Transcript Femoral neck - Calgary Emergency Medicine

Pelvis & Hip Fractures &
Dislocations
Moritz Haager
October 24, 2002
Objectives:
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Epidemiology & relevance
Anatomical review
Classification Systems
Examples
Management
Pelvic Fractures: Epidemiology
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~3% of all fractures in ED
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50-60% secondary to MVA
Motorcycle crashes ~15%
Car vs. pedestrian ~15%
Falls 10-30%
Crush injuries ~5%
Mortality 6-10%; Inc’s to ~50% in unstable pt
Tend to occur in setting of multi-system injury
therefore often serious other injuries
Complications:
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Hemorrhage, neurological injury, deformity, GU injury, GI
injury
Pelvic Anatomy
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Pelvis = sacrum + 2
inominate bones
Inominate bones =
ilium, ischium, pubis
Strength from
ligamentous +
muscular supports
Pelvic Anatomy
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Anterior Support:
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~40% of strength
Symphysis pubis
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Fibrocartilaginous joint
covered by ant & post
symphyseal ligaments
Pubic rami
Posterior Support:
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~60% of strength
Sacroiliac complex
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Sacroiliac ligaments
Iliolumbar ligaments
Pelvic floor
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Sacrospinous ligament
Sacrotuberous ligament
Pelvic diaphragm
Acetabulum
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Divided into 3 columns:
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Anterior superior
column (= ilium)
Anterior inferior column
(= pubis)
Posterior Column
(= ischium)
Vascular Anatomy
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Vessels lie closely
adherent to
posterior pelvic
walls
Most common
cause of bleeding
is venous
Most commonly
injured arteries
are superior
gluteal and
internal pudendal
aa.
History & Physical
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ABC’s & initial stabilization
AMPLE Hx
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Destot’s sign:
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Hematoma above inguinal ligament or scrotum
Grey-Turner’s sign
Earle’s sign:
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Most important feature is mechanism
Presence of bony prominence, palpable hematoma, or
tender # line on DRE
Blood at urethral meatus / vaginal introitus
Examine pelvis only once
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Sensitivity of exam 93% vs. 87% for AP pelvis
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Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5
Imaging
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Plain films
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AP
Inlet view / Outlet view
Judet view (oblique)
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AP alone ~90% sensitive; combined w/ inlet / outlet views ~94%
sensitive
Limited in ability to clearly delineate posterior injuries
Pelvic films are NOT necessary in pts with normal physical
exam + GCS >13
At least one study shows clinical exam reliable in EtOH
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Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5
CT scans
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Evaluates extent of posterior injury better
Superior imaging of sacrum and acetabulum
More detailed info about associated injuries
Inlet & Outlet Views
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Inlet view
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X-ray beam at 60o to
plate directed towards
feet
Used to look for vertical
& horizontal fracture
displacement, and SI
widening
Outlet view
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Beam aimed 30o
towards head
Used to look at sacral
fractures & SI disruption
Imaging
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What you really want to know is if there has
been damage to the posterior structures
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Clues on X-rays:
L5 transverse process avulsion (iliolumbar ligament)
 Ischial spine avulsion (sacrospinous ligament)
 Unable to clearly make out sacral foramina
 Assymmetry of sacral foramina
 Significant displacement of anterior arch fracture
 Sacral avulsion (sacrotuberous ligament)
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Classification Systems:
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2 most common are Tile and Young systems
Tile Classification system:
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Advantages
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Disadvantages
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Comprehensive
Predicts need for operative intervention
Does NOT predict morbidity or mortality
Young Classification System:
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Advantages
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Based on mechanism of injury  predicts ass’d injury
