Aula 10- Fratura da pelve e quadril

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Disciplina de Saúde do Adulto e do Idoso

Ortopedia

Pelve: Ar$culação

Sacro

Sacroilíaca

Coccix

Crista ilíaca

Ilío Acetábulo Isquio

Fêmur

Sínfise Púbica

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Pubis

Pelve: •  Ilío •  Isquio •  Púbis



Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Anterior column

Posterior column

•  Acetábulo

P c

FIGURE 56-5 Two-column concept of Letournel an used in classification of acetabular fractures (see text).

CHAPTER 56 FRACTUR

Ili em



Posterior column

Anterior column

Posterior column

Dome of acetabulum

Qua

A FIGURE 56-6

Superior dome of acetabulum.

FIGURE 56-5 Two-column concept of Letournel and Judet FIGURE 56-7 A, Iliopectin surface surrounding the B, nonarticular cotyloid sur foss used in classification of acetabular fractures (see text). tabulum. Quadrilateral articular socket is composed of and supported by two c acetabulum. of bone, described by Letournel and Judet as an inv Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

(Fig. 56-5). The anterior column is composed of the half of the iliac crest, the iliac spines, the anterior ha acetabulum, and the pubis. The posterior column

A

of Letournel and Judet ctures (see text).

B

FIGURE 56-7 A, Iliopectineal eminence overlies dome of acetabulum. B, Quadrilateral surface lies adjacent to medial wall of acetabulum.

•  Acetábulo

Superior gluteal artery and nerve Piriformis

Dome of acetabulum

Sciatic nerve

of acetabulum.

FIGURE 56-8 Piriformis divides greater sciatic notch and is key to this region. Sciatic nerve is shown leaving pelvis below this ular cotyloid fossa. This Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas muscle; superior gluteal artery, vein, and nerve are above it.

B

55-49 Fixation of subtrochanteric nonunion with blade plate. A, Preoperative radiograph. B and C, After fixation. (Courtesy empleman, MD, Minneapolis, MN.)

Proximal Epífise Metáfise

Osso Esponjoso

Diáfise A

B

Distal C

Osso Cor$cal

D

55-50 Rotation can be assessed by comparison of contour of affected lesser trochanter to that of contralateral hip. (Redrawn ek C: Fractures of the distal femur. In Browner BD, Jupiter JB, Levine AM, et al, editors: Skeletal trauma, ed 4. Philadelphia, 2009, Elsevier.) NIQUE 55-7. Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

FIGURE 55-49 Fixation of subtrochanteric nonunion with bla of David Templeman, MD, Minneapolis, MN.) Cabeça femoral Trocanter Maior

Região Intertrocantérica

Colo

Trocanter Menor Região Subtrocantérica

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Quadril: •  Acetábulo + fêmur proximal

Ligamento Redondo

Fóvea

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Radiograph, AP pelvis

Ar$culação Sacroiliac joint Sacroilíaca Linha Ilioishial line Ilioisquiá$ca (posterior column) (Coluna Posterior)

Parede Anterior wall (of acetabulum) Anterior Sínfise Pubic symphysis Púbica

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Sacro Sacrum Linha Ilíopec$nea Iliopectineal line (Coluna Anterior) (anterior column) Teardrop

Lágrima

Roof Teto (of acetabulum) Posterior wall Parede (of acetabulum)

Posterior

CT pelvis

Iliac crest Crista Ilíaca

Sacrum

Sacro

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Sacroiliac Ar$culação joint Sacroilíaca

Fovea

Po (a

\

CT pelvis

ac

Fóvea

Parede Parede Fovea Posterior Posterior wall Anterior

(acetabulum)

Acetábulo

Femoral head Cabeça Femoral

Acetabulum

Anterior wall Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas (acetabulum)

Terminologia:

Desvios das fraturas

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Fratura do colo : 2726 •  Necrose da cabeça femoral

PART XV FRACTURES AND DISLOCATIONS IN ADULTS Lateral epiphyseal arterial group Subsynovial intracapsular arterial ring Ascending cervical arteries

Medial femoral circumflex artery

FIGURE 55-1

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Extracapsular arterial ring

Blood supply to the femoral head.

