L17, 18. Fractures of the Pelvis and Lower Extremities

Review the bony anatomy of the pelvis.

What are 6 common x-ray views of the pelvis?

1. AP
2. Lateral
3. Inlet view of pelvis (cauded)
4. Outlet view of pelvis (cephalad, often called "Judet views" to see obturator foramen)
5. AP hip with 15 degrees internal rotation
6. lateral hip, frog leg lateral

What are the superior landmarks that can be identified on an AP x-ray? (5)

1. Ilium
2. ASIS
3. AIIS
4. SI joint
5. Sacrum

What are the inferior landmarks that can be identified on an AP x-ray? (6)

1. Acetabulum
2. Femoral head
3. Femoral neck
4. Greater trochanter
5. Lesser trochanter
6. Ischium

What are the 6 types of pelvic fractures?

1. iliac wing
2. anterior/posterior column acetabulum
3. ischial fractures
4. pubic fractures (disruption of symphysis also seen in pregnancy)
5. sacral fractures
6. combined fractures

Iliac wing fractures typically progress from ______________ to _________________.

iliac crest to greater sciatic notch

What type of fracture is this?

iliac wing fracture

What are the 3 components of an anterior column acetabular fracture?

1. anterior ilium
2. anterior wall and dome
3. superior pubic ramus

What are the 3 components of a posterior column acetabular fracture?

1. posterior wall & dome
2. ischial tuberosity
3. greater/lesser sciatic notches

What does a transverse acetabular fracture look like?

There are also anterior and posterior wall acetabular fractures. Posterior wall fractures are associated with what other injury?

posterior hip dislocations

How do you treat acetabular fractures?

nonsurgical management (NWB) for 6-12 weeks if non-displaced

surgery if displaced

What complications are common with acetabular fractures?

high morbidity with post-traumatic OA

heterotopic ossification

What is the MOI for acetabular fractures?

high energy mechanisms (MVA, fall off roof, tree stands, ...)

Ischial fractures are common in what populations?

with sports and in children

Ischial fractures are associated with what type of fracture?

avulsion fracture due to pull of proximal hamstring (sports)

sometimes treated operatively if does not heal & high incidence in skeletally immature

What is osteitis pubis?

inflammation of pubic symphysis caused by repetitive trauma

What is the pathophysiology of osteitis pubis?

- repetitive microtrauma to pubic symphysis
- sports involving repetitive kicking or ballet
- sports involving repetitive hip adduction/abduction

How do you treat osteitis pubis?

nonoperative - NSAIDs, rest, activity modification

steroid injections = controversial

usually self-limiting, but may take several months to resolve

What is the normal width of the pubic symphysis?

What does this radiograph show?

open book fracture

Pubic ramus fractures are common in what populations?

elderly

How do you treat pubic ramus fractures?

non-operative usually

weight bearing as tolerated with walker

pain meds

usually need nursing home rehab due to pain

What is this x-ray showing?

How are sacral fractures treated?

conservatively unless neuro injury (sacral foramen) or unstable pelvic ring injury

Combined fractures are associated with ____________ injuries and have associated injuries, including?

high energy injuries

life-threatening, usually has concomitant injury (neuro, vascular, G/U)

The mortality rate for closed pelvic fractures is _______% and as much as _______% for open pelvic fractures.

1-15%

50%

What other orthopedic injuries are associated with pelvic fractures?

chest (up to 63%)
long bone (up to 50%)
spin fractures (25%)

**need head to toe exam

What non-orthopedic injuries are associated with pelvic fractures?

urogenital
sexual dysfunction up to 50%
head & abdominal injury in 40%

What is AP compression injury?

force directed anterior to posterior (iliac crest downward)

What is LC compression injury?

lateral directed force --> vertical shear (hit from one side of the iliac crest)

What is an open book fracture (technically)? What is it associated with?

anterior posterior compression III - disruption of SI ligaments and vascular injury

_____________ fracture is associated with the highest risk of hypovolemic shock and mortality rate up to 25%.

vertical shear (VS)

What is the key to pelvic trauma?

the physical exam

What is important to do/look for during pelvic exams for fractures?

**Perform only once or risk disruption of formed hematoma

**looking for abnormal extremity position (shortened or externally rotated)

**skin - scrotal, labial, or perineal hematoma, swelling, ecchymosis or flank ecchymosis

What 4 things to trauma patients always need?

C-spine x-ray
CXR
AP pelvis x-ray
neuro exam

**multifactorial injuries common**

What are the most common neurologic lumbosacral plexus injuries?

