Presentations on Management of Open Fractures - PDF

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					                Pelvic Fractures                                  Agenda
Alvin Ong, MD                                 Primary Assessment
Fracture Conference                           Associated Injuries
2009                                          Imaging
                                              Initial Management
                                              Definitive Treatment

              Introduction                                     Pelvic Ring
  Only 3-8% of all fractures                  2 innominate bones
  Occurs in 25% of multiply injured patient   1 Sacrum
                                              Symphysis gap <5 mm
  Associated blunt, soft-tissue injury
                                              SI joint 2-4 mm
  Mortality as high as 20%-25%                  Anterior SI: lateral
  Open pelvic fracture = 30-50% mortality

      “keystone” of bony stability               Important Stabilizing Ligaments
                                                 Anterior Sacroilliac (1)
                                                 Posterior Sacroilliac (2)
                                                 Sacrotuberous (3)
                                                 Sacrospinous (4)

                  Pelvic Ring                                   Pelvic Ring
No inherent stability—Ligaments give stability
                                                 Iliolumbar augment posterior complex
Anterior SIL resist external rotation
                                                   Resist external rotation in double-leg stance
Posterior SIL and IL
                                                 Rami act as struts
  provide posterior stability by tension band
                                                   resist compression/internal rotation in single leg
  strongest in body                                stance
Sacrotuberous—resists shear/flexion SI joint     Ghanayem, J Trauma, 1995
Sacrospinous—resists external rotation             Abdominal wall contributes to pelvic stability

         Possible Bleeders   Retroperitoneal Veins

Iliolumbar artery
Superior gluteal artery
Lateral sacral artery
Internal iliac artery
Internal pudendal
Sacral venous plexus

         Neural Anatomy

          Visceral Anatomy                                       Primary Assessment
                                                          Primary Survey
Bladder/Urethra                                             Airway Maintenance with cervical spine protection
Rectum                                                      Breathing and Ventilation
                                                            Circulation with hemorrhage control
Prostate                                                    Disability: Neurologic status
Vagina                                                      Exposure/Environment Control: Undress patient but
                                                            prevent hypothermia

              Resuscitation                                            Resuscitation
Intravenous lines –2 large bore IVs                        Avoid or correct hypothermia
Crystalloid Solution                                          Warming fluids
Blood Administration                                          Increase ambient temperature
  50-69% of unstable pelvic fractures require 4 or more       Avoid heat loss
  units of blood
  30-40% require 10 or more units
                                                              Hypothermia can lead to coagulation
                                                              problems, arrhythmia, acid-base problems

          Physical Examination                              Physical Examination
   Bimanual compression and distraction of the iliac
   wings                                                Vaginal examination
     Assess for rotational stability                      Bleeding or laceration indicate open fractures
   Manual leg traction                                  Perineal skin evaluation
     Aids in determining vertical stability
                                                          Laceration may indicate open fracture;
   Rectal examination
                                                          laceration may be caused by hyper-abduction
     Palpate prostate – urethral injury
     Guaic test – visceral injury
                                                          of the leg
     Palpate sacrum – assess for fracture

                                                        Hemodynamically Unstable
           Associated Findings
Flank ecchymosis
                                                       Causes of bleeding/hypovolemia:
Scrotal/labial swelling
Associated fractures: spine, long bone, knee, foot
                                                         Intrabdominal injury
Lacerations or degloving of skin                         Intracranial/Spinal injury
  Morel–Lavalle’ Lesion                                  Closed/Open fractures
Associated injuries                                      Coagulopathies (hypothermia, low calcium,
  Vascular, GU, GI, Neurologic                           acidosis)
                                                         PELVIC FRACTURE

     Hemodynamically Unstable
Intra-abdominal Bleeding                    The Orthopod’s initial role
     Assess:                                  Stabilization of pelvic hemorrhage
        Abdominal CT Scan                        Sheet around pelvis
                                                 Pelvic binder
        Peritoneal Lavage
                                                 Anti-shock garments (PSAG)
                                                 External fixation
                                              Referral to center for appropriate fixation
        AP Pelvis
                                            Angiography and embolization
        Physical exam                       Surgical stabilization with packing
        Pelvic CT Scan