Estimates mortality
Disadvantages
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Excludes more minor injuries
Tile Classification System
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Type A: Stable pelvis:
post structures intact
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A1: avulsion injury
A2: iliac wing or ant
arch #
A3: Transverse
sacrococcygeal #
Tile Classification System
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Type B: Partially stable
pelvis: incomplete
posterior structure
disruption
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B1: open-book injury
B2: lateral compression
injury
B3: contralateral / bucket
handle injuries
Tile Classification System
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Type C: Unstable
pelvis: complete
disruption of posterior
structures
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C1: unilateral
C2: bilateral w/ one side
Type B, one side Type
C
C3: bilateral Type C
Young Classification System:
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Lateral Compression
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(50%) – transverse # of
pubic rami, ipsilateral or
contralateral to posterior
injury
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LC I – sacral
compression on side of
impact
LC II – iliac wing # on
side of impact
LC III – LC-I or LC-II on
side of impact w/
contralateral APC injury
Young Classification System:
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AP Compression
(25%)
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Symphyseal and / or
Longitudinal Rami
Fractures
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APC I – slight widening
of the pubic symphysis
and/or anterior SI joint
APC II – disrupted
anterior SI joint,
sacrotuberous, and
sacrospinous ligaments
APC III – complete SI
joint disruption w/ lateral
displacement and
disruption of
sacrotuberous and
sacrospinous ligaments
Young Classification System:
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Vertical Shear (5%)
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Symphyseal diastasis or
vertical displacement
andteriorly and posteriorly
Combined Mechanism
– combination of injury
patterns
Young: Morbidity & Mortality
Fracture
Type
LC - I
Severe
Bladder
Bleeding Rupture
0.5%
4%
Urethral
Injury
2%
Mortality
LC – II
36%
7%
0%
6%
LC – III
60%
20%
20%
13%
APC – I
1%
8%
12%
7%
APC – II
28%
11%
23%
7%
APC – III 53%
14%
36%
25%
VS
75%
15%
25%
25%
CM
58%
16%
21%
17%
6%
Tile B1 / Young APC II
Tile C1/ Young VS
Tile A1
Management
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Stable vs Unstable patient
Stable pt:
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Conservative Tx (bed rest  slow wt bearing)
Tile: A1, A2, A3 (coccyx #’s only)
 Young: APC – I, LC – I, some LC – II
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Unstable pt:
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Tile B & C / Young APC & VS = high energy
injuries
Require surgical management
Timing & methods for stabilization controversial
Management: Unstable Patient
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ABC’s, resuscitation
Evaluate for site(s) of blood loss
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Options for pts not requiring laparotomy:
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DPL, FAST, CT
Laparotomy if indicated
Sheet around pelvis / MAST pants
External fixator
Early ORIF
Angiographic embolization
Early antibiotics for open # (cefazolin & gent)
Hemodynamically Unstable
Pelvic Fracture
Initial Resuscitation
DPL
Gross + blood
Laparotomy
+ Cell Count
CT Abdomen / Pelvis
- Cell Count
?Candidate for
External Fixator
Yes
Persistent
Hemodynamic
Instability
External Fixator
Angio + Embolization
No
Unstable Stable
Management: Unstable Patient
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Does our approach work?
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No prospective RCT’s
Allen et al. Management Guidelines for
hypotensive pelvic fracture patients. Am Surg
2000; 66: 735-38
Retrospective analysis of 75 pts BP<90 & complex
pelvic fracture
 Utilized external fixator, early ORIF, and embolization
 Overall mortality 14.7%
 Predictors of mortality:
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BE < -5
BP < 90 after initial resuscitation
Higher ISS
Avulsion Fractures
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Common pelvic #’s
Mechanism:
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Most common types:
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Forced contraction of muscle avulsing bony
fragment (soccer & gymnastics)
Ischial tuberosity  hamstring
ASIS avulsion  sartorius
AIIS  rectus femoris
Tx:
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PRICE, crutches, f/u with ortho in 1-2 weeks
Sacral Fractures
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Mechanism:
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Presentation:
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Perianal or buttock pain +/- ecchymosis
~22% have neuro sx
Dx:
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Direct trauma or forced flexion
AP pelvis, CT
Tx:
