Transcript
Pelvis injuriesFractures of the femur
(proximal,shaft)
Dr Tamás 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 squashedPosterior internal ligaments intact,Posterior external ligamentsruptured
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 examination1x!!
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 unstablepatient:emergency fixation
Definitive treatment-symphyseolysis: plate fixation
Definitive treatment- transiliacal fx.: plate fixation
Definitive treatment- SI-lysis: platefixation 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, bothcollumn
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.
Pipkin’s classification of femoralhead fractures.
• Type I: Fracture inferior tofovea centralis.
• Type II: Fracture superiorto fovea centralis.
• Type III: Type 1 or 2 + femoral neck fracture.
• Type IV: Type 1, 2 or 3 + acetabular fracture
Treatment of femoral headfractures
• Type I: excision orfixation.
• Type II: ORIF with screwsin youngs; jointreplacement in elderly.
• Type III: same as Type II• Type IV: same as in Type
III + acetabular fracturefixation.
Clinical symptoms of the hipfractures
• abduction
• external rotation• shortening
ObturatorObturatorarteryartery
FovealFovealarteryartery
FemoralFemoralarteryartery
ExtracapsularExtracapsulararterialarterialringring
AscendingAscendingcervicalcervicalarteriesarteries
RetinacularRetinaculararteriesarteries
SubsynovialSubsynovialintracapsularintracapsulararterialarterialringring
The bloodsupply of the femoral head
Capsule
Ligamentum teres
Medial femoralcircumflex artery
Lateral femoralcircumflex artery
Profunda femoris artery
Ascending cervical arteries
Extracapsular arterial ring
B2 Neck fracture, transcervical1 basicervical
2 midcervical adduction3 midcervical shear
B1 Neck fracture, subcapital, with slight displacement
1 impacted in valgus > or = 15°
2 impacted in valgus < 15°3 non impacted
B3 Neck fracture, subcapital, non impacted, displaced
1 moderate displacement in varus and external rotation
2 moderate displacement with verticaltranslation and external rotation
3 marked displacement
Müller (AO), Garden and Pauwels classification of femoral neck fractures
G1 : incomplete, impacted G2 : non-displaced G3 : incomplete displacement G4 : completedisplacement
Pauwels classification refersto the angle of the fracture line
compared to the horizontal
Grade 1: 30°Grade 2: 50°Grade 3: 70°
Treatment of the femoral neckfractures- screw fixation
• Treatment of stable femoral neck fractures (TypeGarden-I and –II) : two cannulated screws
• Treatment of unstable femoral neck fractures (TypeGarden-III and –IV): two cannulated screws+a two-holetension plate
Three-point-buttressing
Screw fixation of the Garden I. fracture
Screw fixation of the Garden III. fracture
Treatment of the femoral neckfractures- 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 trochantericfractures
• 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 thepertochanteric fractures
Fixation of fracture type AO 31-A1(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 31-A3: DCS
Stabilization of fracture type AO 31-A3: Fi-nail
Classification of the femoral shaftfractures
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: improvedmetal-bone contact = increased stability
Indications: fx. in the 3-4-5/7
Interlocking
• Interlocking: increasedrotational stability
Indications: fx. in the 2-3-4-5-6/7
Unreamed interlocking nailing
• Reaming: intramedullarypressure elevation(1969 Lilienström)
• Bone marrowembolisation
(1989 Wenda)• Destroyed lung function
(1997 Pape)
Indications: thorax/headinjury+fx. in the 3-4-5/7
Plate fixation
• Intraarticular and diaphysis fx.
• Compartmentsyndrome
• 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 withinterlocking
• Polytrauma: ISS < 40 - unreamed lockingnailing, ISS > 40 or head/thorax injury- FE.
• Intraarticular and diaphysis fx, compartment syndrome, vascular injury, previously inserted implants-plates
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