AN OVERVIEW ABOUT PELVIC RING FRACTURES WHICH INCLUDES RESUSCITATION, DIAGNOSIS , CLASSIFICATION AND MANAGEMENT OPTIONS

1. PELVIC RING FACTURES
DR.K.VINOTHKUMAR
OGH,HYDERABAD

3. LEARNING OBJCTIVES
• ANATOMY OF PELVIS
• IMAGING
• CLASSIFICATION OF PELVIC FRACTURES
• APPROACHES
• TREATMENT
• NON OPREATIVE
• OPERATIVE

4. ANATOMY

6. LIGAMENTS

8. ANOMALIES
SACRLISATION OF LUMBAR VERTEBRA LUMARISATION OF SACRAL VERTEBRA

10. IMAGING
• UNLIKE OTHER LONG BONES PELVIS IS A COMPLEX 3 DIMENSIONAL
STRUCTURE

11. INLET VIEW
• INTERNAL OR EXTERNAL RETOATION OF
HEMIPELVIS
• OPENING OF SI JOINT
• IMPACTION # OF SACRAL ALA
• AP DISPLACEMENT OF POSTERIOR RING
OUTLET VIEW
• SACRAL FRACTURES WITH RESPECT TO
FORAMINA.

12. XRAY POSITIONING
25° CAUDAL 60° CEPHALAD

14. CT
• CT SCAN CAN AID IN THE RECOGNITION OF MANY OF THESE INJURIES
THAT GO UNDETECTED ON PLAIN RADIOGRAPHS
• THE 3D AND OTHER RECONSTRUCTED IMAGES CAN ASSIST IN
DETERMINATION OF THE SURGICAL APPROACH
STRESS VIEWS : TAKEN UNDER ANEASTHESIA MAY REVEAL
SOME INSTABILITY WHICH IS NOT SEEN IN NORMAL XRAYS

15. CLASSIFICATION
STABLE FRACTURES
ROTATIONALLY UNSTABLE
VERTICALLY STABLE
ROTATIONALLY UNSTABLE
VERTICALLY UNSTABLE

16. YOUNG BURGESS CLASSIFICAITON
• BASED ON MECHANISM OF INJURY

17. Vertical Shear

18. LATERAL COMPRESSION (LC I)
ANTERIOR INJURY: PUBIC RAMI #
POST INJURY: SACRAL # ON SIDE
OF IMAPACT

19. LATERAL COMPRESSION - II
ANTERIOR INJURY: RAMI #
POSTERIOR INJURY:
CRESCENT# (FRACTURE
DISLOCATION OF ILIUM
THROUGH SI JOINT)

20. LATERAL COMPRESSION III (WIND SWEPT PELVIS)
TYPE I OR II INJURY ON SIDE OF IMPACT +
CONTRALATERAL OPEN BOOK INJURY

23. ANTERO POSTERIOR COMPRESSION (APC I)
[ANTERIOR INJURY= SYMPHYSIS DIASTASIS/ RAMI #]
MODE OF INJURY: SEVERE EXTERNAL
ROTATION OF ONE HEMIPELVIS
ANTERIOR INJURY: PUBIC DIASTASIS < 2.5 CM
POSTERIOR INJURY: MILD ANTERIOR
OPENING OF SI JOINT

24. APC II ANT. INJURY: PUBIC DIASTSIS >2.5 CM
POST. INJURY:OPENING OF ANTERIOR SI
JOINT, INACT POSTERIOR SI
LIGAMENTS,RUPTURE OF ANTERIOR SI
LIGAMENTS
(SACROTUBEROUS,
SACROSPINOUS,ANTERIOR SACROILIAC)

25. APC III – COMPLETE SI JOINT DISRUPTION
DISRUPTION OF
INTRAARTICULAR AND
POSTERIOR SI LIGAMENTS .

26. VERTICAL SHEAR
• PRIMARY FORCE VECTOR IS DIRECTED CEPHALAD.
• HEMI PELVIS SHIFTED VERTICALLY
• AVULSION # OF L5 INDICATES UNSTABLE # (ILIO LUMBAR LIGAMENT DISRUPTION)

