TREATMENT

The primary goal for the treatment of pelvic fractures in Several studies of
early pelvic fracture treatment have demonstrated beneficial effects, such as
decreased blood transfusion requirements, decreased systemic complications,
decreased hospital stays, and improved patient survival. [19, 20] Secondary
considerations for operative management of pelvic fractures in the acute setting are
the correction or prevention of significant pelvic translational and rotational
deformities that have been associated with poorer clinical outcomes. [4, 16, 42]

Pubic ramus fractures

Pubic ramus fractures occur as parasymphysial fractures, midramus
fractures, and pubic root fractures in association with distraction and compression
injuries of the pelvis. [30] Displacement of pubic ramus fractures may cause
impingement or laceration of the bladder, vagina, and perineum, and for these
reasons, operative management may be considered. Operative treatment of pubic
rami fractures is indicated to provide additional pelvic ring stability in association
with posterior pelvic ring fixation. Stabilization of pubic rami fractures also may
be considered in fractures involving the obturator neurovascular canal with
accompanying neurologic injury.Treatment options for pubic ramus fractures
include external fixation, percutaneous screw fixation, and ORIF. External fixation
with either multiple pins or single pins in each hemipelvis may be used
successfully in conjunction with stabilization of posterior ring injuries to impart
additional stability to the pelvic fixation construct. [44,45]
Intramedullary fixation of the pubic ramus has been described for treatment
of pubic ramus fractures. [12, 46] Intramedullary pubic ramus fixation with a 4.5-mm
cortical screw has demonstrated fixation strength equivalent to plate fixation and
has demonstrated good results in clinical settings. [38, 47] Intramedullary stabilization
of ramus fractures may be performed with either a percutaneous or open technique
with either antegrade or retrograde screw placement in the pubic ramus.
Extramedullary plate fixation is another option to stabilize pubic ramus fractures
after open reduction and usually is achieved with 3.5-mm pelvic reconstruction
plates.

Diagnosis of Associated Injuries Genitourinary Large case series have

reported that genitourinary injury occurs in as many as 15% to 20% of pelvic
fracture cases.17,18,33-36 Identification of blood at the urethral meatus, gross
hematuria, or significant penile or scrotal swelling or ecchymosis should raise
suspicion for injury to the bladder or urethra and warrant a urology consult and
further work-up, including a urethrogram or possible operative exploration.
Additionally, the pelvic fracture pattern, as seen on the initial anteroposterior
trauma pelvic radiograph, may predict the risk of genitourinary injury. Basta and
coworkers,18 in a case-control review of 119 pelvic fracture patients, correlated
anterior pelvic fractures (in particular, inferomedial pubic bone fracture or pubic
symphysisdiastatis with 1 cm or more of displacement) with associated urethral
injury. The investigators found that each millimeter of pubic symphysis diastasis or
inferomedial pubic bone fracture displacement was associated with a 10%
increased risk of urethral injury. Andrich and associates37 reviewed 108 males and
females with pelvic ring fractures at their institution and found that 27 (25%) had
lower urinary tract injuries (LUTI). Although the study failed to show a correlation
between pelvic fracture mechanism (Tile A, B, or C) and the presence of a LUTI,
the study did find that more severe urethral injuries (complete urethral disruption
and complex LUTI) occurred only in males with Tile C injuries. In a retrospective
review of 721 patients with blunt trauma pelvic fractures, Avey and colleagues38
found 37 bladder ruptures (5%), all of which had hematuria greater than 30
RBC/HPF (red blood cells per high-power field). Pelvic injuries associated with
bladder injury included diastasis of the pubic symphysis greater than 1 cm and
fracture of the obturator ring, with a displacement greater than 1 cm.38

