That is why we carried out the study: "Study on the treatment unstable pelvic ring fractures by external fixation" for two goals: 1.. He shown anatomical lesions of the pelvic fractur
Trang 1MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATIONAL DEFENSE
VIETNAM MILITARY MEDICAL UNIVERSITY
NGUYEN NGOC TOAN
STUDY ON TREATMENT UNSTABLE PELVIC RING FRACTURE
Trang 2THE WORK HAS BEEN COMPLETED AT VIETNAM MILITARY
MEDICAL UNIVERSITY
Scientific instructors:
1 Prof, PhD Nguyễn Tiến Bình
2 Assoc Prof., PhD Phạm Đăng Ninh
Opponent 1: Assoc Prof, PhD Đao Xuan Tich
Opponent 2: Assoc Prof, PhD Lưu Hong Hai
Opponent 3: Assoc Prof, PhD Nguyen Xuan Thuy
The dissertation will be defended in presence of the University Level Dissertation
Assessment Council At………… on………
References at:
1 National Library of Vietnam
2 Library of Vietnam Military Medical University
3 Library of Cho Ray Hospital
Trang 3ANNOUNCING RESULTS OF THE DISSERTATION THEME
1 Nguyen Ngoc Toan (2013); “Lesions characteristic of anatomy of unstable
pelvic ring fractures”, Vietnam Medicine, Volume 408 (2), page 43 – 48
2 Nguyen Ngọc Toan, Pham Dang Ninh, Nguyen Tien Binh (2013);
“Outcomes of treatment unstable pelvic ring fracture by external fixation”, Vietnam
Medicine, Volume 409 (1), page 101 – 105.
Trang 4ABSTRACT
Pelvic fractures are common injuries with a rate of 23-37/100.000 in one year According Failinger (1992), pelvic fractures account for 1 - 3% of all fractures and approximately 2% of hospital admissions caused by trauma Demetriades (2002) and another study showed that pelvic fracture rates from 5 to 9.3% of all fracture types including traumatic shock rate accounts for above 40% According to the statistics of Larry (1994), Ganssen (1996), Chueire (2004) and Barzilay (2005), Zsolt (2007), the pelvic fracture had percentage from 40 to 55.2% of the type of pelvic trauma This is seriously injured, complex, with high mortality rate, and especiallly, the number of pelvic trauma was as much as traumatic brain injuries, ranging from 10-20% of the pelvic fracture In particular, the group with open pelvic fractures have ratio from 20% to 50% In Vietnam, Ngo Bao Khang (1995) and Nguyen Duc Phuc (2004) reported rate of pelvic fractures account for 3-5% of all fracture types, but it had no statistics about mortality
Using external frame to fix the pelvic fracture is very simple and safe, and this technique can be applied at where hospital have an orthopaedic specialist Many authors suggest that, as early pelvic fractures was fixed, pain relief will achieve effectively It’s helpful to control of bleeding and preventing traumatic shock injuries When fractures was fixed, patients have early mobilization and comfortable conditions that the wound was faster recovery
In recent years, at the Department of Orthopaedic Trauma Cho Ray Hospital, orthopadics have treated patients with unstable pelvic fractures by frame outside the quadrilateral shape With this approach, pelvic has corrected for anatomy recovery relatively With this method, a treatment comes from clinical practice that we thought
to anatomy characteristic injury of unstable pelvic fractures in order to improve
efficiency and better treatment That is why we carried out the study: "Study on the
treatment unstable pelvic ring fractures by external fixation" for two goals:
1 Survey lesions characteristic of anatomy of unstable pelvic ring fractures
2 Evaluation outcomes treatment of unsntable pelvic ring fractures by external fixation and commented some factors affecting treatment outcomes
Trang 5Chapter I OVERVIEW 1.2 Pelvis Fracture Injury
Pelvic fractures are usually divided into categories :
- Open and closed fractures of the pelvis
- Stable and unstable pelvic fractures
- Partial fracture of the pelvis is small lesions such as iliac crest, pubic bone,
ischium, sacrum or coccyx
- Acetabular fracture is a particular fracture of the pelvis relating to the hip
