Trauma to Pelvis, Hip, Femur

1. Trauma to Pelvis, Hip, Femur Tintinalli Chapter 273

2. Anatomy

3. Iliopectineal Line Sacrotuberous Ligament Greater Sciatic Foramen Sacrospinous Ligament Lesser Sciatic Foramen Sacrospinous Ligament Sacrotuberous Ligament

4. Pelvic Trauma • Secondary to MVA, pedestrian v. auto, falls in elderly, industrial accidents • Extremely vascular; therefore, pelvic fx’s must be considered in all trauma due to hypovolemia • Risk of neural, GU, GI, reproductive organ injury

5. History • Mechanism of injury • Determine areas of pain • Last urination or defecation • Present bladder sensation • Last food/fluid intake • Last menses/pregnancy

6. Physical Exam • Perineal and pelvic edema, ecchymoses, lacerations, and deformities. • Signs of pelvic fx’s • Earle’s sign -large hematoma or tenderness along fracture line or palpation of a bony prominence on rectal exam • Destot’s sign -superficial hematoma above the inguinal ligament or on the scrotum. • Roux’s sign -distance from the greater trochanter to the pubic spine is greater on one side than the other.

7. Physical Exam • Compress the pelvis lateral to medial, anterior to post., and through the greater trochanter. • Rectal exam- look for displacement of the prostate, rectal tone/injuries, and blood at the urethral meatus. • If a pelvic fracture is found, consider intraabdominal, retroperitoneal, gynecologic (check for vaginal injury), and urologic injuries. • High rate of fetal death is assoc. with pelvic trauma in pregnant pt. Immediate C-section must be considered.

8. Radiologic Evaluation • AP view pelvis mandatory in unconscious patients with multiple injuries • If needed, lateral view, AP hemipelvis, internal/external oblique hemipelvis, inlet/outlet views • CT may be needed (acetabular, sacral fx) • Angiography to determine source of bleeding

9. Young classification of pelvis fractures • AP compression (open book) • Type I- Disruption of the pubic symphysis <2.5cm of the diastasis; no significant post. pelvic injury. • Type II-Disruption of the pubic symphysis >2.5cm with tearing of the ant. Sacroiliac, sacrospinous and sacrotuberous ligaments. • Type III- Complete disruption of the pubic symphysis and post. Ligament complexes with hemipelvic displacement.

11. Young Classification • Lateral Compression • Type I- Post. Compression of the sacroiliac joint without ligament disruption; oblique pubic ramus fracture • Type II- Rupture of the post. sacroiliac ligament; pivotal int. rotation of the hemipelvis on the ant. SI joint with a crush injury of the sacrum and an oblique pubic ramus fracture. • Type III- Type II + AP compression to the contralateral hemipelvis

13. Young Classification • Vertical Shear • Fx of pubic rami anteriorly, while fx of sacrum, SI joint, or iliac wing are seen posteriorly. • Fractures are vertical with vertical displacement of fragments • Ligamentous injury to ant/post sacroiliac, sacrospinous, sacrotuberous and possibly symphysis

14. Vertical Shear

15. Complications of Pelvic Fx • Hemorrhage • Crystalloid, colloid, blood replacement (ave 6 units required) • Bedsheet: pelvic support & stabilization • Early ortho consultation (external fixator) • If available transarterial embolization may be needed (only 2%) only after initial treatment of fluid and blood replacement

17. Acetabular Fractures • Jedet-Letournel Classification • Posterior wall: post acetabular fx with post hip dislocation • Posterior Column: fx sciatic notch  wt bearing portion of acetabulum  obturator foramen (40% sciatic n. injury) • Anterior wall: AIIS  superior ramus • Anterior column: pubic ramus  iliac crest • Transverse: ant to post through acetabulum

18. Trauma to Hip and Femur • Anatomy

19. Clinical Evaluation PE: deformities, shortening, rotation, lacs, bruises, compress greater trochs, ROM Radio: AP and lateral of pelvis, AP hemipelvis, Judet views Significant hip pain with wt bearing and normal xray suggest occult fx

20. Hip Fx Classification • Intracapsular (femoral head and neck) • Capital • Subcapital • Transcervical • Basicervical • Extracapsular • Intertrochanteric • Subtrochanteric

21. Femoral Head Fx • Rare: assoc. with dislocations of the hip • 10-16% posterior hip dislocations • 22-77% anterior hip dislocations • Consult ortho-reduce dislocation and attain anatomic reduction of the fracture fragment

22. Femoral neck fractures Subcapital, transcervical, basicervical • Displaced vs. nondisplaced • Elderly, osteoporois, women, falls/torsion • Extremity: external rotation, abduction, shortened • Pain in groin/inner thigh • Admit, ortho consult in ED

23. Trochanteric Fx • Greater trochanteric fractures-caused by avulsions at the insertion of the gluteus medius • Treatment conservative-surgical fixation for displacement of >1cm • Lesser trochanteric fractures-caused by avulsion secondary to forceful contraction of the iliopsoas-seen in children and young athletic adults • Pain with flexion and internal rotation-2 cm displacement needs surgical treatment

24. Extracapsular Fx • Intertrochanteric fractures • Women, falls, osteoporosis • Pain, swelling, ecchymosis, externally rotated and shortened • Ortho consult/admit/buck traction • Subtrochanteric fractures • Falls or major trauma • Pain, deformity, swelling, crepitance • Hemorrhage into thigh hypovolemia • Ortho consult/traction/ORIF

25. Anterior Hip dislocations • Femoral head rests anterior to coronal plane of acetabulum • Superior • Inferior • True ortho emergency: early closed reduction under sedation • In-line traction with flexion and internal rotation then hip abduction once the head clears the rim of acetabulum

26. Posterior Dislocations • Majority (80-90%) of hip dislocations • Flexed knee vs dashboard, pushing femoral head through the post. capsule • Shortened, adducted, internally rotated and flexed on PE • Associated findings • Acetabular,femoral fractures • Knee injuries • Sciatic nerve injury • Closed reduction: in line traction, flexion to 90 degrees, internal to external rotation

27. Anterior Posterior

28. Femoral shaft fractures • Men, falls, industrial accidents, MVA, GSW • shortening and deformity, traction splint in pre hospital setting except in open fractures • Open fx: broad spectrum atb, debridement, copius irrigation in OR • Definitive mgmt: traction, external fixation, pins and plaster or internal fixation