Hemorrhage All pelvic fractures are associated with some form of bleeding.
Sources of blood loss include cancellous bone at the fracture site, laceration of
retroperitoneal veins in the pelvis, and laceration of branches of the internal iliac
artery, which accounts for approximately 25% of hemodynamically unstable pelvic
fractures.40,41 It is difficult to determine whether a patient is hemorrhaging from a
venous or an arterial bleed. Arteriography can identify arterial bleeding,
venography shows venous bleeding (although it is difficult to distinguish between
major or minor bleeds), and pelvic CT can show the presence of a hematoma
(which is suggestive of a bleed, but not specific). Huittinen and Sltis42 performed
a cadaveric study of 27 patients with pelvic fractures who died from hemorrhage.
Postmortem anatomic dissection and arteriography of the hypogastric artery was
performed. Extravasation from the hypogastric artery through the cancellous bone
and torn tissues was seen in 23 cadavers. Based upon their findings, Huittinen and
Sltis concluded that accurate reposition of the dislocated pelvic fracture is
preferable to ligation of the hypogastric arteries for control of severe hemorrhage
from pelvic fractures. Early identification of patients with hemorrhage is critical
in management. Although evaluation of patients with blunt abdominal injury,
typically, involves a focused assessment with sonography for trauma (FAST)
exam, in patients with pelvic fractures, a negative exam does not rule out
intraperitoneal hemorrhage. Friese and coworkers43 performed a retrospective
review of 96 patients with pelvic fracture and risk factors for hemorrhage (systolic
blood pressure less than 100 mmHg or an unstable fracture pattern) who underwent
a FAST and either operative exploration or CT scan for confirmation. In the study,
there were 11 true positives, 52 true negatives, two false positives, and 31 false
negatives (sensitivity of 26% and negative predictive value of 63%).43 Clinical
factors can be used to help predict which patients with pelvic fractures are more at
risk of bleeding. Blackmore and associates40 performed a retrospective cohort
study of 627 patients with pelvic fractures (20% of whom had major pelvic
hemorrhage) and identified four predictors of hemorrhage, including an emergency
room hematocrit of less than 30, a pulse greater than 130 BPM, displaced obturator
ring fracture, and pubic symphyseal wide diastasis (greater than 1 cm used for
displacement). Patients with zero predictors had a 2% change of major
hemorrhage, whereas patients with three or more predictors had a greater than 60%
chance of having hemorrhage. In a retrospective review of 382 patients with
isolated pelvic or acetabular fractures, Magneussen and colleagues44 found that
isolated pelvic fractures with major ligament disruption (APC I or II, LC III, VS,
or CMI) were more likely to require transfusions (44%) than other pelvic fractures
(8.5%). Patients with APC 3 and VS fractures required the most amount of blood
(12.6 units and 4.6 units, respectively).

Dislocation and fracture of Hip Joint

One should reduce the hip on an urgent basis to minimize the risk of
osteonecrosis of the femoral head; it remains controversial whether this should be
accomplished by closed or open methods. Most authors recommend an immediate
attempt at a closed reduction, although some believe that all fracture-dislocations
should have immediate open surgery to remove fragments from the joint
and to reconstruct fractures.
The long-term prognosis worsens if reduction (closed or open) is delayed more
than 12 hours. Associated acetabular or femoral head fractures can be treated in the
subacute phase.

Closed Reduction

Regardless of the direction of the dislocation, the reduction can be attempted

with in-line tractionwith the patient lying supine. The preferred method is to
perform a closed reduction using general anesthesia, but if this is not feasible,
reduction under conscious sedation is possible. There are three popular methods of
achieving closed reduction of the hip:

1. Allis Method. This consists of traction applied in line with the deformity. The
patient is placed
supine with the surgeon standing above the patient on the stretcher or table.
Initially, the surgeon applies in-line traction while the assistant applies
countertraction by stabilizing the patients pelvis. While increasing the traction
force, the surgeon should slowly increase the degree of flexion to approximately 70
degrees. Gentle rotational motions of the hip as well as slight adduction will often
help the femoral head to clear the lip of the acetabulum. A lateral force to the
proximal thigh may assist in reduction. An audible clunk is a sign of a successful
closedreduction (Fig. 27.6).