         Stabilization Methods                                  Imaging
                            Pelvic binder   AP pelvis during early phase of resuscitation is
Sheet around pelvis
                                            useful to determine presence or absence of
                                            unstable pelvic fracture
                                            AP pelvis can identify 90% of pelvic injuries
                                            It can guide the surgeon to additional imaging
                                            needs, such as CT scan

      Inlet and Outlet Views                        Inlet and Outlet Views
Inlet View – 45 degree caudal tilt
  True AP projection of the pelvic brim        Outlet View – 45 degree cephalad tilt
  Evaluates for posterior displacement           Evaluates for vertical shift of pelvis
  Evaluates for rotation of ilium and sacral     Visualizes Sacral foramen
  impaction injuries

                 CT Scan                                        CT Scan
Best visualization for Sacrum and SI joint     3-D reconstruction may be helpful in
                                               determining overall displacement of the
Rotational and posterior displacement can
                                               pelvic fracture
be easily assessed

               Angiography                                      Indications for Angiography
                                                             Unexplained blood loss after stabilization AND
Useful in assessing and embolization of arterial             aggressive resuscitation
injury                                                       Pulseless extremity
Can determine patency of superior gluteal artery
for viability of large surgical exposures
  Source of arterial bleeding is identified in only 10-15%
  of patients with severe pelvic disruption
  Does not address venous bleeding

               Angiography                                                 Classification
Complication:                                                 Bucholz
  Lead to necrosis of buttock after occlusion of              Tile
  entire internal iliac artery
                                                              Young and Burgess
  Sciatic or femoral paresis
  Bladder wall necrosis
  Emboli to normal vessels
  Associated with high mortality rate

                 Bucholz                                                  Tile
Based on severity of posterior pelvic ring injury      Combination of mechanism of injury and stability
 Type I: anterior ring injury with a stable intact      Type A: stable
 posterior ring                                         Type B: rotationally unstable
 Type II: anterior ring injury with partial             Type C: vertically unstable
 disruption of the SI joint (rotational instability)   Advantages: Tile classification aids in the
 Type III: complete disruption of the SI joint          determination of prognosis and treatment
 with displacement of the hemipelvis

        Young and Burgess                                                APC
Based on mechanism of injury
                                                       Increased incidence of brain, abdominal,
 Anteroposterior compression (APC)                     visceral, and pelvic vascular injury
 Lateral compression (LC)
                                                       Death usually caused by hemorrhage
 Vertical shear (VS)
                                                       APC type I:
 Combined mechanism                                      symphysis widened 1-2cm; SI joint intact
Advantages: this classification alerts the surgeon       Non-operative treatment
 to potential resuscitation requirements and             6.5% pelvic vascular injury
 associated injury patterns

                    APC                                                   APC
APC type II:                                        APC type III:
  symphysis widened >2cm; anterior SI joint           Complete separation of hemipelvis from the pelvic ring;
                                                      no vertical displacement
  disruption, posterior ligaments intact
                                                      Emergent exfix for unstable patients
  Pelvic exfix if hemodynamically unstable            Require fluid resuscitation
  Definitive treatment = exfix or anterior ORIF       Definitive fixation of anterior and posterior structures
  10% pelvic vascular injury                          22% pelvic vascular injury

                      LC                                                    LC

High incidence of associated brain and abdominal    LC type II:
injuries                                              Anterior pelvic injury; Crescent fracture of the
Death related to brain injury, not hemorrhage         iliac wing or near SI joint
LC type I:                                            Emergent exfix for hemodynamic instability
  Anterior pelvic injury with impaction of sacrum     Definitive treatment with ORIF
  Non-operative treatment; TDWB on affected side      8% pelvic vascular injury

                    LC                                                   VS
                                                   Associated injuries similar to those for LC (brain
LC type III:                                       and abdominal)
  LC-I or LC-II on the side of injury; open-book
                                                   Vertical displacement of the hemipelvis
  injury of the SI joint on the opposite side
                                                   Emergent exfix with traction of the leg in
  Usually a result of crush injury
                                                   hemodynamically unstable patients
  Emergent exfix for hemodynamic instability
                                                   Definitive treatment is ORIF of both anterior and
  Definitive treatment with ORIF                   posterior pelvis
  23% pelvic vascular injury                       10% pelvic vascular injury

