Download to read offline
Uploaded byGehad Bedda
pelvis fractures definitive management.ppt
This document discusses the evaluation and treatment of pelvic ring injuries. It defines pelvic ring instability and outlines factors to consider when determining if operative or non-operative treatment is appropriate. Both non-operative and surgical treatment options are presented, including techniques for reducing and fixing various fracture patterns through both open and percutaneous approaches. Biomechanical principles of different fixation methods and expected patient outcomes are also summarized.
![Management of pelvic ring fractures [autosaved]](https://cdn.slidesharecdn.com/ss_thumbnails/managementofunstablepelvicfracturesautosaved-180101211035-thumbnail.jpg?width=640&height=640&fit=bounds)
pelvis fractures definitive management.ppt
- 1. Pelvic Ring Injuries: DefinitiveManagement James C. Krieg, MD Harborview Medical Center Seattle, WA Revised 2009 Created by Steven A. Olson, MD in 2004 First revised by Rafael Neiman, MD in 2007 Second Revision by James C. Krieg, MD in 2009
- 2. Goals • Define pelvicring instability • Decision process: operate or not? • Non-operative treatment • Principles of operative treatment • Preoperative planning • Surgical approaches • Techniques of pelvic reduction and fixation • Biomechanics of fixation techniques • Outcomes of pelvic ring injury
- 3. Introduction: Pelvic Ring Stability •Stability defined as ability to support physiologic load • Physiologic load may be sitting, side lying, or standing, as dictated by patient needs
- 4. Introduction: Pelvic Ring Stability •Posterior ring integrity is important in transferring load from torso to lower extremities
- 5. Defining Instability • Lossof posterior ring integrity often leads to instability • Loss of anterior ring integrity may contribute to instability, and may be a marker to posterior ring injury • Tile classification scheme based on instability patterns
- 6. Is it stable? •Is there deformity? – Deformity on presentation predicts instabilitly
- 7. Is it stable? •Is there deformity? • Is the posterior pelvic ring intact? – CT scan
- 8. Is it stable? •Is there deformity? • Is the posterior pelvic ring intact • Stress radiographs – C-arm image in OR
- 9. Is it stable? •Is there deformity? • Is the posterior pelvic ring intact • Stress radiographs • Are there clues to soft tissue injury? – LS transverse process fx – Ischial spine avulsion – Lateral sacral avulsion
- 10. Describing Instability • Referto previous lecture on Classification • Tile Classification – A stable – B partially stable – C unstable
- 11. Operative Indications • Resuscitation –See previous lecture on Acute Management • Assist in mobilization – Just as stabilizing long bones helps in mobilization of polytrauma patients • Prevent long term functional impairment – Deformity of pelvic ring can impact function
- 12. Non-Operative Management • Lateralimpaction type injuries with minimal (< 1.5 cm) displacement • Pubic rami fractures with no posterior displacement • Minimal gapping of pubic symphysis – Without associated SI injury – 2.5 cm or less, assuming no motion with stress or mobilization – This number is not absolute, so other evidence of instability (like SI injury) must be ruled out
- 13. Non-Operative Management • X-raysare static picture of dynamic situation – It may be that the deformity is worse than seen on X-rays taken – Stress radiographs may be helpful – Post-mobilization radiographs should be taken in all cases of non-operative treatment – Other evidence of instability should be sought • Lumbar transverse process fractures • Avulsions of sacrotuberous/sacrospinous ligaments
- 14. Non-Operative Treatment • TileA (stable) injuries can generally bear weight as tolerated • Walker/crutches/cane often helpful in early mobilization • Serial radiographs followed during healing • Displacement requires reassessment of stability and consideration given to operative treatment
- 15. Non-Operative Treatment • TileB (partially stable) injuries can be treated non-operatively if deformity is minimal • Weight bearing should be restricted (toe- touch only) on side of posterior ring injury • Serial radiographs followed during healing • Displacement requires reassessment of stability and consideration given to operative treatment