27. COMBINED MECHANISM
• RESULT OF MULTIPLE FORCE VECTORS

28. DENIS CLASSIFICATION OF SACRAL FRACTURES
• BASED ON FRACTURE LINE IN RELATION WITH
SACRAL FORAMINA
• ZONE I – FRACTURE LINE LATERAL TO FORAMINA
• ZONE II – FRACTURE LINE THROUGH THE
FORAMINA, HIGH CHANCE OF SACRAL NERVE
INJURY
• ZONE III – FRACTURE MEDIAL TO FORAMINA, HIGH
RISK OF INJURY TO SPINAL CANAL

30. MANAGEMENT
NON OPERATIVE TRATMENT: INDICATIONS :-
• STABLE PELVIC RING INJURIES (LC – I)
• STABLE SACRAL INJURIES. (RISK OF LATE DISPLACEMENT)
• COMORBIDITIES PRECLUDING SURGICAL INTERVENTION
• POOR BONE QUALITY WHERE SCREW PURCHASE MAY BE
PROBLEMATIC
• THE LOW-ENERGY OSTEOPOROTIC PELVIC RING FRACTURE

31. OPERATIVE MANAGEMENT - GENERAL PRINCIPLES:
• POSTERIOR INJURY IS REGARDED AS THE MORE CRITICAL ONE REQUIRING AN
ACCURATE REDUCTION AND STABLE FIXATION.
• ANTERIOR FIXATION CAN NEITHER MAINTAIN POSTERIOR REDUCTION NOR
RESTORE STABILITY
• IN CEPHALAD DISPLACEMENT OF THE HEMIPELVIS WITH COMPLETE INSTABILITY
OF THE POSTERIOR RING, POSTERIOR FIXATION SHOULD ALWAYS BE
SUPPLEMENTED WITH ANTERIOR STABILIZATION
• POSTERIOR PELVIC RING SHOULD BE REDUCED AND STABILIZED FIRST, FOLLOWED
BY ANTERIOR PELVIC RING

32. ANTERIOR RING
• EXTERNAL FIXATION
• PUBIC SYMPHYSIS
PLATING
• PUBIC RAMI PLATING
• PUBIC RAMI PC SCREW
FIXATION
POSTERIOR RING
• SACROILIAC SCREW
FIXATION
• SI JOINT PLATING
• ILIAC WING PLATE/SREW

33. EXTERNAL FIXATION:
INDICATIONS:
• AS AN EMERGENCY PROCEDURE
• TO REDUCE THE POSTERIOR LESION PRIOR TO POSTERIOR
STABILIZATION.
• DEFINITIVE FIXATION: WHEN INTERNAL FIXATION CANNOT BE DONE
( WOUNDS, SPC, TO AVOID MORBIDITY OF OPEN PROCEDURE)
• COMMUNITED FRACTURES

34. TYPES
ILIAC CREST PIN FIXATION SUPRA ACETABULAR PIN FIXATION

35. ILIAC CREST PIN FIXATION
• SITE: 2 CM POSTERIOR TO ASIS. AVOID INJURY TO LATERAL FEMORAL
CUTANEOUS NERVE
• STARTING POINT: INNER 1/3RD MIDDLE 1/3RD JUNCTION.
• PIN DIRECTION: 25 - 40° MEDIALLY 10-15 ° CAUDAL.
• PIN THICKNESS: 5 MM
• UNICORTICAL DRILL HOLE . NOT MORE THAN 2CM DEEP.
• SECOND PIN 2 CM POTERIOR TO FIRST ONE . PINS APPEARS TO
CONVERGE

