PELVIC AND LOWER LIMB FRACTURE &

DISLOCATIONS

Worku K.(MD)
 PELVIC FRACTURES
ANATOMY
• Three bones make up each side of the pelvis (ilium,
iscium, and pubis).
• They are connected to the sacrum by ligaments.
STABILITY OF THE PELVIS
 Pelvic fracture
• Common injury representing ~ 3 % of skeletal injuries.
• Overall mortality from pelvic #s ranges from 5-16 %.
• MR associated with acetabular # is 3%, while open pelvic
fractures associated with a MR of up to 45 % .
• Include
– Pelvic ring disruptions,
– sacral fractures,
– acetabular fractures, and
– avulsion injuries
 Mechanisms of injury
• Pelvic fracture is usually a high energy
trauma , as a result of MVA, fall .
• LOW ENERGY FRACTURES
– Usually # of individual bones that do not damage
true integrity of the ring structure
• Domestic falls
• Sports injuries
• Low velocity MVA’s
MECHANISMS OF INJURY
LOW ENERGY

Isolated fractures of individual bones

VS
HIGH ENERGY

Pelvic ring disruption

HIGH ENERGY
 Associated injuries
• Hemorrhage
– The most common and worrisome
– Venous bleeding is source in 80 to
90 % of cases.
• Intraabdominal
• Bladder and urethra
• Neurologic
– The most common sites include L5
and S1 nerve roots and isolated
peripheral nerves.
• Thoracic aorta rupture
Pelvic ring disruptions
CLASSIFICATIONS
 Open-book fracture

AP x-ray with significant diastasis at symphysis This fracture was associated with a
pubis posterior urethral injury.
Such fractures can cause significant
hemorrhage. Emergent treatment consists of
closing the fracture and stabilizing pelvis by
applying a pelvic binder or tying a sheet
tightly around the lower pelvis.
(A) Rotationally unstable fracture. The symphysis pubis is separated and the anterior
sacroiliac, sacrotuberous, and sacrospinous ligaments are disrupted.
(B) Vertically unstable fracture. The hemipelvis is displaced anteriorly and posteriorly
through the symphysis pubis, and the sacroiliac joint ligaments are disrupted.
(C) Non-displaced fracture of the acetabulum.
 Sacral fracture
• Sacral fracture classification along with the
frequency of neurologic injury
– Zone 1 – Lateral to the sacral neural foramina (5.9
percent, usually L5 root)
– Zone 2 – Through sacral neural foramina (28.4 %, usually
sciatica with rare bladder or bowel involvement)
– Zone 3 – Medial to sacral neural foramina through the
central canal (≥50 percent;
– most involve bowel, bladder, or sexual dysfunction
Acetabular fractures
 Clinical Assessment
History: Mechanism of injury

Physical examination
• ATLS principles
• Soft tissue ant/post
• Abdomen – rectal/vaginal examination
• Urological – scrotal haematoma/high riding
prostate/blood at urethral meatus
• Neurological - motor & sensory function of lower
extremities
RADIOLOGY
MANAGEMENT
 Initial stabilization and approach
•If a significant pelvis injury is found or a patient with a pelvic fracture
remains hemodynamically unstable, the pelvis should be "wrapped"
with either a sheet or a commercial pelvic binder.
•The goal is to stabilize injuries;
•Over-reduction of fractures by wrapping too tightly must be avoided

This pelvic sling includes

a buckle that limits the
amount of force applied
to the pelvis.
Algorithm for the management of blunt trauma
with a significant pelvic fracture
Management of hemodynamically unstable pelvic fracture
• Acetabular injury  
• Relocation of the femoral head if there is an
associated hip dislocation
• Placement of a traction pin
• Avulsion injury  
• Treated conservatively with rest, ice, protected
weight bearing, and analgesics.
• Disagreement exists about operative repair;
generally fragments displaced more than 2 cm are
treated surgically
DEFINITIVE TREATMENT OPTIONS
NON-SURGICAL SURGICAL

Mobilization/ • EX-FIX
TRACTION • ORIF
 NON-SURGICAL
• Most frequently used method
• Bed rest for few days

• Gentle mobilization and protected weight

bearing on side of ring injury

• Little place for prolonged bed rest, pelvic

suspension sling, spica casts, other non-
surgical immobilization
 SURGICAL STABILIZATION
1.EXTERNAL FIXATION
• Hemorrhage management
• Temporary fracture reduction or stabilization
• Definite treatment
 SURGICAL STABILIZATION
2. INTERNAL FIXATION
-Rotational instability
-Anterior stabilization only
-Vertical instability
-Anterior and posterior stabilization
Management of associated soft
tissue injury
GENERAL GUIDELINES
1. Minimally displaced injuries and
partial disruption of bone and
ligamentous stability of the pelvic ring

PROTECTED WEIGHT
BEARING
&
SYMPTOMATIC TREATMENT
 GUIDELINES (cont.)
2. Displaced disruption of the anterior ring without
complete posterior ring disruption

