Pelvic, spinal and sacrococcygeal fractures and luxation

• Pelvic fractures - initial assessment

  These are severe injuries - a large amount are associated with RTAs.

  Assessment of the whole animal is essential. Airway, breathing and circulation. Radiograph or TFAST/TPOCUS chest and AFAST of the abdomen looking at the integrity of the urinary system (bladder rupture). Neurological deficits particularly with sacrococcygeal luxation,.
• What are the management options for pelvic fractures?

  Conservative management - less invasive, less expense, outcome less predictable and recovery more prolonged.

  Surgical management - invasive and expensive, but likely to to provide more rapid and fuller return to function, rapid pain relief, and potentially better outcomes.
• What are the weight bearing axis for the pelvis?

  The ilial shaft and wing.

  The iliosacral articulation.

  The acetabulum.

  
• Sacral fracture and sacroiliac luxation - type

  RTA ‘shunting injury” (the animal is struck from the rear).

  • These injuries may be stable
  • They can be bilateral.
  • Often accompanied by neurological abnormalities including sciatic neuropathies and urinary incontinence, sciatic nerve could be involved, some knuckling and inability to maintain flexion and extension of the hock.
  • Can be very painful particularly if there is bilateral sacroiliac luxation.

  
• Sacral fracture and sacroiliac luxation - treatment

  Can be managed conservatively if more than 50% of articualr surfaces are in contact due to the degree of friction in this joint.

  Surgical management can be difficult and is prone to error including failure to engage the body of the sacrum in lag screw fixation or entering the neural canal with catastrophic consequences.
• What are the surgical options for fixing the sacral fracture and sacroiliac luxation?

  Large lag screw +/- anti-rotational wire, this surgery has significant side effects.

  Trans-ilial pin if one of the hemipelvis’ is intact, not particularly stable.
• What are ilial shaft fractures and how are they managed?

  Usually long oblique fractures.

  Caudal fragment often displaces medically narrowing the pelvic canal diameter, if there is more than 50% narrowing this is an indication for surgery.

  Surgery is a well contoured plate with preferentially one or two screws in the body of the sacrum. Ideally engage six cortices either side of the fracture. A long oblique fracture can be managed with lag screws alone.

  The pelvis is inherently stable and therefore very rigid repair is not always necessary.
• What are the complications of ilial shaft fractures?

  Reduction can be difficult especially if the injury is chronic (greater than 5 days old), particularly in larger dogs, the longer the fractures are out of alignment the harder it is to replace.

  Iatrogenic damage tot eh sciatic nerve is a real risk, when the nerve gets trapped in the fracture site, requires experience, referral is sometimes the best option for surgical management of these conditions.
• Acetabular fractures - overview

  Weight bearing is mainly on the dorsocarnial acetabulum in the dig but mid region in the cat.

  Failing to reconstruct the fractures of the caudal third can result in poor outcome despite apparent reduced weight bearing in this area

  They can be difficult fractures to repair so always give the option to refer. Comminution of the medial wall is particularly difficult to manage.
• What are the surgical management options for acetabular fractures

  Plate fixation (acetabular plate, standard or locking plate or reconstruction plates)

  Mid-acetabulum: screws, wire and methylmethacrylate composite.

  If complex or cost issue then a femoral head and neck excision can be adopted but wait to see what function is gained with a conservative approach before performing surgery.
• Pubic fractures - overview

  These may be of little concern unless they are associated with rupture or loss of the pre-pubic tendon and a ventral hernia.

  Bladder incarceration can occur in this hernia. The pre-pubic tendon breaking allows the bladder to drop out of the abdomen.

  Generally pubic fractures require no treatment and the pre-pubic tendon rupture occurs with an intact pubis.
• Spinal fractures - overview

  These are uncommon - almost always associated with RTAs.

  Subluxation commonly accompanies these fractures.

  Generally occur due to RTAs but can occur as a result of pathologies such as infection or neoplasia.

  Are often associated with neurological deficits. Are very painful, and potentially life threatening.
• What are the initial managements for spinal fractures?

  These patients are unstable.

  The usual approach is applied to these trauma cases (ABCs).

  Careful palpation may reveal the site of spinal instability.

  Support the back at all times.

  The use of a rigid carrying board upon which the patient can be strapped is very useful.

  Give analgesia but avoid anaesthesia or deep sedation unless absolutely necessary as the muscle spasm and tone provide local support over the fracture site.

  Radiograph the spine at first opportunity.
• Neurological evaluation for spinal fractures?

  Should be performed before the X-ray, to localise the site of any potential fracture/luxation.

  Assess tone in the fore and hind limbs and tail.

  Where is the most marked muscle spasm? Is there a cut off of the panniculus/cutaneous trunci reflex? is there a perineal reflex?
• What is the conservative management for spinal fractures?

  These are relatively stable fractures and those occurring in the lumbosacral region can be managed conservatively.

  This consists of cage rest fir 6-8 weeks or external splints (management of the splints is difficult and this form of immobilisation can not be recommended).

  Cats will not tolerate external splints but are amenable to cage rest.

  Careful nursing is required particularly to avoid urine scaldino and decubitus ulcers. Appropriate analgesia should be provided at all times.
• What are the surgical managements for spinal fractures?

  Various methods are available to treat these fractures.

  If there is significant cord compression then a hemilaminectomy may need to be performed.

  This takes out the dorsolateral wall of the vertebral canal and allows blood clots and bone fragments to be removed and the cord decompressed.

  In the cervical region, pins and methacrylate bridges are the most versatile from of fixation - these are placed ventral to the vertebrae.
• What is the prognosis for spinal fractures?

  The prognosis for animals with spinal cord injuries is good if conscious nociception is preserved.

  If this is not the case then the prognosis is poor and owners need to be aware of this prior to the instigation of any treatment.

  Irrespective of whether a conservative or surgical management option is adopted careful nursing particularly of the urinary system is essential and catheterisation with a closed collecting system is very helpful.

  During the period of cage confinement it is essential to provide sensory stimuli for the patient.
• How do sacrococcygeal luxations present?

  Common injuries in the cat following an RTA.

  Present with a flaccid tail, urinary retention or occasionally a flaccid bladder and overflow.

  These cases can present with a grossly distended bladder if the owner was unaware of the original injury.

  On occasions the cat might show concurrent mild sciatic neuropathy due to the involvement of the sciatic nerve.

  The degree of damage is not necessarily indicative of the degree of nerve damage.

  
• How do you diagnosis sacrococcygeal luxations?

  Usually fairly straightforward.

  Distended bladder and flaccid tail no or little sensation.

  The luxation may be palpable as a depression at the base of the tail.

  Radiographic diagnosis although it is important to appreciate that the degree of displacement of the coccygeal vertebrae doesn't reflect the severity of the resulting neurological deficits.

  Always radiograph the chest and pelvis to detect concurrent injuries.
• What are the treatments for Sacrococcygeal luxations?

  Conservative management with manual expressing of the bladder and medications to encourage micturition.

  Bethanechol to increase detrusor tone.

  Phenoxybenzamine or Prazosin to reduce striated muscle tone and dantrolen to reduce smooth muscle tone in the urethra.

  The owner can be taught how to express the bladder at home.
• What is the prognosis for Sacrococcygeal luxations?

  The prognosis for this injury is good to fair but if there is no improvement after 4 weeks the prognosis worsens.

  Cats with deep pain sensation intact at the tail base within 48 hours of their injury have a better long term outlook and ahve been reported to regain bladder control within three days of this positive finding.