1. PELVI-ACETABULAR FRACTURES
Chairman: Dr D R Kale
Presenter: Dr Sidharth Baheti
• Pelvic fractures are potentially life threatening
injuries with an increased incidence due to
high velocity RTAs.
• Survivors are at a significant risk for morbidities
like chronic pain, LLD, Sexual dysfunction etc
• 3-4 % of all fractures usually associated with
• Adult mortality 10-15%
• Mortality is ~50% if hypotensive on initial
• Mortality is ~30% in open fractures
• Significant decrease in mortality and morbidity
if prompt stabilization of an unstable #
5. The bony pelvis lies in close proximity to various vascular
neural and soft tissue structures making these structures
vulnerable in the event of pelvic ring disruptions
6. Historical perspective
• These #s were historically managed conservatively
and many authors reported poor results.
• Holdsworth (1948) in first described that pts with
pure SI dislocations fared worse than
• Slattis reported mortality as high as 17%
• Several publications popularized use of external
• But later it became clear that Ex-Fix may be
adequate for anterior/lateral injuries but not for
7. Clinical Evaluation
Start with ABCDs
Evaluate for other injuries to head, chest,
abdomen and spine
• Skin around the perineum
• Bleeding PV/PR/PU
• LLD and abnormal extremity rotation
• Neuro-vascular status
8. Associated signs:
- Roux's sign:
- a decrease in the distance from the
greater trochanter to the pubic crest on the
affected side in lateral compression frx;
- Earle's sign:
- a bony prominence or large hematoma
as well as tenderness on rectal examination;
9. Moral Lavale Lesion
• Post---Haematoma/defect---SIJ or post #
• ASIS: Pushed towards- IR stability, Apart- ER
• Lower extremity pushed for vertical stability
11. Imaging Pelvic Fractures
• Plain Radiographs- AP view
12. Imaging Pelvic Fractures
• Plain Radiographs- AP view
Pubic Rami #
SIJ and Sacrum
L5 transverse process
Asso acet/proximal femur
13. 2. Plain Radiographs- Inlet view
14. Anterior/posterior Displacement
of Sacrum, SIJ, Illium, symphysis
Rotational deformities of illium
Impacted sacral fractures
15. 3. Plain Radiography Outlet view
Adequate image when pubic
symphysis overlies S2 body
Gold standard for pelvic fractures. Detailed
information about anterior and posterior ring
GU and Vascular structures
17. CLASSIFICATION of pelvic fractures
Young and Burgess Classification
Most common classification used
Based on the mechanism of injury
18. Tile/AO Classification
19. Tile/AO Classification
Type A: STABLE
20. Tile/AO Classification
Type B: Rotationally unstable, Vertically
21. Tile/AO Classification
Type C: Rotation and vertically
24. Principles of Initial Management
• Suspect if high velocity RTA(car vs pedestrian;
Motorcycle) or a fall from height(usually
• Pelvis has no inherent stability and relies on
• Vascular structures are intimately associated
with ligaments and are often injured.
25. German registry
reported a drop
in mortality from
11% to 6% after a
26. Circumferential Pelvic wrapping
First patient; teague 1993,CA
ATLS provider manual in 1997
Can be done with a bedsheet or a Pelvic
27. • Where to wrap??
At the level of the Greater Trochanters
• How much force????