FIGURE 55-1

Blood supply to the femoral head.

Stage III Subcapital FIGURE 55-3

Garden cla

Transcervical Basicervical

often is helpful. The entire become the imaging study neck fractures. Although w to evaluate femoral neck abdomen, and pelvis ofte information.

TREATMENT FIGURE 55-2 Classification of femoral neck fractures by location: subcapital, transcervical, basicervical. Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

A satisfactory reduction complications associated w tures, including nonunion tion can be attempted in fixation is planned. The W

Fratura da Pelve Fratura do Acetábulo Fratura da Cabeça femoral



Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Alta Energia

Fratura Colo e Fratura Transtrocantérica Distribuição Bimodal Adultos Jovens = Alta Energia “Acidentes de Trânsito” Idosos = Baixa Energia “Osteoporose” Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Fratura Colo e Fratura Transtrocantérica Distribuição Bimodal Idosos = Baixa Energia “Osteoporose”



Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Lei de Wolff: Forças de tensão ou tração produzem deformação óssea

Fratura Pelve e Quadril •  Dor •  Encurtamento •  Rotação Externa •  Abertura da Sínfise púbica



Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Príncipios •  Estabilidade Absoluta (Não há movimento) •  Ar$cular •  Redução Anatômica (Direta) •  Não forma calo ósseo •  Estabilidade RelaLva (Existe movimento) •  Metafisária •  Redução Indireta •  Forma calo ósseo Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Príncipios •  Estabilidade Absoluta •  Ar$cular •  Redução Anatômica (Direta) •  Não forma calo ósseo



Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Príncipios •  Estabilidade RelaLva •  Metafisária •  Redução Indireta •  Forma calo ósseo Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

2804

PART XV FRACTURES AND DISLOCATIONS IN ADULTS Interosseous sacroiliac ligaments

A

B

C

Disciplina: Saúde do Adulto e do

FIGURE 56-42 Tile classification of pelvic fractures based on forces acting on pelvis. A, Type B1: External rotation or anteropo terior compression through left femur (arrows) disrupts symphysis, pelvis, and anterior sacroiliac ligament until ilium imping against posterior aspect of sacrum. If force stops at this level, partial stability of pelvis is maintained by interosseous sacroiliac lig ments. B, Type B2-1: Lateral compression (internal rotation) force implodes hemipelvis. Rami may fracture anteriorly, and posteri impaction of sacrum may occur, with some disruption of posterior structures, but partial stability is maintained by intact pelvic flo and compression of sacrum. C, Type C: Shearing (translational) force disrupts symphysis, pelvic floor, and posterior structures, re hemipelvis completely unstable. (From Tile M: Acute pelvic fractures, part I. Causation and classification, J Am Assoc Orthop Su Idosodering – Especialidades Cirúrgicas 4:143, 1996.)

2784

PART XV FRACTURES AND DISLOCATIONS IN ADULTS Simple fracture types

A

B

C

D

E

I

J

Associated fracture types

F

G

H

FIGURE 56-17 Letournel and Judet classification of acetabular fractures. A, Posterior wall fracture. B, Posterior column fracture. C, Anterior wall fracture. D, Anterior column fracture. E, Transverse fracture. F, Posterior column and posterior wall fracture. G, Transverse and posterior wall fracture. H, T-shaped fracture. I, Anterior column and posterior hemitransverse fracture. J, Complete bothcolumn fracture.

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

6

PART XV FRACTURES AND DISLOCATIONS IN ADULTS Lateral epiphyseal arterial group Subsynovial intracapsular arterial ring Ascending cervical arteries

Medial femoral circumflex artery

FIGURE 55-1

Extracapsular arterial ring

Stage I

Stage II

Stage III

Stage IV

Blood supply to the femoral head.

Subcapital FIGURE 55-3 Transcervical Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Garden classification of femoral neck fractures.

A

B

FIGURE 55-8 Concave outline of femoral neck meets convex outline of femoral head in “S” or reversed-“S” curve superiorly, inferiorly, anteriorly, and posteriorly; restoration of these “S” signs is indicative of anatomical alignment. (Redrawn from Lowell JD: Results and complications of femoral neck fractures, Clin Orthop Relat Res 152:162, 1980.)