L5 and SI

What are you evaluating for during a rectal exam associated with pelvic injuries?

to evaluate sphincter tone and perirectal sensation

**up to 10-15% of patients will sustain neurologic injury

What is the most common urogenital finding associated with pelvic fractures?

gross hematuria (more common in males)

Vaginal and rectal examinations are mandatory to rule out what?

occult open fracture

**UP TO 50% MORTALITY**

What do you do for open book pelvis (AP injury) fractures?

PELVIC BINDER WRAP OR WRAP WITH SHEET to tamponade the pelvis and bleeding then external fixation during surgery

**DO NOT take pelvic binder off**

What are the strongest ligaments in the body?

posterior sacroiliac complex

**more important than anterior structures for pelvic ring stability

What is this radiograph showing?

lateral compression fracture

What do you look for on x-ray for vertical shear fractures?

height of iliac crests

Vertical shear fractures are caused by ____________ and ___________ directed force and is associated with what?

posterior and superior directed force

hypovolemic shock and morality rate up to 25%

What are the 3 types of femur fractures?

1. proximal (hip)
2. middle (shaft)
3. distal (supracondylar or intra-articular)

What are the 4 types of proximal femur (hip) fractures?

1. femoral head
2. femoral neck/subcapital
3. intertrochanteric
4. subtrochanteric

What is the most important thing to look for in femoral neck fractures?

is it displaced??

displaced = intracapsular --> poor blood supply --> need replacement

non-displaced = extracapsular --> good blood supply --> can fix

What are the 4 fragility fractures?

low energy fractures that occur in elderly

distal radius, proximal humerus, compression fracture, and hip fractures

Hip fractures have high morbidity and mortality in elderly, including?

loss of function
loss of independence

up to 25-50% mortality at one year

Hip fractures can also occur in younger populations how?

high energy trauma

What are frequent complications with femoral head fractures? How do you treat them?

high incidence of post-traumatic OA and/or AVN

ALWAYS surgical

What is the garden classification of femoral neck fractures?

type 1 & 2 get screws
**type 1 = nondisplaced incomplete fx
**type 2 = nondisplaced complete fx

type 3 & 4 need hemi- or total hip arthroplasty due to disruption of blood supply to femoral head (displaced)

What is a girdlestone-taylor procedure and what are the indications?

indications: very sick, elderly or non-ambulatory with femoral neck fracture

excision of femoral head WITHOUT fixation or repair of fracture

**strictly for pain control --> salvage procedure

How do you treat intertrochanteric hip fractures?

extracapsular fracture & blood supply preserved --> allows for fixation with nail or plate to heal

Subtrochanteric hip fractures can be _______________.

pathological - ie. someone on bisphosphonates with decreased osteoclast activity, tumors, etc

pain occurs prior to fracture, then the person falls

What are the different types of femoral shaft fractures?

What is the MOI for femoral shaft fractures and how do you treat this?

high energy injury or child abuse

adult = surgical
child = nonsurgical unless involves growth plate

Distal femur fractures in skeletally immature patients has a risk of what?

limb length discrepancies

**needs to be followed until skeletal maturity

Where do supracondylar femur fractures occur?

distal meta/diaphyseal junction

How do you treat supracondylar femur fractures?

mostly treated with ORIF

if involving articular surface, must be anatomically reduced

What are complications associated with supracondylar femur fractures?

nonunion more common than shaft fractures

high incidence of OA after surgery

may lead to total knee arthroplasty (TKA)

What is a periprosthetic fracture?

fractures that occur around a total joint implant (can be proximal, around, or distal to implant)

How do you treat periprosthetic fractures?

if stable, then ORIF (plates, screws, bone graft)

if unstable, then revision (have to remove and place longer hip prosthesis or revise knee component) --> HIGH COMPLICATION RATE

Review the bony anatomy of the tibia and fibula.

What are 3 signs of associated ligament injury in tib/fib fractures?

1. avulsion of fibular head
2. second sign - lateral capsular avulsion
3. pellegrini-stieda lesion - calcification insertion MCL

What does an avulsion of the fibular head look like on x-ray?

What does a second sign look like on x-ray?

lateral capsular avulsion

What does a pellegrini-stieda lesion look like on x-ray?

calcification insertion MCL

How do you treat tibial plateau fractures generally?

since these are articular weight bearing surface fractures of the knee, typically treated with surgery unless non-displaced or person is non-ambulatory

The tibia is the major WB bone of body and carries _____% of the transmitted load.

