FRACTURES OF SPINE AND PELVIC

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FRACTURES OF SPINE AND PELVIC
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Fracture of the spine
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Anatomy

• Three-column concept
• The anterior column contains the anterior
  longitudinal ligament, the anterior 2/3 of the
  vertebral body, and the anterior portion of the
  annulus fibrosus.
• The middle column consists of the posterior
  longitudinal ligament, the posterior 1/3 of the
  vertebral body, and the posterior aspect of the
  annulus fibrosus.
• The posterior column includes the neural arch,
  the ligamentum flavum, the facet capsules, and
  the interspinous ligaments

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• The cervical spinal column is extremely
  vulnerable to injury
• The seven cervical vertebrae, whose specific
  facet joint articulations allow movement in the
  planes of flexion, extension, lateral bending,
  and rotation, have attached at the cephalic
  aspect the skull and its contents
• Injury occurs when forces applied to the head and
  neck result in loads that exceed the ability of
  the supporting structures to dissipate energy
• Meyer identified C2 and C5 as the two most common
  areas of cervical spine injury.
• Injuries of the cervical spine produce
  neurological damage in approximately 40 of
  patients

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• Important anterior and posterior supporting
  structures of spine

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Classifications

• Fractures of thoracolumbar spine

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• Three-column classification of spinal
  instability. Illustrations of anterior, middle,
  and posterior columns

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McAfee classification of Fractures of
thoracolumbar spine

• McAfee et al. determined the mechanisms of
  failure of the middle osteoligamentous complex
  and developed a new system based on these
  mechanisms

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1)Wedge compression fractures

• cause isolated failure of the anterior column and
  result from forward flexion. They are rarely
  associated with neurological deficit

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2)Stable burst fractures

• the anterior and middle columns fail because of
  a compressive load, with no loss of integrity of
  the posterior elements

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• 3)Unstable burst fractures

• the anterior and middle columns fail in
  compression, and the posterior column is
  disrupted. The posterior column can fail in
  compression, lateral flexion, or rotation. There
  is a tendency for posttraumatic kyphosis and
  progressive neural symptoms because of instability

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4)Chance fractures

• are horizontal avulsion injuries of the
  vertebral bodies caused by flexion about an axis
  anterior to the anterior longitudinal ligament.
  The entire vertebra is pulled apart by a strong
  tensile force

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5)Flexion distraction injuries

• the flexion axis is posterior to the anterior
  longitudinal ligament. The anterior column fails
  in compression while the middle and posterior
  columns fail in tension. This injury is unstable
  because the ligamentum flavum, interspinous
  ligaments, and supraspinous ligaments usually are
  disrupted

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6)Translational injuries

• are characterized by malalignment of the neural
  canal, which has been totally disrupted. Usually
  all three columns have failed in shear. At the
  affected level, one part of the spinal canal has
  been displaced in the transverse plane

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Classifications

• Fractures of cervical spine

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1.Flexion injury

• the result of compression of anterior column
  and distraction of posterior column
• ? anterior subluxation caused by rupture of
  the ligament of posterior column ( complete or
  incomplete)

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• ? bilateral facet dislocations extreme
  flexionrupture of ligament of middle and
  posterior column (may with approximately 50
  anterior subluxation of the vertebral body. In a
  more severe case, may have full vertebral body
  width displacement anteriorly or a grossly
  unstable motion segment, giving the appearance of
  a floating vertebra )
• ? simple wedge compression commonly seen in
  clinic, and happened more frequently in
  osteoporosis patient

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2. Vertical compression injury

• (1) Jefferson fracture fracture of anterior
  and posterior arch of atlas

A, Drawing indicating axial view of stable
Jefferson fracture (transverse ligament
intact). B, Drawing indicating axial view of
unstable Jefferson fracture (transverse ligament
ruptured)
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• (2) Burst fracture commonly seen in C5 and C6
  The centrum is fragmented, and the displacement
  is peripheral in multiple directions. The centrum
  fails, with significant impaction and
  fragmentation. The posterior aspect of the
  vertebral body is fractured and may be displaced
  into the spinal canal.