- 16. Non-Operative Treatment • Failureof non-operative treatment may be due to displacement after mobilization • Excessive pain which precludes early mobilization may also be failure of non- operative treatment
- 17. Principles of Operative Treatment •Posterior ring structure is important • Goal is restoration of anatomy and enough stability to maintain reduction during healing • Most injuries involve multiple sites of injury – In general, more points of fixation lead to greater stability – This does NOT mean that all sites of injury
- 18. Principles of Operative Treatment •Anterior ring fixation may provide structural protection of posterior fixation • If combined open and percutaneus techniques are used, the open portion is often done first to aid in reduction of the percutaneusly treated injury
- 19. Surgical Treatment: Preoperative Planning •Consider patient related factors – Surgical clearance, resuscitation – Coordination of care • Trauma surgeon, intensivist, neurosurgeon
- 20. Surgical Treatment: Preoperative Planning •Consider patient related factors – Associated injuries • May need general surgeon, genitourinary surgeon, gynecologist, plastic surgeon
- 21. Preoperative Planning • Timingof surgery – Reduction may be easiest in first 24-48 hours • May aid in percutaneus reduction – Patients often not adequately resuscitated in first 24 hours – Potential for surgical “secondary hit” on post- injury days 2-5 • May be a significant issue in open procedures
- 22. Preoperative Planning • Intraoperativeimaging – Radiolucent table – Fluoroscopy – Radiologic Technician and Surgeon understand C-arm views necessary
- 23. Preoperative Planning • Reductiontools – Traction – Pelvic manipulator (e.g. femoral distractor) – Specialized clamps
- 24. Preoperative Planning • Implantsneeded – Extra-long screws – Cannulated screws, often extra-long with appropriate instruments – Specialized plates for contourability (reconstruction plates) – External fixation
- 25. Preoperative Planning • Surgicalapproaches planned – Soft tissues examined – Patient positioning planned • Is it safe to prone patient? • Equipment/padding for safe prone positioning
- 26. Surgical Approaches: Anterior PelvicRing • Pfannenstiel – Exposure of symphysis pubis and pubic bones – Avoid transection of rectus tendons – Elevate rectus subperiosteally rectus symphysis cephalad
- 27. Surgical Approaches: Anterior PelvicRing • Stoppa extension – Exposes symphysis to SI joint along pelvic brim Iliac fossa Pelvic brim Pectineal eminence
- 28. Surgical Approaches: Posterior PelvicRing • Anterior approach – Iliac window of the ilioinguinal – Exposure of SI joint M Tile in Schatzker, Tile (eds). Rationale of Operative Fracture Care, Springer, Berlin, 1996, p221-270
- 29. Surgical Approaches: Posterior PelvicRing • Posterior approach – Exposure of sacrum and posterior ilium – Sacral fractures – Iliac fracture dislocations of the SI joint (crescent fracture)
- 30. Surgical Approaches: Posterior PelvicRing • Posterior approach – Paramedian incision
- 31. Reduction and Fixation: Symphysis •Reduction with clamp – Weber clamp on pectineal eminences Matta and Tornetta, CORR 329, pp129-140, 1996
- 32. Reduction and Fixation: Symphysis •Reduction with clamp – Jungbluth clamp with screws Matta and Tornetta, CORR 329, pp129-140, 1996
- 33. Reduction and Fixation: Symphysis •Pelvic reconstruction plate – Commonly 6 hole plate – Variable directions of screws
- 34. Reduction and Fixation: RamusFractures • Pelvic reconstruction plate • Medullary screw fixation – Retrograde – Antegrade
- 35. Reduction and Fixation: RamusFractures • Pelvic reconstruction plate • Medullary screw fixation – Retrograde – Antegrade
- 36. Reduction and Fixation: RamusFractures • Pelvic reconstruction plate • Medullary screw fixation – Retrograde – Antegrade
- 37. Reduction and Fixation: RamusFractures • Anterior External Fixation – Controls rotation only – Pins in gluteus medius pillar of ilium – Alternative placement in Anterior Inferior Iliac Spine
- 38. Reduction and Fixation: SIJoint Dislocation • Anterior exposure facilitates reduction of dislocation • Iliac window of ilioinguinal approach Pelvic brim SI Joint
