Rebecca J. Webb VetSurg, Ventura, CA, USA Pelvic fractures in dogs are a common orthopedic injury that can result from trauma, such as being hit by a vehicle or falling from a height. Due to the “box‐like structure” of the pelvis, for displacement of fragments to occur, there must be two, but often three, separate fractures or “disruptions to the box of the pelvis” present. The most common fracture configuration is the trio of fractures to the ilium, ischium, and pubis. Sacroiliac luxation (+/− concurrent sacral fracture) is a common concomitant injury that when present, can constitute one of these three “fractures” and allow displacement of the pelvis. Bilateral sacroiliac luxation alone can also lead to significant displacement of the pelvis without additional fractures. Due to the level of trauma required to cause these fractures, they are often associated with significant injuries to other body systems, such as urinary tract avulsions or ruptures resulting in uroabdomen, hernias, and neurological injury. While some of these injuries are obvious at the time of presentation (such as wounds or other fractures), other injuries, such as urinary tract trauma and neurological injury, may only be apparent following thorough physical exam, patient stabilization, and diagnostic imaging. It is important that the clinician performs a detailed clinical and neurological examination prior to making a surgical plan for the patient, as these patients often present acutely following trauma and need to be systemically stabilized prior to surgical intervention for their fractures. The decision of whether to treat a patient with pelvic fractures medically or surgically is based on a multitude of factors, including the location, orientation, and displacement of the fractures, degree of pelvic canal narrowing, concurrent injury to other organ systems, fractures of the forelimbs, and client/patient factors. The goals of surgical management are to restore weight‐bearing, accurately reduce articular fractures, restore pelvic canal width, and improve patient comfort and early mobility. The weight‐bearing segments of the pelvis include the acetabulum, ilium, sacroiliac joint, and sacrum. Typically, fractures of these areas are candidates for surgical repair. Rarely, fractures of the pubic bone may occur in combination with a ventral abdominal hernia. While these fractures may be considered for surgical repair, other fractures of the pubis and ischium are typically managed conservatively since they are not part of the weight‐bearing axis when an animal ambulates. Conservative management typically consists of strict crate restriction, nursing care, and physical therapy when the fragments have become stable enough to allow some activity. Typical candidates for this therapy include stable, minimally displaced fractures of the ilium, minimally displaced luxation of the sacroiliac joint, and most pubic or ischial fractures. Clinicians should pay particular attention to medial displacement of the fragments causing pelvic canal narrowing, as this can lead to long‐term problems for the animal, such as obstipation and difficulty during parturition in intact females. It is important to recognize that following diagnosis, further shifting of the fragments may occur, especially if the client and patient are noncompliant with activity restrictions. When the conservative route is chosen, frequent follow‐up with the patient is of vital importance within the first 7–10 days to monitor for this. During this time, the patient should be reassessed with radiographs, rectal examination, and complete orthopedic and neurological examination to determine if conservative management is still appropriate. If shifting has occurred leading to narrowing of the pelvic canal by 50% or more, surgery should be reconsidered. The pursuit of surgery after this window of time is of questionable benefit, as significant callus formation and muscle contraction make surgical reduction more challenging and may lead to a higher rate of iatrogenic trauma. Cases presenting after this window should be evaluated on a case‐by‐case basis to determine the risk versus benefit of pursuing surgical repair. Patients will typically present with a severe or non‐weight‐bearing lameness. If there are additional injuries to the forelimbs or concurrent neurological injury, the patient may be nonambulatory. Concurrent injuries to the urinary tract, respiratory system, body wall, skin (traumatic wounds), and neurological systems are common, and each of these systems should be thoroughly evaluated prior to surgery. In addition, baseline CBC and chemistry are recommended to evaluate the patient’s systemic stability prior to surgery. Due to blood loss from the fractures and trauma, some patients may require blood products for stabilization prior to anesthesia. Evaluation of the urinary tract is important in trauma patients. A palpable bladder at the time of presentation and a visible bladder on radiographs do not rule out injury to the urinary tract. In patients presenting with pelvic fractures, over 1/3 of these patients will have trauma to the urinary tract diagnosed, of which 16% required surgery to repair the injury. Most of these injuries are to the bladder, but a small proportion occur in the urethra or ureters.1 Repeated evaluation for free abdominal fluid during hospitalization of these patients is important to diagnose these injuries, and if they are suspected, a positive contrast cystourethrogram or ultrasound should be performed. In patients who are nonambulatory and require extended stabilization prior to surgery, a urinary catheter is often placed. However, it is important to note that the placement of a urinary catheter will limit the clinician’s ability to evaluate neurological control of the bladder until the catheter is removed. Thoracic radiographs should be performed as part of the initial diagnostic evaluation of any patient presenting with trauma. Injuries to the respiratory system are commonly diagnosed, including pulmonary contusions, diaphragmatic hernia, and rib fractures among others. When present, repair of a diaphragmatic hernia should precede surgical intervention for the fractures. Pulmonary contusions can vary in significance; while patients with mild contusions may be comfortable breathing room air, patients with significant contusions may require supplemental oxygen therapy until they improve. Respiratory stabilization of these patients should be prioritized prior to considering surgical repair, which may take around 72 hours to resolve, and repeat thoracic radiographs should be performed to re‐evaluate the patient prior to considering an anesthetic event. Injury to the spinal cord or the peripheral nerves (commonly, the lumbosacral trunk and sciatic nerve) can occur secondary to polytrauma. In cases with pelvic fractures, trauma to the lumbosacral trunk is most frequently seen and is commonly associated with craniomedial displacement of ilial wing fractures.2 Luxation of the sacroiliac joint