Transcervical

Use fluoroscopy in both planes to localize placement of the inferocentral wire. Make a skin incision extending 2 to 3 cm proximally. Split the fascia in line with the skin incision, and use a Cobb elevator to gently split the fibers of the vastus lateralis muscle longitudinally. ■ Place the inferocentral wire in perfect position on both views. Placing a guidewire along the anterior femoral neck can be helpful in determining appropriate anteversion. Make sure not to begin below the lesser trochanter and to continue proximally along the calcar. ■ Once the first guide pin is in place, use a parallel guide to place the posterosuperior and then anterosuperior pins to obtain posterior and anterior cortical support in the femoral neck. Advance the threaded guide pins just short of the articular surface. Be very careful not to violate the articular surface. ■ To determine appropriate screw length, measure the length of the guide pin and subtract 5 mm. Self-drilling, self-tapping screws generally are used, but sometimes predrilling of the outer cortex is necessary in patients with dense bone. Washers are used where space permits. ■ A fourth screw (diamond configuration) may be necessary in patients with significant posterior comminution (Fig. 55-9C). ■ Alternatively, place the guide pins through the skin and then make an approximately 1-cm stab incision and deepen it around each guide pin. ■

A

B

C

Extreme care must be taken in the placement of guide pins because inaccurate passage of the pins (multiple attempts or attempts below the level of the lesser trochanter) has been FIGURE 55-9 For fixation of femoral neck fractures, three associated with subtrochanteric femoral fractures. In a biopartially threaded screws can be inserted in an inverted mechanical model, screw configuration was shown to influtriangle configuration (A and B). Four screws can be placed in a ence the occurrence of subtrochanteric femoral fracture. diamond configuration when significant comminution is present Fractures in a femoral neck model were fixed with an apex(C). (Redrawn from Tornetta P: Trauma Instructional Course Lectures, Disciplina: Saúde do Adulto do Idoso – Especialidades Cirúrgicas distal screw or apex-proximal screw configuration. Those Rosemont, IL, 2006, American Academy ofeOrthopaedic Surgeons.)

A

Basocervical

PART XV FRACTURES AND DISLOCATIONS IN ADULTS

A B

Desvio??? Disciplina: Saúde do Adulto e do

C

FIGURE 55-16 In an attempt to minimize femoral neck shortening, partially threaded screw used for compression is changed to f threaded screw. A, Radiograph at time of injury. B and C, After operative reduction and fixation.

Varo

and tamponade may be a major cause in the development osteonecrosis. We usually perform capsulotomies in Idoso of – Especialidades Cirúrgicas

FLUOROSCOPICALLY GUIDED CAPSULOTOMY OF THE HIP

Subcapital A

A B

Osteoporose

FIGURE 55-21 Total hip arthroplasty for treatment of femoral neck fracture. A, Preoperative anteroposterior radiograph. B, One year after total hip arthroplasty. (Courtesy of Andrew Schmidt, MD, Minneapolis, MN.)

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Artroplas$a

CHAPTER 55 FRACTURES AND DISLOCATIONS OF THE HIP

CHAPTER 55 FRACTURES AND DISLOCATIONS OF THE HIP

Transtrocantérica

A

A B

Desvio??

Sem desvio

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

B

2741

2741

CHAPTER 55 55 FRACTURES AND DISLOCATIONS OFOFTHE CHAPTER FRACTURES AND DISLOCATIONS THEHI

Subtrocantérica

A

A

Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

B

B

Fratura da Pelve, Acetábulo ou Cabeça femoral •  Alta Energia Fratura Colo ou Trasntrocantérica •  Distribuição Bimodal •  Alta Energia – Adulto Jovem (Trânsito) •  Baixa Energia – Idoso (Osteoporose) DiagnósLco •  Encurtamento membro •  Rotação externa Exames: •  RX •  TC (planejamento) Disciplina: Saúde do Adulto e do Idoso – Especialidades Cirúrgicas

Tratamento: •  •  •  • 

Fixação Metáfise •  Estabilidade Rela$va •  Redução Indireta Ar$cular •  Estabilidade Absoluta •  Redução Anatômica Osteoporose ou Cominu$va •  Artroplas$a