPT presentation

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Title: Orthopaedic Evaluation of Pelvic Ring


1
Orthopaedic Evaluation of Pelvic Ring
Acetabulum Fractures
  • Department of Orthopaedics
  • Garden City Hospital
  • James M. Steinberg, D.O.

2
Clinical Evaluation
  • Immediate life-threatening problems addressed
    first
  • ATLS protocols (ABCs)
  • Team approach
  • General surgery, Neurosurgery, Vascular surgery
  • Rule out life threatening injuries
  • Head, chest and abdominal injuries
  • Examine for an open pelvic fx
  • Inspect the perineum carefully

3
Associated Injuries
  • Hemorrhage - 75
  • Urogenital - 12
  • Lumbosacral plexus - 8
  • Other associated musculoskeletal - 60-80
  • Mortality rate is about 15-25
  • Important to distinguish b/t stable and unstable
    pelvic injuries

4
Physical Signs of Pelvic Instability
  • Massive flank or buttock contusions and swelling
  • Significant bleeding
  • Deformity of lower extremity that is not
    fractured
  • Leg length discrepancy
  • Markedly internally or externally rotated pelvis

5
Testing for Pelvic Stability
  • AP-Lateral compression test
  • Performed by one person
  • First clot is the best clot
  • Subsequent clotting of retroperitoneal hemorrhage
    difficult due to IV dilution exhaustion of
    clotting factors
  • Palpation of the symphysis
  • widening
  • Palpation of posterior aspect of the pelvis
  • Large hematoma
  • Gap through the disrupted fx area
  • Dislocation of SI joint

6
Radiographic Evaluation
  • AP
  • Anterior lesions pubic rami and symphysis
  • SI joint sacral fxs
  • Iliac fxs
  • L5 transvers process fxs
  • Landmarks
  • Iliopectineal line (limit of anterior column)
  • Ilioischial line (limit of posterior column)
  • Ant posterior lips
  • teardrop

7
Radiographic Evaluation
  • Inlet
  • X-ray taken in supine position with the tube
    directed 60 degrees caudally
  • Determine posterior displacement of SI joint,
    sacrum or iliac wing
  • Determine internal rotation deformities of ilium
    and sacrum

8
Radiographic Evaluation
  • Outlet
  • Taken in supine position with the tube directed
    45 degrees cephalad
  • Determine vertical displacement of hemipelvis
  • Visualize sacral formina

9
Radiographic Evaluation
  • Iliac Oblique
  • 45 degree external rotation view
  • Posterior column (ilioischial line) anterior
    wall

10
Radiographic Evaluation
  • Obturator Oblique
  • 45 degree internal rotation view
  • Anterior column (iliopectineal line) posterior
    wall

11
Radiographic Evaluation
  • CT Scan
  • Allows visualization of posterior structures of
    the pelvis
  • Assess impacted fxs of the acetabular wall, bone
    fragments in the joint, and degree of comminution
  • 3-D reconstruction permits direct visualization
    of the acetabular articular surface by
    subtracting the femoral head

12
Radiographic MeasurementsAcetabulum
  • Roof arc
  • Formed by angle betw a line drawn vertically thru
    the geometric center of the acetabulum from the
    fx line to the geometric center
  • Limited usefulness for both column fxs
    posterior wall fxs
  • Medial roof arc AP view
  • Anterior roof arc obturator oblique
  • Posterior roof arc iliac oblique
  • All three roof arcs should be gt 45 degrees

13
Radiographic Lines Review
14
Pelvic Anatomy
  • Three bones Sacrum and two innominate bones
  • Three ossification centers Ilium, ischium, and
    pubis coalesce at triradiate cartilage
  • Two major joints Two SI and the symphysis pubis
  • The three bones and three joints have no inherent
    stability without ligaments
  • Strongest most important ligaments are the
    Posterior SI Ligaments

15
Pelvic Anatomy
  • Posterior SI ligaments are divided into two
    components short and long
  • Short oblique running from the posterior ridge
    of the sacrum to the PSIS and PIS of the ilium
  • Long run longitudinally from lateral sacrum to
    PSIS and merge with the sacro-tuberal ligaments
  • The long ligaments cover the short

16
Pelvic Anatomy
  • Anterior SI ligaments
  • span across the sacrum to the ilium
  • provide some stability but less than posterior
  • SI joints have two parts
  • inferior has articular surfaces and is synovial
  • upper more dorsal part is fibrous
  • 5 degree tilt of SI joints to accommodate the
    upright position

17
Pelvic Anatomy
  • Symphysis pubis
  • synovial with hyaline cartilage
  • covered by fibrocartilage then surrounded by a
    thick fibrous band
  • reinforced inferiorly by muscle and the arcuate
    ligament
  • thickest portion of the joint is superior and
    anterior

