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Pelvic fractures are usually __________ fractures.
high-energy (therefore, the risk of concurrent injuries is very high)
Displacement of any part of the pelvis implies that...
- at least 2 (usually 3) fractures are present because the pubis, ischium, and ilium attach to the sacrum
- Exceptions: young dogs in which SI and pubis are flexible or in racing greyhounds with stress fractures of the acetabulum
If you have a patient with a pelvic fracture, ALWAYS...
- evaluate for other traumatic injuries, especially thoracic trauma
- ALWAYS take thoracic rads (hemo/ pneumothorax, pulmonary contusions, diaphragmatic hernia)
- do a neurologic exam and monitor frequently
What are important neurologic signs to test with pelvic fractures?
- peripheral nerve damage is most likely and of imminent concern
- examine reflexes- medial toe pinch only tests the femoral nerve, make sure you do lateral toe pinch to test sciatic nerve higher up
- observe for voluntary movement
- anal tone
- urinary incontinence
How do you position a patient for lateral radiographs?
affected side down with hip flexes, upper hip extended (running man)
Describe why there is usually favorable healing of pelvic fractures.
- inherently stable structure that is surrounded by a large muscle mass with a good blood supply
- ilium is mostly cancellous bone, which heals very quickly
What are indications for surgical fixation of a pelvic fracture? (7)
- fracture along a weight-bearing axis
- articular fractures (acetabulum)
- narrowing of the pelvic canal >50%
- neurologic compromise (except if absent deep pain)
- bilateral involvement
- multiple limb fractures
- intended use of the animal (working, breeding)
Why is timing of pelvic fracture repair important?
- repair within 5 days
- it's difficult after 7-10 days because of initial fibrosis and muscle contracture
What are 3 fracture types that are along the weight-bearing axis of the pelvis, and therefore indicate surgical repair?
- ilial body fracture combined with pubic and ischial fractures (free-floating hip joint or free-floating acetabulum)
- sacroiliac luxation
- acetabular fracture
Describe sacroiliac (SI) luxation.
- traumatic separation of the wing of the ilium from the sacrum and craniodorsal displacement of the ilium relative to the sacrum
- check for possible sacral nerve damage
Describe the clinical aspects of sacroiliac luxation.
- palpable laxity when you manipulate the wings of both iliums
- usually associated with other pelvic fractures
- on rad, you should be able to follow one contiguous line along the inside of the ilium into the sacrum; with SI luxation, you won't be able to do this
When is conservative management of SI luxation indicated? (4)
- little to no contralateral injury
- minimal displacement
- small dog or cat
- minimal pain
When is surgery to repair SI luxation indicated? (3)
- moder to severe displacement (>50%)
- palpable laxity
- contralateral hindlimb fractures
What are the goals of surgical repair of SI luxation? (3)
decrease pain, improve recovery, earlier ambulation
What are surgical methods for SI luxation repair?
- dorsal or ventral approach (expose SI joint by brining ilium ventrocaudally)
- lag screw across ilium into sacrum (largest cortical screw possible)- C-shaped cartilage is landmark for sacrum
- trans-ilial bolt to the opposite ilial wing through dorsal spinous process of L7
- trans-sacral bolt from one ilial wing to the other through the sacrum
Describe an ilial body fracture. (4)
- along the weight-bearing axis, so the majority of these fractures need surgery (except cats and small dogs)
- commonly oblique
- craniomedial displacement
- usually associated with other fractures (ischium, pubis, +/- acetabulum)
What are surgical approaches to ilial body fractures?
- lateral approach- gluteal roll up- elevation of gluteal mm from ventral to dorsal from ilial wing--> reduction (challenging)--> bone plate
- can place screw placed into sacral body for added purchased
Describe ilial wing fractures. (4)
- not associated with nerve entrapment or pelvic canal narrowing
- NOT surgical cases
Describe acetabular fractures.
- crepitation on palpation of hip
- DJD and lameness if untreated
- articular fractures always have guarded prognosis
- good outcome dependent on meticulous reconstruction
- always surgical cases
What are the goals of fixation of acetabular fractures? (3)
- perfect anatomic alignment
- rigid fixation
- promote primary bone healing (minimze callus formation within the joint)
What are options for surgical treatment of acetabular fractures? (3)
- primary repair- if reducible fracture, limited damage to cartilage
- FHO-if highly comminuted or financial constraints
- conservative treatment - if non-displaced or very caudal fractures (not recommended)
When is FHO chosen as the surgical option for acetabular fracture?
- Before sx- owner can't afford repair, highly comminuted fracture
- In sx- repair cannot be accomplished
- After sx- arthritis, consider THR
When might sciatic nerve injury occur? What should be done about potential sciatic nerve damage?
- injury from the initial trauma or surgical manipulation
- if neuro signs are suggestive of sciatic damage, surgical exploration is recommended
- if nerve is entrapped, free and stabilize the entrapping structure
- if nerve is severed, amputation is indicated
When do you repair ischial fractures?
- repair if extremely painful or if fragment is severely displaced
- [most will reduce when other pelvic fractures fractures are repaired]
Describe pubic fractures.
- very common with other pelvic fractures
- generally left untreated, EXCEPT prepubic tendon avulsion, ventral abdominal wall hernia
What are signs of separation of pelvic symphasis in young animals with SI luxation? (2)
- dog unable to adduct hind limb
- rotates when adduction muscle contracts
- [treated by fixing SI luxation]
Describe conservative therapy for pelvic fractures. (4)
- cage rest for 4-6 weeks
- controlled exercise (using all 4 limbs)
- recheck in 6-8 weeks with radiographs