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What are your options for posterior ring stabilization of the pelvis

  • anterior SI plating 
    • risk of L4 and L5 injury with placement of anterior sacral retractors  
  • iliosacral screws (percutaneous)
    • good for sacral fractures and SI dislocations
    • safe zone is in S1 vertebral body
    • outlet radiograph 
      • superior-inferior screw placement  
    • inlet radiograph
      • anterior-posterior screw placement
    • L5 nerve root injury complication with errors in screw placement   
    • entry point best viewed on lateral sacral view and pelvic outlet views  
    • risk of loss of reduction highest in vertical sacral fracture patterns 
  • posterior SI "tension" plating
    • can have prominent HW complications


What are poor prognostic factors for pelvic fractures?

SI joint incongruity of > 1 cm
high degree initial displacement
malunion or residual displacement
leg length discrepancy > 2 cm
neurologic injury
urethral injury


How do pediatric pevlic fractures differ from adult fractures?

  • if triradiate cartilage is open the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption
  • for this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment 


Long term complications associated with pelvic fractures

  • Dyspyruneia
  • exctretory dysfuction
  • sexual/erectile dysfunction
  • decreased quality of life
  • chronic pelvic pain
  • Neurologic injury 
    • L5 nerve root runs over sacral ala joint
    • may be injured if SI screw is placed to anterior 
  • DVT and PE 
    • DVT in ~ 60%, PE in ~ 27%
    • prophylaxis essential 
    • mechanical compression
    • pharmacologic prevention (LMWH or Lovenox)
    • vena caval filters (closed head injury)
  • Chronic instability 
    • rare complication; can be seen in nonoperative cases
    • presents with subjective instability and mechanical symptoms
    • diagnosed with alternating single-leg-stance pelvic radiographs 


What are bladder injuries associated with pelvis injuries

  • Present in 12-20% of patients with pelvic fractures
    • higher incidence in males (21%)
  • posterior urethral tear
    • most common urogenital injury with pelvic ring fracture 
      • retrograde urethrogram
  • bladder rupture
    • may see extravasation around the pubic symphysis 
    • associated with mortality of 22-34%
    • diagnosis
      • retrograde cystogram
      • CT retrograde cystogram
        • can be done more quickly and gives more information
  • Diagnosis 
    • made with retrograde urethrocystogram
    • indications 
      • blood at meatus
      • high riding or excesively mobile prostate
      • hematuria
    • technique
      • supine, flouro
      • flush 16/18 french foley with radioopaque dye
      • insert foley and dilate balloon at distal penis (don't overfill, 2-3cc)
      • take a scout film, inject the dye through the foley and take static films as the dyes move through the urethra


What are the complications and treatment of urogential injuries


  • Treatment
    • suprapubic catheter placement 
      • suprapubic catheter is a relative contraindication to anterior ring plating
    • surgical repair
      • rupture should be repaired at the same time or prior to definitive fixation in order to minimize infection risk
  • Complications - 35%
    • urethral stricture - most common
    • impotence
    • anterior pelvic ring infection
    • incontinence


What are the safe zones for SI screws

anterior - iliac cortical densities on lateral

posterior - upper nerve root canal


What is the most important prognostic factor associated with Sacral fracture?

neurologic injury


Neurological injuries associated with sacral fractures

  • Structures at risk
    • Cauda, filem terminale
    • Sarcal plexus
    • Sciatic nerve
  • L5/S1
    • L5 - EHL
    • S1 - plantarflexion/achilles
  • Lower sacral nerve root function (S2-S5)
    • S1/2 are 1/3 of the foramina and carry higher risk than S3/4 which are 1/6 diameter of foramina
    • Sympathetic
      • Inferior hypogastric plexus
    • Parasympathetic
      • Sexual function
      • anal sphincter tone / voluntary contracture
      • bulbocavernosus reflex
      • perianal sensation 
  • Unilateral sacral nerve root preservation is adequate for bowel and bladder control
  • preservation of at least one S3 root in bilateral resection preserves bowel and bladder function in the majority of patients


What is your order of fixation for combined pelvis/acetabulum?

  • posterior ring
  • acetabulum
  • anterior ring


What are indicators on plain radiographs that there might be a sacral fracture?

  • AP(sacrum at 45 degree)/Inlet/Outlet views
  • Low yeild on AP pelvis and plain radiology alone
  • Signs concerning for sacral fracture
    • L4/5 TP fracture
    • Anterior pelvic ring disruption
    • Stepladder sign
      • Foraminal and lumbar facet disruption
    • sacral arcuate lines
    • asymmetric foramina


What is the dennis classification?

