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Pelvic Injuries — Orthopaedic Notes

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1. Anatomy and Conceptual Framework

• Anterior ring — pubic symphysis and pubic rami
• Posterior ring — sacroiliac (SI) joints, sacrum, ilium

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2. Imaging

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3. Pelvic Ring Injuries — Classification

Young-Burgess Classification (mechanism-based)

Lateral Compression (LC) — all have anterior transverse pubic ramus fracture

Anteroposterior Compression (APC) — all have symphyseal diastasis

Vertical Shear (VS)

• Fall mechanism; vertical fractures through rami + complete posterior disruption
• Vertical displacement of hemipelvis; equivalent to APC III in instability
• Mortality and transfusion requirements similar to APC II/III

Combined Mechanism (CM)

• Organ injury pattern similar to lower-grade APC and LC patterns

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Tile Classification (stability-based)

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4. Emergency Management

1. Apply pelvic binder or sheet immediately if increased pelvic volume is identified — reduces pelvic volume and tamponades venous bleeding
2. Skeletal traction for vertical instability
3. Resuscitation — volume + early transfusions
4. CT scan to evaluate for arterial injury
5. Angiographic embolization if arterial source confirmed
6. Pelvic packing (retroperitoneal) — excellent for venous tamponade; popularized in Europe

⚠️ Always establish and follow a treatment protocol to reduce variation in decision-making.

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5. Treatment of Pelvic Ring Injuries

Nonoperative

• Indications: stable fracture patterns (LC I, APC I)
• Weight bearing as tolerated for isolated anterior injuries
• Protected weight bearing for combined anterior + posterior ring injuries

Operative Indications

• Symphysis diastasis > 2.5 cm
• Anterior + posterior SI ligament disruption
• Vertical instability of posterior hemipelvis
• Sacral fracture displacement > 1 cm

Anterior Injuries

Posterior Injuries

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6. Sacral Fractures

Denis Classification (zone relative to foramen)

Sacral Dysmorphism (20–44% of population)

Treatment

• Nonoperative: stable/minimally displaced; weight bearing as tolerated for incomplete fractures where ilium is contiguous with intact sacrum (e.g., LC impaction fractures); touch-toe WB for complete fractures
• Operative (displaced > 1 cm): percutaneous IS/trans-sacral screws; posterior plating; transiliac sacral bars; open foraminal decompression for neurologic injury in Zone II

Complications

• Urologic injury (highest with displaced Zone II)
• L5 nerve root injury (Zone II)
• Cauda equina syndrome (Zone III)
• Chronic low back pain, malunion

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7. Acetabular Fractures

Mechanism

• Flexed hip with axial load ("dashboard mechanism") — most common
• Pattern determined by position of hip and direction of impact

Radiographic Evaluation

1. Posterior wall
2. Anterior wall
3. Roof
4. Teardrop
5. Ilioischial line
6. Iliopectineal line

Letournel Classification

• Posterior wall (PW) — most common simple type
• Posterior column (PC)
• Anterior wall (AW)
• Anterior column (AC)
• Transverse (involves both columns)

• Posterior column + posterior wall
• Transverse + posterior wall
• T-type
• Anterior column + posterior hemitransverse (AC/PHT)
• Both-column (ABC fracture) — spur sign on obturator oblique = intact iliac wing remaining in anatomic position; no intact articular support from acetabulum to axial skeleton on sequential axial CT

Treatment Principles

• Restore articular congruity and hip stability
• Avoid injury to blood supply of femoral head
• DVT screening and prophylaxis
• During surgery: hip extended, knee flexed to reduce sciatic nerve tension

Surgical Approaches

Percutaneous Fixation

• PC screw: retrograde (ischium, hip flexed) or antegrade (mini lateral window approach); use Judet images for trajectory
• AC screw: through superior ramus OR supra-acetabular corridor; use obturator oblique outlet (shows corridor + avoids joint), iliac oblique (avoids inferior breach), obturator inlet (avoids medial/lateral breach)

Complications

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8. Risk Factors for Death

• Blood transfusion requirement in first 24 hours
• Unstable fracture type: APC II, APC III, LC II, LC III, VS, combined mechanism
• Open fracture

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Key Mnemonics & High-Yield Points

• "Open book" = APC injury → apply binder to close the book
• Stable = LC I and APC I; everything else warrants close attention
• 85% of pelvic hemorrhage is venous — binder + packing first; angio only if arterial source confirmed
• Posterior wall = most common simple acetabular fracture
• Both-column fracture = spur sign on obturator oblique; only fracture with secondary congruence (femoral head stays congruent with displaced fragments)
• Zone II sacral fracture = L5 nerve root most at risk; highest urologic injury
• Zone III sacral fracture = cauda equina
• Sacral dysmorphism in 20–44% — increases risk of screw penetration; recognize on outlet view
• ICD (iliac cortical density) = landmark for safe IS screw placement; screw must remain posterior to ICD

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Paediatric Orthopaedics — Congenital Conditions

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PART 1: Developmental Dysplasia of the Hip (DDH) / Congenital Dislocation of the Hip (CDH)

1. Definition

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2. Spectrum of Disease

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3. Risk Factors

1. Breech positioning — highest risk (30–50%)
2. Positive family history (ligamentous laxity) — ≥20%
3. Female sex — 85% of cases
4. Firstborn child (less intrauterine space)

• Left hip most commonly affected (67% of cases)
• Increased maternal oestrogens
• Postnatal: swaddling with hips in extension
• Associated conditions: torticollis (20%), metatarsus adductus (10%); no association with clubfoot

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4. Pathoanatomy — Obstacles to Concentric Reduction

1. Iliopsoas tendon
2. Pulvinar (fibrofatty tissue)
3. Hypertrophied ligamentum teres
4. Contracted inferomedial hip capsule
5. Transverse acetabular ligament
6. Inverted (infolded) labrum

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5. Diagnosis

Clinical Examination

⚠️ In bilateral dislocation, abduction may appear symmetrically decreased — easily missed.

