this ppt contains mechanism of injury,classification,diagnosis and management outline of the pelvic fractures.

1. PELVIC FRACTURES
DR JOYDEEP MANDAL

2. PELVIC FRACTURES
 Fractures of the pelvis account for less than
5% of all skeletal injuries, but it is important
because it associated with:-
1. Soft tissue injuries and blood loss.
2. Shock.
3. Sepsis.
4. ARDS.
 Because of those mortality rate exceeds
10%.

5. PELVIC FRACTURES
Fractures of the adult pelvis, exclusive of
the acetabulum, generally are either
stable fractures resulting from low-
energy trauma, such as falls in elderly
patients, or fractures caused by high-
energy trauma that result in significant
morbidity and mortality.

6. Mechanisms of injury
 The basic mechanisms of pelvic ring
injury are:
1. Anteroposterior compression (APC).
2. Lateral compression (LC).
3. Vertical shear (VS).
4. Combinations of these.

7. Anteroposterior compression (APC)
 Usually caused by a frontal collision between
pedestrian and a car. This injury may lead to:
1. Fracture of the rami.
2. The innominate bones are sprung apart and
externally rotated with disruption of the
symphysis.
3. The anterior sacroiliac joint is partially torn.
4. Fracture of the posterior part of the ilium.
 This is called open book injury.

9. Lateral compression (LC)
 Side to side compression of the pelvis causes
the ring to buckle and break. This is due to a
side –on impact in a road accident or a fall
from a height.
 This injury may lead to
1. Anteriorly the pubic rami on one side or both
sides are fractured.
2. Posteriorly there is severe sacroiliac strain or
fracture of the sacrum or ilium, either on the
same side of the pubic fracture or on the
opposite side.

11. Vertical shear (VS)
The innominate bone on one side is
displaced vertically, fracturing the pubic
rami and disrupting the sacroiliac region
on the same side. This is typically occurs
when falls from a height on one leg.
These are severe unstable injuries with
gross tearing of the soft tissues and
associated with retroperitoneal
hemorrhage.

13. Combination injuries
In severe pelvic injuries there may be a
combination of the above.

14. CLASSIFICATIONS

15. TILES CLASSIFICATION

16. YOUNG AND BURGRESS
CLASSIFICATION

19. Clinical features and
clinical assessment
1. Fracture of the pelvis should be suspected in
every patient with serious abdominal injury or
lower limb injury.
2. HO road traffic accident, fall from a height or
crush injury.
3. Severe pain, swelling and bruises in the lower
abdomen, perineum, thighs, scrotum or valva.
4. Extravasations of urine.
5. Symptoms and signs of bleeding and
hemorrhagic shock.

21. Clinical features and clinical
assessment
6. Tenderness all over the pelvic bone
especially when attempt to compress
or distract the pelvis.
7. Tender abdomen due to bleeding or
intrapelvic structure injuries.
8. Rectal examination should be done in
every case.

23. Clinical features and clinical
assessment
9. Bleeding in external meatus indicates
urethral injury. If no bleeding ask the patient
to void and give direct look to the urine, if the
patient able to void this indicates either no
urethral injury or there is only minimal
damage to the urethra.
Note no attempt should be made to pass a
catheter, as this could convert the partial
injury to complete injury.
10. Neurological examination should be done to
exclude sacral and lumber plexus injury.

24. Radiography
1. plain radiography: 5 views are necessary
1. Anteroposterior view.
2. Pelvic inlet view in which the tube is cephalad to
the pelvis and tilted 45° downwards.
3. Pelvic outlet view in which the tube is caudad to
the pelvis and tilted 45° upwards.
4. Right oblique view.
5. Left oblique view.

25. RADIOGRAPH POSITIONING : AP VIEW
 Patient lies supine with the x ray beam centered over the
pelvis

26. RADIOGRAPH POSITIONING : INLET VIEW
 X Ray beam is directed 45 degrees caudally.
 Simulates a direct view of pelvis from above along its longitudinal axis.