  • Zone I 
    • a sacral alar fracture lateral to foramina 50% 
    • 97% undiagnosed
    • often minimally displaced with APC and LC types
    • can be more displaced with vertical shear fractures
    • nerve injury rare (6%) and are usually L5 nerve root
  • Zone II - transforaminal 
    • 97% undiagnosed
    • 28% neuro deficits usually involving L5, S1 and S2
  • Zone III (spinal canal) 
    • 57% neuro deficits with cauda equina syndrome (bowel, bladder, sexual dysfunction) being the most common 


What are the classification systems for sacral fractures?

  • Associated with pelvis ring
    • Tile/Young-Burgess
  • Isler classification - Lumbar-sarcral junction
    • A - lateral to facet
    • B - L5/1 facet
    • C - medial to facet
      • Very unstable
  • ​Denis - best to classifiy risk of neuro
  • Descriptive classification
    • H pattern = lumbopelvic dissociation
    • transverse = higher neuro complications
    • lambda
    • verticle


What are 4 principles that will guide your treatment of sacral fractures

1) those with an associated stable or unstable pelvic ring injury,

2) those with associated lumbosacral facet injury

3) those with associated lumbosacral dislocation

4) those with neurologic injury and persistent cauda equina or spinal cord compression. 


What are options for surgical fixation of the sacrum

  • Indications
    • >1 cm displacement
    • unstable pelvic ring
    • comprimised soft tissues
    • persistent pain with non-op
    • displacement following non-op
    • neurological damage
      • requires decompression
  • Percutaneous screw fixation
    • screws may be placed as sacroiliac, trans-sacral or trans-iliac trans-sacral 
    • useful for sagittal plane fractures
    • technique
      • screws placed percutaneously under fluoroscopy
      • beware of L5 nerve root
      • avoid overcompression of fracture
        • may cause iatrogenic nerve dysfunction
    • cons
      • may result in loss of fixation or malreduction
      • does not allow for removal of loose bone fragments
      • do not use in osteoporotic bone
  • Posterior tension band plating
    • approach
      • posterior two-incision approach 
    • technique
      • may use in addition to iliosacral screws
    • pros
      • allows for direct visualization of fracture
    • cons
      • wound healing complications
  • Iliosacral and lumbopelvic fixation 
    • approach
      • posterior approach to lower lumbar spine and sacrum
    • technique
      • pedicle screw fixation in lumbar spine
      • iliac screws parallel to the inclination angle of outer table of ilium
      • longitudinal and transverse rods
    • pros
      • shown to have greatest stiffness when used for an unstable sacral fracture 
    • cons
      • invasive
  • Decompression of neural elements
    • indirect
      • reduction through axial traction
    • ​direct
      • posterior approach followed by laminectomy or foraminotomy



What are the indications for non-op or operative fixation of sacral fracture

  • Non-op
    • <1cm
    • no neuro
    • insufficiency
  • Operative
    • ​>1 cm displacement
    • unstable pelvic ring
    • comprimised soft tissues
    • persistent pain with non-op
    • displacement following non-op
    • neurological damage
      • requires decompression


What is the definition of a cresent fracture

  • combination of vertical iliac fx and SI dislocation
  • posterior superior spine (sometimes iliac crest) remain attached to sacrum by posterior SI ligaments
  • lateral ilium dislocates from sacrum as anterior SI ligament rupture
  • When large ilium fragment remains with sacrum and a vertical fracture pattern is seen it is termed a crescent fracture


What are the view necessary for SI fixation?  What nerve root is at risk?

  • inlet view 
    • shows anterior-posterior position of SI joint(s) for screw placement 
  • outlet view 
    • shows cephalad-caudad position of SI joint(s) for screw placement   
  • lateral sacral view 
    • ensures safe placement of SI or sacral screws relative to the anterior cortex of the sacral ala and the nerve root tunnel


Options for treatment of an ilium fracture

  • Wound Management
    • evaluation
      • soft tissue disruption or internal degloving injury
      • possible soft tissue or bowel entrapment in the fracture site
    • prophylactic antibiotics as appropriate 
    • serial debridements as necessary
  • Open Reduction Internal Fixation
    • approach
      • posterior approach 
      • ilioinguinal approach  
      • Stoppa approach (lateral window) 
    • recommend early reconstruction
      • single pelvic reconstruction plate or lag screw along the iliac crest
      • supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim or sciatic buttress
    • coordination with trauma team
      • injury to bowel may require diversion procedures
      • plan surgical intervention with trauma team to minimize recurrent trips to the operating room


