Pelvis injuries

Fractures of the femur

(proximal,shaft)
Dr Tams Bodzay

Pelvis anatomy

Pelvis function
- axial load bearing

- protection: abdominal, pelvic structures

Pelvic injury mechanism

Falling from altitude

Compression
Motor vehicle accident

High energy trauma

Associated injuries
Blood loss:1500 2000 ml (shock)
- fracture site: 70 %
- venous plexus: 20 %
- arterial bleeding: 10%
Associated injuries:
- urethra
- urinary bladder (extra- intraperitoneal)
- rectum

Classification
- localisation of the injury
- instability (Tile-AO)
- direction of the force (Young-Burgess)

Type A
(stable)

Young patients: sport injuries / muscle attachment/

Elderly patients: falls

Type B
(rotational instability)

Type B 1.( open book)

Symphysis opens up /3-6 cm/
Posterior internal ligaments ruptured,
Posterior external ligaments intact

Type B 2.
Symphysis squashed
Posterior internal ligaments intact,
Posterior external ligaments
ruptured

Typ. C
(rotational + vertical instability)

 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

Diagnostics- CT

Treatment
-

Stable injury= non-operative treatment

Unstable injury= operative treatment

Instability:
- (bio)mechanical

- HEMODINAMICAL !!
(Blood loss:1500 2000 ml ;shock)

Hemodinamically unstable
patient:emergency fixation

Definitive treatmentsymphyseolysis: plate fixation

Definitive treatment- transiliacal fx.:

plate fixation

Definitive treatment- SI-lysis: plate

fixation or iliosacral screw fixation

Definitive treatment- sacrum fx:

Classification
I- posterior type:wall,
collumn, wall+
collumn,
II- anterior type:wall,
collumn, wall+
collumn,
III- transverse type:
transverse, T, both
collumn

Diagnostics- X ray
AP view
Ala view
Obturator view

AP view

Ala view

Obturator view

Diagnostics- CT

Operativ treatment- approaches

Operativ treatment- screw fixation

Operativ treatment- plate fixation

Dashboard injury ?

Dashboard injury

acetabular fx.
femoral head fx.
femoral neck fx.
femur diaphyseal fx.
femur distal fx.
patellar fx.
PCL tear.
tibial head fx.

Pipkins classification of femoral

head fractures.
Type I: Fracture inferior to
fovea centralis.
Type II: Fracture superior
to fovea centralis.
Type III: Type 1 or 2 +
femoral neck fracture.
Type IV: Type 1, 2 or 3 +
acetabular fracture

Treatment of femoral head

fractures
Type I: excision or
fixation.
Type II: ORIF with screws
in youngs; joint
replacement in elderly.
Type III: same as Type II
Type IV: same as in Type
III + acetabular fracture
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

Mller (AO), Garden and Pauwels classification of femoral neck fractures

B1 Neck fracture, subcapital,

with slight displacement
1 impacted in valgus > or =
15
2 impacted in valgus < 15
3 non impacted

G1 : incomplete, impacted
displacement

B2 Neck fracture,
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, subcapital, 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

Treatment of the femoral neck

fractures- 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

Three-point-buttressing

Screw fixation of the Garden I.

fracture

Screw fixation of the Garden III.

fracture

Treatment of the femoral neck

fractures- arthroplasty

Type Garden-IV;subcapital fracture

Time between injury and surgery > 48 hour
Impossible reduction
Pathologic femoral neck fracture

Arthroplasty

hemiarthroplasty : age > 80

years

total hip arthroplasty: age <

80 years

Classification of the trochanteric

fractures

A-1 Trochanteric, simple

A-1.1 Cervicotrochanteric
A-1.2 Pertrochanteric
A-1.3 Trochanterodiaphyseal

A-2 Pertrochanteric,
multifragmentary
A-2.1 One intermediate
fragment
A-2.2 Two intermediate
fragments
A-2.3 More than two
intermediate fragments

A-3 Intertrochanteric
A-3.2 Intertrochanteric
A-3.2 Reversed, simple
A-3.3 With additional fracture of
medial cortex

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 Lilienstrm)
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

External fixator

Open femoral shaft fractures (Type III.)

Septic complications
Femoral shaft fractures + polytrauma
(ISS > 40)

Implant choice
Mono/multitrauma: reamed nailing with
interlocking
Polytrauma: ISS < 40 - unreamed locking
nailing, ISS > 40 or head/thorax injury- FE.
Intraarticular and diaphysis fx,
compartment syndrome, vascular injury,
previously inserted implants-plates