can lead to trauma to the neighboring lumbosacral trunk and sacral nerves. Trauma to these nerves can lead to deficits in innervation of the anal sphincter and urinary bladder, as well as to the sciatic nerve and all of its innervations. Of those patients with neurological deficits, approximately 80% had good functional recovery within 16 weeks following initial trauma.2 However, the absence of deep pain to the limb, loss of perineal sensation, and absence of anal tone are concerning physical exam findings, and the severity of this injury should be conveyed to the client at diagnosis. A tip is to perform the patient’s neurological exam either prior to pain medication administration or if opioids or gabapentin have been administered, wait until the effects have abated; ataxia secondary to gabapentin or sedation secondary to opioids may be confused with a neurologic deficit. Avulsion of the insertion of the rectus abdominus muscle on the pubis or fracture to the pubis can lead to concurrent ventral abdominal herniation of the viscera. This herniation can lead to entrapment and necrosis of the herniated viscera if not recognized early. Repair of the hernia is typically expedited and performed when the patient is stable. Ilial fractures most commonly occur in the midbody of the ilium and are typically oblique (Figure 48.1). The location of the fracture may vary but typically is located immediately caudal to the sacroiliac joint. The caudal fragment typically displaces medially and cranially. This may lead to significant pelvic canal narrowing or damage to the nearby lumbosacral trunk. The hind limb and hemipelvis should be clipped of fur from one inch past the dorsal midline (onto the other side of the pelvis) to the midline of the ventral abdomen. The clip should extend caudally to include the perineum on the surgical side and an inch or two cranial to the palpable wing of the ilium. Along the limb, the clip should extend to just past the tarsus, as the proximal limb will be included in the field. Placement of an anal purse string suture is recommended to help prevent contamination of the sterile field. A hanging limb prep of the clipped field should be performed, this allows the surgeon to have access to the limb for manipulation during surgery, which is helpful for reduction. The approach for ilial fractures is primarily through a lateral incision followed by a “gluteal roll‐up”. During this approach, a lateral incision is made over the ilium, and the gluteal muscles are released from their origin on the ilium ventrally and cranially then retracted or “rolled up” dorsally to access the underlying ilium and cranial aspect of the acetabulum.3 The use of multiple Gelpi (or other) retractors is recommended to adequately expose the ilium. Reduction of the fracture can be achieved through multiple routes. Initially, manipulation of the caudal fragment with bone‐holding forceps to distract it caudally and laterally from its medial position is attempted. During placement of the forceps and manipulation of the fragment, the surgeon should pay particular care to avoid damage to the lumbosacral trunk on the dorsal and medial aspect of the ilium. The greater trochanter can be used as a secondary point of manipulation of the fragment. The placement of a large towel clamp around the greater trochanter can give the clinician more power to distract and manipulate the caudal segment (Figure 48.2). During the reduction of the fracture, it can be helpful to place a rolled towel underneath the limb to prevent adduction of the limb toward the body, which will aid further in reduction (Figure 48.3). Figure 48.1 Pre‐operative radiographs of a closed long oblique ventromedially displaced right ilial wing fracture in a small breed dog. Source: © Rebecca Webb. Figure 48.2 Right long oblique ilial fracture in the process of reduction. The towel clamp being held in the image is around the greater trochanter to aid in the manipulation of the fragments for reduction. The cranial clamp is placed across the long oblique fracture in this case to complete the reduction. Patient’s head is to the right of the image. Source: © Rebecca Webb. These methods of manipulation are often sufficient for cats and small dogs. However, in large dogs or in patients with chronic fractures, further manipulation may be required. Manipulation of the ischium, provided it is intact, can be helpful in these cases by grasping the palpable ischiatic tuberosity. To access the area, a small approach over the palpable tuber ischii is made, and bone‐holding forceps are placed around the ischium. The caudal segment can then be distracted caudally and manipulated into the desired position more easily than with the previously mentioned methods. This method should be used with care in young patients with open physes and soft bone, as damage to the physis or fracture of the bone can occur in these patients. Once the fragments are mostly reduced, pointed reduction forceps are placed across oblique fractures to complete the reduction (Figure 48.4). A tip is to use reduction forceps with a blunted tip (e.g., clamshell bone reduction forceps) in young animals or those with soft bones to reduce the risk of iatrogenic trauma. To secure the reduction, a small Kirshner wire (K‐wire) can be placed across an oblique fracture to maintain the reduction (Figure 48.4). This K‐wire is helpful, as it often allows the clinician to remove the pointed reduction forceps and allow easier access to the bone for bone plate and screw placement. Placement of the wire can be challenging due to the narrow width of the ilial wing; it is helpful to place a finger from the clinician’s nondominant hand in the region where the clinician wants the wire to exit, as this will help improve the clinician’s accuracy with the placement of the K‐wire. If this is done, be careful to not drill the pin into the finger positioned at the exit site. Figure 48.3 A rolled sterile towel is placed underneath the limb to prevent adduction of the limb and assist with the reduction of the long oblique right ilial fracture. Patient’s head is to the right of the image. Source: © Rebecca Webb. Figure 48.4 The central pointed reduction forceps are placed across a long oblique right ilial fracture, and visualization is improved with two Gelpi retractors. Following the placement of the forceps, a small Kirshner wire has been placed across the oblique fracture in a cranioventral to caudodorsal direction to maintain the reduction during the application of the implant. Patient’s head is to the right of the image. Source: © Rebecca Webb. Descriptions of using the plate to help reduce challenging ilial fractures have been described.4
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Pelvic Fractures
Introduction
Indications/Pre‐op Considerations
Indications
Preoperative Considerations
Urinary Tract
Respiratory System
Neurological System
Abdominal Wall
Surgical Procedures
Ilial Fracture
General Preparation
Approach
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