28. Pneumatic Anti-shock Garment
• Inflatable device traditionally used by the
• Great value in transport and initial
stabilization of patient; acts as a air splint
29. Disadvantages of PASG
• Risk of displacement in LC injuries
• Restricts access to patient
• Increased risk of compartment syndrome
30. External Fixation
– pelvic ring injuries with an external rotation
component (APC, VS, CM)
– unstable ring injury with ongoing blood loss
– ilium fracture that precludes safe application
– acetabular fracture
– theoretically works by decreasing pelvic volume
– stability of bleeding bone surfaces and venous
plexus in order to form clot
– pins inserted into ilium
• single pin in column of supracetabular bone from AIIS
– obturator outlet or "teepee" view to visualize this column of
– AIIS pins can place the lateral femoral cutaneous nerve at risk
• multiple half pins in the superior iliac crest
– place in thickest portion of anterior ilium, gluteus medius
tubercle or gluteal pillar
– should be placed before emergent laparotomy
32. Angiography / Embolization
– controversial and based on multiple variables
– protocol of institution, stability of patient,
proximity of angiography suite , availability and
experience of staff
– CT angiography useful for determining presence or
absence of ongoing arterial hemorrhage (98-100%
negative predictive value)
33. Non-Operative Management
• Lateral impaction type injuries with minimal
(< 1.5 cm) displacement
• Pubic rami fractures with no posterior
• Minimal gapping of pubic symphysis
– Without associated SI injury
– 2.5 cm or less, assuming no motion with stress or
– This number is not absolute, so other evidence of
instability (like SI injury) must be ruled out
34. Non-Operative Management
• X-rays are static picture of dynamic situation
– It may be that the deformity is worse than seen on
– Stress radiographs may be helpful
– Other evidence of instability should be sought
• Lumbar transverse process fractures
• Avulsions of sacrotuberous/sacrospinous ligaments
35. Non-Operative Treatment
• Tile A (stable) injuries can generally bear
weight as tolerated
• Walker/crutches/cane often helpful in early
• Serial radiographs followed during healing
• Displacement requires reassessment of
stability and consideration given to operative
36. Non-Operative Treatment
• Tile B (partially stable) injuries can be treated
non-operatively if deformity is minimal
• Weight bearing should be restricted (toetouch only) on side of posterior ring injury
• Serial radiographs followed during healing
• Displacement requires reassessment of
stability and consideration given to operative
37. Principles of Operative Treatment
• Posterior ring structure is important
• Goal is restoration of anatomy and enough
stability to maintain reduction during healing
• Most injuries involve multiple sites of injury
– In general, more points of fixation lead to greater
– This does NOT mean that all sites of injury need
38. Principles of Operative Treatment
• Anterior ring fixation may provide structural
protection of posterior fixation
• If combined open and percutaneus techniques
are used, the open portion is often done first to
aid in reduction of the percutaneusly treated
• LETOURNEL’s Golden rule: Posterior stabilization
to be done before anterior as posterior is the
main weight bearing part.
39. Anterior Pelvic Ring Injuries
Indications for ORIF
• Symphyseal dislocation >2.5cm(static or
• To augment posterior fixation in vertically
• Locked symphysis.
40. Surgical Approach to the
Anterior Pelvic Ring
•8 cm incision
•A Foley catheter and
nasogastric tube are inserted
41. •The cut edges of the
muscles superiorly to
reveal the symphysis
and pubic crest.
• If access to the back of
the symphysis is
required, use the
fingers to push the
bladder gently off the
back of the bone
42. Symphyseal Dislocations
• Ant Ex Fix = Internal Fixation for controlling
rotation but Internal fixation >>> for resisting
• Ex fix particularly useful in open injuries or pts
requiring GI/GU procedures.
43. ORIF of Symphyseal disruptions
• Apply circumferential wrap at the level of the
• Internally rotate the legs and tape them.
• Ant approach to pubic symphysis.
• Place reduction forceps anteriorly so that
plate can be put on the superior surface.
44. • Inlet view: judge the alignment of the plate;
• Outlet view judge the length of screws;screws
should have a bicortical purchase.
45. Fractures of the Pubic ramus
• Fractures medial to insertion of inguinal
ligament should be treated like symphyseal
• Comminuted fractures: ORIF
• Minimal comminution: Ramus screw(ante vs
46. Fractures of the Pubic ramus
• Reduction technique
Secure a precontoured plate in the supraacetabular bone.
One tine of the reduction forceps on the medial
fragment and another on the most medial hole
of the plate.
47. Posterior Pelvic Ring Injuries
• Indications for ORIF:1. Displaced illiac wing fractures that enter and exit
both the crest and GSN/SIJ.
