Shat Kriyakala in surgical practice - Shalya Tantra – General Surgery | Ayana Ayurveda

TIBIAL SHAFT (DIAPHYSEAL) FRACTURES

Specific Fracture Type	Etiology	Fracture Mechanism	Clinical Features	Investigations / Imaging	Conservative Management	Surgical Management	Prognosis
Upper Third Shaft Fracture	RTA, fall	Bending, direct trauma	Pain, swelling, deformity	X-ray leg including knee & ankle	Cast if undisplaced	IM interlocking nail	Fair
Middle Third Shaft Fracture	RTA, assault	Direct blow	Deformity, abnormal mobility	X-ray leg	Functional brace	IM nailing (gold standard)	Good
Lower Third Shaft Fracture	Twisting injuries	Indirect rotational force	Pain, swelling near ankle	X-ray	Cast	IM nail / plate fixation	Slightly delayed union
Segmental Tibial Fracture	High-energy trauma	Severe direct violence	Gross deformity, high soft tissue damage	X-ray, CT	Temporary splint	External fixation → IM nail	Poor
Comminuted Tibial Fracture	High-speed RTA	Crush injury	Severe swelling, open wounds	X-ray	Rarely	IM nail / external fixator	Guarded
Open Tibial Fracture	RTA, industrial injury	Direct trauma	Visible bone, bleeding, contamination	X-ray, wound assessment	Temporary splint, antibiotics	Debridement + fixation	Risk of infection
Stress (March) Fracture	Repetitive stress	Repeated microtrauma	Localized pain, minimal swelling	X-ray (may be normal), MRI	Rest, activity modification	Rare	Excellent

DISTAL TIBIAL FRACTURES

Specific Fracture Type	Etiology	Fracture Mechanism	Clinical Features	Investigations / Imaging	Conservative Management	Surgical Management	Prognosis
Distal Metaphyseal Fracture	Fall, twisting injury	Bending + rotation	Ankle pain, swelling	X-ray ankle & leg	Cast if stable	ORIF / IM nail	Good
Tibial Plafond (Pilon) Fracture	Fall from height, RTA	Axial compression	Severe ankle pain, swelling, skin compromise	X-ray, CT scan (essential)	Temporary splint	Staged fixation, ORIF	Poor; high OA risk
Medial Malleolus Fracture	Twisting injury	Rotational force	Ankle pain, tenderness	X-ray ankle mortise view	Cast if undisplaced	Screw fixation	Good
Distal Intra-articular Fracture	High-energy trauma	Compression + shear	Restricted ankle movements	CT scan	Rare	ORIF	Variable

BONY PELVIS

The bony pelvis is a robust, basin-shaped ring formed by two innominate bones (ilium, ischium, pubis) and the sacrum/coccyx, designed for weight-bearing and stability. Key surgical landmarks include the iliac crests, ASIS, pubic symphysis, acetabulum, and sacroiliac (SI) joints. It is divided into the false (greater) pelvis above the pelvic brim and the true (lesser) pelvis below, containing critical vascular (internal iliac artery, corona mortis) and neural (lumbosacral plexus) structures.

Key Surgical Anatomical Features

Pelvic Ring Structure: Composed of a posterior arch (sacrum, SI joints) and an anterior arch (pubic symphysis, rami). Stability relies on strong ligaments, including the sacrospinous and sacrotuberous ligaments.
The Innominate Bone (Coxal Bone): Composed of three fused bones (ilium, ischium, pubis) which meet at the acetabulum.
- Ilium: Forms the upper portion, ending in the iliac crest (safe site for bone graft harvest).
- Ischium: Forms the lower posterior portion, featuring the ischial tuberosity (site of hamstring attachment) and the ischial spine (landmark for pelvic floor procedures).
- Pubis: Forms the anterior portion, with superior/inferior rami surrounding the obturator foramen.
Acetabulum: The socket for the femoral head, formed by the union of all three pelvic bones.
Sacrum: A triangular bone at the base of the spine consisting of five fused vertebrae, articulating laterally with the ilium at the sacroiliac joint.