So the classification and treatment differ from pelvic fractures significantly
Currently, the authors agree acetabular fractures classified as a separate type
1.2.3 Morphology pelvic fracture injury
* Pelvic Injuries
- Tile (1984, 2003) [147, 150], from the previous 70 years of the twentieth century, assessed anatomy of pelvic fractures were less intent in study because the majority of patients with pelvic fractures were used conservation treatments It is very
little cases of surgical treatment and the studying on cadaver pelvic fracture basically
- Malgaigne (1859) describes pelvic fractures in which anterior lessions (disruption of the symphysis, inferior and superior pubic) and posterior lession (vertical ileum disruption, SI joint dislocation), 1/2 pelvic displaced upwards by muscles contracting [96] Since 1980, people has started research on lesions of the pelvic fracture Along with the development of the internal fixation to treat pelvic fracture, and the type of fracture was made clearly
- Buchholz (1981) [36] describe 47 cadaver dissections had pelvic fractures He shown anatomical lesions of the pelvic fracture which comprises posterior lession about 19 cases SI dislocation, 6 cases sacral wing fractures, 1 case iliac wing fracture,
1 case trauma combined injury Anterior lession included 12 cases of bilateral pubic rami fractures, 8 cases pubic rami fractures, symphysis pubis dislocation with 6 cases and 4 case with combined injury
Trang 6The author argues that the exact location of the pelvic lesion assessment is not important as much as the level of the pelvis stable
- In 1990, Young and Burgess have studied 210 cases of pelvic fracture (162 fractures of the pelvis and 48 case of acetabular fractures), anatomical lesions of the pelvic fracture was assessed by 3 posture XQ (straight, Inlet, Outlet) The author’s classification based on mechanism of injury and kind of pelvic fracture stable, including 4 types ( LC: 106 patients - 65.4 %; APC: 25 patients - 15.4 %; VS: 9 patients - 5.6 %, CM : 11 patients - 11 6.8 % and 11 patients with iliac wing fractures
- 6.8 %) Thereby, It is very important to predict complications and identify therapeutic strategies with different fractures
Classification of Young and Burgess (1990) Based on the mechanism of injury,
anatomical lesions and stable of the pelvis, the authors divide into 4 pelvis fractures type:
Figure 1.9 Classification of Pelvis Fracture according to Young & Burgess (1990 )
* Source : Tile M (2003 ) [150]
Trang 7
+ Lateral Compression (LC): anterior injury rami fractures
+ Antero - Posterior Compression (APC): anterior injury = symphyseal diastasis/rami fractures
+ Vertical Shear (VS): vertical displacement of hemipelvis with symphyseal diastasis or rami fractures anteriorly; iliac wing or sacral fracture or SI dislocation posteriorly
+ Combined Mechanism (CM) any combination of above injuries
* Status of pelvic instability
Pelvic fractures were divided into two groups: stable and unstable pelvic ring fractures Evaluating this condition helps physicians predict the severity of the injury and provide appropriate therapeutic strategies Unstable pelvic fracture must have lost completely continuous ring at least 2 location, losing pelvis stiffness [43], [150] Young and Burgess (1990) [35], Tile (1996, 1999, 2003) [148, 149, 150] and the other authors are unified perspective: unstable pelvic fracture is a bone fracture or pelvic joints dislocation (pubic rami fractures, symphysis pubis dislocation) in both posterior and anterior lessions, as a result one side or two sides of the pelvis deformation, displacement or rotation in both vertical and longitudinal
- Unstable pelvic ring fracture incompletely (unstable in longitudinal, stable in vertical): external rotation fracture type (APC) and the internal rotation fracture (LC)