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3. Extension injury

• (1) Distractive extension
• either failure of the anterior ligamentous
  complex or a transverse fracture of the centrum
• evidence of failure of the posterior
  ligamentous complex, with displacement of the
  upper vertebral body posteriorly into the spinal
  canal, in addition to the changes seen in the
  previous injuries

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• (2) Hangmans fracture
• vertical fracture of the vertebral arch of dens

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4. Fracture of unknown mechanisms --Dens
fracture

• Anderson and DAlonzo classified odontoid
  fractures into three types
• Type I is oblique fracture through upper part of
  odontoid process
• Type II is fracture at junction of odontoid
  process and body of second cervical vertebra
• Type III is fracture through upper body of
  vertebra

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• Three types of odontoid process fractures

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Clinical evaluation

• Once the patient has been stabilized according to
  trauma care principles, patients history can be
  reviewed. Details of the mechanisms of injury can
  arouse or confirm suspicion of trauma to the
  spinal column
• The patients symptoms at the time of injury may
  provide important information in the assessment
  of neurologic impairment. Transient paresis or
  paresthesias suggest a major fracture pattern

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• The physical examination should include palpation
  of the spine from head to sacrum. Any areas of
  tenderness or bruising are noted
• A careful neurological evaluation is done
• The rectal examination is important. Perianal
  sensation is provided by the lower sacral roots.
  The patients ability to contract the sphincter
  voluntarily indicates sacral root motor function
• Assessment of the bulbocavernosus reflex
  determines whether the patient is in spinal shock
  or whether a permanent complete lesion exists

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• Plain roentgenograms and CT scanning provide
  static images
• Occult ligamentous injuries are not readily
  identified on plain films or CT scans, and
  flexion and extension views of the thoracolumbar
  spine are risky
• MRI is helpful in detecting occult ligamentous
  injuries and hemorrhage into surrounding soft
  tissue structures and in determining the extent
  of neural damage and the degree of cord edema

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Acute management

• Almost 50 of patients who sustain spinal trauma
  have other associated injuries
• Patient management begins at the accident site.
  The key is to suspect spinal column injury in any
  patient who has multiple trauma
• The most common spine injuries occur as the
  result of motor vehicle accidents, falls, and
  sports injuries. These patients should not be
  moved until the spine has been temporarily
  immobilized. This is usually archived with a
  rigid spine board. A hard collar is usually
  carefully applied

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• Any turning or transfer of the patient must be
  done with gentle in-line traction and log-rolling
• Appropriate maintenance of airway, breathing, and
  circulation must be initiated before further
  attention to the spine is given

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Treatment

• Timing of surgery
• In the presence of a progressive neurological
  deficit, emergency decompression is indicated
• In patients with complete spinal cord injuries or
  static incomplete spinal cord injuries, some
  authors advocate delaying surgery for several
  days to allow resolution of cord edema.
• For neurologically normal patients with unstable
  spinal injuries and those with nonprogressive
  neurological injuries, open reduction and
  internal fixation should be carried out as soon
  as possible

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Surgical treatment

• In most patients early open reduction and
  internal fixation are indicated to obtain
  stability and allow early functional
  rehabilitation
• Cervical spine fractures may be stabilized
  through an anterior, a posterior, or a combined
  approach
• Unstable injuries of the cervical spine, with or
  without neurological deficit, generally require
  operative treatment

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Several basic principles

• ?The injury must be clearly defined before
  surgery by plain roentgenograms, high-resolution
  CT scanning with sagittal and coronal
  reconstruction, or MRI
• ?Laminectomy has a limited role in the treatment
  of cervical fractures or dislocations and may
  contribute to clinical instability and
  neurological deficit

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• ?Compression of the cervical cord or roots by
  retropulsed bone fragments or disc material
  usually is anterior therefore anterior
  decompression and fusion, with or without
  internal fixation, are indicated
• ?For posterior ligamentous or bony instability,
  posterior stabilization with internal fixation
  and bone grafting are indicated

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• Burst fracture of L2 in 42-year-old woman,
  with incomplete paraparesis, 3 weeks after
  injury.
• A and B, Myelograms show significant extradural
  compression at L2 level from bone retropulsed
  into spinal canal.
• C and D, CT scans show degree of canal compromise
  at L2 level.

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• E and F, CT scans show adequate decompression of
  spinal canal and proper placement of iliac strut
  graft from L1 to L3. Patient made excellent
  neurological recovery and regained ambulatory
  status, with return of bowel and bladder function

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• A, Compressive flexion injury in 20-year-old
  woman with complete C5 quadriplegia.
• B, CT scan shows encroachment on subarachnoid
  space and flattening of cervical cord, with
  fractures of left lateral mass.
• C, CT scan with sagittal reconstruction shows
  fracture of C5 vertebral body with mild
  displacement of posterior vertebral margin into
  spinal canal

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• D, CT scan after anterior decompression and iliac
  crest strut grafting.
• E,CT scan with sagittal reconstruction shows
  adequate decompression of spinal cord and proper
  position of graft from C4 to C6.
• F, Three years after surgery, lateral
  roentgenogram shows incorporation of graft and
  solid arthrodesis from C4 to C6.

