Introduction Mechanism typically high energy blunt trauma Mortality rate 1-15% for closed fractures, as much as 50% for open fractures hemorrhage is leading cause of death overall closed head injury is the most common for lateral compression injuries increased mortality associated with systolic BP <90 on presentation age >60 years increased Injury Severity Score (ISS) or Revised Trauma Score (RTS) need for transfusion > 4 units higher Young-Burgress classification grade Associated injuries orthopaedics chest injury in up to 63% long bone fractures in 50% spine fractures in 25% non-orthopaedic urogenital sexual dysfunction up to 50% head and abdominal injury in 40% Prognosis high prevalence of poor functional outcome and chronic pain poor outcome associated with SI joint incongruity of > 1 cm high degree initial displacement malunion or residual displacement leg length discrepancy > 2 cm nonunion neurologic injury urethral injury Pediatric pelvic ring fractures children with open triradiate cartilage have different fracture patterns than do children whose triradiate cartilage has closed if triradiate cartilage is open the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption for this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment Anatomy Osteology ring structure made up of the sacrum and two innominate bones stability dependent on strong surrounding ligamentous structures displacement can only occur with disruption of the ring in two places neurovascular structures intimately associated with posterior pelvic ligaments high index of suspicion for injury of internal iliac vessels or lumbosacral plexus Ligaments anterior symphyseal ligaments resist external rotation pelvic floor sacrospinous ligaments resist external rotation sacrotuberous ligaments resist shear and flexion posterior sacroiliac complex (posterior tension band) strongest ligaments in the body more important than anterior structures for pelvic ring stability anterior sacroiliac ligaments resist external rotation after failure of pelvic floor and anterior structures interosseous sacroiliac resist anterior-posterior translation of pelvis posterior sacroiliac resist cephalad-caudad displacement of pelvis iliolumbar resist rotation and augment posterior SI ligaments Vascular common iliac system begins near L4 at bifurcation of abdominal aorta external iliac artery courses anteriorly along pelvic brim and emerges as the common femoral artery distal to the inguinal ligament internal iliac artery dives posteriorly near SI joint and divides in the posterior division (giving of superiior gluteal artery) and anterior division (becoming obturator artery) corona mortis is a connection between the obturator and and external iliac systems mean distance of 6.2cm from the pubic symphysis venous plexus in posterior pelvis accounts for 90% of the hemorrhage associated with pelvic ring injuries Neurologic Lumbosacral trunk crosses anterior sacral ala and SI joint L5 nerve root exits below L5 TP a courses over sacral ala 2cm medial to SI joint Classification Tile classification A: stable A1: fracture not involving the ring (avulsion or iliac wing fracture) A2: stable or minimally displaced fracture of the ring A3: transverse sacral fracture (Denis zone III sacral fracture) B: rotationally unstable, vertically stable B1: open book injury (external rotation) B2: lateral compression injury (internal rotation) B2-1: with anterior ring rotation/displacement through ipsilateral rami B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury) B3: bilateral C: rotationally and vertically unstable C1: unilateral C1-1: iliac fracture C1-2: sacroiliac fracture-dislocation C1-3: sacral fracture C2: bilateral with one side type B and one side type C C3: bilateral with both sides type C Young-Burgess Classification Descriptions Xray CT Anterior Posterior Compression (APC) APC I Symphysis widening < 2.5 cm APC II Symphysis widening > 2.5 cm. Anterior SI joint diastasis . Posterior SI ligaments intact. Disruption of sacrospinous and sacrotuberous ligaments. APC III Disruption of anterior and posterior SI ligaments (SI dislocation). Disruption of sacrospinous and sacrotuberous ligaments.APCIII associated with vascular injury Lateral Compression (LC) LC I Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture. LC II Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture). LC III Ipsilateral lateral compression and contralateral APC (windswept pelvis). Common mechanism is rollover vehicle accident or pedestrian vs auto. Vertical Shear (VS) Vertical shear Posterior and superior directed force. Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25% Physical Exam Symptoms pain & inability to bear weight Physical exam inspection test stability by placing gentle rotational force on each iliac crest low sensitivity for detecting instability perform only once look for abnormal lower extremity positioning external rotation of one or both extremities limb-length discrepancy skin scrotal, labial or perineal hematoma, swelling or ecchymosis flank hematoma lacerations of perineum degloving injuries (Morel-Lavallee lesion) neurologic exam rule out lumbosacral plexus injuries (L5 and S1 are most common) rectal exam to evaluate sphincter tone and perirectal sensation up to 10-15% of patients will sustain neurologic injury urogenital exam most common finding is gross hematuria more common in males (21% in males, 8% in females) vaginal and rectal examinations mandatory to rule out occult open fracture Imaging Radiographs recommended views AP part of initial ATLS evaluation look for asymmetry, rotation or displacement of each hemipelvis evidence of anterior ring injury needs further imaging inlet xray beam angled 40° caudad (may be as little as 25 degrees) adequate image when S1 overlaps S2 body (i.e. perpendicular to S1 endplate) ideal for visualizing anterior or posterior translation of the hemipelvis internal or external rotation of the hemipelvis widening of the SI joint sacral ala impaction outlet xray beam angled ~40° cephalad (may be as much as 60 degrees) adequate image when pubic symphysis overlies S2 body ideal for visualizing vertical translation of the hemipelvis flexion/extension of the hemipelvis disruption of sacral foramina and location of sacral fractures findings radiographic signs of instability > 5 mm displacement of posterior sacroiliac complex presence of posterior sacral fracture gap avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of 5th lumbar vertebrae) CT routine part of pelvic ring injury evaluation better characterization of posterior ring injuries helps define comminution and fragment rotation visualize position of fracture lines relative to sacral foramina radiographic signs of sacral dysmorphism: anterior up-sloping upper sacral ala irregular, non-curcular, sacral nerve root tunnels residual S1 disk tongue-and-groove SI joint Studies Serum labs hgb serum lactate base excess Initial Management & Resusitation Bleeding Source intraabdominal (present in up to 40% of cases) intrathoracic retroperitoneal extremity (thigh compartments) pelvic common sources of hemorrhage venous injury (80%) shearing injury of posterior thin walled venous plexus leads to retroperitoneal hematoma (can hold up to 4L of blood) bleeding cancellous bone uncommon sources of hemorrhage arterial injury (10-20%) superior gluteal most common (posterior ring injury, APC pattern) internal pudendal (anterior ring injury, LC pattern) obturator (LC pattern) Treatment resuscitation PRBC:FFP:Platelets ideally should be transfused 1:1:1 this ratio shown to improve mortality in patients requiring massive transfusion pelvic binder/sheet indications initial management of an unstable ring injury contraindications hypothetical risk of over-rotation of hemipelvis and hollow viscus injury (bladder) in pelvic fractures with internal rotation component (LC) no clinical evidence exists of this complication occurring pitfalls binder can mask pelvic ring injuries, creating false negative radiographs and CT images stress examination under anesthesia may be indicated in patients who present to the trauma slot in a pelvic binder, hemodynamic instability, and negative pelvis radiographs/CT scan external fixation indications pelvic ring injuries with an external rotation component (APC, VS, CM) unstable ring injury with ongoing blood loss should be placed before emergent laparotomy contraindications ilium fracture that precludes safe application acetabular fracture angiography / embolization indications controversial and based on multiple variables including: protocol of institution, stability of patient, proximity of angiography suite , availability and experience of IR staff CT angiography useful for determining presence or absence of ongoing arterial hemorrhage (98-100% negative predictive value) contraindications not clearly defined technique selective embolization of identifiable bleeding sources in patients with uncontrolled bleeding after selective embolization, bilateral temporary internal iliac embolization may be effective complications include gluteal necrosis and impotence Definitive Treatment Overview by Classification Classification Treatment Anterior Posterior Compression (APC) APC I Non-operative. Protected weight bearing APC II Anterior symphyseal plate or external fixator +/- posterior fixation APC III Anterior symphyseal multi-hole plate or external fixator and posterior stabilization with SI screws or plate/screws Lateral