18
Pelvic Anatomy
  • Sacrotuberous ligament
  • runs from the sacrum to the ischial tuberosity
  • thickens to form the falciform tendon that blends
    with the obturator membrane and the posterior
    origin of the gluteus maximus
  • Along with the posterior SI ligaments the
    sacrotuberous ligament provides vertical
    stability

19
Pelvic Anatomy
  • Sacrospinous ligament
  • triangular and runs from the sacrum and coccyx to
    the sacrotuberous ligament to insert into the
    iliac spine
  • divides posterior column into the greater and
    lesser sciatic notch and is covered by the pelvic
    floor
  • The sacrospinous ligaments helps provide
    rotational control

20
Pelvic Anatomy
  • Iliolumbar ligaments
  • secure the pelvis to the lumbar spine from the
    L4,5 transverse process to the posterior iliac
    crest
  • Lumbosacral ligaments
  • run from the transverse process of L5 to the
    sacral ala
  • Transversely placed ligaments resist rotational
    forces
  • short posterior SI, anterior SI, iliolumbar
    sacrospinous ligaments
  • Vertically placed ligaments resist vertical shear
  • long posterior SI, sacrotuberous, lateral
    lumbarsacral ligaments

21
Pelvic Ligaments
22
Pelvic Anatomy
  • Intact pelvis is divided into the true and false
    pelvis by the pelvic brim (iliopectineal line)
  • False pelvis is lined by the iliacus muscle and
    contains abdominal contents
  • True pelvis floor consists of
  • coccyx, coccygeal and levator ani muscles
  • urethra, rectum and vagina that pass through it
  • obturator membrane the greater and lesser
    sciatic notches

23
Pelvic Anatomy
  • Obturator vessels exit in the superior portion of
    the foramen
  • Superior and inferior gluteal vessels, piriformis
    muscle and sciatic nerve exit through the greater
    sciatic notch
  • L5 root exits under the L5 transverse process to
    cross the sacral ala 2 cm medial to the SI joint
  • The median sacral artery lies on the anterior
    midline of the sacrum

24
Pelvic Anatomy
  • Superior rectal artery is midline and posterior
  • Common iliac divides into the internal and
    external iliacs at the pelvic brim
  • Bladder is superior to the pelvic floor
  • Weak link in the urethra is below the pelvic
    diaphram at its bulbous portion

25
Acetabular Anatomy
  • Acetabulum is regarded as a socket contained
    within 2 arms of an inverted Y
  • Two-column pelvis
  • Posterior column ilioischial component
  • Anterior column iliopubic component

26
Stability
  • McBroom Tile sequentially sectioned pelvic
    ligaments to determine the spectrum pelvic
    stability
  • Symphysis sectioned diastasis was no greater
    than 2.5 cm due to intact anterior SI ligaments
    and sacrospinous ligaments
  • Symphysis and sacrospinous ligaments sectioned
    greater than 2.5 cm of diastasis was noted
    (rotationally unstable)

27
Stability
  • Sectioning of the symphysis, sacrospinous,
    sacrotuberous, and posterior SI ligaments the
    pelvis was unstable in rotation and vertically
  • Bony equivalents to ligament disruptions
  • SI dislocation
  • Vertical pubic rami fractures
  • L5, L4 transverse process fractures
  • Avulsions of the iliac spine and ischial
    tuberosity

28
AP Force PatternPelvic Fractures
  • External rotation of the hemipelvis
  • Pelvis springs open, hinging on the intact
    posterior ligaments
  • Force applied to the ASIS will externally rotate
    both hemipelvi
  • Often seen in pedestrian vs auto and MCA

29
Lateral Compression ForcePelvic Fractures
  • Most common pattern
  • Creates impaction through cancellous bone of the
    sacrum and SI joint
  • Force thru posterior half of ilium
  • Classic lateral compression with min soft tissue
    disruption (stable)
  • Force directed over anterior half of iliac wing
  • Rotation of hemipelvis inward with poss
    disruption of posterior SI ligament complex
  • Force through the greater trochanter
  • Poss transverse acetabular fx
  • Often due to MVA
  • High incidence of brain and visceral injuries but
    less incidence of pelvic vascular injuries

30
Anterior Lateral CompressionPelvic Fractures
  • Rotates the hemipelvis inward pivoting around the
    SI joint
  • Anterior portion of the sacrum will be crushed
    followed by disruption of the posterior SI
    ligaments
  • Sacrospinous and more importantly the
    sacrotuberous are intact therefore vertically
    stable and rotationally unstable
  • If force continues it will externally rotate the
    opposite hemipelvis

31
External Rotation AbductionPelvic Fractures
  • Common in MCA
  • Force is through femoral shaft and head
  • Tends to tear the hemipelvis from the sacrum
  • Completely tears the posterior ligamentous
    structures