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• a complete C5 quadriplegia

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• a complete C5 quadriplegia

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• Anteroposterior and lateral roentgenograms of
  C3-5 fusion with ORION anterior internal fixation
  device

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• Lateral view of cervical spine after internal
  fixation of C4-5 dislocation with lateral mass
  plates and screws

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Treatment of dens fracture

• Type I fractures are uncommon, and even if
  nonunion occurs after inadequate immobilization,
  no instability results
• Type II fractures are the most common
• Type III fractures have a large cancellous base
  and heal without surgery in 90 of patients

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• Anterior fixation of dens fracture with
  cannulated screws

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Spinal Cord Injury
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Pathophysiology of spinal cord injury

• Most spinal deficit is attributed to contusion
  and compression rather than to complete
  transection.
• The initial blunt injury leads to a sequence of
  molecular-level events that result in ischemia,
  tissue hypoxia, and secondary tissue degeneration

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Spinal shock

• After a severe spinal cord injury, a state of
  complete spinal areflexia can develop which lasts
  for a varying length of time, this state,
  conventionally termed Spinal shock, is
  classically evaluated by testing the
  bulbocavernosus reflex, a spinal reflex mediated
  by S3-S4 region of the conus medullaris. This
  reflex is frequently absent for the first 4 to 6
  hours after injury but usually returns within 24
  hours

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Spinal cord injury

• ?Central cord syndrome is the most common.
• It consists of destruction of the central area of
  the spinal cord, including both gray and white
  matter.
• Generally patients have a quadriparesis involving
  the upper extremities to a greater degree than
  the lower. Sensory sparing is variable, usually
  sacral pinprick sensation is preserved.
• Frequently patients show immediate partial
  recovery after being placed in skeletal traction
  through skull tongs.
• Prognosis is variable, more than 50 of patients
  have return of bowel and bladder control

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• ?Brown-Séquard syndrome
• It is an injury to either half of the spinal cord
  and usually is the result of a unilateral laminar
  or pedicle fracture, penetrating injury, or a
  rotational injury resulting in a subluxation.
• It is characterized by motor weakness on the side
  of the lesion and the contralateral loss of pain
  and temperature sensation.
• Prognosis for recovery is good

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• ?Anterior cord syndrome
• It usually is caused by a hyperflexion injury in
  which bone or disc fragments compress the
  anterior spinal artery and cord.
• It is characterized by complete motor loss and
  loss of pain and temperature discrimination below
  the level of injury.
• The posterior columns are spared to varying
  degrees resulting in preservation of deep touch,
  position sense, and vibratory sensation.
• Prognosis for significant recovery in this injury
  is poor

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• A and B, Central cord syndrome spinal cord is
  pinched between vertebral body and buckling
  ligamentum flavum.
• C, Brown-Séquard syndrome.
• D, Anterior cervical cord syndrome

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Conus medullaris syndrome

• Conus medullaris syndrome, or injury of the
  sacral cord (conus) and lumbar nerve roots within
  the spinal canal, usually results in areflexic
  bladder, bowel, and lower extremities.
• Most of these injuries occur between T11 and L2
  and result in flaccid paralysis in the perineum
  and loss of all bladder and perianal muscle
  control.
• The irreversible nature of this injury to the
  sacral segments is evidenced by the absence of
  the bulbocavernosus reflex and the perianal wink

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Cauda equina syndrome

• Cauda equina syndrome, or injury between the
  conus and the lumbosacral nerve roots within the
  spinal canal, results in areflexic bladder,
  bowel, and lower limbs.
• With a complete cauda equina injury, all
  peripheral nerves to the bowel, bladder, perianal
  area, and lower extremities are lost, and the
  bulbocavernosus reflex, anal wink, and all reflex
  activity in the lower extremities are absent
• It is important to remember that the cauda equina
  functions as the peripheral nervous system, and
  there is a possibility of return of function of
  the nerve rootlets
• Most often the cauda equina syndrome presents as
  a neurologically incomplete lesion.

