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Pelvic Fracture (Tile's Classification)

Three types:
  1. Tiles type A-vertically and rotationally stable
  2. Tiles type B-Vertically stable rotationally unstable
  3. Tiles type C-Vertically and rotationally unstable
Stable pelvic injury
Unstable pelvic injury

High yield points regarding pelvic injury

  1. Straddle Fracture
    Bilateral fracture of both pubic rami
  2. Open Book Injury
    1. It is antero — posterior compression rotationally unstable unstable but vertically stable injury. In this pelvis is opened like a book, with the intact posterior ligaments acting as the binding of the book.
    2. Anterior ring injury is either disruption of symphisis pubis or a widened pubic ramus fracture.
  3. Malgaigne Fracture
    1. Dislocation of symphysis with a fracture of ilium near sacroiliac (SI) joint or
    2. Fracture of both pubic rami with the dislocation of the sacroiliac joint.
  4. Bucket Handle Injury
    It is lateral compression but vertically stable injury.
    When the fractures of the pubic rami are on the opposite side to the sacroliac dislocation Q the fracture is referred to as bucket handle injury. (Contralateral lateral compression injury).
  5. Jumpers fracture:
    Forceful axial loading of spine and pelvis may lead to a pelvic ring injury that has been called the “Jumper’s fracture” or “Suicidal jumper’s fracture”.
    As the name implies the injury is often seen after a fall from a height, as in sucidal attempt, causing dissociation of central portion of sacrum from the lateral portion.
    The sacrum fails at its weakest points, the neural foramina.
  6. Crescent Fracture, is a type II lateral compression injury that is vertically stable (d/t maintenance of part of posterior SI ligament, sacrotuberous and sacrospinous ligaments) but rotationally unstable (d/t vertical disruption of iliac wing).

Complication of Pelvic Fracture

  1. In pelvis fracture intrapelvic haemorrhage is by far, the most serious complication.
  2. Haemorrhage frequently results from fracture surfaces and small vessels in the retro peritoneum.
  3. Amount of blood loss is around 4—8 units. It must be emphasised, however, that these cases may need transfusion of very large quantities of blood. It is not uncommon for the amount of blood transfused to be in excess of the patients’s total blood volume.
  4. In cases of hemodynamic instability, an external fixator should be applied immediately to decrease motion at fracture sites as well as to decrease pelvic volume and generate temponade of the pelvic venous plexus.
  5. Urogenital injuries are common in pelvic fractures (5- 10%), especially in men. These injuries should be suspected in conscious patients .Membranous part of urethra most commonly injured.
External fixator in pelvic injury-Life saving procedure

High yield points regarding acetabular injury

  1. Acetabular fractures are classified by judet and letournel classification
  1. Indication for Emergency Surgery are irreducible hip dislocation, progressive neurological deficit; open fractures or vascular injuries.
  2. Morel — Lavallee lesion is a localized area of internal degloving / subcutaneous fat necrosis over the lateral aspect of hip caused by same trauma that causes the pelvic and acetabular fracture. Associated with a higher (12%) rate of post-operative infection, wound dehiscence and healing by secondary intention. The presence of a significant Morel-Lavallee is relative contraindication for elective surgery.(Definitive fixation)
Morel — Lavallee lesion
  1. Lavallee lesion can be suspected by hypermobility of the skin and subcutaneous tissue in the affected area from the shear type separation of the subcutaneous tissue from the underlying fascia lata. Alternatively, some fractures can be treated through ilioinguinal approach, thus avoiding the affected area.
  2. Recurrent (posterior) dislocation and sciatic nerve injury indicate injury of posterior column or posterior wall; so these are approached through (posterior) Kocher- Langenback approach.
  3. Kocher - Langenbeck (K - L) Approach
    1. This is a posterior approach used for all posterior wall, posterior column, and posterior column plus posterior wall fractures of acetabulum. It is also used for most transverse and transverse plus posterior wall fracture.
    2. Sciatic nerve palsies as a result of initial injury occurs in ~10 ~15% of patients with acetabular fracture. Sciatic nerve injury as a result of surgery occurs in 2-6% of patients and is more often associated with posterior fracture patterns treated through Kocher- Langen beck and extensile exposures.

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