Marvin Tile

Pelvic Disruption: Assessment and Classification

A precise radiologic technique for assessing the forces producing pelvic disruption has been helpful in arriving at a logical classification of pelvic injury. The radiologic examination should include anteroposterior, inlet and outlet views, as well as tomograms and occasionally computed-assisted tomographic evaluation (CT scanning). On the basis of this radiologic assessment with some biomechanical studies, a classification of three major forces producing injury is suggested. The anteroposterior and lateral compression types, while vastly different, may both have stable and unstable subtypes associated with them. The vertical shear fracture is always unstable. An accurate history and physical examination in conjunction with the above radiologic principles will lead the surgeon to a precise determination of the fracture pattern. A knowledge of the forces necessary to produce this pattern is helpful in the management of the patient with this particular traumatic lesion.

Acute Pelvic Fractures: I. Causation and Classification

&NA; Acute pelvic fractures are potentially lethal, even with modern techniques of polytrauma care. The appropriate treatment of such fractures is dependent on a thorough understanding of the anatomic features of the pelvic region and the biomechanical basis of the various types of lesions. Although the anterior structures, the symphysis pubis and the pubic rami, contribute approximately 40% to the stiffness of the pelvis, clinical and biomechanical studies have shown that the posterior sacroiliac complex is more important to pelvic‐ring stability. Therefore, the classification of pelvic fractures is based on the stability of the posterior lesion. In type A fractures, the pelvic ring is stable. The partially stable type B lesions, such as “open‐book” and “bucket‐handle” fractures, are caused by external‐ and internal‐rotation forces, respectively. In type C injuries, there is complete disruption of the posterior sacroiliac complex. These unstable fractures are almost always caused by high‐energy severe trauma associated with motor vehicle accidents, falls from a height, or crushing injuries. Type A and type B fractures make up 70% to 80% of all pelvic injuries. Because of the complexity of injuries that most often result in acute pelvic fractures, they should be considered in the context of polytrauma management, rather than in isolation. Any classification system must therefore be seen only as a general guide to treatment. The management of each patient requires careful, individualized decision making.

Long-term outcomes in open pelvic fractures.

BACKGROUND Open pelvic fractures represent one of the most devastating injuries in orthopedic trauma. The purpose of this study was to document the injury characteristics, complications, mortality, and long-term, health-related quality of life outcomes in patients with open pelvic fractures. METHODS The trauma registry at an adult trauma center was used to identify all multiple system blunt trauma patients with a pelvic fracture from January of 1987 to August of 1995 (n = 1,179). Demographic data, mechanism of injury, and fracture type were determined from hospital records. Short-term outcome measures included infectious complications, mortality, and length of stay in hospital. Long-term outcomes of survivors were obtained by telephone interview using the SF-36 Health Survey and the Functional Independence Measure. RESULTS Open pelvic fractures were uncommon, occurring in 44 patients (4%). Patients with open fractures were about 9 years younger, on average, than patients with closed fractures (30 vs. 39, p < 0.001). Similarly, patients with open fractures were more likely to be male (75 vs. 57%, p < 0.02), more likely to have been involved in a motorcycle crash (27 vs. 6%, p < 0.001), and more likely to have an unstable pelvic ring disruption (45 vs. 25%, p < 0.001). Open pelvic fracture patients required more blood than closed pelvic fracture patients, both in the first day (16 vs. 4 units, p < 0.001) and during the total hospital admission (29 vs. 9 units, p < 0.001). Five patients with perineal wounds did not receive a diverting colostomy; in turn, these individuals had a total of six pelvic infectious complications (one abscess, two with osteomyelitis, and three perineal wound infections). Overall, 11 patients died, six patients were lost to follow-up, and 27 were long-term survivors (mean duration of 4 years). Chronic disability was common after a pelvic fracture, with problems related to physical role performance and physical functioning, and was particularly severe after an open pelvic fracture (p < 0.05 for both as measured by the SF-36). CONCLUSIONS Patients with open pelvic fractures often survive, need to be treated with massive blood transfusions, and often require a colostomy. They are frequently left with chronic pain and residual disabilities in physical functioning and physical roles, and many remain unemployed years after injury.