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Paraplesia index

• To record the function of motor, sensory and
  bowel and bladder control respectively,
• 0normal,
• 1impaired,
• 2complete loss
• all scores are added, for a total maximal and
  minimal score of 6 and 0

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Complications

• 1) Respiratory failure and infections
• 2) Urinary tract infections are common, an
  intermittent catheterization program should begin
  immediately.
• 3) Skin breakdown (bedsore) in the insensate
  patient is commonplace and must be prevented by
  frequent turning and pressure relief measures.
• 4) Body temperature maladjustment

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Treatment

• 1) Adequate alignment and stabilization
• 2) The prevention of further injury to the
  comprised cord and the protection of uninjured
  cord tissue, (to reduce spinal cord edema and
  secondary injury), e.g. high-dose intravenous
  methylprednisolone (MPS), mannitol
• 3) Surgical treatment

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Goals of surgery

• 1) establishment of a balanced and stable spine
  with fusion of the minimal number of motion
  segments
• 2) return of the patient to optimal functional
  capacity as quickly and safely as possible
• 3) maximization of neurologic function
• 4) minimization of cost impact, complications,
  and hospital stay

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Indication of operation

• Fracture dislocation of spine with interlocking
  of facets
• Unsatisfied reduction of fracture of spine or the
  spine is unstable
• The spinal cord is compressed by cracked bone in
  the spinal canal which is approved by
  radiological examination
• Paralysis level increase which indicates the
  presence of active bleeding within the spinal
  canal

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PELVIC FRACTURES
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Anatomy

• The pelvis is composed anteriorly of the ring of
  the pubic and ischial rami connected with the
  symphysis pubis.
• A fibrocartilaginous disc separates the two pubic
  bodies.

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• 3. Posteriorly, the sacrum and the two
  innominate bones are joined at the sacroiliac
  joint by the interosseous sacroiliac ligaments,
  the anterior and posterior sacroiliac ligaments,
  the sacrotuberous ligaments, the sacrospinous
  ligaments, and the associated iliolumbar
  ligaments.
• 4. This ligamentous complex provides stability
  to the posterior sacroiliac complex, since the
  sacroiliac joint itself has no inherent bony
  stability.

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• A, Major posterior stabilizing structures of
  pelvic ring
• B, Tile compares relationship of posterior pelvic
  ligamentous and bony structures to suspension
  bridge, with sacrum suspended between two
  posterosuperior iliac spines

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Classifications

• Pennal et al. developed a mechanistic
  classification in which pelvic fractures are
  described as
• anteroposterior compression injuries,
• lateral compression injuries, or
• vertical shear injuries

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• Tile modified the Pennal system to make it an
  alphanumeric system involving three groups based
  on the concept of pelvic stability
• Type A Stable (posterior arch intact)
• A1 Avulsion injury
• A2 Iliac wing or anterior arch fracture
  caused by a transverse sacrococcygeal fracture

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• Type B Partially stable (incomplete disruption
  of posterior arch)
• B1 Open book injury (external rotation)
• B2 Lateral compression injury (internal
• rotation)
• B2-1Ipsilateral anterior and posterior
• injuries
• B2-2Contralateral (bucket handle)
• injuries
• B3 Bilateral

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Tile classification of pelvic fractures based on
forces acting on pelvis
Type B1 External rotation or anteroposterior
compression through left femur (arrows) disrupts
symphysis, pelvis, and anterior sacroiliac
ligament until ilium impinges against posterior
aspect of sacrum. If force stops at this level,
partial stability of pelvis is maintained by
interosseous sacroiliac ligaments.
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• Type B2-1 Lateral compression (internal
  rotation) force implodes hemipelvis. Rami may
  fracture anteriorly, and posterior impaction of
  sacrum may occur, with some disruption
  of posterior structures, but partial stability is
  maintained by intact pelvic floor and compression
  of sacrum.

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• Type C Unstable (complete disruption of
  posterior arch)
• C1 Unilateral
• C1-1Iliac fracture
• C1-2Sacroiliac fracture-dislocation
• C1-3Sacral fracture
• C2 Bilateral, with one side type B, one side
  
• type C
• C3 Bilateral

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• Type C Shearing (translational) force
  disrupts symphysis, pelvic floor, and posterior
  structures, rendering hemipelvis completely
  unstable.

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• Young and Burgess proposed a different
  modification of the original Pennal
  classification, adding a new category for
  combined mechanism injuries

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Lateral compression (LC) injuries

• Category Common characteristic
  Differentiating characteristic
• LC 1 Anterior transverse
  Sacral compression
• fracture (pubic rami)
  on side of impact
• LC 2 Anterior transverse
  Crescent (iliac wing) fracture
• fracture (pubic rami)
• LC 3 Anterior transverse
  Contralateral open book
• fracture (pubic rami)
  (APC) injury

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Anteroposterior compression (APC)