- Unstable pelvic ring fractures completely (unstable both longitudinal and vertical rotation): one side of pelvic fracture (VS, Malgaigne or Voillermier), or fractures on both sides (CM)
1.3.5 Treatment of pelvic ring fractures by external fixation
Indications of the external fixation for usntable pelvic ring fracture:
Mear (1980, 1986) , Tile (1984 , 2003), Majeed (1990), Pennig (1989) , agree
on to the indication external fixation for pelvis as follows:
- Temporary purpose, hemostatic, anti- shock pain in the emergency treatment;
- Open fractures of the pelvis ;
- Treat unstable fracture incompletely types (APC , LC);
Trang 8- Implement to posterior arcs fixation (internal fixation or traction) for unstable pelvic ring fractures completely (VS, CM)
- Unstable pelvic fracture is severe injury, a common emergency trauma, indicated for the treatment of surgical intervention But the understanding of type of fracture is to improve the effectiveness of treatment , both in the world and in certain countries There have no study has been carried out to understand more clearly the anatomical lesions of unstable pelvic ring fractures, especially, characteristic lesions
of this complex fracture types in Vietnam and assessment treatment experience is the reason why we conducted this topic
Chapter 2 PATIENTS AND METHODS 2.1 Patients
94 patients with unstable pelvic ring fractures due to different causes, aged
16-63 (mean 30.6 ± 6.3), 55 males and 39 females, male/female is 1.41 ISS scores ranged from 16 to 45 points, (mean 26.4 ± 7.2) All these cases were diagnosed and treated at the Department of Orthopaedic Trauma, Cho Ray Hospital, for period of time from 03/ 2007 to 11/2011
* Patient selection criteria
- The patient was diagnosed with unstable pelvic ring fractures classified by Young and Burgess (1990)
- All of the patients were treated by external fixation
- Age ≥ 16
* Exclude criteria
- Fractures of the pelvis together with acetabular fractures;
- Treatment used orther medthod
2.2 Methods
Observation series cases clinical trials, longitudinal monitoring, no control group including prospective and retrospective
Trang 9- A prospective study: 79 patients in the hospital from 8/2008 to 11/2011, was conducted after research proposal and complete data collection sheet
- Retrospective study: 15 patients in the hospital from 03/ 2007 to 7/2008, the last time before the research proposal should have a more complete additional indicators and data to be collected
2.2.2 Study on anatomical lesions
* Pelvic Injuries
- Closed fractures - open pelvic according to Jones (2002)
- Classification of pelvic ring injuries according to Young and Burgess (1990 ) + APC fracture, anterior and posterior pressure ;
+ LC fractures, side pressure ;
+ VS fracture, tear force vertical;
+ CM fracture, combines the two sides of the pelvic fractures (VS + VS or VS + APC or VS + LC)
- Assessment posterior pelvic injury:
+ SI joints injury;
+ Sacral wing fracture;
+ Iliac wing fracture;
+ Combine ( fractures, SI dislocation )
- Assessment anterior pelvic injury:
+ Symphyseal diastasis;
+ Anterior ring fracture (one side or both sides);
+ Combine (Symphysis + anterior pelvic ring)
* Whole body condition and combined trauma
- Shock
+ Traumatic shock, standards of Nguyen Thu (2002)
+ Level of shock: Halvorsen (1990)
- Combined trauma: pelvic organs and others
- Severity of the patients
Trang 102.2.3 Treatment of pelvic fractures by external fixation
The frame of Cho Ray hospital designed front quadrangle (Figure 2.2)
The frame structure includes :
- 2 horizontal bars and steel cross bracing = 6 mm in diameter
- 2 vertical bars curved steel link = 8 mm
- The configuration connecting rods linked together
- 4 SCHANZ screws = 5 mm, length 15 cm
Figure 2.2 Frame pelvic external fixation of Cho Ray hospital
* Treatment Strategy
- Patients not in shock or had stable treatment: external fixation set delayed
