الفهرس 
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Abstract
CHAPTER EIGHT:
SUMMERY
Recent years have seen improvements in all phases of pelvic fracture management. Today’s orthopaedic trauma surgeons have a better understanding of the pathophysiology of pelvic fractures, better surgical plans for fracture management, and a better understanding of which factors are most important in determining outcome
Familiarity with pelvic anatomy is essential for the treatment of pelvic fractures. With an increase in minimally invasive approaches in fixation methods, knowledge of pelvic anatomy is vital to safe reduction and fixation of displaced fractures. The pelvic anatomy is complex and must be understood in three dimensions. The intimacy of vital soft tissue structures such as vessels, nerves, and viscera with the osseous anatomy presents a narrow window of safety for the operating surgeon. Miscalculation of a centimeter during dissection or placement of drills can cause severe hemorrhage or permanent nerve injury. The best strategy for preventing damage during surgery and limiting the damage of the initial injury is having detailed knowledge of every aspect of pelvic anatomy.
Modern classification systems for pelvic ring injuries represent a key instrument for orthopedic trauma surgeons for evaluating the extent of pelvic trauma and judging the risk for potentially life-threatening injuries. By combining the concepts of stability, force direction, and pathoanatomy, a meaningful classification may be developed to aid in patient management. No classification can answer all the questions regarding a specific injury. The two most popular schemes in use today are the Tile system and the Young-Burgess system. Both have been incorporated into the Orthopaedic Trauma Association system, which is comprehensive and allows highly specific injury description. The Tile system combines directional patterns of pelvic disruption with radiographic signs of stability or instability. The Young-Burgess system, similar to the Tile scheme, seeks to link the direction of the force that created the injury to the fracture pattern seen radiographically.
In all patients with suspected disruption of the pelvic ring, conventional anteroposterior (AP), inlet and outlet radiographs of the pelvis are obtained illustrating the zones of injury, the patterns of displacement and potential anatomical variations. A true lateral view of the sacrum allows recognition of sacral dysmorphism and identifies unusual transverse fractures. Two-dimensional CT is useful in evaluating the severity and geometry of the fractures, revealing obvious and subtle posterior injuries. In the case of displaced or comminuted fractures, three-dimensional CT reconstruction demonstrates the rotational deformity of the fragments.
Emergency and trauma unit assessment of the patient must include evaluation of the immediate life-threatening problems associated with pelvic fractures. A pelvic ring injury is considered a signpost leading to other concomitant life-threatening injuries, including major head, chest, abdominal, and retroperitoneal vascular injuries.
After stabilization of an acutely injured patient, assessment of multiple factors will help to determine definitive management. This evaluation is necessary to decide the appropriate management based on the balance between our ability to decrease the chance of late pain, malunion, and nonunion following pelvic injuries and the need to avoid complications of the injury or subsequent treatment. This assessment begins with a clinical determination of pelvic stability, defining precisely the anatomic locations of each injury to the pelvis radiographically, followed by classification of the injury. Despite suspicion of instability based on mechanism, exam, or radiographs, definitive treatment may be determined or modified based on patient factors such as associated injuries, status of the soft tissue in and around the zone of injury, or comorbidities.
The final decision as to whether and how to treat the patient with operative management should be made after consideration of the individual patient factors and injury factors. In general, fractures that do not require reduction can often be managed without internal fixation. In general, Tile type I injuries are treated nonoperatively. Tile type II injuries are treated with anterior ring reduction and fixation alone in most cases. Tile type III injuries are treated with posterior ring reduction and fixation in every case managed operatively.
Percutaneous screw fixation is often described as the preferred treatment for stabilization of pelvic ring injuries. In reality the challenge for the surgeon is in obtaining the reduction and not the insertion of the screw. The percutaneous insertion of a screw can be performed in association with either closed or open reductions. A variety of techniques have been described to assist in obtaining a closed pelvic ring reduction including skeletal traction, manipulation of the ipsilateral lower extremity, Schanz pins in the iliac crest, as well as stabilization of the contralateral hemipelvis. All of these techniques require access to a long radiolucent table, and high-quality intraoperative fluoroscopic imaging. The use of percutaneous screw fixation of the pelvis should not be undertaken by an inexperienced surgeon.
Because of the systemic nature of the injury and the wide spectrum of methods of treatment required, complications of pelvic fractures are often frequent and severe. The polytrauma setting and the systemic nature of the injury make the patient susceptible to the development of adult respiratory distress syndrome, thromboembolic disease, pneumonia, and multiple organ failure.