85%

Review Tibial Anatomy:

anterior =
lateral =
medial =

anterior - tibial tubercle
lateral - Gerdy's tubercle (IT band)
medial - pes anserinus (medial hamstrings)

What is the most common tibial plateau fracture?

lateral plateau fractures

Why is a neurovascular assessment important in tibial plateau fractures?

popliteal trifurcation- tethered position

common peroneal nerve- tethered laterally

What are the 6 P's of compartment syndrome?

1.) Pain out of proportion to injury
2) Pain with passive motion
3) Pallor
4) Paresthesias
5) Pulselessness
6) Paralysis (late sign)

What are 6 causes of compartment syndrome?

1. fracture (tibia most common)
2. burns
3. anticoagulation bleeding
4. too tight cast or splint
5. post vessel repair (ie. popliteal bypass during reperfusion)
6. severe infection (IVDA abscess in arm/forearm)

How do you treat compartment syndrome?

emergent fasciotomies

What are 5 associated injuries in tibial plateau fractures?

1. meniscal tears (50%)
2. ACL/Collateral tear (30%)
3. peroneal nerve injury
4. knee dislocation (vascular compromise)
5. post-traumatic OA
6. compartment syndrome

What is seen on this x-ray?

displaced, comminuted, intra-articular, tibial plateau fracture with associated fracture of fibular head

What is seen on this radiograph?

displaced (depressed) lateral tibial plateau fracture

How do you treat tibial plateau fractures?

non-operative if non-displaced

operative if >2 mm articular depression, open fractures, compartment syndrome, or associated neuro/vascular injury

What are frequent complications of tibial plateau fractures? (7)

1. Knee Stiffness (trauma from injury or surgery; extensor
retinacular injury; scarring; postoperative immobility)
2. Infection (ill-timed dissections through compromised soft
tissues)
3. Compartment Syndrome
4. Malunion or nonunion (post-traumatic OA)
5. Peroneal nerve injury
6. Popliteal artery laceratio
7. AVN

What nerve is vulnerable in tibia and fibular shaft fractures?

common peroneal nerve

What is the gold standard for treatment of tib/fib shaft fractures?

Intramedullary fixation has improved the care of these difficult fractures by progressing weight bearing and minimizing healing problems associated with prolonged immobilization (stiffness, muscle atrophy)

Diagnose this fracture on x-ray.

partially comminuted, mildly displaced, midshaft tibial fracture with butterfly fragment

Diagnose this fracture on radiograph.

displaced, oblique, comminuted, angulated fracture of proximal tibial and fibular shafts

What does this picture show?

Open midshaft, displaced, shortened oblique open, comminuted fracture of the tibia and fibula

What is the first thing to do with open fractures?

immediate IV antibiotics to avoid infection (typically Ancef IV)

True or False: Open fractures do not have a high risk of compartment syndrome.

True

What are frequent complications of tibial shaft fractures? (10)

1. malunion
2. nonunion
3. infection
4. soft tissue loss
5. stiffness of knee/ankle
6. knee pain - IM nailing
7. reflex sympathetic dystrophy (CRPS) - initial pain and swelling followed by atrophy of leg
8. compartment syndrome
9. NV injury
10. fat embolism --> PE

What is CRPS? What are the signs?

complex regional pain syndrome

hypersensitivity & skin changes, including more hair, glossy appearance, redness, swelling

What are treatment options for CRPS?

mobilize, PT, sympathetic nerve blocks

What is a tibial plafond/pilon fracture and its MOI?

intraarticular fracture of distal tibia

MOI: low energy rotation or high energy axial compression forces

What is the treatment of tibial plafond fractures?

splint then cast
traction
lag-screw fixation
ORIF with plates
Ex-fix with or without internal fixation

**99% need surgery**

What is the goal of tibial plafond treatment?

obtain best possible articular reduction and axial alignment while respecting soft tissue

Why are staged procedures used and what does it involve?

ligamentotaxis (molding fracture fragments into alignment as a result of tension applied across fracture by surrounding intact soft tissues) with external fixation followed by internal fixation for tibial plafond fractures

allows skin/soft tissue to heal

What is a fracture blister?

a result of the severe soft tissue swelling from a fracture & leads to blistering of skin

Do NOT cut through this skin!!! It will not heal and WILL get infected.

What ligament is the most commonly injured in ankle sprains?

anteroinferior tibiofibular (AITFL)

What are the 4 parts of the ankle syndesmosis?

1. anterior inferior tibiofibular
2. posterior inferior tibiofibular
3. inferior transverse
4. interosseous membrane

**very important when evaluating ankle fractures**

Review the bony anatomy of the ankle as seen on radiograph.