32
Shear ForcePelvic Fractures
  • High energy applied perpendicular to the bony
    trabecular pattern
  • Will lead to triplanar instability
  • Disrupts the sacrospinous and sacrotuberous
    ligaments
  • Ligament avulsions in the young and bony
    fractures in the elderly
  • Vertical shear injuries result from falls

33
Mechanism of InjuryAcetabular Fractures
  • Femoral head acts as a hammer
  • Direct Force
  • Direct blow to greater troch
  • Hip in neutral position transverse fx
  • Hip externally rotated ant. column
  • Hip internally rotated posterior column
  • Indirect Force
  • Dashboard injury to flexed knee
  • As hip flexion increases, inf portion of
    posterior wall fx
  • As hip flexion dec below 90 degrees, sup portion
    of posterior wall fx

34
Pelvic Fracture Classifications
  • Letournel
  • Young-Burgess
  • Tile

35
LetournelAnatomic
  • A. Iliac wing
  • B. Ilium into SI joint
  • C. Transsacral
  • D. Unilateral sacral fracture
  • E. SI fracture-dislocation
  • F. Acetabular fractures
  • G. Pubic rami fractures
  • H. Ischial fractures
  • I. Symphysis diastasis

36
Young-BurgessMechanism of Injury
  • Alerts the surgeon to the potential resuscitation
    problems associated with pelvic fractures
  • Three major components
  • Lateral compression force
  • Anterior-posterior compression force
  • Vertical shear force

37
Lateral Compression Force
  • Type I posterior-lateral force causes sacral
    impaction transverse rami fxs (stable injury)
  • Type II more anterior-lateral force causes
    disruption of posterior ligaments but is
    vertically stable (may have an anterior sacral
    impaction)
  • Type III lateral force continues across the
    pelvis to produce external rotation injury to
    contralateral hemipelvis (windswept pelvis)

38
AP Compression Force
  • Type I lt2.5cm of pubic diastasis or vertical
    fxs of one or both pubic rami no posterior
    injury
  • Type II gt2.5cm of pubic diastasis with opening
    of the anterior SI joints but is vertically
    stable
  • Type III complete disruption anteriorly and
    posteriorly with significant sacral diastasis or
    displaced vertical rami fxs (completely unstable
    fx)

39
Vertical Shear Force
  • Hemipelvis is torn from the sacrum
  • Completely unstable fx
  • Associated with significant retroperitoneal
    hemorrhage and other major injuries

40
Tile Classification
  • Type A Stable
  • A1 - Fxs outside of the pelvic ring
  • A2 - Stable, minimal displacement
  • A3 - Transverse fxs of sacrum and coccyx

41
Tile Classification
  • Type B Rotationally Unstable, Vertically
    Posteriorly Stable
  • B1 - External rotation (open book)
  • B2 - Internal rotation unstable (lateral
    compression injury)
  • B3 - Bilateral rotationally unstable injury

42
Tile Classification
  • Type C Rotationally, Posteriorly and
    Vertically Unstable
  • C1 - Unilateral injury
  • C2 - Bilateral injury, one side vertically
    unstable and the other rotationally unstable
  • C3 - Bilateral injury, both hemipelvi are
    completely unstable

43
Acetabulum Fracture Classification
  • Judet-Letournel
  • Based on trauma and resultant damage to the two
    columns
  • Ten fracture patterns five elementary five
    associated

44
Elementary FracturesAcetabulum
  • Posterior Wall
  • Marginal impaction
  • Fx-dislocations
  • Posterior Column
  • Typically detaches in one fragment
  • Femoral head often dislocates centrally
  • Anterior Wall
  • Iliopectineal line disrupted
  • Teardrop displaces inward
  • Anterocentral displacement of femoral head

45
Elementary FracturesAcetabulum
  • Anterior Column
  • Break in iliopectineal line
  • Anteromedial displacement of femoral head
  • Transverse
  • Ilioischial teardrop keep normal relationship
  • Innominate bone in two fragments
  • Articular surface divided in one of three ways
  • Thru the roof (transtectal)
  • At the junction of roof acetabuli (juxtatectal)
  • Thru the fossa acetabuli (infratectal)

46
Associated FracturesAcetabulum
  • Posterior Wall Column
  • Wall is usually markedly displaced rotated
  • Posterior hip dislocation often associated with
    sciatic nerve injury
  • Transverse Posterior Wall
  • 2/3 femoral head dislocates posteriorly
  • 1/3 femoral head dislocates centrally
  • T-shaped
  • Combines tranverse fx (transtectal, juxtatectal
    or infratectal) with a vertical fx that divides
    the ischiopubic fragment into 2 parts

47
Associated FracturesAcetabulum
  • Anterior Column Posterior Hemitransverse
  • Ant wall/column with a fracture line that divides
    the posterior column
  • Both Column
  • Central acetabular fracture
  • Floating acetabulum
  • Wing sign
  • Most complex of all acetabular fxs
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