Compression (LC) LC I Non-operative. Protected weight bearing (complete, comminuted sacral component. Weight bearing as tolerated (simple, incomplete sacral fracture). LC II Open reduction and internal fixation of ilium LC III Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference. Vertical Shear (VS) Vertical shear Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference. Nonoperative weight bearing as tolerated indications mechanically stable pelvic ring injuries including LC1 anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of posterior ring displacement APC1 traumatic widening of symphysis < 2.5 cm with intact posterior pelvic ring isolated pubic ramus fractures parturition-induced pelvic diastasis bedrest and pelvic binder in acute setting with diastasis less than 4cm Operative ORIF indications symphysis diastasis > 2.5 cm SI joint displacement > 1 cm sacral fracture with displacement > 1 cm displacement or rotation of hemipelvis open fracture chronic pain and diastasis in parturition-induced diastasis or acute setting >4-6cm technique for open fractures aggressive debridement according to open fracture principles anterior subcutaneous pelvic fixator (INFIX) indications same indications as anterior external fixation and symphyseal plating complications heterotopic ossification, femoral nerve injury, infection diverting colostomy indications consider in open pelvic fractures especially with extensive perineal injury or rectal involvement Techniques Pelvic Binding technique centered over greater trochanters to effect indirect reduction do not place over iliac crest/abdomen ineffective and precludes assessment of abdomen may augment with internal rotation of lower extremities and taping at ankles transition to alternative fixation as soon as possible prolonged pressure from binder or sheet may cause skin necrosis working portals may be cut in sheet to place percutaneous fixation early pelvic binding and CT have been associated with underestimation of pelvic ring instability fluroscopic exam under anesthesia can be used to assess stability in these circumstances External fixation theoretically works by decreasing pelvic volume stability of bleeding bone surfaces and venous plexus in order to form clot pins inserted into ilium supra-acetabular pin insertion single pin in column of supracetabular bone from AIIS towards PSIS obturator outlet view helps to identify pin entry point iliac oblique view helps to direct pin above greater sciatic notch obturator oblique inlet view helps to ensure pin placement within inner and outer table AIIS pins can place the lateral femoral cutaneous nerve at risk pedicle screws with internal subcutaneous bar may be used superior iliac crest pin insertion multiple half pins in the superior iliac crest place in thickest portion of ilium (gluteal pillar) may be placed with minimal fluoroscopy ORIF anterior ring stabilization single superior plate apply through rectus-splitting Pfannenstiel approach may perform in conjunction with laparotomy or GU procedure posterior ring stabilization anterior SI plating risk of L4 and L5 injury with placement of anterior sacral retractors iliosacral screws (percutaneous) good for sacral fractures and SI dislocations safe zone is in S1 vertebral body outlet radiograph view best guides superior-inferior screw placement inlet radiograph view best guides anterior-posterior screw placement L5 nerve root injury complication with errors in screw placement entry point best viewed on lateral sacral view and pelvic outlet views risk of loss of reduction highest in vertical sacral fracture patterns posterior SI "tension" plating can have prominent HW complications anterior and posterior ring stabilization necessary in vertically unstable injuries ipsilateral acetabular and pelvic ring fractures in general, reduction and fixation of the pelvic ring should be performed first Rehabilitation stable fractures treated nonsurgically patients may mobilize immediately with protected weight bearing after stable fracture pattern in confirmed (may require post-mobilization views to confirm stability) unstable fractures treated surgically patient mobility and weight bearing depend on the location of the posterior pelvic ring fracture mobility includes weight-of-limb weight bearing ipsilateral to the posterior pelvic injury with full weight bearing on contralateral side patients with bilateral posterior pelvic ring injuries limited to bed-to-chair transfers only when radiographic healing has occured weight bearing can be gradually advanced Complications Urogenital Injuries present in 12-20% of patients with pelvic fractures higher incidence in males (21%) includes posterior urethral tear most common urogenital injury with pelvic