Ultrasound (< 4–6 months of age)

• Dynamic ultrasound — investigation of choice before femoral head ossification
• Normal α angle > 60° on coronal view; femoral head bisected by iliac line
• Useful to assess reduction in Pavlik harness and diagnose capsular laxity

Radiographs (> 4 months)

• Acetabular index — normal < 25°
• Perkin line — ossific nucleus should be medial to this line
• Shenton line — disrupted in dislocation
• Delayed ossification of femoral head on affected side

Advanced Imaging

• Arthrography — assesses adequacy of closed reduction; look for "thorn sign" (normal labral position)
• CT or MRI post-reduction — confirms concentric reduction

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6. Treatment (age-dependent)

Note: Diagnosis after age 8 years (age 6 in bilateral DDH) may contraindicate reduction as the acetabulum has little remodelling capacity.

Pavlik Harness — Key Points

• Designed for infants < 6 months
• Maintains ~100° flexion + mild abduction ("human position" / Salter position)
• Must be within the safe zone of Ramsey (between maximum adduction before redislocation and excessive abduction causing AVN)
• Worn 23h/day for ≥ 6 weeks after reduction, then part-time 6–8 weeks
• Contraindicated in teratologic dislocations
• Excessive flexion → transient femoral nerve palsy
• If not reduced within 3 weeks → discontinue ("Pavlik disease") to prevent acetabular erosion

• Age > 7 weeks at initiation
• Bilateral dislocations
• Absence of Ortolani sign

Pelvic Osteotomies (summary table)

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7. Complications

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PART 2: Congenital Muscular Torticollis (CMT) / "Wry Neck" / "Stiff Neck"

1. Definition

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2. Pathogenesis

• Tearing of SCM fibres during childbirth → haematoma → necrosis + fibrosis of muscle fibres
• Histology: deposition of collagen and fibroblasts around atrophied muscle cells
• Also occurs in caesarean births → additional causes include intrauterine crowding and primary SCM myopathy
• A palpable SCM mass is present in approximately two-thirds of cases (also diagnosable by USS)

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3. Clinical Features

• Head tilts to the side of the lesion
• Chin rotates away from the lesion
• Palpable firm mass in the SCM in ~2/3 of cases
• If untreated → plagiocephaly (facial asymmetry) and facial hemihypoplasia on the affected side
• Associated with DDH in 20% of cases; associated with other intrauterine positioning abnormalities

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4. Differential Diagnosis

Torticollis is secondary to fibrosis of the sternal head of SCM — a palpable mass within SCM is a key distinguishing feature from atlantoaxial subluxation.

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5. Treatment

• Physiotherapy (passive stretching of the affected SCM) — effective in the vast majority of cases; recommended from as early as possible
• Stretching: tilt head to opposite side and rotate chin towards affected side
• Surgical transection of the SCM — reserved for refractory/resistant cases that do not respond to conservative management (rare); performed when:
  • Persistent after 1 year of conservative treatment
  • Significant facial asymmetry
  • Restricted ROM after age 1 year
• Surgery involves bipolar SCM release; complications include haematoma and scar

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PART 3: Congenital Clubfoot (Congenital Talipes Equinovarus — CTEV)

1. Deformity Components — Mnemonic: CAVE

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2. Epidemiology

• Boys affected twice as often as girls
• 50% bilateral
• Incidence: ~1–2 per 1,000 live births

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3. Aetiology

• Majority idiopathic, but strong genetic component (PITX1-TBX4 transcriptional pathway)
• Associated conditions:
  • Arthrogryposis
  • Myelomeningocele
  • Streeter dysplasia (hand anomalies)
  • Diastrophic dwarfism
  • Prune-belly syndrome
  • Tibial hemimelia

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4. Imaging

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5. Treatment

Ponseti Method (first-line; 95% success for idiopathic cases)

• 90% of patients require percutaneous Achilles tendon lengthening at end of casting to address hindfoot equinus
• Last cast placed in 70° abduction
• Foot abduction brace (FAB) mandatory after casting — non-compliance is the main cause of recurrence

Surgical Treatment

• Reserved for refractory/resistant cases (~5% of idiopathic presentations)
• Posterior tibial artery must be protected (dorsalis pedis often insufficient)
• Procedures:
  • Tendon lengthening
  • Subtalar, tibiotalar, and talonavicular release + realignment
  • Older children (3–10 years): medial opening-wedge or lateral column-shortening osteotomy or cuboid decancellation for adductus
  • Late presentation: triple arthrodesis (contraindicated in insensate feet — causes rigidity → ulceration)

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6. Complications of Treatment

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Summary Comparison Table

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