- 39. Reduction and Fixation: SIJoint Dislocation • Clamp applied from lateral, posterior ilium to anterior sacral ala
- 40. Reduction and Fixation: SIJoint Dislocation • Plating – Need more than one plate to avoid linkage displacement – Can be used in tandem or with SI screw
- 41. Reduction and Fixation: SIJoint Dislocation • SI screw – Cannulated for ease of placement – Partially threaded for reduction – Fully threaded for improved fixation – Knowledge of anatomy and imaging is essential – Be aware of sacral dysmorphism
- 42. Reduction and Fixation: SIJoint Fracture/Dislocation “Crescent Fracture” • SI screw – If caudal segment is in the path of fixation screw – Opportunity for percutaneus treatment
- 43. Reduction and Fixation: SIJoint Fracture/Dislocation “Crescent Fracture” • SI screw and plate – Anterior ORIF if large fragment – Supplement as needed with SI screw
- 44. Reduction and Fixation: SIJoint Fracture/Dislocation “Crescent Fracture” • ORIF with plate – Posterior approach
- 45. Reduction and Fixation: SIJoint Fracture/Dislocation “Crescent Fracture” • ORIF with plate – Posterior approach
- 46. Reduction : Sacral Fracture •Indirect reduction – Anterior ring reduction
- 47. Reduction : Sacral Fracture •Indirect reduction – Anterior ring reduction Open reduction pubic root
- 48. Reduction : Sacral Fracture •Indirect reduction – Anterior ring reduction
- 49. Reduction : Sacral Fracture •Indirect reduction – Distractor – Traction
- 50. Reduction : Sacral Fracture •Indirect reduction – Distractor – Traction
- 51. Reduction : Sacral Fracture •Direct reduction – Posterior exposure – Clamp application • Pointed Weber clamps – Can decompress as well if needed
- 52. Reduction : Sacral Fracture Mattaand Tornetta, CORR 329, pp129-140, 1996
- 53. Fixation: Sacral Fracture • Iliosacralscrews – Upper 2 sacral segments – Fully threaded screws – Know morphology, anatomy
- 54. Fixation: Sacral Fracture • Iliosacralscrews – Upper 2 sacral segments – Fully threaded screws – Know morphology, anatomy
- 55. Fixation: Sacral Fractures • Lumbopelvicfixation – Vertical control – Can be useful in unstable H or Y type sacral fracture • Transiliac plating
- 56. Biomechanics of PelvicFixation: • No clinical comparison studies exist • Experimental biomechanical data exist • In general, it seems that more points/planes of fixation provide better stability • How much stability is enough is injury dependant
- 57. Biomechanics of PelvicFixation: Anterior Fixation • Anterior plating superior to external fixation in internal/external rotation • Neither technique very effective at control of vertical displacement • Anterior fixation can “protect” posterior fixation from failure
- 58. Biomechanics of PelvicFixation: Anterior Fixation • Two hole symphyseal plate inadequate • Retrograde pubic screw higher failure rate than antegrade
- 59. Biomechanics of PelvicFixation: Posterior Fixation • Options include single SI screw, multiple SI screws, double plating of SI joint, transiliac plate of sacral fracture, or plate plus SI screw for sacral fracture or SI dislocation • Any of the above are more stable than single SI screw in unstable injuries
- 60. Biomechanics of PelvicFixation: Posterior Fixation • Lumbopelvic fixation – Lumbopelvic dissociation (unstable Y, H, or U type sacral fractures) – Sacral fractures with significant instability – Can provide axial (vertical) stability that is not as dependant on fracture reduction/stability
- 61. Outcomes • Pain common •Improvement occurs for at least a year in most patients • Neurologic injury most common predictor of poor outcome
- 62. Outcomes • SI dislocationshave poor tolerance for residual displacement • Sacral fractures have more tolerance for displacement, but parameters poorly understood • Injury Severity Score and fracture type do not correlate with functional outcome
- 63. Conclusions: Pelvic Ring Injury •Complex constellation of injuries • Treatment based on comprehensive understanding of potential pelvic ring instability, displacement, and associated injuries • Surgical techniques for reduction and stabilization continue to evolve
- 64. Acknowledgment Return to Pelvis Index E-mail OTA about Questions/Comments Ifyou would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected]