Pelvic Ies

Pelvis injuriesFractures of the femur (proximal,shaft) Dr Tamás Bodzay Pelvis anatomy pelvic structures .protection: abdominal.axial load bearing .Pelvis function . Pelvic injury mechanism • • • Falling from altitude Compression Motor vehicle accident High energy trauma . venous plexus: 20 % .urinary bladder (extra.fracture site: 70 % .rectum .intraperitoneal) .Associated injuries • Blood loss:1500 – 2000 ml (shock) .arterial bleeding: 10% • Associated injuries: .urethra . Classification .direction of the force (Young-Burgess) .localisation of the injury .instability (Tile-AO) . Type A (stable) Young patients: sport injuries / muscle attachment/ Elderly patients: falls . Symphysis squashed Posterior internal ligaments intact. Posterior external ligaments ruptured .Type B (rotational instability) Type B 1. Posterior external ligaments intact Type B 2.( open book) Symphysis opens up /3-6 cm/ Posterior internal ligaments ruptured. C (rotational + vertical instability) .Typ. • 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 . CT .Diagnostics. Treatment - Stable injury= non-operative treatment - Unstable injury= operative treatment Instability: .shock) .HEMODINAMICAL !! (Blood loss:1500 – 2000 ml .(bio)mechanical . Hemodinamically unstable patient:emergency fixation . Definitive treatmentsymphyseolysis: plate fixation . : plate fixation .Definitive treatment.transiliacal fx. SI-lysis: plate fixation or iliosacral screw fixation .Definitive treatment. sacrum fx: .Definitive treatment. . T. wall+ collumn. collumn.posterior type:wall. wall+ collumn. • III.transverse type: transverse. • II. both collumn . collumn.Classification • I.anterior type:wall. Diagnostics.X ray • AP view • Ala view • Obturator view . AP view . Ala view . Obturator view . CT .Diagnostics. Operativ treatment.approaches . screw fixation .Operativ treatment. plate fixation .Operativ treatment. Dashboard injury ? . tibial head fx. femoral neck fx. patellar fx. . femur distal fx.Dashboard injury • • • • • • • • acetabular fx. PCL tear. femur diaphyseal fx. femoral head fx. Pipkin’s classification of femoral head fractures. • Type II: Fracture superior to fovea centralis. • Type I: Fracture inferior to fovea centralis. 2 or 3 + acetabular fracture . • Type IV: Type 1. • Type III: Type 1 or 2 + femoral neck fracture. joint replacement in elderly. • Type III: same as Type II • Type IV: same as in Type III + acetabular fracture fixation. • Type II: ORIF with screws in youngs.Treatment of femoral head fractures • Type I: excision or fixation. . Clinical symptoms of the hip fractures • abduction • external rotation • shortening . The blood supply of the femoral head Capsule Obturator artery Ligamentum teres Foveal artery Medial femoral circumflex artery Lateral femoral circumflex artery Femoral artery Extracapsular arterial ring Ascending cervical arteries Profunda femoris artery Retinacular arteries Ascending cervical arteries Extracapsular arterial ring Subsynovial intracapsular arterial ring . Garden and Pauwels classification of femoral neck fractures B1 Neck fracture. non impacted. displaced 1 moderate displacement in varus and external rotation 2 moderate displacement with vertical translation and external rotation 3 marked displacement G3 : incomplete displacement G4 : complete Grade 1: 30° Grade 2: 50° Grade 3: 70° .Müller (AO). transcervical 1 basicervical 2 midcervical adduction 3 midcervical shear G2 : non-displaced Pauwels classification refers to the angle of the fracture line compared to the horizontal B3 Neck fracture. impacted displacement B2 Neck fracture. with slight displacement 1 impacted in valgus > or = 15° 2 impacted in valgus < 15° 3 non impacted G1 : incomplete. subcapital. subcapital. 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 .Treatment of the femoral neck fractures. Three-point-buttressing . Screw fixation of the Garden I. fracture . Screw fixation of the Garden III. fracture . subcapital fracture Time between injury and surgery > 48 hour Impossible reduction Pathologic femoral neck fracture .Treatment of the femoral neck fractures.arthroplasty • • • • Type Garden-IV. Arthroplasty hemiarthroplasty : age > 80 years total hip arthroplasty: age < 80 years . 2 Reversed. simple A-1. multifragmentary A-2.Classification of the trochanteric fractures • • • • A-1 Trochanteric.2 Two intermediate fragments A-2.3 More than two intermediate fragments • • • • • • • • • • A-3 Intertrochanteric A-3.3 With additional fracture of medial cortex .2 Pertrochanteric A-1.1 One intermediate fragment A-2.2 Intertrochanteric A-3.3 Trochanterodiaphyseal • A-2 Pertrochanteric.1 Cervicotrochanteric A-1. simple A-3. Implants for the fixation the pertochanteric fractures . Fixation of fracture type AO 31A1(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 31A3: 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 3-45/7 . Interlocking • Interlocking: increased rotational stability Indications: fx. in the 2-34-5-6/7 . 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 . ) • Septic complications • Femoral shaft fractures + polytrauma (ISS > 40) .External fixator • Open femoral shaft fractures (Type III. ISS > 40 or head/thorax injury. previously inserted implants-plates . vascular injury. compartment syndrome.FE.unreamed locking nailing.Implant choice • Mono/multitrauma: reamed nailing with interlocking • Polytrauma: ISS < 40 . • Intraarticular and diaphysis fx.