     Combined Mechanism                                  Open Pelvic Fractures
Combination of LC and VS or LC and APC             High mortality rate (30% - 50%)
Exfix for hemodynamic instability with or          Potential for major vascular injury with
without traction                                   hemorrhage
Definitive treatment based on injury pattern       High incidence of associated
                                                   gastrointestinal and genitourinary injuries
10% pelvic vascular injury
                                                   Diverting colostomy may be required
                                                   Requires aggressive multidisciplinary

         Associated Injuries                                  Vascular
Vascular                                    Hemorrhage occurs in up to 75% of pelvic
Neurologic                                  fractures
Visceral                                    Three source of bleeding
  Urologic                                    Osseous
  Rectal/Gastrointestinal                     Vascular
  Gynecologic                                 Visceral
Degloving - Moral-Lavalle                   Intra-abdominal source is present in 40% of
                                            patients with pelvic fractures

                  Vascular                                  Neurologic
                                            Fracture of sacrum or dislocation of SI joint can
Major source of bleeding is the venous      lead to injury to lumbosacral plexus
plexus                                      Sacral fractures: Denis Classification
Retroperitoneal space holds up to 4 L of         Zone 1: 6% if fracture lateral to foramen
blood                                            Zone 2: 28% if fracture through foramen
Arterial source of bleeding is present in        Zone 3: 50% if medial to foramen
only10-15% of patients
Superior gluteal artery is the most
commonly injured vessel

          Neurologic Damage                                  Visceral Injury
L5 & S1, most common
L2 to S4 possible
                                               Blunt vs. impaled by bony spike
Dependent on fx location/displacement amount
Pohlemann, CORR 1994                              Rectum
  Amount of displacement more important than      Vagina
  location                                        Prostate

                      Urologic                                      Urologic
15-17% of pelvic fractures                     Bladder
Scrotal/labial swelling                          Extraperitoneal (EP) vs.
                                                 intraperitoneal (IP)
                                                 Due to blunt force or bony
  15% of men                                     impalement
  Indicators:                                    IP occurs in 15% and needs
     Blood in meatus                             operative treatment
     High-riding prostate
                                                 EP can be treated non-
     Straddle-type fracture
                                                 operatively (catheter drainage
  Retrograde Urethrogram                         and broad spectrum abx)

Occurs in less than 1%
Laceration of rectum or perforation of small
and/or large bowel
Rectal tears accompany perineal wounds
Requires diverting colostomy

                                                             Morel–Lavalle’ Lesion
                                                     Closed degloving injury
Laceration of the vagina                               Greater trochanter
Results from dislocation or fractures of the pubic     pelvic and acetabular fx
rami                                                   Shear injury
Large laceration may involve perineum and                SubQ tissue torn
rectum                                                   Cavity of hematoma/liquefied fat
                                                         Not initially apparent/overlooked
Inferior rami fracture that causes impingement
may require operative intervention                     Infected in 1/3 of cases
Urethral injury rare in women                            Hak and Matta, OTA 1996:    high incidence of colonization

                                     Requires debridment prior to surgery

        Acute Intervention                            Sheet
Stabilization of Pelvic Hemorrhage   Sheet can be wrapped around iliac wings
  Traction                           and held with towel-clamp or knot
  Sheet/Pelvic Binder                Hips slightly flexed and internally rotated
  Anti-shock Garment
  Pelvic clamp/External fixator
Angiographic embolization

            Pelvic Binder                              Anti-shock Garment
                                                MAST (Military antishock trousers)
                                                  Limits access for examination
                                                  Decreases lung function
                                                  Can contribute to lower extremity compartment

                                                          External Fixator
          External Fixator
Indicated in the unstable patient who does
not respond to initial fluid resuscitation
Stabilizes pelvis, preventing redisruption of
? May decrease pelvic volume
Not adequate for posterior pelvic disruption

            Pelvic C-clamp                                   Definitive Fixation
Applied to the posterior ilium in line with sacrum
Requires fluoroscopy and expertise                   Anterior
Higher risk of iatrogenic injury                       External fixator
Not available in many institutions                     Plate fixation (ORIF)
Good for stabilizing posterior disruption            Posterior
                                                       Iliosacral screw
                                                       Plate fixation

