Acetabular Reconstruction Fixation Methods in Associated Fracture Patterns
Department of Orthopaedic Trauma, St. Elizabeth Health Center and Department of Orthopaedic Surgery, Northeastern Ohio Universities College of Medicine, Youngstown, Ohio, U.S.A. Daniel R. Schlatterer and Robert M. Harris Department of Orthopaedic Trauma, Atlanta Medical Center, Atlanta, Georgia, U.S.A. INTRODUCTION TO ASSOCIATED FRACTURE PATTERNS OF THE ACETABULUM The associated patterns of acetabular fractures were described by Letournel and are described elsewhere in this text. They tend to...
Acetabular Reconstruction Fixation Methods in Simple Fracture Patterns
Department of Orthopaedic Trauma, St. Elizabeth Health Center and Department of Orthopaedic Surgery, Northeastern Ohio Universities College of Medicine, Youngstown, Ohio, U.S.A. Daniel R. Schlatterer and Robert M. Harris Atlanta Medical Center, Department of Orthopaedic Trauma, Atlanta, Georgia, U.S.A. INTRODUCTION TO SIMPLE FRACTURE PATTERNS OF THE ACETABULUM Acetabular surgery is one of the more intensive and complex surgeries performed in orthopaedics. This includes the complexity of the...
Indications For Nonoperative Management
Nonoperative management of acetabular fractures may be considered for non-displaced fractures or minimally displaced fractures lt 2 mm displacement , fractures that do not involve the weight-bearing dome of the acetabulum as determined on CT or by roof-arc angles, and in cases of secondary congruence 31 . The hip must remain congruently reduced without evidence of subluxation on radiographs and CT scans obtained with the patient out of traction. For displaced fractures, an adequate...
POSTERIOR RING INJURIES Sacroiliac Joint Injuries
The sacroiliac articulation is one of the most complex joints orthopedic surgeons deal with. The anatomy of the sacrum and surrounding structures make diagnosis and fixation difficult. Recognition of these injuries was difficult before the advent of roentgen-ograms. Until recent times, these injuries were treated conservatively, with no surgical intervention. Most pelvic injuries are stable, meaning they will not displace significantly when faced with physiologic loads 1 . For the unstable...
Emergency Surgery
The emergency surgical management of patients with mechanically unstable pelvic injuries and hypovolemic shock begins in the emergency room. Advanced trauma lifesupport teaching is now widely applied 9 . Shock recognition is followed by search for the source of hemorrhage while volume resuscitation is initiated. Clues to the nature of pelvic injuries are obtained from the history of injury e.g., a fall from a height or a motorcyclist sustaining a straddle injury and physical examination....
Surgical Approach
The patient is usually positioned either supine or floppy lateral, depending on the potential for a combined posterior approach. If a lateral position is chosen, a beanbag is most often used for stability and can be deflated, allowing the patient to fall back to a more supine position once the patient has been prepped and draped. Alternatively, the patient can be left lateral and a true simultaneous anterior and posterior dissection can take place utilizing two experienced surgeons, although...
Pertinent Anatomy
Unlike the posterior approach, much of the anterior anatomy is unfamiliar to many orthopedic surgeons. Three abdominal wall flat muscles, the external oblique, the internal oblique, and the transversus abdominus are integral to the superficial approach. The three combine for a single fascial insertion on the anterior iliac crest, but, below the ASIS, the three divide to form the roof and floor of the inguinal canal. The external oblique forms the roof of the canal down to the superficial...
The Contributions Of Letournel
In 1964, Judet et al. published their now classic article entitled Fractures of the Acetabulum, Classification and Surgical Approaches for Open Reduction 23 . This manuscript describes the use of the AP and two 45 oblique views of the pelvis to evaluate the acetabular fractures. These radiographic views, now known as Judet views, named after the author, include the AP pelvis, the obturator view, and the iliac oblique view. These are now the standard radiographic films used for evaluation of...
1. Cooper Sa. Surgical Essays 1818 Part I Second Ed. 51
1. Schroeder WE. Fracture of the acetabulum with displacement of the femoral head into the pelvic cavity Central Dislocation of Femur . Bulletin of the Northwestern Medical School 1909 9-42. 2. Cooper SA. Surgical essays 1818 Part I Second Ed. 51. 3. Palmer DW. Central dislocation of the hip with report of three cases. Am J Surg 1921 35 5 118-121. 4. Whitman R. The treatment of central luxation of the femur. Ann Surg 1920 71 62-65. 5. Skillern PG, Pancoast HK. Fracture of the floor of the...
Sciatic Buttress Acetabulum
The 1980s saw a substantial increase in the overall knowledge base of orthopedic surgery throughout the world with regard to treatment of acetabular fractures. The majority of these developments can be tied to Letournel's publication of the English translation of his text in 1981 20 . These advancements include i the formal description of the plain radiography of the pelvis and acetabulum ii the completion of the current-day Letournel classification system of acetabular fractures iii the...
ANTERIOR RING INJURIES Ramus Fractures
Fractures of the anterior aspect of the pelvis can occur due to a lateral compression mechanism or from an anteroposterior compression mechanism. Lateral compression type injuries typically produce horizontal fracture planes, where the bone cracks and the fragments slide past each other. Anteroposterior compression APC type injuries produce vertical fracture planes as the bone is pulled apart, separating the two fragments. In practice, truly horizontal or vertical fracture alignment is rare,...