2. Stimson Gravity Technique. The patient is placed prone on the stretcher with
the affected leg hanging off the side of the stretcher. This brings the extremity into
a position of hip flexion and knee flexion of 90 degrees each. In this position, the
assistant immobilizes the pelvis, and the surgeon applies an anteriorly directed
force on the proximal calf. Gentle rotation of the limb may assist in reduction (Fig.
27.7). This technique is difficult to perform in the emergency department

3. Bigelow and Reverse Bigelow Maneuvers. These have been associated with
iatrogenic femoral neck fractures and are not as frequently used as reduction
techniques. In the Bigelow maneuver,
the patient is supine, and the surgeon applies longitudinal traction on the limb. The
adducted and internally rotated thigh is then flexed at least 90 degrees. The femoral
head is then levered into the acetabulum by abduction, external rotation, and
extension of the hip. In the reverse Bigelow maneuver, used for anterior
dislocations, traction is again applied in the line of the deformity. The hip is then
adducted, sharply internally rotated, and extended.

Following closed reduction, AP pelvis radiographs should be obtained to

confirm the adequacy of reduction. The hip should be examined for stability while
the patient is still sedated or under anesthesia. If there is an obvious large displaced
acetabular fracture, the stability examination
need not be performed.

If possible, stability is checked by flexing the hip to 90 degrees in neutral

position under fluoroscopy. A posteriorly directed force is then applied. If any
sensation of subluxation is detected, the patient will require additional diagnostic
studies and possibly surgical exploration or traction.

Following successful closed reduction and completion of the stability

examination, the patient should undergo CT evaluation.

Open Reduction
Indications for open reduction of a dislocated hip include:
1. Dislocation irreducible by closed means
2. Nonconcentric reduction
3. Fracture of the acetabulum or femoral head requiring excision or open
reduction and internal fixation
4. Ipsilateral femoral neck fracture

A standard posterior approach (KocherLangenbeck) will allow exploration

of the sciatic nerve, removal of posteriorly incarcerated fragments, treatment
of major posterior labral disruptions or instability, and repair of posterior
acetabular fractures.

An anterior (SmithPeterson) approach is recommended for isolated femoral

head fractures. A concern when using an anterior approach for a posterior
dislocation is the possibility of complete vascular disruption. By avoiding
removal of the capsule from the femoral neck and trochanters (i.e., taking
 down the capsule from the acetabular side), the lateral circumflex artery is
preserved.

An anterolateral (WatsonJones) approach is useful for most anterior

dislocations and combinedfracture of both femoral head and neck.

A direct lateral (Hardinge) approach will allow exposure anteriorly and

posteriorly through thesame incision.

In the case of an ipsilateral displaced or nondisplaced femoral neck fracture,

closed reduction ofthe hip should not be attempted. The hip fracture should
be provisionally stabilized through alateral approach. A gentle reduction is
then performed, followed by definitive fixation of thefemoral neck.

Management after closed or open reduction ranges from short periods of bed
rest to variousdurations of skeletal traction. No correlation exists between
early weight bearing andosteonecrosis. Therefore, partial weight bearing is
advised.

If reduction is concentric and stable: A short period of bed rest is followed by

protected weight bearing for 4 to 6 weeks.
If reduction is concentric but unstable: Operative intervention should be
considered, followed by protective weight bearing.

Fracture shaft Femur

Emergency treatment

Traction with a splint is first aid for a patient with a femoral shaft fracture. It is
applied at the site of the accident, and before the patient is moved. A
Thomassplint, or one of the modern derivations of this practical device, is ideal:
the leg is pulled straight and threaded through the ring of the splint; the shod foot is
tied to the cross-piece so as to maintain traction and the limb and splint are firmly
bandaged together. This temporary stabilization helps to control pain, reduces
bleeding and makes transfer easier. Shock should be treated; blood volume is
restored and maintained, anda definitive plan of action instituted as soon as the
patients condition has been fully assessed.
 Definitive treatment