          Anterior Fixation                                      Anterior Fixation
                                                     External fixation can be utilized as
                                                     definitive fixation in open book pelvic
  Symphysis open greater than 2.5cm
                                                     fractures, especially in:
  Locked symphysis
                                                       Unstable patients
  Open fracture protruding into the vagina
                                                       Open fracture with contamination
  Marked displacement
                                                       Suprapubic tube or colostomy
                                                       Saddle fracture/segmental fractures

             Anterior Fixation                                      Symphysis Pubis Disruption
 Anterior pubic symphysis plating                                  Pfannenstiel
   Performed in diastasis greater than 2.5cm                       plating technique
   If there is posterior injury or multiplanar                       Controversies exist
   instability, consider double plating                              single plate
                                                                     dual plate

  Symphysis Pubis Disruption                                                 Posterior Fixation
Plating technique: how to decide?
  Single plate w/ stable posterior ring/fixation planned           Indication:
  Tile recommends:                                                   Unstable SI complex with more than 1 cm
     “dual plating reserved for the unusual situation where          displacement
     posterior injury cannot be addressed due to physiologic         Open fractures with posterior wound
                                                                     Unstable posterior complex associated with
     “the anterior construct can then better withstand superior-
     inferior and anterior-posterior forces”
                                                                     acetabular fractures
     single plate and ex fix is also appropriate                     Neurologic compromise: prevent further nerve

            Percutaneous Fixation                                                    Posterior Fixation
    Indications                                                           Iliosacral screw
       reduced by closed means
                                                                              Solid vs. Cannulated screws can be utilized
       good spatial reasoning/tech
    Advantages                                                                Solid screw are stronger
       Supine or Prone                                                        Partially threaded screws for compression
       Less dissection: less risk of infection                                Fully threaded screws for comminuted fracture
    Identify radiographic anatomy                                             of the sacrum
       safe zone

            Percutaneous Fixation                                                  Percutaneous Fixation
  Take Care To Avoid Injury to Neurovascular Structures                        Inlet view: center of body
                                                                               Outlet view: Between the S1 foramen ala

L5/S1 nerve roots, sacral canal, branches of the internal iliac system.
                                                                                      from Matta JM, Saucedo T: Clin Orthop 242:83, 1989; original by Zilbert

                                                  Posterior Fixation

         Posterior Fixation                       Anterior SI plating
Posterior plating
  SI dislocation
  Not commonly utilized
  Limited fixation because of the L5 nerve root

                L5                      L5

            Posterior Approach: prone
Indications                                    Advantages
     SI joint disruption                         visualization
     Sacral fracture                             uncomplicated
Contraindications                                Use clamps for reduction
     Soft tissue issues                        Disadvantages
     Patient unable to tolerate                  soft tissue

                                                                               Posterior Approach: prone
                                                                            SI joint
                                                                            disruption/Sacral fx
                                                                              Transiliac plate or rod
                                                                              Tension band plating
                                                                              Iliosacral screw
                                                                              Plate and screws

Matta, Surgical Approaches to the Acetabulum

                                                      Non-Operative Management
                                                  LC-1, and APC-1
                                                     Lateral impaction/minimal displacement
                                                     Pubic rami fx/no posterior displacement
                                                     Gapping symphysis < 2.5 cm
                                                     bed to chair mobilization/WBAT with support
                                                     serial xray after mobilization
                                                     monitor for subsequent displacement
                                                     posterior ring displacement > 1cm: STOP WBAT
                                                  Very unstable patients: require prolonged immobility (poor
  Matta and Tornetta, CORR 329, pp129-140, 1996

          Post-operative Protocol                                 Complications
Skeletal stabilization allows for early             Nerve Injury
mobilization                                        Thromboembolism
                                                    Morel Lavalle Lesion
TDWB on the affected side
                                                    Nonunion and malunion
Wheelchair if B/L involvement                          Sitting imbalance
                                                       Leg length discrepancy
                                                       Pain (pelvic, lower back)
                                                    Sexual dysfunction
                                                       Erectile dysfunction
                                                       Painful intercourse

Thank You


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