ring fracture bladder rupture may see extravasation around the pubic symphysis associated with mortality of 22-34% diagnosis made with retrograde urethrocystogram indications for retrograde urethrocystogram include blood at meatus high riding or excessively mobile prostate hematuria treatment suprapubic catheter placement suprapubic catheter is a relative contraindication to anterior ring plating surgical repair rupture should be repaired at the same time or prior to definitive fixation in order to minimize infection risk complications long-term complications common (up to 35%) urethral stricture - most common impotence anterior pelvic ring infection incontinence parturition sequelae (i.e. caesarean section) Neurologic injury L5 nerve root runs over sacral ala joint may be injured if SI screw is placed to anterior anterior subcutaneous pelvic fixator may give rise to LFCN injury (most common) or femoral nerve injury DVT and PE DVT in ~ 60%, PE in ~ 27%, fatal PE in 2% prophylaxis essential mechanical compression pharmacologic prevention (LMWH or Lovenox) vena caval filters (closed head injury) Chronic instability rare complication; can be seen in nonoperative cases presents with subjective instability and mechanical symptoms diagnosed with alternating single-leg-stance pelvic radiographs Infection risk factors include: obesity diabetes prolonged operation time prolonged ICU stay larger amount of packed red blood cell transfusions, associated genitourinary and abdominal trauma open fractures preoperative angioembolization is controversial
QUESTIONS 1 of 64 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 Previous Next (OBQ13.249) A 72-year-old woman falls down the stairs and is now unable to bear weight secondary to right groin pain. Injury radiograph and CT scans are seen in Figures A through C. What is the Young-Burgess classification of this injury and the most appropriate treatment plan? Review Topic QID: 4884 FIGURES: A B C 1 Bilateral weight bearing as tolerated for Anterior Posterior Compression Type I injury 6% (237/4162) 2 Touchdown weight bearing on the right for Lateral Compression Type I injury 20% (835/4162) 3 Bilateral weight bearing as tolerated for Lateral Compression Type I injury 68% (2817/4162) 4 Posterior sacroiliac screw, followed by non-weight bearing for Lateral Compression Type II injury 6% (233/4162) 5 Posterior sacral plate, followed by non-weight bearing for Lateral Compression Type III injury 0% (8/4162) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ05.272) A 65-year-old female presents with the injury seen in Figures A and B after a motor vehicle collision. She is hemodynamically unstable and undergoes emergent pelvic supra-acetabular external fixation followed by laparotomy. She is now hemodynamically stable and cleared for surgery. She has no evidence of neurologic deficit on examination. Which of the following factors is a relative contraindication to open reduction and plating of her posterior pelvic injury from an anterior approach? Review Topic QID: 1158 FIGURES: A B 1 Sacral fracture 29% (473/1608) 2 Prior laparotomy 45% (728/1608) 3 Supra-acetabular external fixtator 11% (172/1608) 4 Parasymphyseal fractures 5% (84/1608) 5 Ipsilateral proximal femur fracture 8% (129/1608) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.213) A 27-year-old woman gives birth by normal spontaneous vaginal delivery. Two weeks after delivery she reports anterior pelvic pain and a radiograph is obtained (Figure A). What is the next step in management? Review Topic QID: 1099 FIGURES: A 1 Pelvic external fixator 3% (17/554) 2 Open reduction and reconstruction plating of the symphysis 16% (90/554) 3 Protected weightbearing and binder as needed and observation 77% (427/554) 4 Open reduction and wiring of the symphysis 2% (10/554) 5 Symphysiotomy 1% (3/554) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.80) Risk of postoperative fixation failure for a complete sacral fracture has been associated with what variable? Review Topic QID: 466 1 Anterior pelvic ring fixation method 9% (72/789) 2 Vertical nature of sacral fracture 55% (436/789) 3 Iliosacral screw length 16% (127/789) 4 Number of iliosacral screws 7% (58/789) 5 Age > 50 12% (94/789) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ12.143) A 37-year-old male is struck by a car while walking at night. He is hemodynamically unstable at initial evaluation in the trauma bay. Advanced Trauma Life Support protocols are started, and an initial survey is completed. A chest radiograph and a pelvis AP radiograph (Figure A) are obtained. What is the most appropriate next step? Review Topic QID: 4503 FIGURES: A 1 The patient should be taken directly to the OR for percutaneous placement of a pelvic