The patient with multiple injuries The association of femoral shaft fractures with
other injuries, including head, chest, abdominal and pelvic trauma, increases the
potential for developing fat embolism, ARDS and
multi-organ failure. The risk of systemic complications can be significantly
reduced by early stabilization of the fracture, usually by a locked intramedullary
nail. However, surgery to introduce a reamed intramedullary nail may produce
untoward effects in those with severe chest injuries, especially when carried out
within 24 hours of the fracture. It is thought the trauma of surgery and blood loss
induces inflammatory changes that may increase both morbidity and mortality
this phenomenon is called the second hit, referring to a second episode of trauma,
albeit surgical, on the patient. Consequently, in the multiply injured patient,
particularly one with severe chest trauma, prompt stabilization with an external
fixator may be wise; the fixator can be exchanged for an intramedullary nail when
the patients condition stabilizes. The timing of this second procedure is
problematic.
Some guidance can be sought from measurement of circulating levels of
interleukin-6, a pro-inflammatory cytokine (Pape, van Griensven et al.2001); when
the levels start to decrease, it should be safe to perform second hit interventions.
Clinically this occurs around 57 days after admission, but this window is by no
means applicable to all patients nor
is it conclusive at this time. Performing the exchange to an intramedullary nailalso
carries the risk of transferring contaminants from pin sites to the intramedullary
nail; the earlier the operation is performed, the lower the risk. In the patient who
spends a protracted period in the intensive care unit, it may be safer to use external
fixation
as definitive treatment, perhaps with a return to theatre later to allow insertion of
new pins to increase the stability of the construct.

THE ISOLATED FEMORAL SHAFT FRACTURE

Traction, bracing and spica casts Traction can reduce and hold most
fractures in reasonable alignment, except those in the upper third of the femur.
Joint mobility can be ensured by active exercises. The chief
drawback is the length of time spent in bed (1014 weeks for adults) with the
attendant problems of keeping the femur aligned until sufficient callus has formed
plus reducing patient morbidity and frustration.
Some of these difficulties are overcome by changing to a plaster spica or
in the case of lower third fractures functional bracing when the fracture is
sticky, usually around 68 weeksThe main indications for traction are (1)
fractures in children; (2) contraindications to anaesthesia; and (3) lack of suitable
skill or facilities for internal fixation.It is a poor choice for elderly patients, for
pathologicalfractures and for those with multiple injuries. The various methods of
traction are described in Chapter 23. For young children, skin traction without
a splint is usually all that is needed. Infants less than 12 kg in weight are most
easily managed by suspending the lower limbs from overhead pulleys (gallows
traction), but no more than 2 kg weight should be used and the feet must be
checked frequently for circulatory problems. Older children are better suited to
Russellstraction (Chapter 23) or use of a Thomas splint. Fracture union will have
progressed sufficiently by 24 weeks (depending on the age of the child) to permit
a hip spicato be applied and the child is then allowed up.
Consolidation is usually complete by 612 weeks. Adults (and older
adolescents) require skeletal tractionthrough a pin or a tightly strung Kirschner
wire behind the tibial tubercle. Traction (810 kg for an adult) is applied over
pulleys at the foot of the bed. The limb is usually supported on a Thomas splint
anda flexion piece allows movement at the knee (Figure 29.22). However, a splint
is not essential; indeed, skeletal traction without a splint (Perkins traction) has the
advantages of producing less distortion of the fracture and allowing freer
movement in bed (Figure 29.23). Exercises are begun as soon as possible.Once the
fracture is sticky (at about 8 weeks in adults) traction can be discontinued and the
patient allowed up and partial weightbearing in a cast orbrace. For fractures in the
upper half of the femur, a plaster spicais the safest but it will almost certainly
prolong the period of knee stiffness. For fractures in the lower half of the femur,
cast-bracing is suitable. This type of protection is needed until the fracture has
consolidated (1624 weeks).
Plate and screw fixation Plating is a comparatively easy way of obtaining
accurate reduction and firm fixation. The method was popular at one time but went
out of favour because of a high complication rate. This occurred when plates were
applied through a wide open exposure of the fracture site and perfect anatomical
reduction of all bone pieces. Such extensive surgerydamaged the healing potential
and led to tardy union and implant failure. However, plates have encountered
resurgence: today, they are inserted through short incisions and placed in a
submuscularplane, rather than deep to periosteum; an indirect(closed) reduction of
the fracture is done; fewer screws are used, and usually placed at the ends of the
plate, leading to a less rigid hold on the fracture. This technique of minimally
invasive plate osteosynthesis(MIPO) has led to better union rates. However,
postoperative weightbearing will need to be modified as the implant is not as
strong as an intramedullary nail. The main indications for plates are (1) fractures at
either end of the femoral shaft, especially those with extensions into the
supracondylar or pertrochantericareas, (2) a shaft fracture in a growing child, and
(3) a fracture with a vascular injury which requires repair (Figure 29.24).