Fractures of the talus: experience of two level 1 trauma centers.

Fifty-eight patients with 60 talar fractures were retrospectively reviewed. There were 39 men and 19 women. The age average was 32 (range, 14–74). Eighty six percent of the patients had multiple injuries. The most common mechanism of injury was a motor vehicle accident. Twenty-seven (45%) of the fractures were neck, 22 (36.7%) process, and 11 (18.3%) body. Forty-eight fractures had operative treatment and 12 had non-operative management. The average follow-up period was 30 months (range, 24–65). Thirty-two fractures (53.3%) developed subtalar arthritis. Two patients had subsequent subtalar fusion. Fifteen fractures (25%) developed ankle arthritis. None of these patients required ankle fusion. Fractures of the body of the talus were associated with the highest incidence of degenerative joint disease of both the subtalar and ankle joints. Ten fractures (16.6%) developed avascular necrosis (AVN), only one of which had subsequent slight collapse. Avascular necrosis occurred mostly after Hawkins Type 3 and 2 fractures of the talar neck. Three rating scores were used in this series to assess the outcome: the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Maryland Foot Score, and Hawkins Evaluation Criteria. The outcome was different with every rating system. However, the outcome with AOFAS Ankle-Hindfoot Score and Hawkins Evaluation Criteria were almost equivalent. Assessment with the three rating scores showed that the process fractures had the best results followed by the neck and then the body fractures.

Anterior approach and stabilization of the disrupted sacroiliac joint

Pelvic fractures with disruption of the important weight-bearing sacroiliac area can lead to impaired gait due to malunion or pelvic obliquity, back or buttock pain arising from the sacroiliac joint, and permanent neurologic damage. In eight patients with sacroiliac joint dislocation, an anterior retrofascial approach and stapling of the sacroiliac joint was performed. Six of these patients maintained an anatomic reduction of the sacroiliac joint and their results were rated as excellent. Two of the eight patients had a slight loss of reduction and because of intermittent mild pain were rated as having fair results. In another eight patients, plate fixation of the anterior sacroiliac joint was done. New stabilization methods utilizing dynamic compression plates, reconstruction plates, and a new four-hole plate have been developed to provide more secure fixation of these unstable injuries.

Pelvic disruption: principles of management.

Using the previously outlined classification of pelvic disruption to assess the displacement and stability, a logical method of treatment for the individual case follows. Anteroposterior fractures of the open-book variety and with intact posterior sacroiliac ligaments require simply reduction of the fracture (closure of the book), and immobilization by a sling, plaster spica or external skeletal fixators. The lateral compression types all produce some degree of inward rotation of the hemipelvis. If the supine position does not reduce the hemipelvis spontaneously, a general anesthetic and the application of external rotation forces are often required. Immobilization can be maintained either by complete bed rest with traction through a supracondylar femoral pin or with external skeletal fixators. Pelvic slings or binders will increase the deformity and are contraindicated. The very unstable types of vertical shear fractures can be reduced easily with traction, but maintenance of reduction is difficult. Fracture healing may be delayed because of instability through the hemipelvis and some degree of compression through the posterior fracture is desirable, either by various forms of external skeletal fixation, or occasionally by open reduction. Pelvic fractures associated with acetabular disruption and requiring open reduction of the acetabular fracture also require anatomic repositioning of the pelvic fragments simultaneously, in order to anatomically restore the integrity of the acetabulum. Finally, the pelvic fracture should not be neglected during the early phase of general resuscitation of the patient, but management should proceed concomitantly with the management of the associated injuries. Delay in treatment of the pelvic injury makes management much more difficult and even hazardous at a later phase.