Symphysis Pubis Injuries
Most pubic diastasis injuries arise from an anteroposterior compression mechanism. The Young-Burgess classification system provides an elegant mechanistic approach to describing these injuries 23 . The system promotes an understanding of the pathoanat-omy and guides our treatment. The classification describes three types of anteroposter-ior compressions. Type 1 involves diastasis of the symphysis pubis of less than 2.5 cm, with no disruption of the posterior pelvic structures APC I . Type 1 is...
Posterior Approach To The Sacrum And Si Joint
The posterior approach allows an open reduction and internal fixation of fractures of the sacrum, posterior iliac wing, ruptures of the SI joint, and fixation of transiliosacral crescent fractures Fig. 3 . The approach is safe with regard to neurovascular structures since there is no true internervous plane. It has to be taken into account, however, that the prone positioning may not be adequate in acute cases for patients with concomitant severe intracerebral, intraabdominal, or thoracic...
Acute Management of Pelvic Fractures A European Perspective
Axel P. Gansslen and Christian Krettek Department of Trauma, Hannover Medical School, Hannover, Germany Hans-Christoph Pape Department of Orthopaedic Surgery, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, U.S.A. Department of Urology, Hannover Medical School, Hannover, Germany During resuscitation of polytrauma patients with associated pelvic injuries, a specific subgroup, characterized by unstable pelvic fractures combined with a hemodynamic instability related to the...
B
Figure 6 B Staged surgical reconstruction in severe infection. Inadequate fecal diversion resulted in massive intrapelvic sepsis, with an abscess extending from the perineum into the subcutaneous tissue anterior to the diastasis. After referral for definitive care, the iliac-crest external fixator was swapped for an anterior construct, and colostomy and mucus fistula were performed. Aggressive local wound management was instituted. Once the infection was setting, posterior sacroiliac screw...
Anterolateral Approach To The Iliac Wing
The anterolateral Olerud approach, corresponding to the first window of the ilioinguinal Letournel approach Fig. 2 , allows exposure of the iliac wing and direct access to the anterior part of the SI joint. This approach is used for reduction and fixation of iliac wing fractures, transiliosacral crescent fractures, and disruptions of the SI joint. Apart from excellent direct visual control of these anatomical structures, optimal guidance of the drilling direction close to the SI joint is...
Anterior Approach To The Symphysis And Pubic Bone
The anterior elements of the pelvic ring consist of the symphysis pubis and the superior pubic rami. Variations on the simple approach to these anterior structures can allow greater exposure for reduction and fixation of acetabular and posterior ring injuries. For the simple anterior approach, the urogenital triangle is shaved following perurethral catheterization. This has often been performed beforehand during the resuscitation phase of the patient management. In cases of complete urethral...
Treatment of Additional Pelvic Injuries
There is as yet no consensus on whether extraperitoneal bladder ruptures should be treated surgically. Of all extraperitoneal bladder ruptures, 90 to 100 are associated with pelvic fractures Fig. 9 , whereas only 5 to 10 of all pelvic fractures are combined with bladder ruptures 117-119 . Whereas some authors support the conservative therapy of single, small lesions by catheterization for at least 10 days, others promote a mandatory surgical repair 117,120 . We use surgery, with a formal repair...
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Laparotomie Hemostasis Stabilization pelvic ring Further diagnostics Polytrauma management Further diagnostics Polytrauma management Figure 14 Emergency algorithm for pelvic trauma with three decisions within the first 30 minutes after admission. and manual compression, and an emergency stabilization of the pelvic ring is considered depending on the fracture type. In type C injuries, a pelvic C-clamp 82 has proved to be useful 54 . In rare occasions, a pelvic sling is tied around the pelvis....
Conclusion
Damage control orthopedics currently appears to be the treatment of choice for poly-traumatized patients with unstable pelvic fractures and additional hemodynamic instability who are at high risk to develop systemic complications, such as multiple organ failure. The authors feel that the following principles are relevant the procedure can be conceived as part of the resuscitation effort by maintaining blood volume and tissue oxygenation, thus minimizing the damage induced by the procedure while...
Classification of Pelvic Ring Injuries
Department of Trauma and Reconstructive Surgery, Charit University Medical School Berlin, Berlin, Germany Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado, U.S.A. Orthopaedic Trauma Surgery, Resurgens Orthopaedics, Atlanta, Georgia, U.S.A. The osseous pelvic ring consists of the bilateral iliac, ischial, and pubic bones, which are posteriorly completed by the sacrum. In combination with the strong ligaments, the pelvis...
Anatomy of the Pelvis
Departamento de Ortopedia y Traumatolog a, Fundaci n Santa Fe de Bogot , Bogot , Colombia Department of Orthopaedic Trauma, St. Elizabeth Health Center and Department of Orthopaedic Surgery, Northeastern Ohio Universities College of Medicine, Youngstown, Ohio, U.S.A. Familiarity with pelvic anatomy is essential for the treatment of pelvic fractures. With an increase in minimally invasive approaches in fixation methods, knowledge of pelvic anatomy is vital to safe reduction and fixation of...