Intramedullary nailing Intramedullary nailing is the method of choice for

most femoral shaft fractures. However, it should not be attempted unless the
appropriate facilities and expertise are available. The basic implant system consists
of an intramedullary nail (in a range of sizes) which is perforated near each end so
that locking screws can be inserted transversely at the proximal and distal ends;
this controls rotation and length, and ensures stability even for subtrochanteric
and distal third fractures (Figure 29.25).
These important details should be rememberedwhen using locked
intramedullary nails:
1. Reamed nails have a lower need for revision
surgery when compared to unreamed nails.
2. Select a nail that is approximately the size of the medullary isthmus so that it
fills the canal reasonably well (after reaming) and adds to stability small diameter
nails are quicker to insert but more frequently lead to the need for revision surgery.
3. Consider alternative means of fracture fixation if the isthmus is so narrow that a
large amount of canal reaming will have to be done in order to fit the smallest
diameter nail available.
4. Use a nail of sufficient length to fully span the canal.
5. Antegrade insertion (through either the piriformisfossa or the tip of the greater
trochanter, depending on the design of nail) or retrograde insertion (through the
intercondylar notch distally) are equally suitable techniques to use; there is a small
incidence of hip and thigh pain
withantegrade nails, whereas there is a smallproblem with knee pain with
retrograde nails.
Retrograde insertion of intramedullary nails isparticularly useful for: obese
patients; when there are bilateral femoral shaft fractures (as the procedure can be
performed without the need for a fracture table and the added time for setting up
for each side); when there is a tibial shaft fracture on the same side; and if there is
a femoral neck fracture more proximally, as screws can be inserted to hold this
fracture without being impeded by the nail. Stability is improved by using
interlocking screws; all locking holes in the nail should be used. Often there is
enough shared stability between the nail and fracture ends to allow some
weightbearing early on. The fracture usually heals within 20 weeks and the
complication rate is low; sometimes malunion (more likely malrotation) or delayed
union (from leaving the fracture site over-distracted) occurs.
 Open medullary nailing is a feasible alternative where facilities for closed
nailing are lacking. A limited lateral exposure of the femur is made; the fracture is
reduced and a guidewire is passed between the main proximal and distal fragments.
A small exposure to achieve reduction does not significantly affect the risk of
complications or fracture healing as compared to closed nailing. External fixation
The main indications for external fixation are (1) treatment of severe open injuries;
(2) management of patients with multiple injuries where there is a need to reduce
operating time and prevent the second hit; and (3) the need to deal with severe
bone loss by the technique of bone transport. External fixation is also useful for (4)
treating femoral fractures in adolescents (Figure 29.26).
Like closed intramedullary nailing, it has the advantage of not exposing the
fracture site and small amounts of axial movement can be applied to the bone by
allowing a telescoping action in the fixator body (with some designs of external
fixator). As the callus increases in volume and quality, the fixator can be adjusted
to increase stress transfer to the fracture site, thus promoting quicker consolidation.
However, there are still problems with pin-site infection, pin loosening and (if the
half-pins are applied close to joints) limitation of movement due to
interferencewith sliding structures.The patient is allowed up as soon as he or she is
comfortable and knee movement exercises are encouraged to prevent tethering by
the half pins. Partial weightbearing is usually possible immediately but this will
depend on the x-ray appearance of callus this may take some time (more than 6
weeks) if the fixator is a rigid device. Most femoral shaft fractures will unite in
under 5 months but some take longer if the fracture is badly comminuted or contact
between fracture ends is poor.