external fixator 2% (76/4319) 2 Dedicated inlet and outlet views of the pelvis to better classify the fracture 0% (16/4319) 3 Continued resuscitation and immediate CT of the chest, abdomen and plevis 1% (57/4319) 4 Emergent trip to interventional radiology for pelvic embolization 0% (20/4319) 5 Immediate application of pelvic binder, continued resuscitation and re-evaluation of hemodynamic status 95% (4118/4319) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.205) A 25-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. He is intubated in the field and receives 2 liters of LR and continues to be tachycardic and hypotensive. A massive transfusion protocol is initiated. Which of the following is true regarding the transfusion of packed red blood cells, platelets, and fresh frozen plasma? Review Topic QID: 3298 FIGURES: A 1 PRBC should be transfused until Hgb>8 3% (12/472) 2 PRBC, platelets, and FFP should be transfused in equal ratios 86% (404/472) 3 Platelets and fresh frozen plasma should be given when INR >1.4, platelet count <100,000 5% (24/472) 4 FFP is not needed unless INR>1.5 3% (12/472) 5 Platelets should not be transfused unless platelet count <10,000 3% (15/472) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ08.152) A 24-year-old male sustains the injury seen in Figure A after being thrown from a motorcycle at a high speed. Which of the following fixation methods has been shown to be the most stable fixation construct for this injury? Review Topic QID: 538 FIGURES: A 1 Posterior bridge plating and anterior ring external fixation 4% (24/561) 2 Percutaneous iliosacral screw and anterior ring external fixation 8% (44/561) 3 Percutaneous iliosacral screw and anterior ring internal fixation 86% (484/561) 4 Transiliac screw 1% (3/561) 5 Two percutaneous iliosacral screws 1% (4/561) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (SBQ12TR.7) Which of the following is an appropriate initial step in the management of a multiply injured patient with an unstable pelvic ring fracture and hemodynamic instability? Review Topic QID: 3922 1 Application of an external fixator 4% (103/2886) 2 Pelvic angiography 1% (26/2886) 3 Pelvic packing 1% (16/2886) 4 Application of a pelvic binder 94% (2718/2886) 5 Percutaneous Iliosacral screws 0% (9/2886) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.148) A 34-year-old female presents to the trauma bay with hemodynamic instability following a motor vehicle collision. A chest radiograph shows a left-sided hemothorax and her pelvis radiograph is shown in Figure A. Which of the following is the next most appropriate step in managment? Review Topic QID: 3236 FIGURES: A 1 Circumferential pelvic sheeting 95% (1514/1593) 2 Retrograde urethrogram to evaluate for associated urologic injury 0% (7/1593) 3 Emergent transport to OR for pelvic anterior external fixator placement 2% (35/1593) 4 CT scan to assess for occult femoral neck fracture 0% (1/1593) 5 Bedside posterior pelvic C-clamp application 2% (29/1593) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ05.229) What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window? Review Topic QID: 1115 1 External iliac artery 5% (34/736) 2 Pudendal nerve 11% (80/736) 3 Corona mortis 12% (89/736) 4 L5 nerve root 61% (452/736) 5 Ilioinguinal nerve 11% (78/736) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ05.98) Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following? Review Topic QID: 984 1 pubic symphysis 2% (14/633) 2 anterior sacroiliac ligaments 1% (7/633) 3 posterior sacroiliac ligaments 89% (564/633) 4 sacrospinous ligament 4% (25/633) 5 sacrotuberous ligament 3% (22/633) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ07.133) A 41-year-old woman is brought to the emergency department after she was the unrestrained driver in a rollover motor vehicle accident. She was placed in a cervical collar and intubated at the scene. Her blood pressure is 80/40 and pulse is 140. She has obvious open fractures of the right forearm and left ankle. On exam, the lower extremities are externally rotated and the pubic symphysis is widened and unstable. Intravenous access is obtained and radiographs are pending. What is the most urgent next step in management? Review Topic QID: 794 1 Lateral radiograph to clear the cervical spine 1% (4/608) 2 External fixator application to the left ankle in the operating room 0% (2/608) 3 External fixator application to the pelvis in the operating room 1% (8/608) 4 Pelvic binder application 97% (591/608) 5 Reduction and splinting of the right forearm 0% (1/608) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ12.236) Alternating single-leg-stance radiographs are most helpful for evaluation of which of the following diagnoses? Review