2. Pelvic Fracture AnatomyAnatomy 2 innominate 1sacrum 2 innominate 1sacrum Innominate bone ilium,ischium,pubis Innominate bone ilium,ischium,pubis Join by strong ligament complex Join by strong ligament complex 1

3. Minor injury Minor fall Minor fall Stable vital sign Stable vital sign Non-displaced Fx Non-displaced Fx Fx not involve ring Fx not involve ring Treatment-bed rest Treatment-bed rest 2

4. Minor injury 3

5. Major injury High energy trauma High energy trauma Unstable vital sign Unstable vital sign High mortality,morbidity High mortality,morbidity Associated injury Associated injury 4

6. Associated injury Rupture bladder Rupture urethra L-S plexus injury 5

7. Associated injury Hypovolemic shock Retroperitonium hematoma bleeding bony surface bleeding bony surface venous plexus bleeding venous plexus bleeding vascular injury vascular injury 6

8. Mechanism of injury AP compression (open book) SI joint widening Symphysis seperation 7

9. Mechanism of injury Lateral compression(internal rotation) Fx ilium Lock symphysis 8

10. Mechanism of injury Vertical shear (Malgaigne Fx) SI dislocate Symphysisdislocate 9

11. Major injury initial management RecuscitationRecuscitation Pelvic stabilization external fixatorPelvic stabilization external fixator Definite treatment pelvic sling ORIFDefinite treatment pelvic sling ORIF 10

12. Fracture of proximal femur Surgical anatomy Vascular anatomy 11

13. Fracture neck of the femur Intracapsular Fx Intracapsular Fx High rate of nonunion, avascular necrosis High rate of nonunion, avascular necrosis 2 aged groups 1.Young adult high energy 2.Older with osteoporosis minor fall 2 aged groups 1.Young adult high energy 2.Older with osteoporosis minor fall 12

14. Fracture neck of the femur 13

15. Fracture neck of the femur PE: Limb slightly shortening Limb slightly shortening Pain at groin Pain at groin Tenderness at midinguinal point Tenderness at midinguinal point Older patient,minor injury Please X ray both hip AP,lat crosstable 14

16. Young adult,good bone quality Reduction and multiple pinning Young adult,good bone quality Reduction and multiple pinning TreatmentTreatment 15

17. TreatmentTreatment Older with osteoporosis Hemiarthroplasty Hemiarthroplasty 16

18. Nonunion Nonunion Avascular necrosis Avascular necrosis Venous thrombosis Venous thrombosis Nonunion Nonunion Avascular necrosis Avascular necrosis Venous thrombosis Venous thrombosisComplication 17

19. Intertrochanteric Fracture Fx line from greater to lesser trochanter Fx line from greater to lesser trochanter More common in woman menopause More common in woman menopause Extracapsular fracture Extracapsular fracture Older with osteoporosis -minor fall Older with osteoporosis -minor fall 18

20. PE: Limb shortening,external rotation Limb shortening,external rotation Swelling,ecchymosis at hip Swelling,ecchymosis at hip Tenderness at greater trochanter Tenderness at greater trochanter 19

21. Treatment Non operative traction 6 wks. high complications Pressure sore venous thrombosis infection Pressure sore venous thrombosis infection 20

22. Operative treatment is preferable surgical risk, early ambulation 21

23. Subtrochanteric Fracture Fx at level of lesser trochanter and a point 5 cm. Distally Fx at level of lesser trochanter and a point 5 cm. Distally thick cortical bone thick cortical bone high mechanic stress high mechanic stress high energy trauma high energy trauma 22

24. Treatment Operative treatment is preferable 23

25. Posterior dislocation 80% most common Anterior dislocation 5% Central dislocation 15% Hip Dislocation 24

26. Dashboard injury Blow to femur in adduction internal rotation of the hip Blow to femur in adduction internal rotation of the hip Posterior dislocation 25

27. Posterior dislocation PE: hip flexion,internal rotate and adduct ass.knee ligament injuries assess sciatic nerve 26

28. X-ray Head out of acetabulum smaller femoral head femur adduct, internal rotate(disappear lesser trochanter) 27

29. Treatment Early diagnosis prompt closed reduction Allis’s maneuver failed closed reduction- open reduction 28

30. Posterior dislocation Allis’s maneuver Stabilized pelvis longitudinal traction 90 degree hip flexion upward traction 29

31. Posterior dislocation Allis’s maneuver 30

32. Management after reduction Test for stability X-ray both hip AP evaluate joint space Stable reduction skin traction- pain subside ambulation with crutches Unstable reduction ORIF 31

33. Posterior dislocation Fragment entrap in joint Joint space widening 32

34. Anterior dislocation Blow to femur in abduction,external rotate of hip joint Blow to femur in abduction,external rotate of hip joint 33

35. Early diagnosis prompt closed reduction Allis’s maneuver failed closed reduction- open reduction Treatment 34

36. General anesthesia Traction along axis Internal rotation Lateral traction Anterior dislocation Reduction technique 35

37. Anterior dislocation Clinical manifestation X ray 36

38. Anterior dislocation Traction along axis Internal rotation Stabilized pelvis Lateral traction 37

39. Anterior dislocation Post reduction X ray pelvis AP Skin traction until pain subside(5-7 d) Ambulation with crutches 38

40. Fracture shaft of the femur High energy injury Bleeding 1- 2.5 L. Ass. femoral neck Fx. Ass. hip dislocation High energy injury Bleeding 1- 2.5 L. Ass. femoral neck Fx. Ass. hip dislocation 39