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No neuro deficits  PRICE & ortho in 1 week
+ neuro deficits  urgent ortho consult
Sacral Fractures
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Classification:
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Type A: ~90%
vertical transforaminal # line – usually ass’d pelvic #’s
 Neuro deficits less common
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Type B:
Transverse # line below S2
 Neuro deficits less common
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Type C:
Transverse # line above S2
 High incidence of neuro deficit
 Least common sacral #
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Coccyx Fractures
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Mechanism:
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Presentation:
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Pain w/ sitting, standing, or defecating
Local tenderness
Dx:
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Direct trauma (falls)
Clinical
Tx:
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STD (Stool softeners, Tylenol, Donut cushion)
Coccygectomy if persistent chronic pain
Duverney’s (Iliac Wing) Fractures:
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Mechanism:
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Presentation:
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Localized pain, swelling, tenderness
Trendelenburg gait
Ileus, abdominal tenderness
Dx:
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Direct trauma
30% have ass’d acetabulaR #
AP pelvis
Tx:
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No abd findings  PRICE, ortho f/u in 1 week
Abd rigidity / ileus  r/o intraabdominal injury
Acetabular Fractures
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20% of pelvic fractures
Sciatic nerve injury in 13%
MVA most common mechanism
4 types:
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Posterior rim
Transverse
Iliopubic column
Ilioischial column
Acetabular #: Posterior Rim
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Most common
Mechanism:
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Dx:
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Knee-on-dashboard
Post hip dislocation common
AP pelvis +/- CT
Tx:
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Admit, Ortho consult
Reduce post dislocation w/in 6 hrs if present
Document neurovascular status
Post Reduction: Allis Method
Post Reduction: Stimson Method
Transverse Fractures
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Mechanism:
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Dx:
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Lateral  medial force on greater trochanter
with hip flexed (T bone MVA)
May have ass’d central hip dislocation
AP pelvis: disruption of teardrop
CT
Tx:
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Admit, ortho consult
Iliopubic Column Fractures
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Mechanism:
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Dx:
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Lateral  medial force to greater trochanter with
hip in flexion & external rotation (laying down
the bike)
May get central or anterior femur dislocation
AP pelvis: disruption of arcuate line + ant rim,
tear drop medially displaced
CT
Tx:
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Admit, ortho consult
Ilioischial Column Fractures
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Mechanism:
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Dx:
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Ant  post force to knee w/ thigh in abduction &
flexion
Sciatic nerve injury in 25-30%
AP pelvis: ilioischial line disruption +/- medial
displacement of femoral head
CT
Tx:
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Admit, ortho consult
Proximal Femur Injuries
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Fractures:
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Dislocations:
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Femoral neck, intertrochanteric, femoral head,
greater & lesser trochanter, subtrochanteric
Anterior, posterior, central hip dislocations
Rising incidence due to aging population &
MVA’s
Young pts  high energy trauma
Elderly pts  minor mechanisms – need high
index of suspicion
Anatomy
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Ward’s triangle
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Weakest part of
proximal femur
Vascular anatomy
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Distal blood supply
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AVN / non-union in 10%
of non-displaced, & 3040% displaced #’s
Blood supply:
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Retinacular
(epiphyseal) aa.
Foveal a.
Metapyseal a.
Neuroanatomy
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Femoral n.
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Injury causes weak knee extension and sensory
deficit superior & medial to patella
Main sensory to hip joint  femoral nerve block
Sciatic n.
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Injury causes weak lower leg & hamstring mm.
