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Review OF Literature

Presented by;Dr. Rakhi RatnamMPT-II (Orthopedics)

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Pelvic Complex Fracture and its Rehabilitation

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Contents: Introduction Epidemiology Mechanism Of Injury Clinical Evaluation Classification – Pelvic fracture

- Acetabulum fracture

- Jumper’s Fracture

- SI Joint disruption

- Coccyx Fracture Complications Emergency care and Management Rehabilitation Evidences References

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Introduction

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EpidemiologyIncidence- 3-8%Mortality- 5-16%An Australian study of pelvic ring fractures

demonstrated an incidence of 23 per 100,000 persons per year.

British study found the incidence of acetabular fractures to be 3 per 100,000 persons per year.

(Pelvic trauma: Initial evaluation and management, Literature review;2013)

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German Chapter of the AO-International & German Trauma Society have reported 21.3% of Pelvic complex fracture.

A new international report, The Asian Audit, by the International Osteoporosis Foundation, says over the past 30 years fractures have gone up threefold in Asia, with India and China topping the charts. India hobbles to second place in pelvic fractures with 4.4 lakh people falling prey every year.

http://indiatoday.intoday.in/story/indias-bone crisis/1/116534.html

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Anterior View Of the Symphysis Pubis

Suprapubic ligament

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Blood Vessels

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Mechanism of injuryRoad traffic accidents (20-66%)Pedestrian collisions (14-59% )Motorcyclist collisions (5-9.3% )Fall from height

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658194/

Emergency Medicine Journal : EMJ

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Evaluation:Clinical ExaminationRadiological Examination

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EvidenceIn 1990, a level three prospective study

first dealt with concerns about examining the pelvis, looking at 36 patients with blunt trauma (excluding multiple injuries). The results found that springing the pelvis had a specificity of 71% and a sensitivity of 59%, suggesting that routine use of this examination should be abandoned.

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EvidenceNoakes et al, evaluated Pelvic stress fracture in 5 female

marathoners because of intense training sessions. Most patients experienced persistent groin discomfort during any activity for the first 4 weeks after injury, but all recovered completely after 8 to 12 weeks of rest. Authors confirmed the diagnosis if the following three features are present in a long distance runner presenting with groin pain: First, activity causes such severe discomfort in the groin that running is impossible. Second, the athlete develops discomfort in the groin when standing unsupported on the leg corresponding to the injured side (positive standing test). In some cases the pain is so severe that standing on one leg is impossible. Third, deep palpation reveals extreme, exquisite nauseating tenderness localized to the pubic ramus and not to the overlying soft tissues

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Classification:A. Tile’s Classification

TYPE AStable

• A1- Fractures of the pelvis not involving the ring

• A2- Stable, minimally displaced fractures of the ring

TYPE BRotationally unstable , vertically

stable

•B1- Open book•B2- Lateral compression: ipsilateral•B3- Lateral compression: contralateral (bucket- handle)

TYPE CRotationally and vertically

unstable

•C1- Rotationally and vertically unstable•C2- Bilateral•C3- Associated with an acetabular fracture

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EvidenceStudy conducted to assess 3260 patients

with pelvic and acetabular fracture confirmed that 2551 patients had pelvic fracture and there were concomitant 15.3% acetabular fracture. The pelvic ring fracture was classified as stable in 54.8% (type A injury), as rotationally unstable in 24.7% (type B injury), and as unstable in translation in 20.5% (type C injury).

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Type A18

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Type B

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Type C

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B. Young and Burgess system Lateral

Compression (LC)

I- Sacral compression on impact

sideII- Iliac wing fracture on

side of impact

III- Contralater

al open book injury

Antero- Posterior

Compression (APC)I- Slight

widening of pubic

symphysisII- Widened

interior sacroiliac

jointIII-

Complete SI joint

disruption

Vertical Shear (VS)

Vertical displaceme

nt of symphysis diastasis

Combined Mechanism Injury (CM)LC/VS most

common

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Evidence:Study conducted by Young in year 1990,

concluded that a classification system based on the mechanism of injury and direction of injury force allow correct and timely application of external fixators, thus favouring to a more favourable outcome.

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Lateral Compression

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APC-I

•Slight widening of the pubic symphysis .

•Intact sacrotuberous and sacrospinous ligaments

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APC- II

• Widened anterior SI Joint

•Disrupted sacrotuberous and sacrospinous ligaments

• Intact posterior SI Ligaments

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APC-III

•Complete SI Joint disruption with lateral displacement

• disrupted sacrotuberous and sacrospinous ligaments

•Disrupted posterior SI ligaments

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Vertical Shear

• Vertical displacement of symphyseal diastasis usually through SI joint.

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Combined Mechanical Injury

•Combination of other injury patterns, usually LC/VS

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Denis Classification Of Sacral Fractures

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Sacral insufficiency fracture

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Acetabulum Fracture Classification Of Letournel and Judet:

Posterior wall

fracture

Posterior

column fracture

Anterior wall

fracture

Anterior

column

fracture

Transverse

fracture

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Complications:HemorrhageVenous thromboembolismGastrointestinal InjuryGenitourinary InjuryNeurologic InjuryOpen FracturesMalunion, Nonunion

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Evidences:Study conducted on 48 men and 8 women

in year 2011 at PGI Chandigarh to evaluate the venous thromboembolism(VTE) in postoperative period of pelvic fracture and concluded that 16 patients developed VTE. 12 patients developed proximal DVT, 2 cases distal DVT and 10 cases pulmonary embolism. Pulmonary angiography and indirect computed tomographic venography were used as a diagnostic tool.