2. Multiplanar instability(disruption of ligaments)
3. Non impacted comminuted displaced sacral
4. Vertical or cephalad displacement.
5. U shaped fractures with spino-pelvic
48. Approaches to posterior pelvic ring
Posterior approach to SIJ
• Pt is placed prone with logitunal traction.
• In severely displaced fractures we can rigidly fix the
49. Approaches to posterior pelvic ring
Posterior approach to SIJ
50. Anterior Approach to the Sacroiliac Joint
• Make a curved incision over
the iliac crest, beginning 7 cm
posterior to the anterior
superior iliac spine. Curve the
incision anteriorly and
medially along the line of the
inguinal ligament for 5 cm.
51. • Subperiosteally dissect the illiacus muscle and
retract medially to reach the anterior part of
• Care should be taken not to injure L5 nerve
52. Posterior approach to Sacrum
53. Sacroilliac Joint Dislocations
• Posterior approach----Only inferior joint
• Anterior approach----Superior Ala visualized
• Longitunal traction is the single most
• Important to let the pelvis hang free as
pressure on ASIS will lead to ext rotation
54. • Two reduction forceps
55. Illio-Sacral screw Placement
• Inlet projection—screw
towards anterior aspect
• Outlet ---screw is above
the S1 foramen
• Screw to be directed
56. Be aware of sacral dysmorphism
57. Illiac wing fractures and fracture
dislocations( Crescent fractures)
• Illiac wing fractures exiting through the SIJ are crescent #.
• Crescent fragment is the variable sized that contains the
PSIS and PIIS and remains attached to the sacrum.
• Smaller the “CRESCENT” fragment > damage to posterior
59. SACRAL Fractures
• Can be regarded as a pelvic injury, spinal injury
Indications for fixation:Ant and post ring disruption with vertical sheer
Comminuted # with rotation
Rarely in impacted # with Internal rotation
60. Illiosacral screw
61. Spinal-Pelvic fixation
1. Spinal point of fixation- L5(usually)
2. Illiac screw just inf to PSIS
3. Illiac screw is connected to pedicle screw with appropriate
rods and screw-rod clamps
This bypasses the lines of force transmission from spine to illium
through the construct instead of the sacrum
62. Post-Operative Care
• Mobized to chair 1st day post-op
• Toe touch weight bearing upto 10 weeks
• Stable injuries immediate post-op FWB.
• DVT prophylaxis.
• Prophylaxis for hetereropic ossification.
Inability to achieve reduction
Newly recognized post-op neurologic deficits
Loss of fixation and reduction
64. ACETABULAR FRACTURES
• Generally caused by high energy trauma
• Such high energy injuries usually have a high
incidence of major associated injuries
• The fracture or fracture dislocation produced
depends on the magnitude and the direction of
the injuring force as well as on the strength of
• Fractures depend
on the position of
the femoral head
at the moment of
Posterior column #
Anterior column #
Superior dome #
Inferior aspect of the
67. Acetabulum - Anatomy
• Incomplete hemispherical
socket with an
– inverted horse-shoe shaped
– non articulating cotyloid
• The articular surface is
composed of and supported
by two columns of bone
(described by Letournel and
Judet) as an inverted ‘Y’
68. Acetabulum – Anatomy
‘The Column Concept’
• Used in the classification of the fractures
• The anterior column
– Iliac crest, iliac spines, the anterior half of the acetabulum
and the pubis.
• The posterior column
– Ischium, ischial spine, posterior half of the acetabulum and
the dense bone forming the sciatic notch
• The shorter posterior column ends at its intersection
with the anterior column at the top of the sciatic
69. Acetabulum - Anatomy
• The dome or roof is the weight bearing
portion of the articular surface that supports
the femoral head
• The quadrilateral surface is the flat plate of
bone forming the lateral border of the pelvic
• The iliopectineal eminence is the prominence
in the anterior column that lies directly over
the femoral head.
