PELVIS AND LOWER LIMB Grant Kennedy

1. PELVIS AND LOWER LIMBGrant Kennedy

2. Objectives • To cover this huge topic adequately in just over an hour. • Special thanks to Tintinalli, UTDOL, Dr. Buckley, Rob and Shawn’s REMERGS web page.

3. Pelvic Fractures: Epidemiology Majority due to high impact blunt trauma (MVA, pedestrian vs. vehicle etc.) but also secondary to falls in frail elderly • Mortality overall = 10% • Mortality 50% if open #

4. Pelvic Anatomy • Pelvis = sacrum, coccyx + 2 innominate bones • Innominate bones = ilium, ischium, pubis • Sacrum + innominate bones form a ring • Strength from ligamentous supports (largely posterior aspect of ring)

5. Pelvic Anatomy • 5 joints: • Lumbosacral • Sacroiliac (x2) • Sacrococcygeal • Symphysis

6. Pelvic Anatomy

7. Anterior Support: Symphysis pubis Fibrocartilaginous joint covered by ant & post symphyseal ligaments Pubic rami Posterior Support: ~majority of stability Iliolumbar ligaments Sacroiliac ligaments Sacrospinous ligament Sacrotuberous ligament

8. Vessels lie close to posterior pelvic walls Venous bleeding most common (sacral plexus) Most commonly injured arteries are superior gluteal and internal pudendal Vascular Anatomy

9. Pelvic Anatomy • Nerve supply through the pelvis derived from lumbar and sacral plexuses • Other structures: lower GI/GU

10. History & Physical • AMPLE Hx • Mechanism/Ambulating at Scene • Numbness/Weakness/Bowel + Bladder Dysfxn • Inspect: • Destot’s sign: Hematoma above inguinal ligament or over scrotum • Blood at urethral meatus (urologic injury?)—if so, ED cystourethrogram. Insert foley a small amount (and lightly put up the balloon). Inject 100-150 cc of dye into bladder and have x-ray taken at same time. • Flank ecchymoses

11. History + Physical Examine pelvis only once! • AP compression on ASIS • AP compression on symphysis • Lateral compression on iliac crests Distal neurovascular exam! Bimanualshould be performed on all women w/ pelvic # • If blood, do speculum to assess for vaginal laceration (open #) DREin everyone (High riding prostate? Lack of tone?) • Earle’s sign: • Presence of bony prominence, palpable hematoma, or tender # line on DRE

12. Imaging • Plain films are NOT necessary in stable trauma patient with no lower abdo-pelvic complaints, normal exam and GCS >13 • X Rays: • AP • Inlet/Outlet • Judet • CT Scan: • Evaluates extent of posterior injuries and retroperitoneal bleeding, superior imaging of sacrum and acetabulum, associated injuries

13. Imaging • AP VIEW: • Identifies most fractures • Look for disruption in iliopubic and ilioischial lines, sacral foramina, radiographic U, Shenton’s Lines • Following are abnormal: • Symphysis >5mm • Vertical offset left vs. right rami (>1-2mm) • SI joint > 5mm

15. Inlet view X-ray beam at 60o to plate directed towards feet Used to look for AP displacement of ring fractures. Outlet view Beam aimed 30o towards head Used to see Sup-Inf displacement.

16. Imaging • Look for any evidence of damage to the posterior pelvic structures • Clues on X-rays: • L5 transverse process avulsion (iliolumbar ligament) • Ischial spine avulsion (sacrospinous ligament) • Unable to clearly make out sacral foramina • Assymmetry of sacral foramina • Avulsion at lower lip of lateral sacrum (sacrotuberous ligament)

17. Pelvic Fracture Complications • Hemorrhage: up to 6L of blood can collect in retroperitoneal space! • Open #: high mortality if not recognized; communication to rectum, vagina, skin • examine posterior skin carefully, do not probe wounds, • perineal wounds = operative debridement/irrigation, • rectum = diverting colostomy

18. Pelvic Fracture Complications • Urologic Injury: (15%) # of symphysis have highest incidence of urologic injury, • Microhematuria = no need for cystourethrogram • Gross hematuria = cystourethrogram + CT • Neurologic Injury: with sacral #, sx of cauda equina, plexopathy, radiculopathy

19. Pelvic Fracture Complications • Gynecologic Injury: laceration, abruption, uterine perforation • Intra-abdominal Injury: rectum, colon, small bowel • Injuries by Association: due to high force mechanism… thoracic aortic rupture, diaphragmatic rupture

20. Pelvic Fractures • 5 General Categories: • 1. Pelvic Ring • 2. Acetabular • 3. Sacral • 4. Avulsion type • 5. Single bone

21. Pelvic Ring Fractures • Young Classification System: • Differentiates fracture patterns based on mechanism of injury/direction of causative force • 3 major fracture patterns: • 1. lateral compression (50%) • 2. antero-posterior compression (25%) • 3. vertical shear (5%)