• APC 1 Symphyseal diastasis Slight
  widening of pubic symphysis
• 
  and/or Sl joint stretched but intact
• 
  anterior and posterior ligaments
• APC 2 Symphyseal diastasis Widened Sl
  joint,
• or anterior vertical
  disrupted anterior ligaments
• fracture
  intact posterior ligaments
• APC 3 Symphyseal diastasis Complete
  hemipelvis separation but no
• or anterior vertical
  vertical displacement complete sacroiliac
• fracture
  joint disruption complete anterior and
• 
  posterior ligament disruption
• 
  

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Vertical shear (VS) injuries

• VS Symphyseal diastasis or
  Vertical displacement anteriorly
• anterior vertical fracture
  and posteriorly, usually through
• 
  Sl joint, occasionally through
• 
  iliac wing and/or sacrum

CM Anterior and/or posterior,
Combination of other injury vertical
and/or transverse patterns LC/VS or
LC/APC components
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• In a subsequent series, lateral compression
  (LC) injuries were the most common injury
  pattern, accounting for 41 of the patients,
  followed by anteroposterior compression (APC)
  injuries (26), acetabular fractures (18),
  combined mechanism (CM) injuries (10), and
  vertical shear (VS) injuries (5). Hypovolemic
  shock and large blood requirements were more
  common in patients with vertically unstable APC
  type 3 injuries than in those with vertically
  stable anteroposterior or lateral compression
  injuries.

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Sacral fractures have been classified separately

• Denis classification of sacral fractures, in
  which three zones of injury are differentiated
• zone I, sacral ala
• zone II, foraminal region
• zone III, spinal canal

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• type 1 fractures occur lateral to the neural
  foramina through the sacral ala
• type 2 fractures are transforaminal
• type 3 fractures occur medial or central to the
  neural foramina. Transverse fractures of the
  sacrum are classified as type 3 injuries because
  they involve the spinal canal

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Clinical findings

• A history of high-energy injury caused by motor
  vehicle or motorcycle collisions or falls from
  heights
• Pelvic fractures are associated with other
  injuries such as head, chest, abdominal and
  retroperitoneal vascular injuries that may be
  life-threatening

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physical examinations

• (1)Appropriate measurement of leg-length
  discrepancies and evaluation of internal and
  external rotational abnormalities and open wounds
  are important
• (2)The evaluation of soft tissue injuries, e.g.
  contusions, hemorrhage, hematomas
• (3)Rotational instability can be assessed by
  pushing on the anterosuperior iliac wings both
  internally and externally to determine whether
  the pelvis opens and closes. Pull-push evaluation
  of the leg can be used to determine any vertical
  migeration of the pelvis

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Roentgenographic evaluation

• The standard roentgenographic projections
  required for evaluation of pelvic fractures are
  an anteroposterior view of the pelvis and the
  40-degree caudal inlet and 40-degree cephalad
  outlet views described by Pennal
• Computed tomography is an essential part of the
  evaluation of any significant pelvic injury.

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• A, Forty-degree caudad inlet view of pelvis
• B, Forty-degree cephalad outlet view of pelvis

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• A, Tile type B1 pelvic injury with diastasis of
  symphysis and anterior widening of sacroiliac
  joint.
• B, CT scan shows that posterior sacroiliac joint
  ligaments are intact

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Complications

• The potential complications of high-energy pelvic
  fractures include injuries to the major vessels
  and nerves of the pelvis and the major viscera,
  such as the intestines, the bladder, and the
  urethra.
• Reported mortality from severe pelvic fractures
  ranges from 10 to as high as 50 in open pelvic
  fractures

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• 1)  retroperitoneal vascular injuries
• 2)  major visceral injuries liver,
• kidney, or spleen and intestines
• 3)  bladder and urethra injuries
• 4)  rectal injuries
• 5) nerve injuryes lumbosacral
• plexus and sciatic nerve

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Treatment

• 1) Priority should be given to the treatment of
  airway, breathing, and circulation peoblems
• 2) For mildly displaced lateral compression
  injuries, bed rest usually is sufficient
• 3) Operative reduction and internal fixation of
  pelvic fractures traditionally have been delayed
  for a few days to allow evaluation and treatment
  of life-threatening injuries, preoperative
  planning, and assembly of necessary equipment

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Posterior screw fixation of sacral fractures and
sacroiliac dislocations. Patient positioning.
Anteroposterior, caudad, and cephalad image
intensifier projections show drill bit and screw
position.
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Transiliac rod fixation of sacral fractures. A,
Large Steinmann pin (8 to 10 mm) is drilled from
outer aspect of one ilium through opposite
ilium. B, Second rod is inserted approximately
1.5 cm distal and parallel to first.
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• Iliosacral screw fixation for sacroiliac or
  sacral fracture

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• Transiliac rods for fixation of sacral fracture

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• Anterior plating of sacroiliac joint

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