Effect of pin location on stability of pelvic external fixation

Pelvic external fixators allow two locations of pin purchase: anterosuperior (into the iliac crest) and anteroinferior (into the supraacetabular dense bone, between the anterior superior and anterior inferior iliac spine). The purpose of this study was to compare the stability of these two methods of fixation on Tile Type B1 (open book) and C (unstable) pelvic injuries. Five unembalmed cadaveric pelves (mean age, 68 years; four males and one female) were loaded vertically in a servohydraulic testing machine in a standing posture. The AO tubular system and Orthofix were used. On each pelvis, a Type B1 injury was simulated. Each external fixator was applied in each location in random order. Cyclic loads were applied through the sacral body to a maximum of approximately 200 N while force and displacement of the pelvic ring were recorded digitally. Sacroiliac joint motion was quantified tridimensionally with displacement transducers, mounted on the sacrum and contacting a target fixed to the posterior superior iliac spine. A Type C injury was created and augmented with two iliosacral lag screws, and the tests were repeated. For the Type B1 injuries with anteroinferior pin purchase, the mean stiffness was 201.2 N/mm for the AO frame and 203.2 N/mm for the Orthofix. For the anterosuperior frames the mean stiffness was 143.9 N/mm for the AO frame and 163.3 N/mm for the Orthofix. For Type B1 and Type C injuries, the anteroinferior location of pin purchase resulted in significantly reduced sacroiliac joint separation. There were no significant differences between the frame types. Dissection of the preinserted anatomic specimen revealed no evidence of injury to the lateral femoral cutaneous nerve after blunt dissection and drilling with protective drill sleeves. It is concluded that the anteroinferior location of external fixation pins is a safe technique with the potential for increased stability of fixation.

Acute Pelvic Fractures: II. Principles of Management.

&NA; The past two decades have seen many advances in pelvic‐trauma surgery. Provisional fixation of unstable pelvic‐ring disruptions and open‐book fractures with a pelvic clamp or an external frame with a supracondylar pin has proved markedly beneficial in the resuscitative phase of management. In the completely unstable pelvis, external clamps and frames can act only as provisional fixation and should be combined with skeletal traction. The traction pin is usually used only until a definitive form of stabilization can be applied to keep the pelvic ring in a reduced position. If the patient is too ill to allow operative intervention, the traction pin can remain in place with the external frame as definitive treatment. Symphyseal disruptions and medial ramus fractures should be plated at the time of laparotomy. Lateral ramus fractures can usually be controlled with external frames. A role has been suggested for percutaneous retrograde fixation of the superior pubic ramus; however, the benefits to be gained may not be enough to outweigh the serious risks of penetrating the hip, and this technique should therefore be used only by surgeons trained in its performance. The techniques for posterior fixation are becoming more standardized, but all still carry significant risks, especially to neurologic structures.

Analysis of the Analgesic Efficacy of Acetaminophen 1000 mg, Codeine Phosphate 60 mg, and the Combination of Acetaminophen 1000 mg and Codeine Phosphate 60 mg in the Relief of Postoperative Pain

Patients who experienced pain after surgery were administered a single dose of 1 of 3 treatments: acetaminophen 1000 mg, codeine phosphate 60 mg, or a combination of these. Patients rated their pain intensity on ordinal and visual analog scales just prior to medication and at intervals thereafter for up to 5 hours. They also rated pain relief, pain half gone, and any adverse effects. Sum of pain intensity difference and total pain relief scores were analyzed using Dunnetts procedure. The drug combination was statistically superior to codeine as measured by SPID, TOTPAR, pain half gone, and time to remedication. The combination achieved better mean scores than acetaminophen on all efficacy measures, but was (margnally) statistically superior only in pain half gone. No appreciable differences in adverse effects were noted among the treatments. The difficulty of showing the analgesic efficacy of codeine in a single dose trial is discussed.

Fractures of the Pelvis

In the past decade, traumatic disruption of the pelvic ring has become a major focus of orthopedic interest. Previously, conventional orthopedic wisdom held that surviving patients with disruptions of the pelvic ring recovered well clinically from their musculoskeletal injury. However, the literature on pelvic trauma was mostly concerned with life-threatening problems and paid scant attention to the late musculoskeletal problems reported in a handful of articles published prior to 1980. In spite of the clinical impression that most patients do well, some authors have suggested otherwise