- If patients with shock, shock treatment must be immediately
+ If the shock is stable, proceed setting fixation emergency delayed
+ If shock is treated aggressively but still not stable, after excluding bleeding from the outside pelvic organs (abdomen, chest ), only to put external fixation pelvic
to anti-shock
Trang 11Figure 2.4 The patient after operation (75) 2.2.4 Method of assessment results
* Evaluate early results
- Results of the anatomical correction
Table 2.1 Criteria for anatomical recovery results
Anatomical recovery Excellent Good Fair Poor
Symphyseal diastasis or anterior
pelvic displacement (cm) < 1 1 - < 2,5 2,5 – 3,5 > 3,5 Displacement of remaining posterior
pelvic arc (cm) < 0,5 0,5 - < 1 1 - 1,5 > 1,5
- Evaluate changes and bone healing time
- The complications of the technique
* Evaluate longterm outcomes
Time evaluation longterm results: after reduction and removed frame at least
03 months (minimum 06 months after injury)
- Evaluation of the pain [4], [48]
- Functional outcome for standards of Majeed (1989) (Table 2.2)
- The overall result: to assess the overall treatment outcome of pelvic fractures according to the following criteria: results of anatomical outcome, functional outcome and healing of pelvic bone Through the actual process conducting research,
we build treatment assessment scores overall results for pelvic fractures (table 2.3)
Trang 12Chapter 3 RESULTS 3.1 General Characteristics Of Patients
3.1.1 Age and sex
94 patients included 55 men (58.5 %), 39 women (41.5 %) The male/ female = 1.41; youngest 16 ages, oldest 63 ages; mean 30.6 ± 6.3
3.1.2 Causes of injury
Table 3.2 Causes of injury (n = 94)
Causes Patient Ratio (%)
Traffic Accident
auto moto Patient
3.2 Characteristics of Anatomical Lesions
3.2.1 Characteristics of the pelvic ring fracture
* Classification of unstable pelvic fractures according to the open – close fracture
Table 3.4 Distribution of patients according to the nature of open-close fracture
Result: closed fracture pelvis majority (75.5%) There are 23 cases of open pelvic fractures
Trang 13* Classification according to Young and Burgess
Table 3.5 Pelvic fracture classification according to Young and Burgess (n = 94)
Classification Patients Ratio(%)
Result: the most common type of fracture APC (45.7%), 26.6% LC
* Lesion position of the anterior pelvic arc
Table 3.7 Distribution by anterior pelvic arc lesions (n = 94)
(*) Sympyseal diastasis combined with anterior pelvic fractures
Result: lesion fractures (ischium and ramus) of anterior pelvic account for a
high proportion (63.8%)
* Lessions position of the posterior pelvic arc
Table 3.8 Distribution of lessions position of the posterior pelvic arc (n = 94)
One side Two side Total (n=94)
Trang 14Result: 188 posterior pelvic sides of 94 patients with 178 lesions sides (10 cases of VS one side only) SI joint damage 81/94 (86.2%), in which the two types of lesions inside the pelvic joints of 38 cases (40.4%) accounted for the highest percentage in the type of posterior arcs injury
3.2.2 Combined injuries
The wound is the most common injury in different positions and levels (90.4%), followed by fractures and other dislocation joints accounted for 53.1% There are 11 cases of traumatic brain injury may include: 6 cases of concussion; 3 brain trauma and intracranial hematoma 2 cases
3.2.3 Traumatic shock
Number of patients with traumatic shock: 64/94 (68.1%)
- 30 patients hospitalized in a state of shock;
- 34 cases of shock, were treated before hospitalized
3.4 Pelvic fracture treatment outcomes
3.4.1 The early outcomes
* Anatomical recovery
Table 3.19 Anatomical recovery results (n = 94)
Anatomical recovery Type
Result: the two types of fractures with APC, LC that anatomical recovery rate
is excellent and good about 50/68 patients (73.5%) The type incompletely unstable fractures (APC, LC) results recovery higher than the unstable fracture completely (VS, CM)