70. Acetabulum – Anatomy
• The sciatic nerve
• The superior gluteal Artery and Nerve
• Corona mortis
(Letournel and Judet)
• Simple fractures
– fractures of the posterior wall, posterior column,
anterior wall, anterior column and transverse
• Associated fractures
– T-shaped fractures, fractures of the posterior
column and posterior wall, transverse + posterior
wall fracture, anterior fracture + hemitransverse
posterior fracture and both column fracture.
72. Signs and symptoms
• Apart from local examination
– Look out for associated life threatening injuries
– A, B, C first before the rest
– Older patients
• Arrhythmia, transient ischemic attacks may have led to the fall
– SDH can occur when older patients fall.
73. Radiographic Evaluation
– A CT scan
– 3 plain radiographic views
• Antero-posterior view of the hip
• 45° iliac oblique view
• 45° obturator oblique view
Judet view 45° oblique view
74. Plain Radiographs
1 - AP View
• Start evaluation with this view
• Iliopectineal line – represents the anterior column;
Ilioischial line – represents the posterior column; Posterior
lip – represents the posterior wall; Anterior lip – represents
the anterior wall; Dome; Tear-drop
75. Plain Radiographs
2 - The obturator oblique view
• Anterior column
• Posterior wall
fragments and their
77. CT Scan
• 3 mm interval axial cuts
• Include the entire pelvis to
avoid missing a portion of
• Compare with opposite hip
Anterior and posterior wall fragments, marginal
impaction, retained bone fragments in the joint,
comminution, presence or absence of a dislocations
and any sacroiliac joint pathology.
• Initial treatment – follow ATLS protocols
• Operative treatment of acetabular fractures
are usually not performed as an emergency
• Normally, a closed reduction Skeletal
79. Operative Surgical anatomy
• Posterior wall fragments
– vary in the size and degree of comminution
– Well appreciated in a CT scan.
– Unrecognized fracture lines maybe detected at
– So the posterior wall fracture should never be
fixed with lag screw alone.
– The posterior wall fragment receives its blood
supply from the capsule avoid detaching the
capsule from its blood supply.
80. Operative Surgical anatomy
• Posterior Column fractures
– Can occur anywhere along the posterior column
from the ischial spine to the sciatic notch.
– Typically, the column fragment rotates.
– It is necessary to derotate the fragment and check
81. Operative Surgical anatomy
• Anterior Column fractures
– Occur at various levels along the anterior column.
– Although the pubic ramus is part of the anterior
column, ramus fracture usually indicates the
presence of a pelvic fracture rather than an
82. Operative Surgical anatomy
• Transverse fractures
– Run across the acetabulum.
– transtectal: fracture courses through the weight-bearing
– juxtatectal: fracture courses above the cotyloid fossa, so
that a significant portion of the wt bearing dome is left
– infratectal: fracture courses below the wt bearing dome.
• T-type fractures
– Transverse fracture with a fracture line seperating the
anterior column from the posterior column
83. Operative Surgical anatomy
• Anterior and posterior hemi-transverse
– This is an anterior column fracture with and
additional fracture line that runs transversely
across the posterior column.
– Here, the displacement is usually anterior and the
posterior column not significantly disturbed.
– Thus reducing the anterior column usually reduces
the posterior column.
84. Operative Surgical anatomy
• Both column fractures
– Entire acetabulum is separated from the axial skeleton.
– Sometimes, it is called as a floating acetabulum.
– Since the entire acetabulum is separated from the ilium,
the actual joint can appear congruent.
– This radiographic appearance is called the secondary
– Spur sign
85. Spur sign
• Pathognomonic of both
column fratures. see in
obturator oblique view
87. Kocher – Langenbeck approach
• The Kocher-Langenbeck
approach is a
nonextensile approach to
the posterior acetabular
88. Outline all bony landmarks
with a sterile marking pen:
(1) posterior superior iliac
(2) greater trochanter
(3) shaft of femur
incise the subcutaneous
the gluteus maximus muscle
the tractus iliotibialis (using a
89. Isolate the piriformis tendon
and the conjoined tendons
of the obturator internus and
superior and inferior gemelli
They are tagged and incised
1 cm lateral from their
90. Illio-Inguinal Approach
developed by Emile
Letournel based on
to provide anterior
access for fractures
of the acetabulum.