22. Lateral Compression (50%) – transverse # of pubic rami, ipsilateral or contralateral to posterior injury LC I – sacral compression on side of impact LC II – iliac wing # on side of impact LC III – LC-I or LC-II on side of impact w/ contralateral APC injury Young Classification:

23. AP Compression (25%) Symphyseal and / or Longitudinal Rami Fractures APC I –diastasis of the pubic symphysis and/or anterior SI joint APC II – disrupted anterior SI joint, sacrotuberous, and sacrospinous ligaments (intact post SI ligs) APC III – complete SI joint disruption w/ lateral displacement and disruption of sacrotuberous and sacrospinous ligaments

24. Tile B1 / Young APC II

25. Vertical Shear (5%) Symphyseal diastasis or vertical displacement anteriorly and posteriorly; usually through SI joint, occasionally through iliac wing Young Classification System:

26. Tile C1/ Young VS

27. Pelvic Fracture Management • Stable vs. Unstable • Young Classification: • LC I, APC I = several days bedrest +/- external fixator, followed by progressive weight bearing as tolerated • LC II and III, APC II and III, VS = surgery

28. Pelvic Fracture Management • Buckley: • Full weight bearing for lateral compression #s that lack significant deformity, isolated pubic rami fractures • Indications for surgery: ongoing hemorrhage, displaced posterior pelvic injury, symphysis diastasis >2.5 cm

29. Pelvic Fracture Management of the Unstable Patient • ABC’s & initial stabilization (IV access, crystalloid, blood products) • Application of Pelvic Sheet/Binder/External fixator (open-book with intact posterior ligaments has most potential for benefit) • Adjuncts: Foley (but not if blood at meatus) • FAST to assess for intraperitoneal injury (and help with disposition—laparotomy vs. angio) • AP pelvis • ABX (ancef) and Tetanus if open.

30. Pelvic Fracture Management of the Unstable Patient • FAST +, Unstable = Laparotomy first • FAST -, Unstable = Angio • STABLE but with significant # = CT. If ‘brash’ on CT = ongoing bleed, needs angio

31. PELVIC BINDER • Benefits: • Reduces pelvic volume (tamponade effect) • Stabilizes # fragments • Improves patient comfort

32. PELVIC BINDER • Application: • Apply at level of greater trochanters • Avoid over-reduction (esp lateral compression #) as can increase internal rotation deformity, increase bleeding • Aim for anatomical reduction (legs, trochanters, patellae should be neutral)

34. Acetabulum Forms the ‘socket’ for the femoral head • Fusion of 3 bones: • 1. iliac (superior dome—chief weight-bearing surface) • 2. pubis (anterior-inferior—thin, easily fractured) • 3. ischium (posterior-inferior-thick)

35. Acetabulum

36. Acetabulum • Also classically described as having 2 columns: • 1. Anterior column (anterior iliac wing, superior pubic ramus, anterior wall of acetabulum) • 2. Posterior column (ischium, ischial tuberosity, posterior wall of acetabulum)

38. Acetabular Fractures • Nearly all associated with hip dislocations • Sciatic nerve injury common • MVA most common mechanism • Imaging: • Judet views (AP, 45 degree iliac oblique, 45 degree obturator oblique) • CT scan (x-ray negative but suspicious; clarifying operative or non-operative) • Judet-Letournel Classification System: • Simple (5 types) vs. Complex (combos)

39. Acetabular Fractures • Judet Classification • Simple Fractures: • 1. Posterior Wall • 2. Posterior Column • 3. Anterior Wall • 4. Anterior Column • 5. Transverse

41. Acetabular Fracture Management • ABCs • Neurovascular exam • Reduction of hip dislocation • Ortho consult • Admission Buckley: • Non-Displaced = non weight bearing x 6-8 weeks • Displaced >2mm intra-articular = surgery

43. Sacral Fractures • Mechanism: • Direct trauma or forced flexion • Key distinction is Vertical (high energy/unstable) vs. Transverse • O/E: pain on DRE • Dx: • AP pelvis, CT

44. Vertical Sacral Fractures • Denis Classification: • Zone 1—lateral to sacral neural foramina (6% L5 root injury) • Zone 2—through sacral neural foramina (28% sciatic injury) • Zone 3—medial to sacral neural foramina (50% bowel/bladder, sexual dysfunction)

46. Transverse Sacral Fractures Potential for neurologic injury depends on level of # line Nerve root injury uncommon below S4 High incidence of neuro deficit if # line above S2

47. Sacral Fractures • Treatment of High-Energy Vertical: ABCs etc. Surgical stabilization • Treatment of Transverse: • Neuro deficits  urgent spine consult • No neuro deficits ice, bed rest, analgesia & ortho f/u in 1 week

48. Coccyx Fractures • Mechanism: • Fall in seated position • Presentation: • Pain w/ sitting, standing, or defecating • Local tenderness • Dx: • Clinical. X-rays not needed! (pain on compression during DRE) • Tx: --rest, ice, donut-ring cushion, stool softeners • Coccygectomy if persistent chronic pain

49. CASE • 13 yo boy presents with pain in his hip after kicking a soccer ball…