Surgical Landmarks & Considerations

Anterior Superior Iliac Spine (ASIS): Attachment point for the inguinal ligament and sartorius muscle.
Pubic Symphysis: Midline fibrocartilaginous joint where the two pubic bones meet anteriorly.
Sacral Promontory: The projecting anterior edge of the S1 vertebra, crucial for obstetric and gynecologic procedures and referencing vascular structures.
Corona Mortis: A vascular anastomosis between the external iliac/inferior epigastric and obturator vessels located on the superior pubic ramus; it is high-risk for bleeding during anterior pelvic surgery.
Sciatic Foramina: Greater and lesser, defined by the ischial spine and sacrotuberous/sacrospinous ligaments, serving as conduits for muscles, nerves, and vessels.

Imaging & Access

Standard Views: AP pelvis, inlet (viewing the pelvis from top), and outlet (viewing from bottom).
Surgical Approaches: Anterior approaches (ilioinguinal, Stoppa) are common for fracture fixation, requiring identification of the corona mortis and corona mortis

ANTERIOR PELVIC RING FRACTURES

Specific Fracture Type	Etiology	Fracture Mechanism	Clinical Features	Investigations / Imaging	Conservative Management	Surgical Management	Prognosis
Pubic Rami Fracture (Superior / Inferior)	Low-energy fall (elderly), RTA	Direct blow, lateral compression	Groin pain, difficulty walking, local tenderness	X-ray pelvis AP, CT if doubt	Analgesia, bed rest, early mobilization	Rarely required	Good
Pubic Symphysis Diastasis	RTA, crush injury	Anteroposterior compression	Pelvic pain, instability, widened symphysis	X-ray pelvis AP, CT scan	Pelvic binder	External fixation / ORIF	Depends on stability
Isolated Anterior Ring Injury	Fall, sports injury	Low-energy trauma	Local pain without shock	X-ray pelvis	Conservative	Rare	Excellent

POSTERIOR PELVIC RING FRACTURES (UNSTABLE)

Specific Fracture Type	Etiology	Fracture Mechanism	Clinical Features	Investigations / Imaging	Conservative Management	Surgical Management	Prognosis
Sacral Fracture	RTA, fall from height	Vertical shear, compression	Severe pelvic pain, neurological deficit	X-ray pelvis, CT scan	Bed rest (stable)	Percutaneous screws / ORIF	Guarded if neuro injury
Sacroiliac Joint Disruption	High-energy trauma	Vertical shear	Pelvic instability, limb length discrepancy	CT scan pelvis	Pelvic binder	SI screws / external fixation	Guarded
Posterior Iliac Fracture	Direct trauma	Lateral compression	Buttock pain, instability	CT scan	Rare	ORIF	Variable

ACETABULAR FRACTURES

Specific Fracture Type	Etiology	Fracture Mechanism	Clinical Features	Investigations / Imaging	Conservative Management	Surgical Management	Prognosis
Anterior Column Fracture	RTA	Force transmitted through femoral head	Hip pain, restricted movements	X-ray pelvis, Judet views, CT	Traction, NWB	ORIF	Fair
Posterior Column / Wall Fracture	Dashboard injury	Posterior force	Hip dislocation, sciatic nerve injury	CT scan	Rare	ORIF	Risk of OA
Both Column Fracture	High-energy trauma	Axial compression	Severe pain, instability	CT scan 3D	Temporary traction	ORIF	Guarded

Associated Injury	Clinical Clue	Investigation
Urethral injury	Blood at meatus	Retrograde urethrogram
Bladder rupture	Hematuria	CT cystography
Vascular injury	Shock	CT angiography
Nerve injury	Sensory/motor deficit	Clinical ± MRI