91. Illio-Inguinal Approach
Make a curved incision beginning
posterior to the ASIS and extend
past the midline 2 cm proximal to
the external oblique aponeurosis
is incised from the ASIS to the
lateral border of the rectus
sheath, passing cranial to the
external inguinal ring.
92. Illio-Inguinal Approach
Mobilize the spermatic cord or round
ligament in a sling. The posterior wall
of the inguinal canal is now exposed
Divide the rectus abdominal muscle 1 cm
proximal to its insertion into the symphysis
pubis. Divide the muscles forming the
posterior wall of the inguinal canal
Ligate and divide the inferior epigastric
93. Illio-Inguinal Approach
Using a swab, push the peritoneum upwards to
reveal the femoral vessels. Mobilize the iliacus
muscle from the inner aspect of the ilium.
Isolate the femoral vessels together in the
femoral sheath and protect them with a rubber
sling. Pass a second sling around the tendon of
iliopsoas with the femoral nerve lying on top of it
94. • The first window encompasses the entire internal
iliac fossa from the sacroiliac joint posteriorly to
the iliopectineal eminence anteriorly.
• The second window provides access to the pelvic
brim and quadrilateral surface from the sacroiliac
joint to the lateral third of the superior pubic
• Through the third window the entire medial
portion of the superior ramus and symphysis can
95. Extended Iliofemoral approach
• It gives excellent visualization of the ilium, the superior
dome and the posterior column. The anterior column can
be seen up to the iliopectineal eminence. This exposure is
similar to that provided by the triradiate approach with the
additional benefit of access to the bone above the sciatic
96. Triradiate transtrochanteric
• It is ideal for fractures with both column injuries where in the
entire outer table of the pelvis from the anterior superior iliac
spine to the top of the sciatic notch can be seen.
97. Combined anterior and posterior
• Patient is in lateral position with no fixed support. It allows
for the surgeon to roll the patient prone or supine if
98. Approaches for specific fractures
99. Approaches for specific fractures
100. Indications for non-operative treatment
• Non displaced and minimally displaced
• Fractures that traverse the wt bearing dome,
but with less than 2 mm displacement –
managed by non wt bearing and or skeletal
traction for 8 weeks.
101. Indications for non-operative treatment
• Fractures with significant displacement but, in which the
region of the joint involved is judged to be unimportant
• This can be determined by the roof arc measurement
described by Matta and Olson as 45 degrees for each roof arc,
medial, anterior and posterior.
• Most authors agree that displaced fractures through the
weight bearing dome should be treated with ORIF, regardless
of how they ‘line up’ in traction.
102. Roof arc measurement
103. Medical contraindications to surgery
• Multisystem injury
• An open wound in the anticipated surgical
field The Morel – Lavallée lesion
• Presence of a suprapubic catheter is a
contraindication for ilioinguinal approach.
• Elderly patients with osteoporotic bone –
where ORIF may not be feasible.
104. Indications for operative treatment
• In fracture incongruity due to
– Posterior column or wall injuries
– Displaced fractures of the superior dome
– Retained bony fragments
• In the limb
– Sciatic nerve injury
– Fracture of the ipsilateral femur
– Injury to the ipsilateral knee
• In the patient – polytraumatised patient
105. Treatment of specific fracture patterns
• Posterior wall fractures
– Posterior Langenbeck approach with the patient
positioned either prone or lateral using lag screw and a
reconstruction plate placed from the ischium over the
retro acetabular surface onto the lateral ileum. (If the
fracture extends superiorly into the dome, a trochanteric
osteotomy may be performed to allow additional
– To avoid AVN of the posterior wall, the posterior wall
fragments must not be detached from the posterior
capsule. The knee must be kept flexed throughout the
procedure to avoid injury to the sciatic nerve.
