Pelvis injuries Fractures of the femur (proximal,shaft) Dr Tamás Bodzay

Pelvis injuries Fractures of the femur (proximal,shaft) Dr Tamás Bodzay

Pelvis anatomy

Pelvis function - axial load bearing - protection: abdominal, pelvic structures

Pelvic injury mechanism Falling from altitude Compression Motor vehicle accident High energy trauma

Associated injuries Blood loss:1500 2000 ml (shock) - fracture site: 70 % - venous plexus: 20 % - arterial bleeding: 10% Associated injuries: - urethra - urinary bladder (extra- intraperitoneal) - rectum

Classification - localisation of the injury - instability (Tile-AO) - direction of the force (Young-Burgess)

Type A (stable) Young patients: sport injuries / muscle attachment/ Elderly patients: falls

Type B (rotational instability) Type B 1.( open book) Symphysis opens up /3-6 cm/ Posterior internal ligaments ruptured, Posterior external ligaments intact Type B 2. Symphysis squashed Posterior internal ligaments intact, Posterior external ligaments ruptured

Typ. C (rotational + vertical instability)

AP compression (B1) Lateral compression (B2) Vertical shear (C)

Pelvic injuries 3 % of the all injuries 25% by the politrauma patients Mortality:16% Mortality by hemodinamical unstable patients: 30% Mortality by open injuries:55%

Diagnostics-physical examination 1x!!

Diagnostics- X ray

Diagnostics- CT

Treatment - Stable injury= non-operative treatment - Unstable injury= operative treatment Instability: - (bio)mechanical - HEMODINAMICAL!! (Blood loss:1500 2000 ml ;shock)

Hemodinamically unstable patient:emergency fixation

Definitive treatmentsymphyseolysis: plate fixation

Definitive treatment- transiliacal fx.: plate fixation

Definitive treatment- SI-lysis: plate fixation or iliosacral screw fixation

Definitive treatment- sacrum fx:

Classification I- posterior type:wall, collumn, wall+ collumn, II- anterior type:wall, collumn, wall+ collumn, III- transverse type: transverse, T, both collumn

Diagnostics- X ray AP view Ala view Obturator view

AP view

Ala view

Obturator view

Diagnostics- CT

Operativ treatment- approaches

Operativ treatment- screw fixation

Operativ treatment- plate fixation

Dashboard injury?

Dashboard injury acetabular fx. femoral head fx. femoral neck fx. femur diaphyseal fx. femur distal fx. patellar fx. PCL tear. tibial head fx.

Pipkin s classification of femoral Type I: Fracture inferior to fovea centralis. Type II: Fracture superior to fovea centralis. Type III: Type 1 or 2 + femoral neck fracture. Type IV: Type 1, 2 or 3 + acetabular fracture head fractures.

Treatment of femoral head Type I: excision or fixation. Type II: ORIF with screws in youngs; joint replacement in elderly. Type III: same as Type II Type IV: same as in Type III + acetabular fracture fixation. fractures

Clinical symptoms of the hip fractures abduction external rotation shortening

The blood supply of the femoral head Capsule Ligamentum teres Medial femoral circumflex artery Lateral femoral circumflex artery Profunda femoris artery Ascending cervical arteries Extracapsular arterial ring Obturator artery Foveal artery Femoral artery Extracapsular arterial ring Ascending cervical arteries Retinacular arteries Subsynovial intracapsular arterial ring

Müller (AO), Garden and Pauwels classification of femoral neck fractures B1 Neck fracture, subcapital, with slight displacement 1 impacted in valgus > or = 15 2 impacted in valgus < 15 3 non impacted B2 Neck fracture, transcervical 1 basicervical 2 midcervical adduction 3 midcervical shear B3 Neck fracture, subcapital, non impacted, displaced 1 moderate displacement in varus and external rotation 2 moderate displacement with vertical translation and external rotation 3 marked displacement G1 : incomplete, impacted G2 : non-displaced G3 : incomplete displacement G4 : complete displacement Pauwels classification refers to the angle of the fracture line compared to the horizontal Grade 1: 30 Grade 2: 50 Grade 3: 70

Treatment of the femoral neck fractures- screw fixation Treatment of stable femoral neck fractures (Type Garden-I and II) : two cannulated screws Treatment of unstable femoral neck fractures (Type Garden-III and IV): two cannulated screws+a two-hole tension plate

Three-point-buttressing

Screw fixation of the Garden I. fracture

Screw fixation of the Garden III. fracture

Treatment of the femoral neck fractures- arthroplasty Type Garden-IV;subcapital fracture Time between injury and surgery > 48 hour Impossible reduction Pathologic femoral neck fracture

Arthroplasty hemiarthroplasty : age > 80 years total hip arthroplasty: age < 80 years

Classification of the trochanteric A-1 Trochanteric, simple A-1.1 Cervicotrochanteric A-1.2 Pertrochanteric A-1.3 Trochanterodiaphyseal A-2 Pertrochanteric, multifragmentary A-2.1 One intermediate fragment A-2.2 Two intermediate fragments A-2.3 More than two intermediate fragments A-3 Intertrochanteric A-3.2 Intertrochanteric A-3.2 Reversed, simple A-3.3 With additional fracture of medial cortex fractures

Implants for the fixation the pertochanteric fractures

Fixation of fracture type AO 31- A1(stable pertochanteric fracture): DHS

Stabilization of fracture type AO 31-A2: Fi-nail

Stabilization of fracture type AO 31-A2: PFNA-nail

Fixation of fracture type AO 31- A3: DCS

Stabilization of fracture type AO 31-A3: Fi-nail

Classification of the femoral shaft fractures A1 A2 A3 B1 B2 B3 C1 C2 C3

Non-operative treatment

Operative treatment Intramedullary nailing Plate synthesis External fixator

Intramedullary nailing Biomechanical Biological

Intramedullary nailing Closed technique Early mobilisation Good weight-bearing capacity Low grade septic complication Rapid bony consolidation

Reaming Metal-bone contact: relative stable Reaming: improved metal-bone contact = increased stability Indications: fx. in the 3-4- 5/7

Interlocking Interlocking: increased rotational stability Indications: fx. in the 2-3- 4-5-6/7

Unreamed interlocking nailing Reaming: intramedullary pressure elevation (1969 Lilienström) Bone marrow embolisation (1989 Wenda) Destroyed lung function (1997 Pape) Indications: thorax/head injury+fx. in the 3-4-5/7

Plate fixation Intraarticular and diaphysis fx. Compartment syndrome Vascular injury Previously inserted implants

External fixator Open femoral shaft fractures (Type III.) Septic complications Femoral shaft fractures + polytrauma (ISS > 40)

Implant choice Mono/multitrauma: reamed nailing with interlocking Polytrauma: ISS < 40 - unreamed locking nailing, ISS > 40 or head/thorax injury- FE. Intraarticular and diaphysis fx, compartment syndrome, vascular injury, previously inserted implants-plates