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.
As is true of fractures of other bones, low-energy trauma to the pelvis generally produces stable fractures that can be treated symptomatically with crutch- or walker-assisted ambulation and that can be expected to heal uneventfully in most patients. High-energy pelvic fractures often are managed operatively, with the treatment method determined by the degree of pelvic stability remaining after the injury.
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.
The Young-Burgess (1986; 1987) system is as follows:
1. APC injury
The hallmark of the AP compression injury is pubic diastasis with or without disruption of the SI joints. The location and degree of diastasis is correlated with the magnitude of force imparted to the pelvis and with the amount of resulting instability. The AP compression causes the pelvis to open: one or both hemipelves undergo external rotation. According to the Young-Burgess classification system, 3 degrees of AP compression injury are identified.
APC- I injuries : Less than 2.5 cm of the pubic diastasis is noted, either at the symphysis or through vertically oriented rami fractures. The SI joints and posterior ligaments remain intact, and stability is maintained.
APC- II injuries : The amount of anterior diastasis exceeds 2.5 cm. In addition, diastasis occurs in 1 or both of the SI joints. This incomplete posterior arch disruption results in rotational instability. The posterior ligaments are not injured; therefore, vertical stability is preserved.
Lateral compression injury results in internal rotation of the affected hemipelvis. This internal rotation decreases rather than increases the pelvic volume. Consequently, pelvic vascular injuries and resulting hemorrhage are less common with this injury than with other injuries. Lateral compression injuries are associated with brain and intra-abdominal injuries.
LC- I injuries : These involve a force directed posteriorly to the lateral aspect of the hemipelvis, which results in an ipsilateral sacral buckle fractures; ipsilateral horizontal pubic rami fractures; or, less commonly, disruption of the pubic symphysis with overlap of the pubic bones. The posterior ligaments remain intact; therefore, the pelvis is stable.
LC- II injuries : These involve more internal rotation of the hemipelvis. As in type I injuries, ipsilateral sacral buckle fractures and horizontal pubic rami fractures are associated with fracture of the ipsilateral iliac wing or disruption of the ipsilateral posterior SI joint. The pelvis is rotationally unstable, but its vertical stability is maintained.
LC- III injuries : The force continues from the ipsilateral side across the midline to affect the contralateral hemipelvis. The ipsilateral hemipelvis sustains either a type I or type II injury with associated internal rotation. The contralateral pelvis undergoes external rotation. Contralateral vertical pubic rami fractures or disruption of the ligaments may occur. As in type II injuries, the pelvis is rotationally unstable but vertically stable.
A vertically oriented force applied to a hemipelvis, usually by the femur, results in a vertical shear injury. At the anterior aspect, vertically oriented fractures of the pubic rami occur. Posteriorly, the ipsilateral SI joint (or occasionally the contralateral SI joint) and its associated ligaments are disrupted.
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.
Neurological examination should be done to exclude sacral and lumber plexus injury.
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:
Open book injuries if the diastasis less than 2.5 cm only bed rest and posterior sling to close the book. If the diastasis more than 2.5 cm the book should be closed surgically either by closed reduction and external fixation or if the patient need laparotomy so open reduction and internal fixation by special plates and screws or by K. wire.