Topic QID: 4596 1 Leg length discrepancy 3% (121/4479) 2 Pelvic ring instability 57% (2568/4479) 3 Femoroacetabular impingement 2% (92/4479) 4 Hip abductor weakness 33% (1496/4479) 5 Lumbosacral instability 4% (181/4479) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ12.3) A 7-year old boy presents to the emergency room following a ATV accident with complaints of left pelvic pain. In the emergency room he is alert and oriented and is hemodynamically stable. On physical exam he is unable to bear weight on his left lower extremity. There is no tenderness to palpation at the posterior pelvis. A radiograph is performed and shown in Figure A and CT examination shows the posterior ring is stable and age-appropriate. What is the most appropriate treatment for this injury pattern? Review Topic QID: 4363 FIGURES: A 1 Nonoperative management with weight bearing as tolerated 84% (3957/4709) 2 Percutaneous sacroiliac screw 4% (193/4709) 3 Pelvic external fixation 4% (188/4709) 4 Anterior pelvic ring plating 4% (186/4709) 5 Anterior and posterior pelvic ring plating 3% (149/4709) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ10.144) Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following? Review Topic QID: 3232 1 Head injury 10% (114/1180) 2 Pulmonary injury 6% (69/1180) 3 Traumatic amputation 0% (4/1180) 4 Need for transfusion 83% (982/1180) 5 Upper extremity fractures 0% (4/1180) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ04.158) A 31-year-old male sustains an ipsilateral displaced transverse acetabular fracture, pubic rami fractures, and a sacroiliac joint dislocation. What structure should be reduced and stabilized first? Review Topic QID: 1263 1 Pubic rami 2% (26/1143) 2 Posterior column 4% (42/1143) 3 Anterior column 3% (37/1143) 4 Sacroiliac joint 86% (980/1143) 5 Quadrilateral plate 5% (54/1143) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.96) A 35-year-old male involved in a high-speed motor vehicle collision presents to the trauma bay hypotensive and with a clinically unstable pelvis. A pelvis radiograph is shown in Figure A. He is placed in a pelvic binder, and his blood pressure normalizes temporarily. An abdominal CT demonstrates free fluid and air in the intraperitoneal cavity, and a laparotomy is indicated. What is the most appropriate next step in orthopaedic management? Review Topic QID: 3190 FIGURES: A 1 Percutaneous SI screw placement 2% (12/711) 2 External fixation placement 91% (647/711) 3 Pubic symphysis plating 7% (47/711) 4 Posterior pelvic plating 0% (1/711) 5 Anterior sacroiliac plating 0% (0/711) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ08.205) During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure? Review Topic QID: 591 1 L4 nerve root 1% (13/1883) 2 L5 nerve root 88% (1650/1883) 3 S1 nerve root 9% (168/1883) 4 Sacroiliac joint cartilage 0% (4/1883) 5 External iliac artery 2% (42/1883) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ08.188) For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable? Review Topic QID: 574 1 Length of hospital stay 5% (31/622) 2 Association with neurological deficit(s) 1% (5/622) 3 Length of intensive care stay 9% (58/622) 4 Cardiac collapse 0% (3/622) 5 Mortality 84% (522/622) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ08.207) A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What is the most common urological injury associated with this injury pattern? Review Topic QID: 593 FIGURES: A 1 Testicular torsion 0% (2/1141) 2 Posterior urethral tear 93% (1065/1141) 3 Bladder denervation 4% (40/1141) 4 Testicular rupture 1% (10/1141) 5 Renal hematoma 2% (19/1141) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ11.30) A 23-year-old male is an unrestrained driver in a motor vehicle accident and sustains an unstable pelvic ring fracture. During fluoroscopic-aided fixation, a lateral sacral view is used for proper placement of which of the following fixation methods? Review Topic QID: 3453 1 Anterior column percutaneous screw placement 1% (38/3345) 2 Posterior column percutaneous screw placement 2% (72/3345) 3 Posterior iliosacral plating 1% (46/3345) 4 Supra-acetabular pin placement 2% (54/3345) 5 Percutaneous iliosacral screw placement 93% (3119/3345) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ11.248) A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system? Review Topic QID: 3671 1 Crescent fracture located on the side of impact 65% (1376/2106) 2 Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments 8% (168/2106) 3 Complete SI disruption with lateral displacement 2% (44/2106) 4 Sacral compression fracture on side of impact with transverse pubic rami fractures 23% (474/2106) 5 Open-book injury with contralateral sacral compression fracture 