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PELVIS and FEMUR (Fractures of the pelvis (Complications (• Haemorrhage,…

- - - - • AP compression (impact from the front or rear).
      - • Lateral compression (impact from side).
      - • Vertical shear (usually a fall from height).
      - • Combined mechanical (mixture of all of the above).
  - - - • Check for an occult sacroiliac ligament injury (local bruising and tenderness with pain on stressing the joint); this suggests the injury could be unstable.
      - • Fractures of both superior and inferior pubic rami on the same side are a single break in terms of ring stability.
      - • Other stable patterns include ilium fractures into sciatic notch or sacrum.
      - • Remember that if a significant single break in the ring is present, there is a chance that concurrent ligamentous injury exists. Thus, a CT scan is often required prior to mobilization to confirm stability.
      - • Isolated fractures of the ilium, ischium, or pubis are normally treated with bed rest, analgesia, and early mobilization as soon as the pain allows.
      - • Fractures that extend to the acetabulum (joint) require further investigation to plan treatment, but are usually stable if isolated.
      - • Simple pubic rami fractures in the elderly (osteoporotic) can be treated conservatively with bed rest and early rehabilitation.
    - - Unstable fractures are liable to massive haemorrhage within the soft tissues of the pelvis. This is mostly because the pelvic ring is grossly displaced during the injury and tearing of the extensive posterior presacral venous plexus occurs. A patient's entire blood volume can be lost, hence the high mortality rate.
        
        Establish haemodynamic control
        
        • Approach patient according to ATLS guidelines (ABCDE).
        
        • Haemorrhage is leading cause of death with pelvic injuries.
        
        • Tachycardia and hypotension suggest bleeding.
        
        • Establish at least two large calibre IV infusions and commence resuscitation with warm crystalloid 2000mL, and then reassess.
        
        • Send blood for urgent cross-match of 4–6U. O –ve blood is given if no response to initial fluid challenge.
        
        • Continued bleeding must be controlled by reducing the pelvic volume. This may be achieved by:
        
        • Pelvic binder or binding a bedsheet tightly around the pelvis and internally rotating the hips—very effective as an emergency procedure.
        • Application of an external pelvic fixator is a more definitive solution, but should be done in the trauma theatre.
        
        • Laparotomy is contraindicated unless there are life-threatening intra-abdominal injuries that must be treated since this effectively ‘decompresses’ the pelvis again superiorly.
        
        • Urethral injury occurs, especially with anterior compression bony injuries. If there is blood at the urethral meatus, perineal bruising, haematuria, or a high riding prostate on rectal examination, then catheterization should only be performed by an experienced urologist (very often suprapubically). Investigation for injury is with a retrograde urethrogram or IVU once the patient is stable.
    - - • Significant AP compression mechanism can result in an ‘open book’ pelvis. Severe subtypes of the lateral compression or vertical sheer fractures are very unstable and associated with other injuries.
      - • Once ATLS stabilization is complete, CT scanning is required to define the fracture and plan treatment.
      - • External fixation is excellent to temporarily control unstable fractures and manage definitively. It can help to control haemorrhage in a haemodynamically unstable patient.
      - • Once stable, liaise with local pelvic fixation centres to arrange definitive fixation if required.
      - • ORIF with screws and plates for the symphysis pubis of ilium fractures. Posterior pelvic instability involving the sacrum require screw fixation.
- - - - • Intracapsular fractures. Occur within the joint capsule (proximal to the intertrochanteric line).
      - • Extracapsular fractures. Occur distal to the joint capsule (involving or distal to intertrochanteric line).
      - • It is then important to describe fractures as displaced or undisplaced.
      - • The relationship to the blood supply is key:
        
        • The femoral head receives its supply via the medial and lateral femoral circumflex arteries which form the extracapsular ring and give rise to the cervical arteries (the lateral being most important). There is also supply via the intraosseus nutrient vessels and the ligamentum teres.
        
        • Displaced intracapsular fractures disrupt their blood supply and have a high rate of avascular necrosis (AVN) of the femoral head and non-union.
        
        • Extracapsular fractures maintain the blood supply to the head (thus reduced AVN and generally heal well).
        
        • Other classification systems are not generally required.
        
        • Subtrochanteric fractures. Occur below the level of the lesser trochanter. May be through an area of pathological bone (metastasis) or high energy in young.
  - - - • Displaced fractures are usually obvious.
      - • Undisplaced, intracapsular compression fractures may be difficult to see on X-ray. If high clinical suspicion of fracture, then further investigation is warranted; isotope bone scan (highly sensitive, poor specificity), MRI (gold standard), or CT scan.
  - - - • Undisplaced impacted in the elderly. Treated by early mobilization with analgesia; 15% late displacement rate, requiring operative intervention.
      - • Undisplaced. Treated by internal fixation with either cannulated screws or a 2-hole dynamic hip screw (DHS).
      - • Displaced. Treated by hemiarthroplasty.
      - • Total hip arthroplasty can be used if symptomatic pre-existing arthritis or those with few comorbidities and high functioning (controversial).
      - • In children or young adults, reduction (open or closed) and fixation is employed.
    - - • Closed reduction on the traction table and open fixation with the use of a DHS.
      - • Intramedullary hip screw (IMHS) may be used in 4-part fractures.
      - • Subtrochanteric and reverse obliquity fractures require stabilization, utilizing an intramedullary nail or fixed angle plating system.