Trauma to Pelvis, Hip, Femur

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Trauma to Pelvis, Hip, Femur

• Tintinalli
• Chapter 273

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Anatomy
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Sacrotuberous Ligament
Greater Sciatic Foramen
Sacrospinous Ligament
Lesser Sciatic Foramen
Sacrospinous Ligament
Sacrotuberous Ligament
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Pelvic Trauma

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

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History

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

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Physical Exam

• Perineal and pelvic edema, ecchymoses,
  lacerations, and deformities.
• Signs of pelvic fxs
• Earles sign -large hematoma or tenderness along
  fracture line or palpation of a bony prominence
  on rectal exam
• Destots sign -superficial hematoma above the
  inguinal ligament or on the scrotum.
• Rouxs sign -distance from the greater trochanter
  to the pubic spine is greater on one side than
  the other.

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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.

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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

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Young classification of pelvis fractures

• AP compression (open book)
• Type I- Disruption of the pubic symphysis lt2.5cm
  of the diastasis no significant post. pelvic
  injury.
• Type II-Disruption of the pubic symphysis gt2.5cm
  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.

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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

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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

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Vertical Shear
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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

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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

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Trauma to Hip and Femur

• Anatomy

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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

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Hip Fx Classification

• Intracapsular (femoral head and neck)
• Capital
• Subcapital
• Transcervical
• Basicervical
• Extracapsular
• Intertrochanteric
• Subtrochanteric

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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

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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

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Trochanteric Fx

• Greater trochanteric fractures-caused by
  avulsions at the insertion of the gluteus medius
• Treatment conservative-surgical fixation for
  displacement of gt1cm
• 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

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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

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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

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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

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Anterior Posterior
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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

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