Fracture Pelvis

Patients with a high risk for clotting require thromboprophylaxis. Some risk factors for venous thromboembolism include age greater than 40 years, prolonged immobility, history of prior venous thromboembolism (DVT, pulmonary embolism [PE]), cancer, major surgery (abdominal, pelvic, or lower extremity), fracture (pelvis, hip, or leg), CHF, Ml, stroke, obesity, and high-dose estrogen use. 

A man driving a battery platform tractor lost control and drove over the edge of the platform. [He suffered a] fractured pelvis, two cracked vertebrae, bruised abdomen. (Railway Inspectorate Report)... 

Distal radius for internal- external fixation, cervical fusion, oral and maxillofacial surgery, orthognathic applications, posttraumatic metaphyseal defects Blocks Tibial plateau fractures, pelvis, and femur, acetabulum, pseudarhrosis defects Granules bone cysts in hand, feet, knee, and spine... 

Vascular inujury Major orthopedic surgery (e.g., knee and hip replacement) Trauma (esp. fractures of the pelvis, hip, or leg) Indwelling venous catheters... 

Vitamin D deficiency in adults cannot affect the epiphyseal plate, as it has disappeaced, but it can prevent normal mineralization of the osteoid layer in bone that turns over. In vitamin D deficiency the osteoclasts continue to create tunnels and pits in the bone. The osteoblasts continue to synthesize the protein matrix however, complete mineralization of the osteoid may not occur. The result is osteomalacia - This disease may present as bone pain about the hips. Osteomalacia can be diagnosed using a bone biopsy, A sample is taken from the iliac crest — the hip bone. An abnormally wide osteoid is indicative of the disease. X-rays can also be used to diagnose osteomalacia, which is characterized by arrays or zones of tiny fractures in sucli bones as the pelvis and femur. 

Bone tissue is constantly being renewed by the concerted action of osteoblasts and osteoclasts. Bone remodeling has two main phases a resorption phase consisting in the removal of old bone by osteoclasts, and a later phase of new bone formation driven by osteoblasts [6], Thus, the activity of osteoblasts and osteoclasts determines bone mass, bone geometry, bone quality, and, subsequently, bone strength [7, 8]. Osteoporosis is a prevalent disorder consisting in decreased bone mass and/or abnormal bone microarchitecture that impairs bone strength and increases the risk of fracture. Therefore, patients with osteoporosis may suffer fractures as a result of minor trauma, or even in the absence of trauma. The most common osteoporotic fractures are those of the vertebral bodies, the hip, the wrist, the shoulder, and the pelvis. 

AB, a 5. -year-old man. was trapped for 7 hours in a railway accident. He sustained severe multiple injuries including crush injuries to both thighs, fractures of the pelvis and scalp lacerations. On arrival at Accident Emergency he was still conscious and breathing spontaneously. His pulse was 130/min and his BP was 60/40 iiimHg. A set of U Es showed the following ... 

Autografts are bone tissue harvested from a donor site within the same individual (typically from the iliac crest of the pelvis) and transplanted to the fracture site. The innately autologous nature of these scaffolds combined with their highly osteoinductive properties has led them to be considered the gold standard . However, while they are useful for providing a filler material that is conducive to bone regeneration without any risk of rejection, material is limited and the removal of bone from the donor site often results in residual pain and morbidity [28]. 

Clinical studies report millimetric accuracy on tool and implant positioning. These types of systems have been applied extensively in orthopedics, (the spine, ) pelvis, fractures, - hip, and knee neurosurgery, and craneofacial and maxillofacitd surgery. 

Various secondary ossification centres develop in the pelvis at different ages. Accessory ossification centres may develop at the tip of the ischial spine and the rim of the acetabulum between 14 and 18 years of age (Fig. 7.26). The normal apophyseal centres on the inferior border of the ischium (Fig. 7.27) should not be mistaken for avulsion injuries, although they may be separated by violent hamstring contraction. The fusing ischiopubic synchondroses maybe mistaken for healing fractures, particularly... 

With knowledge of common accidental fractures, the finding of a fracture at an unusual site will suggest an unusual mechanism of injury. In the absence of a history of an unusual mechanism, abuse should be considered. Unusual sites of fractures in infants and toddlers include phalanges (Fig. 11.9), meta-carpals, metatarsals, pelvis and scapula (Fig. 11.10). Pelvic fractures have been described in association with sexual abuse (Johnson et al. 2004). 