What are complications and injuries associated with ilium fractures

  • Iliac wing fractures have high incidence of associated injuries
    • open injuries 
    • bowel entrapment
    • soft tissue degloving
  • Complications
    • Malunion with deformity of the iliac wing
    • Internal iliac artery injury
    • Bowel perforation
    • Lumbosacral plexus injury


Complications associated with fracture table use

  • Difficult to assess length and reduction
  • Difficult to get reduction
    • posterior translation distal fragment
  • Significant perineal soft tissue injury
  • Pudendal nerve palsy
    • erectile dysfunction
    • reduced by intraoperative muscle relaxants
  • Hemilithotomy
    • sciatic nerve in well leg
    • compartment syndrome in well leg
      • direct compression on calf
      • low SBP intra-op
  • Lateral decubitus
    • crush syndrome


Causes of complications associated with misuse of the fracture table

  • Prolonged duration of traction
    • release when no longer needed
    • periodic release during long procedures
  • Excessive traction
    • more important than prolonged traction
    • adequate muscle relaxants
  • Excessive adduction
    • reduced with abduction of affected limb 
  • Small post 
  • hemilithotomy position


Recommendations to decrease risk of complications with traction table

  • obese patient use flat-top
  • place post between genitals and contralateral leg
  • well-padded post (>10cm)
  • do not adduct past neutral
  • surgery >120min should release traction periodically
  • avoidance of hemilithotomy when possible


When can you not nail an open tibia at time of initial surgery

  • Open segmental fracture, irrespective of the size of the wound
  • Gunshot wounds -high velocity and short-range shotgun injuries
  • Open fracture with neurovascular injury
  • Farm injuries, with soil contamination, irrespective of the size of the wound
  • Traumatic amputations
  • Open fractures over 8 hours old
  • Mass casualties; eg, war and tornado victims 


Acceptable alignment for humeral shaft fracture and contraindications to coaptation splinting

  • < 20° anterior angulation
  • < 30° varus/valgus angulation
  • < 3 cm shortening
  • contraindications to functional bracing
    • severe soft tissue injury or bone loss
    • unreliable patient
    • polytrauma
    • brachial plexus injury
    • proximal one-third humeral fracture
    • inability to maintain reduction (segmental fracture)
    • radial nerve palsy is NOT a contraindication to functional bracing       


Relative indication for operative fixation of humeral shaft fractures

  • Open fracture
  • Associated articular fracture Neurovascular injury
  • Floating elbow
  • Impending pathologic fracture Polytrauma
  • Failure of closed management  


Prevelance of nonunion and risk factors in humeral shaft fracture treatment


  • Nonunion
    • ​no evidence of interval healing of serial XR taken 6-8 weeks apart
  • defined as lack of union after 6 months
    • 2 to 10% in nonoperative managment
      • proximal 
        • medial comminution
        • medial displacement
        • 2 part fracture
    • 15% with primary ORIF
  • risk factors
    • axial distraction on injury films represents high level of soft tissue injury and increase chance of nonunion
    • open fx
    • unstable or segmental fx
    • infection
    • initial treatment with hanging cast
    • shoulder or elbow stiffness (motion directed to fracture site)
    • patient factors (smoking, obesity, alcoholism, malnutrition, noncompliance)
  • treatment
    • compression plating with bone grafting   
      • shown to be superior to both IM nailing with bone grafting and compression plating alone
      • use anterolateral approach (allows exploration of radial nerve)
    • vascularized fibula bone graft and compression plating
      • indicated if > 6 cm bone defect
      • technique
        • use bone graft as an intramedullary dowel (1-2 cm inside each end)
        • stabilize with 4.5 dynamic compression plate
      • peroneal artery (fibula) is anastomosed to brachial artery
      • peroaneal vein anastomosed with basilic or cephalic vein



Indications for exploration of the radial nerve

  • Open fracture
  • High-velocity gunshot or penetrating injury
  • Vascular injury
  • Nerve deficit after closed reductiona Distal third (Holstein-Lewis) fractures 


Compare Humeral shaft IM nail and plates

  • Nerve injury same risk
  • Reports of higher rates of nonunion with IM nail
  • reports of better function with plate


What is the blood supply to the patella?

anterior to quads, posterior to the patellar tendon

form a ring around the patellar and penetrate anteriorly

avoid anterior soft tissue stripping

25% necrosis rate with fracture