41. Deformity of thigh angulation shortening PE.of hip and knee Vascular assessment dorsalis pedis a. posterior tibial a. Deformity of thigh angulation shortening PE.of hip and knee Vascular assessment dorsalis pedis a. posterior tibial a. Physical examination 40

42. Splinting - Thomas’s splint Film femur include hip-knee detect neck Fx-dislocate hip Temporary stabilization with proximal tibial traction Splinting - Thomas’s splint Film femur include hip-knee detect neck Fx-dislocate hip Temporary stabilization with proximal tibial traction Management 41

43. Management Non-operative treatment Traction 6-8 wks. Femoral castbrace 10-12wks. Operative treatment ORIF with plate-screw Intramedullary nailing Non-operative treatment Traction 6-8 wks. Femoral castbrace 10-12wks. Operative treatment ORIF with plate-screw Intramedullary nailing 42

44. Transverse Fx midshaft femur ORIF with plate-screw 43

45. Comminuted Fx midshaft femur Intramedullary nail 44

46. Fx distal femoral metaphysis 9 cm. above joint line Posterior displacement of the distal fragment High rate of stiffed knee Fx distal femoral metaphysis 9 cm. above joint line Posterior displacement of the distal fragment High rate of stiffed knee Supracondylar fracture 45

47. How to described Fx? T or Y Fx (combined) T or Y Fx (combined) Intercondylar Fx (intra-articular) Intercondylar Fx (intra-articular) Supracondylar Fx (extra-articular) Supracondylar Fx (extra-articular) 46

48. Conservative Traction stiffed knee Operative Early function Early knee motion Treatment 47

49. T Fracture of distal femur ORIF with plate and screw T Fracture of distal femur ORIF with plate and screw 48

50. Largest sesamoid Function -lever arm for knee extension -protect condyle Largest sesamoid Function -lever arm for knee extension -protect condyle Fracture of the patella 49

51. Mechanism of injury Avulsion(traction) Quads. pull up Knee flexion Direct injury 50

52. Sign & symtom Swelling,effusion Palpable defect Unable to extend knee actively Swelling,effusion Palpable defect Unable to extend knee actively 51

53. Non displaced Fx Cylinder cast prevent knee flexion Cylinder cast prevent knee flexion 52

54. Displaced transverse Fx ORIF 53

55. Most common long bone Fx medial surface palpable Open Fx common frequent complication Most common long bone Fx medial surface palpable Open Fx common frequent complication Fracture of the tibia 54

56. Swelling,deformity Ascess vascular dorsalis pedis a. posterior tibial a. marked swelling compartment syn. Swelling,deformity Ascess vascular dorsalis pedis a. posterior tibial a. marked swelling compartment syn. Symtom & Sign 55

57. Treatment Conservative Closed reduction apply long leg cast Closed reduction apply long leg cast 56

58. X ray post reduction X ray post reduction Criteria for accept alignment Varus,vulgus < 5 degree AP angulation <10 degree Malrotation <10 degree Shortening < 1cm. Contact surface >50% Varus,vulgus < 5 degree AP angulation <10 degree Malrotation <10 degree Shortening < 1cm. Contact surface >50% 57

59. After long leg cast 4-6 weeks After long leg cast 4-6 weeks Change to PTB cast 8-12 wks. Until Fx consolidation Change to PTB cast 8-12 wks. Until Fx consolidation Patella Tendon Bearing PTB cast Patella Tendon Bearing PTB cast 58

60. Treatment Operative Failed closed reduction Unacceptable alignment Multiple fractures open fracture Failed closed reduction Unacceptable alignment Multiple fractures open fracture Intramedullary nail 59

61. External fixator ORIF plate & secrew 60

62. Complication Compartment syndrome Compartment syndrome Early detection Release pressure remove cast,splint fasciotomy Early detection Release pressure remove cast,splint fasciotomy 61

63. Malunion Vascular injury Infection 62

64. A man 23 yr. MCA 10 min. Single injury Pain at Rt. ankle, can’t palpable dorsalis pedis and posterior tibial artery A man 23 yr. MCA 10 min. Single injury Pain at Rt. ankle, can’t palpable dorsalis pedis and posterior tibial artery 63

65. X ray ankle AP, Lat Fx of distal fibular Diastasis of syndesmosis Fx of medial mall. Ankle subluxation 64

66. How do you manage this case? How do you manage this case? Vascular injury? Joint subluxation Vascular injury? Joint subluxation 4 R R egcognition R eduction R etention R ehabiliation 4 R R egcognition R eduction R etention R ehabiliation 65

67. AP view Mortise view Lateral view 66

68. head body neck Fracture of the talus 67

69. Talar neck Fx most common Caused by hyperdorsiflexion 3/5 cover by cartilage Vascular enter at talar neck Talar neck Fx most common Caused by hyperdorsiflexion 3/5 cover by cartilage Vascular enter at talar neck Fracture of the talus 68

70. Subtalar jt. dislocation Talar neck Fx Ankle dislocation 69

71. ORIF talar neck with screw 70

72. Fracture of the Calcaneus Most common tarsal bone Fx Extra-articular Fx Direct injury Intra-articular Fx(Subtalar Jt.) Fall from height Most common tarsal bone Fx Extra-articular Fx Direct injury Intra-articular Fx(Subtalar Jt.) Fall from height 71

73. Physical Examination Heel widening,short Ecchymosis Tenderness at heel Squeeze test T-L spine exam Heel widening,short Ecchymosis Tenderness at heel Squeeze test T-L spine exam 72

74. X ray Calcaneus lateral Axial view Calcaneus lateral Axial view 73

75. Treatment Non displaced Fx Short leg cast 6 wks. Displaced Fx ORIF Non displaced Fx Short leg cast 6 wks. Displaced Fx ORIF 74