106. Treatment of specific fracture patterns
• Posterior column fracture
– Though uncommon if significantly displaced, requires ORIF
(Kocher Langenbeck approach).
– Typical fixation is with a lag screw combined with a
contoured reconstruction plate along the posterior
– Rotational deformity must be corrected by placing a Shanz
screw in the ischium to control rotation while the fracture
is reduced with a reduction clamp
107. Treatment of specific fracture patterns
• Anterior wall and anterior column fracture
– Isolated anterior wall fractures are uncommon.
– Sometimes, they are associated with anterior hip
– Fractures requiring surgery are fixed with a buttress plate
applied through an ilioinguinal or iliofemoral approach.
– Anterior column fractures are approach similarly with
fixation by a contoured plate along with a pelvic brim.
108. Treatment of specific fracture patterns
• Transverse fractures
– Transtectal fractures have the worst prognosis and
accurate reduction is essential.
– Juxtatectal fractures also usually require reduction.
– Typical reduction is through a posterior approach using a
Farabeuf clamp to reduce the fractures while rotation is
controlled by a Shanz screw in the ischium.
– Posterior fixation typically is with a buttress plate along the
posterior column and anterior fixation using a lag screw
placed into the anterior column from a position above the
109. Treatment of specific fracture patterns
• Posterior Column fracture with associated posterior
– A Kocher-Langenbeck approach is used with or with out a
– The column fracture is reduced first.
– A short reconstruction plate is placed posteriorly along the
posterior edge of the column. A separate plate is used for
the wall fragment.
– T screws through the plate secure rotational reduction on
the posterior column fragment.
110. Treatment of specific fracture patterns
• Transverse fracture with associated posterior
– The common fracture can be difficult to reduce.
– The posterior wall component requires a posterior
exposure, but reduction of the anterior part of the
transverse fracture can be difficult through a
Kocher-Langenbeck approach and extensile or
combined approach is frequently necessary.
111. Treatment of specific fracture patterns
• T-type and anterior column-posterior Hemitransverse fracture
– They are treated through an ilioinguinal approach with a
contoured plate placed along the pelvic brim and lag
screws extending into the posterior column.
– For a T-type fracture with severe posterior displacement
but minimal anterior displacement, posterior approach
alone may be sufficient with placement of anterior column
– If both the anterior and posterior components of the
fracture are significantly displaced, an extensive or
combined approach are required.
112. Treatment of specific fracture patterns
• Both column fractures
– These have varying degrees of comminution and can be
extremely complex and difficult to treat.
– Many both column fractures can be treated through an
anterior ilioinguinal approach.
– But a posterior or extensile exposure is required for
involvement of the sacroiliac joint, significant posterior
wall fracture, or intraarticular comminution.
– Reduction is begun from the most proximal portion of the
fracture and proceed towards the joint.
113. Implants for acetabular fractures
114. Post-operative care
Closed suction drain
Antibiotic for 48 – 72 hours
Passive motion of the hip on the 2nd or 3rd day.
Touch down ambulation & crutches on 2nd to 4th
• The minimal weight bearing status is continued for 8
weeks in patients with simple fractures and 12 weeks
in most others.
• Rehabilitation of the abductor muscle group is
– Thromboembolic disease
116. Specific Complications
• Sciatic nerve injury
– Thirty percentage of acetabular fractures have associated
sciatic nerve injury.
– In 2 – 6 % of patients, it occurs as a result of surgery and is
more often associated with posterior fracture pattern
treated through a Kocher-Langenbeck and extensile
– The peroneal component of sciatic nerve is more often
involved than the tibial component.
– Complete peroneal palsies have the worst prognosis. Tibial
component has greater chances of recovery.
117. Specific Complications
• Other nerves
– Femoral nerve injury – though rare, care to be taken
during the anterior ilioinguinal approach.
– Superior Gluteal nerve injury is vulnerable in the greater
sciatic notch, resulting in abductor paralysis.
– Pudendal nerve injury
– Injury to the lateral femoral cutaneous nerve causes
sensory loss in the lateral aspect of the thigh.