REDUCTION & ANTERIOR

RING STABILIZATION
 GUIDELINES (cont.)
3. Complete disruptions of the posterior ring
 COMPLICATIONS
• HEMORRHAGE
• GENITO-URINARY
– Bladder
– Urethra
– Ureteral

• GASTRO-INTESTINAL
• OPEN PELVIC FRACTURES
• Infection
• DVT (25-61%)
• Fatal pulmonary embolism
(0.5-10%)
• Non-union & malunion
 Pitfalls and pearls
• Treat patients with pelvis fractures as trauma patients. Pelvis injuries are
associated with significant bleeding, concomitant internal injuries, and
high mortality.
• Do not assume that the extent of bleeding correlates with the severity of
the fracture pattern [ 31 ]. Any pelvic fracture can cause significant
bleeding. Elder patients may have life-threatening hemorrhage from
pelvic fractures sustained in low energy falls.
• Do not underestimate the extent of the fracture based on plain
radiographs. Posterior pelvis injuries (ligaments and sacral fractures) are
difficult to assess on plain films; CT scanning is necessary.
• Obtain subspecialty consultation early for concerning signs or injuries. The
management of pelvic injuries can be complex and often requires surgical
stabilization or angiography
Injuries and fractures around the
hip joint
 Introduction
• Hip fractures are more common in the elderly
– Associated with simple falls
• Hip dislocation more common in the young
– In the young is due to high energy injuries
• Poor treatment leads to a lot of morbidity
HIP DISLOCATION
 Types
• posterior
• anterior
• central

• Some are associated with fractures

 Clinical features
• Posterior type -80% of hip dislocations
• Caused by an axial force along the femur
with the knee and hip flexed and hip
adducted.
• Posterior:-Leg shorter, adducted,
internally rotated and slight flexion
• Anterior:- Abducted, external rotation
and slight flexion
 Caution!!
• Please check for the sciatic nerve function
• Before and after reduction

• Check the ankle pulses

- Dorsalis pedis pulse
- Posterior tibial pulse
 TREATMENT
• GOAL: EMERGENCY REDUCTION UNDER GA
OR SEDATION
– Control pain
– Prevent injury to sciatic nerve
– Prevent osteonecrosis

– Prevent early onset of post-traumatic

osteoarthritis
 Reduction technique
• Various techniques have been described.
-Allis
- Watson Jones
-Stimson
-Bigelow
-Friars
 Post-reduction treatment

• Check hip stability

• Maintain patient comfort. Splint, NSAIDS
• ROM precautions/REST (No adduction, Internal
Rotation).
• Traction for 3 to 6 weeks.
• Early mobilization.
• Touch down weight-bearing for 4-6 weeks.
• Repeat x-rays before allowing weight-bearing.
 Complications
• Sciatic nerve injury
• Arterial injury
• Osteonecrosis (AVN)
• Osteoarthritis
• Myositis ossificans
• Persistent or recurrent dislocation
 Operative Treatment: Indications

 Irreducible Hip Dislocations

 Hip dislocation with femoral neck fracture
 Incarcerated fragment in joint
 Incongruent reduction
 Unstable hip after reduction
 Summary
• Hip dislocation is a medical emergency.
• Reduction should be done ASAP
• Watch out for the complications
• Early treatment gives good outcome
Neck of femur fractures
 Introduction
• Associated with osteoporosis
• Mechanism:- fall on the greater trochanter.
• Younger people major trauma

• RISK OF AVN AND POOR HEALING IS

COMMON
 Blood supply to femoral head

• Retinacular arteries

• Artery of ligamentum
teres

• Nutrient artery
 Garden’s Classification
• I –Incomplete fracture

• II- Complete fracture but undisplaced

• III- Partial displacement

• IV- Complete displacement

CLASSIFICATION
 TREATMENT
• Options
– Non-operative
• very limited role
• Activity modification
• Skeletal traction
– Operative
• ORIF
• Hemiarthroplasty
• Total Hip Replacement
 Complications
• Morbidity & mortality
• AVN
• Non-union
• Osteoarthritis
Intertrochanteric Fractures
 Introduction
• Common in the elderly
• Are extra-capsular as compared to neck
fractures which are intra-capsular
• Heal quite easily
• Seldom leads to AVN
 Clinical features
• Mechanism:- Fall on the side or a twisting
force to the leg
• Tender hip region, Leg is shorter, externally
rotated and patient is unable to lift it
 Treatment
• Non-operative
• -Skeletal traction

• Operative
• -DHS
• -Angle blade plate
• -Cephalomedullary nails eg Gamma nail
 Traction
• Skeletal traction in abduction
• For 8-12 weeks
• Radiographs to check for reduction and later
union
• Later mobilize on partial weight bearing
Femoral shaft fracture
Femoral shaft fractures
 Worse Prognosis
• Older patient
• Comminuted or markedly displaced
• Both bones of forearm or leg
• Inclusion of articular surface
• Oblique or spiral fracture
• Cervical/lumbar vs. thoracic spine
 Treatment methods