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Retrospective study conducted at KLEU(Dr. Prabhakar kore hospital)from April 2000 to Dec 2010. During the 10 year period 11 females (age 8-49 yrs) presented with urethral injury in conjunction with pelvic fracture. Nine of these females had avulsion of the urethra and the remaining two had avulsion with longitudinal tears of the bladder continuing to the proximal urethra with pelvic fracture.

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Nerve injury is a common complication of major pelvic injuries. Study conducted on 73 patients who suffered major pelvic injuries, 24 (33%) had resultant neurologic deficits. The extent of nerve injury is proportionate to the severity of the posterior pelvic bone injury.

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Management:

Emergency Care managementSurgical managementRehabilitationLong term follow up

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•

Conservative management

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Surgical management

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APC II fracture

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X- ray of the patient,after 3 months of treatment. Posterior wall fracture line required a trochanteric osteotomy to protect the abductors.

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Rehabilitation

EvidenceStudy conducted in year 2002 on post

operative management of acetabular fracture has summed up the mobilization protocol after Surgical management.

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EvidencesStudy conducted on elderly population

in year 2006 concluded early initiation of Physiotherapy, walker assisted ambulation with toe touch, Range of motion at the hip and strengthening exercises for Quadriceps. Fracture treatment must be highly individualized because of high degree of diversity.

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According to American Academy Of Orthopedic Surgeons (AAOS), pelvic binder, pelvic clamp, or a sheet wrap MUST be used to immobilize the injury.

Pelvic binding devices provide a simple alternative to surgical fixators. These devices can be applied in the prehospital environment, potentially allowing control of unseen major haemorrhage.

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Phase 1.Goals are- reduce swelling and painPT Rx Starts immediately after the surgeryPhase 2.Goals are- ROM, Strength, FlexibilityPT Rx is given for several weeks

Rehabilitation

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Phase 3: six to eight weeks Goals are- restore your preinjury activity and

performance level balance, stretching and strength training.Phase4: Goals are- Strength, balance, flexibility Prevent post traumatic arthritis

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Long term outcomes:Study conducted in year 2010 to assess the

long-term outcome of pelvic ring injuries in 24 patients on follow up of average 33 months. The clinicoradiological assessment was done using Pelvic scoring system adapted by cole etal and concluded that pain and limp were present in 13 patients and residual working disability was found in 9 patients.

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Evidence: Pregnancy related outcome Study conducted on 16 pregnant females

concluded that Uncomplicated pregnancies and deliveries are possible after pelvic fracture. The new cesarean delivery rate among these women is significantly increased with over half related to patient and obstetrical preferences.

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References:

1. Rockwood and Green’s Fracture in Adults. Lippincott publication. Volume 2;VI Edition; Page numbers-1583-1665

2. Campbell’s Operative Orthopedics. Elsevier publication. Volume 3; XI Edition; Page numbers-3237-3309

3. Ramesh kumar sen, Amit kumar, Sameer Aggarwal. Risk factors of Venous thromboembolism in Indian patients with Pelvic-Acetabular trauma; Journal of orthopedic surgery 2011;19(1):18-29

4. Nerli RB, Sujata Jali, M. B. Hiremath. Female Urethral injuries related to Pelvic Fractures. Journal of trauma and treatment;April 05, 2012

5. Majeed et al. Neurologic deficits in major pelvic injuries. Clinical orthopedics and clinical research; 1992 Sep;(282):222-8.

6. O.Johnell et al. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis International;2006:17;1726-33

7. Damayanti Dutta. India’s Bone Crisis; India Today (16th October 2010)

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8. Caroline lee, Keith Porter. The prehospital management of Pelvic fractures. Emergency Medical journal;2007 February; 24(2): 130–133.

9. Ellen f. Binder, Marybeth brown et al. Effects of extended outpatient rehabilitation after pelvic frature. JAMA, August 18,2004 –vol 292,no-7.

10. Eric Pagenkopf, MD, Andrew Grose et al. Acetabular Fractures in the Elderly: Treatment Recommendations. Musculoskeletal journal of hospital for special surgery.2006;2(2):161-171.

11. Pohlemann T , Tscherne H, Baumgärtel F. Pelvic fractures: epidemiology, therapy and long-term outcome. Overview of the multicenter study of the Pelvis Study Group. 1996 Mar;99(3):160-7.

12. Jeremy w.r young. Fracture of the pelvis: current concepts of rehabilitation. Review article;AJR,1990:1169-1175.

13. Ramesh k sen. Outcome analysis of pelvic ring fractures. Indian journal of orthopedics; 2010 Jan-Mar; 44(1): 79–83.

14. Gansselen A, Pohlemann T, Paul C. Epidemiology of pelvic ring injuries. US National Library of Medicine National Institutes of Health. 1996;27 Suppl 1:S-A13-20.

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15. M. Thaker. Post operative management of acetabular fracture. Indian J Orthop 2002;36:29-3016. Noakes,Smith,Linderberg. Pelvic stress fractures in long distance runners. American journal of sports medicine. 1985 Mar-Apr;13(2):120-123.17. Chesser TJ, Cross AM, Ward AJ. The use of pelvic binders in the emergent management of potential pelvic trauma. Injury 2012;43:667–9.18. Stanley Hoppenfield.Treatment and Rehabilitation of Fractures. Lippincott Publication. Page no. – 31-49

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