1% (30/2106) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ11.181) Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess? Review Topic QID: 3604 1 Pubic symphysis diastasis, intact anterior sacroiliac ligaments, intact sacrotuberous ligament, intact posterior sacroiliac ligaments 1% (22/2567) 2 Pubic symphysis diastasis, torn anterior sacroiliac ligaments, intact sacrotuberous ligament intact posterior sacroiliac ligaments 25% (651/2567) 3 Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments 6% (151/2567) 4 Pubic symphysis diastasis, torn anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments 65% (1675/2567) 5 Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, torn posterior sacroiliac ligaments 2% (49/2567) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.165) A 32-year-old male sustains an APC-III pelvic ring disruption after a motor vehicle collision. Which of the following imaging techniques best describes the correct utilization of intraoperative flouroscopy for percutaneous iliosacral screw placement across S1? Review Topic QID: 3588 1 Inlet view helps best guide superior-inferior orientation 6% (130/2138) 2 AP pelvis best guides anterior-posterior screw orientation 1% (14/2138) 3 AP pelvis best guides superior-inferior screw orientation 5% (113/2138) 4 Outlet view best guides anterior-posterior screw orientation 8% (168/2138) 5 Outlet view best guides superior-inferior screw orientation 79% (1699/2138) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ09.40) What risk factor leads to the highest rate of postoperative loss of reduction in unstable posterior pelvic ring injuries? Review Topic QID: 2853 1 Type of anterior fixation 10% (65/630) 2 Male sex 3% (19/630) 3 Usage of a transiliac bar 1% (5/630) 4 Vertical sacral fracture 55% (345/630) 5 Sacroiliac joint fracture-dislocation 30% (192/630) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.31) A 23-year-old female is an unrestrained driver in a motor vehicle collision, sustaining the injury shown in Figure A. She subsequently undergoes reduction and percutaneous bilateral iliosacral screw placement. Which of the following is the most likely neurologic complication associated with percutaneous iliosacral screw insertion? Review Topic QID: 3454 FIGURES: A 1 Weakness in knee extension 2% (39/2549) 2 Decreased patellar reflex 0% (12/2549) 3 Weakness in great toe extension 87% (2217/2549) 4 Weakness in ankle plantar flexion 8% (206/2549) 5 Decreased Achilles reflex 3% (69/2549) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ04.60) A 40-year-old male laborer sustained a fall from height and has isolated pelvic pain. He is otherwise hemodynamically stable. A radiograph is shown in Figure A. A stress examination under anesthesia does not show any further anterior diastasis or posterior pelvic ring displacement. Computed tomography reveals no asymmetry of the sacroiliac joints. What is the most appropriate management of this injury? Review Topic QID: 1165 FIGURES: A 1 protected weight-bearing and pain control 85% (1044/1232) 2 open reduction and internal fixation 12% (154/1232) 3 skeletal traction followed by open reduction and internal fixation 1% (7/1232) 4 pelvic external fixation 1% (18/1232) 5 pelvic external fixation followed by sacroiliac screws 0% (6/1232) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ08.41) What nerve is most at risk when applying the external fixator shown in Figure A using a minimally invasive fluoroscopic technique of pin insertion? Review Topic QID: 427 FIGURES: A 1 Ilioinguinal nerve 14% (75/535) 2 Obturator nerve 1% (6/535) 3 First branch of the femoral nerve 4% (20/535) 4 Lateral femoral cutaneous nerve 74% (395/535) 5 Superior gluteal nerve 7% (36/535) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Evidence Pre Operative Care for Pelvic Ring Fractures - Strategies to avoid bed sores? Trauma - Pelvic Ring Fractures Tested Article: Pelvic Ring Disruptions: Effective Classification System and Treatment Protocols. Trauma - Pelvic Ring Fractures
Login to View Community Videos Login to View Community Videos 2019 Orthopaedic Trauma & Fracture Care: Pushing the Envelope Pelvic Packing - Phil Stahel, MD (OTFC 2019, 5.4) Trauma - Pelvic Ring Fractures 3/27/2019 161 views Login to View Community Videos Login to View Community Videos 2019 Orthopaedic Trauma & Fracture Care: Pushing the Envelope Coordination of Care: High Energy Pelvic Fractures - Phil Stahel, MD (OTFC 2019, 1.3) Trauma - Pelvic Ring Fractures 3/14/2019 111 views Upgrade to View Premium Videos Upgrade to View Premium Videos Emergency Pelvic C Clamp Application Gaurav Sanjay Trauma - Pelvic Ring Fractures 4/30/2014 2090 views See More See Less
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