The AP radiograph should be closely reviewed for signs of pelvic ring discontinuity by identifying various anatomical lines, the absence of which implies ring disruption or a fracture. These lines are the ischio-ilial line, ilio-pectineal line, and the anterior and posterior acetabular walls. The ilio-ischial line is formed by the posterior structures of the pelvis and the ilio-pectineal by the anterior acetabular structures (Ersoy et al. 1995) (Fig. 12.3). 

Avulsion fractures of the posterior inferior iliac spine and the transverse process of the 5 lumbar vertebra are rare but indicative of severe trauma. The former occurs as a result of external rotation of the hemi-pelvis which avulses the sacrospinous ligament at its insertion. The latter injury results when the ilio-lumber ligament is avulsed from the tip of the transverse process of L5 by shearing forces in the vertical plane. These injuries should arouse suspicion of pelvic instability. 

The forces which cause pelvic fractures are applied in three primary directions or vectors. These vectors are anterior and posterior compression (AP), lateral compression (LC) and vertical shear forces. It is possible that more than one of these vectors can be applied to the pelvis at any one time which will result in hybrid pattern and a more complex fracture (Young et al. 1986). 

There maybe fractures of the pubic rami as in Type I. There is further diastasis of the anterior aspect of the sacroiliac joints and these are classically referred to as the open book or spun pelvis type injuries. Sacroiliac diastasis is best assessed by CT. There may be some partial instability on AP compression. In children, there may be fracturing of the adjacent bone rather than ligament rupture. This is a reflection of the relative strength of the ligaments compared with bone in the growing skeleton (Figs. 12.6,12.7). 

This is the most severe type and results in total sacroiliac joint disruption. Features of the Type 1 and 2 pattern may be present. There is widening of the sacroiliac joint and there is diastasis both posteriorly as well as anteriorly due to the posterior sacroiliac ligament rupture. On clinical examination, the hemi-pelvis is unstable in all directions of force and typically requires operative stabilisation. It is possible for the sacroiliac joint to remain intact but there is fracture of the sacroiliac bone. Complications include bladder rupture, and vascular injury (Figs. 12.8,12.9). 

This is the so-called windswept pelvis. There is internal rotation of the pelvis on the side of impact but external rotation of the opposite side. As a consequence, there are lateral compression injuries on one side of the pelvis with AP compression fractures on the other. 

This is usually the result of forces transmitted through the axial skeleton from an impact into the head and shoulders through to the lower limbs. There may be symphyseal diastasis, anterior arch fractures or posterior disruption of the sacroiliac joints with cephalic displacement. Vertical injuries are often severe with disruption of all the ligaments plus associated pelvic instability. Radiographs demonstrate ipsilateral or contralateral pubic rami fractures, with disruption of the sacroiliac joint. The major differentiating feature from compression injuries is the cephalic displacement of the pelvis on the side of the impact (Fig. 12.14). 

These fractures are unstable injuries with disruption of the posterior sacro-iliac complex. These injuries are very rare in children. In Type Cl injuries, there is a unilateral injury of the hemi-pelvis. Type C2 are bilateral injuries of the pelvis with some partial stability on one side. Type C3 are bilateral injuries in which both hemi-pelvis are unstable. 

In recognition of the fact that fractures of the immature pelvis behave in a different fashion than those of adults, Torode and Zieg proposed a new classification which attempts to correlate the type of fracture with associated injuries and expected outcome (Torode and Zieg 1985) (Fig. 12.18). 

This group includes fractures of the pubic rami or symphysis, because of the elasticity of the child s pelvis, significant displacement can occur without damage to the posterior elements of the pelvic ring (Fig. 12.20). 

In the pelvis, avulsion occurs primarily at six sites, which not surprisingly are the sites of the major muscle attachments. The three commonest sites are the anterior superior iliac spine (ASIS) (the origin of sartorius), the anterior inferior iliac spine (AIIS) (the rectus femoris origin) and the ischial tuberosity (the origin of the hamstring group). With these fractures acutely there is a clinical history of severe exertion, followed by pain and reduced function (Wootton et al. 1990) (Fig. 12.23). 

The primary imaging assessment of the paediatric hip typically involves an AP radiograph of the pelvis. If it is the first presentation then lateral views are indicated. Initial trauma films should be taken without gonad protection, as this may obscure fractures. If the child is being followed up and the pathology is... 

The spectrum of metabolic bone diseases will result in a generalized weakness of bone thereby predisposing to pathological fracture formation. In rickets, due to a dietary deficiency of vitamin D, this can manifest as insufficiency fractures in the pelvis and long bones of the lower limb (Fig. 21.14). Advances in the management of chronic renal failure... 

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