• Closed reduction and spica cast

immobilization
• Skin traction
• Skeletal traction
• Femoral cast brace
• External fixation
• Internal fixation
Fracture around the Knee
 Anatomy
• 4 ligament structures
• ACL
• PCL
• MCL
• LCL & PLC (lateral side)
• Popliteus
• Biceps femoris
• Popliteofibular lig.
• ITB
• Capsule
• Patella tendon
 Mechanisms of Injury
• Low energy
• Sports
• Morbidly obese patient
levering over planted foot
• High energy
• Motor vehicle collisions
• Pedestrians struck by autos
 Epidemiology
• True incidence is probably
underreported
• Because 20% - 50%
spontaneously reduced
 Classification

• Anterior- Anterior. Directed force on ant. Thigh

• Posterior- Post.directed force on ant. Tibia knee
flexed (dash board injury)
• Medial/Lateral- Varus/ valgus stress
• Rotatory
Patellar fracture
 Mechanism of injury

• Direct blow to the

anterior knee
(dashboard injury)
• Fall from height
• Rapid knee flexion
with quadriceps
resistance
 Classification

• Allows prediction of
treatment
• Types
– Transverse
– Marginal
– Vertical
– Comminuted
– Osteochondral
 Nonoperative Treatment
• Indicated for nondisplaced fractures
– <2mm of articular stepoff and <3mm of diastasis
with an intact extensor mechanism
• May also be considered for minimally
displaced fractures in the elderly
• Patients with a extensive medical
comorbidities
 Nonoperative Treatment
• Long leg cylinder cast for 4-6 weeks

• Immediate weight bearing as tolerated

• Rehabilitation includes range of motion
exercises with gradual quadriceps
strengthening
• Operative
tension band wire
 Tibial Plateau Fractures

Mechanism of Injury
• Can have both shear and compressive forces
– Valgus (or varus) force split
– Axial load depression
– Combined force split/depression (80%)
• Higher velocity (bumper fracture) leads to an
increase
– Comminution
– Displacement
– Soft tissue injury
Demographics
 1% of all fractures
 8% of all fractures in the elderly
 Lateral plateau involved 55-70%
 Medial plateau involved 10-20%
 Both involved 10-30%
 Radiographic Evaluation
• AP, Lateral on Large Cassettes

• Obliques
– I

• Traction Films
– Defines fragments
– Bridging Ex-fix can provide traction
• CT scan with reconstruction

• Arteriography when necessary

• ? MRI –
 Classification
Schatzker, Clin Orthop, 1979

• Type I - Split Lateral Tibial Plateau Fx

• Type II - Split/Depression Lateral Plateau Fx
• Type III - Pure Depression Lateral Plateau Fx
• Type IV - Medial Tibial Plateau Fx
• Type V - Bicondylar Split Fx
• Type VI - Tibial Plateau Fx with Metaphyseal -
Diaphyseal Separation
 Non-Operative Recommendation
Articular incongruity 5 mm or less
and
Stable knee in full extension
and
Normal varus/valgus alignment
• Operatve
plating
Fractures of the shafts of the
tibia and fibula
 General principles
• the most common long bone fractures
• Indirect and direct trauma
• Direct trauma high incidence of soft tissue
injury
• 1/3 tibia is subcutaneous tends to be open.
•
 After care
• Elevation
• Don’t cover POP
• Check Circulation
• Record Pain Points
• Pain Character
• Crutches when
• Change to PTB CAST WHEN?
INJURIES AROUND THE ANKLE JOINT
TYPES OF SPRAIN:
• Grade I Sprain: Grade I ankle sprains cause stretching of the
ligament. The symptoms tend to be limited to pain and swelling. Most
patients can walk without crutches, but may not be able to jog or jump.

• Grade II Sprain: A grade II ankle sprain is more severe

& there is partial tearing of the ligament. There is usually
more significant swelling and bruising caused by bleeding
under the skin. Patients usually have pain with walking, but
can take a few steps.
• Grade III Sprain: Grade III ankle sprains are
complete tears of the ligaments. The ankle is usually quite
painful, and walking can be difficult. Patients may complain
of instability, or a giving-way sensation in the ankle joint.
 Ankle Sprain Treatment

The early treatment of ankle sprain is the

"RICE" method of treatment.
• Rest
• Ice
• Compression
• Elevate
 Anteroposterior View
• Quantitative analysis
– Tibiofibular overlap
<10mm is abnormal - implies
syndesmotic injury
– Tibiofibular clear space
>5mm is abnormal - implies
syndesmotic injury
– Talar tilt
>2mm is considered abnormal

Consider a comparison with radiographs of

the normal side if there are unresolved
concerns of injury
 Lateral View
• Posterior mallelolar
fractures
• AP talar subluxation
• Distal fibular translation
&/or angulation
• Syndesmotic relationship
• Associated or occult injuries
– Lateral process talus
– Posterior process talus
– Anterior process calcaneus
 Operative Treatment: Surgical Indications

• Instability
– Talar subluxation

• Malposition
– Joint incongruity

– Articular stepoff
THANK YOU