27. RADIOGRAPH POSITIONING : OUTLET VIEW
X Ray beam is directed 45 degrees cephalad.
Simulates looking at sacrum and SI joint en face.

28. X RAY PELVIS : AP VIEW

29. X RAY PELVIS : AP VIEW
PUBIC SYMPHYSIS SHOULD BE COLINEAR WITH THE SACRAL SPINOUS PROCESS

30. X RAY PELVIS : AP VIEW
 The Iliopectineal line should
be traced back to its
intersection with lateral
margin of ala.
 It should be at the same
level ( usually at superior
margin of S2 foramen)
bilaterally.

31. X RAY PELVIS : AP VIEW
 Asymmetry of SI
joint or foramina :
possibility of SI joint
dislocation or sacral
fracture.

32. X ray Pelvis : AP view
 Fracture of L5 transverse
process : Vertical shear
injury due to avulsion of
the processes via
Iliolumbar ligament.

33.  Symphyseal
diastasis or
pubic rami
fracture : may
have additional
injuries in the
posterior ring.

34. X RAY PELVIS : INLET VIEW
• AP translation of hemi
pelvis.
• External/ Internal
rotation of hemi
pelvis.
• Opening of SI joint.
• Impaction # of sacral
ala.

35. X RAY PELVIS : OUTLET VIEW
• Vertical shift of hemi
pelvis.
• Sacral fractures relative
to foramina.
• Flexion or Extension
deformity of pelvic ring

36. CT SCAN
 CT scan gives accurate details and
much information about the injury.
 CT scanning is imperative in any
suspected pelvic injury or in suspected
sacral fractures.
2mm to 3mm axial sections are
recommended.

37. CT SCAN
LATERAL X RAY OF SACRUM and CT SCAN of the same patient showing
SACRAL FRACTURE DISLOCATION WITH SPINAL PELVIC
DISASSOCIATION.

38. Urethrography for diagnosis of
urethral injury

40. Management
1. Early management
Treatment should not await full and
detailed diagnosis. Doctor should move
according to the priority of life saving
measures with the already available
information.Six questions must be asked
and the answers acting upon as they
emerge:

41. Management
1. Is there a clear airway?
2. Are the lungs adequately ventilated?
3. Is the patient losing blood?
4. Is there an intra abdominal injury?
5. Is there a bladder or urethral injury?
6. Is the pelvic fracture stable or not?

42. Management
After exclusion of the above, the doctor
now has a good idea about the patient
general condition and the associated
injuries so further investigation can be
done.

43. Management
2. Management of severe bleeding
 Treatment of shock – Rapid fluid resuscitation,blood
transfusion.
 Wrapping of pelvis with sheets with internal rotation & slight
flexion of the knees.
 Anterior external fixation,pelvic C- clamp,pneumatic
antishock garments.
 Pelvic packing & angiographic embolisation if required.
3. Management of urethral and bladder
injury.

44. Management
4.Control of contamination
 Repair of genitourinary and rectal injuries.
 Debridement of necrotic tissue in case of open injury.
5.Laparotomy if required

45. Management
5. Treatment of the fracture
1. Isolated fractures and minimally
displaced fractures(LC 1 & APC 1):
need only bed rest with lower limb
traction.

46. Management
2. More severe pelvic fractures (LC 2 &
APC2) with pubic symphysis diastasis of
more than 2.5 cm,pubic rami fractures
with more than 2 cm displacement or
other rotationally unstable fractures with
limb length discrepancy of more than 1.5
cm require surgical intervention either by
external fixation or by closed reduction
and internal fixation.

51. Management
4. AP-III and VC are the most dangerous
and the most difficult to treat. These
are unstable fractures and needs
reduction and fixation by either external
fixation or plate and screws.

53. Secondary complications
1. Sciatic nerve injury.
2. Urogenital problem like stricture,
incontinence and impotence.
3. Persistent sacroiliac pain due to
unstable pelvis.

54. ACKNOWLEDGEMENT