Pelvis fracture-Classification, Symptoms & Management |2021

Pelvis fracture
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Pelvis fracture

Fracture of the pelvis can constitute a majority injury and can result from road traffic accidents. They are broadly classified into two types  eg. heavy impact trauma or fall from hight. Pelvis fracture accounts for less than 5%  of all skeletal injuries. Association with: Soft tissues injury, blood loss, shock, spesis, ARDS.

Pelvic ring has 2 arches:
-Posterior arches -Behind acctubular surface
-Anterior arches – In front of accetabular surface.
Pathoanatomy
In pelvic ring is broken and fragment displacement there can be frcature dislocation of the ring.
-Displacement is generally slight.
-External rotation of the hemi pelvis
-Internal rotation of the hemi pelvis
-Rotation superiorly
-Vertical displacement
1. Stable fracture: Does not involve pelvic ring and are minimally displaced.
2. Unstable frcature: Involve pelvic ring and widely displaced.
Mechanism of injury:
-Pelvic fracture due to high velocity  trauma following RTA (Road traffic accident)  or fall from height.
-Lateral compression
-Anteroposterior compression
-Vertical shear forces
-Inferior forces
-Frcature of adult pelvis  exclusive of acetabulum are either stable fracture from low energy trauma.
1. Anteriorposterior compression
Caused by frontal collision
May lead to fracture of ramii and fracture  of posterior part of ileum . This is called open book injury.
2. Lateral compression 
Side to side compression of pelvc causes ring to buckle and break due to RTA (Road traffic accident)
3. Vertical shear
Bone is displaced vertically frcature pubic rami and disrupting sacroiliac region on same side. These are severe unstable injuries with gross tearing of soft tissue.
4. Combination injuries
In severe pelvic injury there may be combination of all.
Classification 
-Frcature not affecting integrity of pelvis ring
-Frcature of affecting
Key and conwell’s classification 
Frcature of individual bone without break in pelvic ring.
a. Avulsion fracture:
-Anteriorsuperior iliac spine
-Anteriorinferior iliac spine
-Ischial tuberosity
b. Frcature of pubis or ischium
c. Fracture of wing of ileum
d. Fracture of sacrum
e. Frcature of sacrum or disloction of coccyx
Single break in pelvic ring
-Frcature of both ispilateral rami
-Frcature or near subluxation of sympathetic pubis
-Fracture near or subluxation of sacroiliac joint.
Double break in pelvis ring
-Straddle fracture
-Malgalgnes fracture
Acetabulum fracture 
-Undisplaced
-Displaced
Tile’s classification 
Type A: Stable
Type B: Fracture pelvis not invoving ring
Type A2: Stable, but minimally displaced
Type B: Rotation unstable, vertical stable
TypeB1: Open book injury
TypeB2: Lateral compression -ipsilateral
Type B3: Lateral compression- contralateral
Type C: Rotation and vertical unstable
Type C1: Rotation and vertical unstable
Type C2: Bilateral
Type C3: Associations with acetabular fracture.
Clinical features
1. Symptoms 
-History of high velocity trauma
-State of hypovolaemic shock
-Intra abdominal injury and genitourinary injuries
2. Clinical sign
-Signs and shock
-Tenderness over frcature site
-Severe pain,  swelling and bruises in lower abdomen.
-Rectal examination should be done.
-Bleeding in extrameatus indicates urethral injury
3. Clinical test
-Compression test
-Direct pressure test
-Distraction test
4. Radiography
-Plain AP view
-Oblique view 45°
-Outlet view 40
-Internal and external rotation view
-Internal view 40
-CT scan
-Urethrography For urethral injury
Management 
It is important to identify possible of life threatening hypovolumic shock and association visceral injuries. Once the patient is stablized assessment should be done.
1. Injury with minimal or no displacement
-Bed rest for 3-4 Weeks
-Once fracture sticky and pain subsides mobilization and weight bearing is permitted.
-6-8 weeks to get up
2. Injury with anterior opening of pelvis
-For minimal opening treatment is same as above.
-Reduction is for opening more than 2.5cm done by manual pressure on 2 iliac wings
a. External fixation: Reliable and comfortable
b. Internal fixation: In pubis symptoms  disruptions
c. Hammock sling traction
3. Injuries with vertical displacement 
-Treatment by bilateral upper tibial skeletal traction.
-Heavy weight to achieve reduction.
-Retention is by spica cast, canvus sling.
Complications 
Hemorrhage
Injuries to lower urinary tract
Testicular injuries and vaginal lacreation
Peristant sacroiliac pain due to unstable pelvic
Physiotherapy Management 
To restore stable pelvis in weight bearing and static and dynamic posterior and activities
Freedom of walking and ambulation activities
To restore normal range of motion
To strengthen and increase endurance
1. Isolated fracture of ileum, pubic rami and sacroiliac subluxation. 
During bed rest strong full range of motion of ankle and toes.
Isometric for quadriceps, hamstrings, gluteal and trunk
Active range of motion external rotation for ankle and toes.
After immobilization for pain, heat therapy routine activities by 3-4 weeks.
2. Frcature of pelvis with disruption of pelvis ring 
Heavy skeletal traction for 6 weeks
Isometric strengthening exercise
Eduction patient of self rolling and superior sitting
Progress to sit and assisted standing
Weight bearing and walking on parallel bars.
Gait training is necessary
Postural jaundice
For flexor tightness lie in prone position
Function regain by 8-10 weeks
Patient treated by surgery immobilization for 3 weeks

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