and sensory deficit of post thigh and below knee
Hip Dislocations
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Etiology
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Types:
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Adults: high energy mechanism (MVA)
Elderly, prosthetic joints, kids < 6yo: minor mech
Posterior >> anterior > central
Orthopedic emergencies:
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Urgent reduction after ABC’s / stabilization
Significant neurovascular complications
Often multiple associated injuries
Mandate CT post-reduction
Dislocations: presentation
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Posterior
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Anterior
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PID – Posterior (shortened), Internally rotated, adducted
Knee-on-dashboard mechanism
10% sciatic nerve injury
Superior: extension & external rotation
Inferior: abduction, external rotation, flexion
Central
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Shortening, severe pain w/ any ROM
High energy lateral blow
Risk for serious bleeding from acetabulum / sciatic nerve
Imaging
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Plain Films: ant vs. post dislocations
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Femoral head size
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Posterior dislocation  femoral head smaller
Lesser trochanter visibility
Post dislocation  adduction & internal rotation,
lesser trochanter not seen
 Ant dislocation  external rotation; lesser trochanter
clearly visible
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CT
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Indicated for more detailed evaluation of femoral
neck, intra-articular #’s, and acetabulm
Dislocations: Tx
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Urgent:
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Simple ant & post dislocations should be
reduced using Allis or Stimson method
Should be done w/in 6 hrs of injury unless ass’d
femur #
Ortho consult for others
Femoral Head Fractures
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Usually occur 2o to hip dislocation
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Pipkin classification
Dx:
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Anterior: 22-77% ass’d FH #
Posterior: 10-16% ass’d FH #
Post-reduction AP pelvis
Often subtle
Tx:
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Surgical
Femoral Neck Fractures
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Mechanism:
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Presentation:
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Elderly –Osteoporosis: minor falls & min ass’d injuries
Young – high energy mech  multi-trauma
Non-displaced – can present w/ minimal Sx
Displaced – BESS (aBducted, Externally rotated,
Shortened, Severe pain w/ ROM)
Dx:
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AP + lateral films of hip
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often difficult to see non-displaced #’s
MRI, Bone Scan
Femoral Neck Fractures
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Garden
Classification
Rosen: displaced
vs. non-displaced
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Non-displaced (1520%)
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X-ray clues:
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Increased sub-capital
density
Kinked S and reverse
S curves
Discontinuous
cortical lines
Displaced
Femoral Neck Fractures
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Tx:
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Analgesia
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Why did this pt fall?
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Narcotics, Femoral nerve block
R/o cardiac, neuro, infectious etc
Non-displaced:
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Displaced:
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Impacted  stable, early mobilization (96% heal)
Not impacted  ORIF
ORIF / arthroplasty
Complications:
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AVN, non-union, DVT/PE, loss of fixation
Intertrochanteric Fractures:
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Similar to femoral neck #’s in mechanism,
presentation, Dx, and Tx
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Elderly pts, minor mech
Non-displaced #’s can be difficult to see
Tend to bleed more (up to 1.5L) – rate of
AVN < 1%
Mortality 10-30% in 1st year
Tend to be more externally rotated
Ortho consult  mostly surgical Tx
Subtrochanteric Fractures:
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#’s b/w lesser trochanter & point 5 cm distal
Similar to intertrochanteric #’s in patient
population, mechanism, Sx, and Dx
Common site for pathologic #’s:
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Paget’s, renal osteodystrophy, osteogenesis
imperfecta, metastatic CA (esp breast)
Also can bleed significantly
Tx is controversial – need ortho consult
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Cortical bone  slow healing & non-union
Tend to be comminuted  difficult to reduce
Greater Trochanter Fractures
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Mechanism:
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Presentation:
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Limping, pain / tenderness, hip flexed
Dx:
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7-17 yo: avulsion from muscle contraction
Adults: direct blow  communition
AP + lat plain films
Tx:
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Controversial; PRICE vs. ORIF
Ortho consult
Lesser Trochanter Fractures
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Mechanism:
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Presentation:
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Groin pain, inability to lift leg when seated
(iliopsoas insufficiency)
Dx:
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85% occur in <20 yo
Avulsion injury (iliopsoas) – resisted hip flexion
AP + Lateral films
Tx:
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Good prognosis -- bed rest, early mobilization
Femoral Neck Stress Fractures
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Mechanism:
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Presentation:
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Vague groin, hip, or knee pain & above Hx
Slow onset, worse w/ activity, better w/ rest
Antalgic gait, local tenderness, pain on ROM
Dx:
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Repetitive loading  fatigue (runners)
Difficult – often missed  may displace
Plain films – often –ve in 1st 2 weeks
CT, bone scan, MRI
Tx:
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Conservative: NWB x 6 weeks - avoid activity x 1 month
Femoral Nerve Block
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Analgesia to shaft & proximal femur
Avoids hypotension & respiratory depression
Recent Cochrane Review unable to confirm or
deny benefit of using local blocks
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Parker et al. Nerve blocks for hip fractures. Coch Data Sys Rev. 2002
Technique:
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Clean & prep
Palpate femoral a.  freeze skin laterally
10 – 20 ml 0.5% bupivicaine lateral to femoral a. in 2-3
cm fan-like distribution
Onset: 15 min; Duration: up to 8 hrs