36. PROCEDURE
ASIS
AIIS
INCISION OVER ILIAC CREST 2 CM BEHIND THE ASIS

37. DRILLING THE FIRST CORTEX ADVANCING THE PIN BETWEEN TWO TABLES OF ILIAC BONE

38. GUIDING PIN WHICH INSERTED
BETWEEN THE ILIACUS AND
INNER TABLE
ILIAC CREST PIN

39. SUPRA ACETABULAR PIN TECHNIQUE:
• BIOMECHANICALLY STRONGER.
• PATIENT CAN SIT.
• FLUROSCOPY DEPENDENT
• SITE: 4-6 CM INFERIOR, 3-4 CM MEDIAL TO ASIS.
• STARTING POINT: AIIS .
• PIN DIRECTION: 10-20 CRANIALLY, 20-30 MEDIALLY. TOWARDS PIIS
• SECOND PIN: 2CM SUPERIOR

42. PELVIC INFIX
• DONE BY ADAPTING SPINAL INSTRUMENTS TO PELVIS
• INSERTION OF PEDICLE SCREW AS SUPRA ACETABULAR PIN
• SPINAL ROD CONTURED, CUT AND PASSED BETWEEN ABDOMINAL
FAT LAYER AND RECTUS.

44. INTERNAL FIXATION TECHNIQUES
ANTERIOR FIXATION:
INDICATIONS:
• PUBIC DIASTASIS >2.5 CM
• AUGMENTATION OF POSTERIOR FIXATION IN UNSTABLE PELVIC RING
INJURIES
• SIGNIFICANTLY DISPLACED RAMI FRACTURES
• LOCKED SYMPHYSIS
• STRADDLE FRACTURES (BILATERAL SUPERIOR AND INFERIOR RAMI
FRACTURES)
• PAIN AND INABILITY TO MOBILIZE (RELATIVE INDICATION)

45. CONTRAINDICATIONS:
• BLADDER RUPTURE
• COLOSTOMY
• SUPRAPUBIC CATHETER
• APPROACHES:STOPPA APPROACH
PFANNENSTIEL INCISION
SKIN INCISION WITH EXPOSED FASCIA

46. LINEA ALBA EXPOSED

50. FIXATION OF RAMI FRACTURES
• MANY FRACTURES CAN BE TREATED CONSERVATIVELY
• USED FOR GROSSLY DISPLACED RAMI # OR AUGMENT POSTERIOR
FIXATION
• APPROACH: EXTENSION OF STOPPA OR ILIOINGUINAL APPROACH

52. PERCUTANEOUS SCREW FIXATION
• AVOIDS EXTENSIVE DISSECTION OF OPEN REDUCTION.
ANTEROGRADE SCREW (RIGHT)
• THE STARTING POIN MIDPOINT ON A
LINE BETWEEN THE TIP OF THE
GREATER TROCHANTER AND A SPOT
ABOUT 4 CM POSTERIOR TO THE ASIS
RETROGRADE SCREW (LEFT)
• ENTER JUST LATERAL TO PUBIC
TUBERCLE

54. POSTERIOR RING FIXATION
INDICATION
• SI DISLOCATION
• DISPLACED CRESCENT FRACTURES
• SACRAL FRACTURES
• LUMBOPELVIC DISASSOCIATION

55. PERCUTANEOUS VS OPEN
OPEN SI JOINT REDUCTION
• COMBINED ACETABULUM FRACTURE
• PERCUTANEOUS REDUCTION NOT
ADEQUATE
• NO LINEAR REDUCTION VECTOR
PERCUTANEOUS
• LESS INVASIVE
• AVOID WOUND COMPLICATIONS
• LINEAR REDUCTION VECTOR AVAILABLE

57. ILIOSACRAL SCREW FIXATION
• INDICATIONS: SI JOINT
DISLOCATIONS, CRESCENT
FRACTURE,SACRAL BODY
FRACTURE
• POSITION : SUPINE/ PRONE
• SITE: INTRSECTION OF LINE
DRAWN FROM GT AND ASIS
• STARTING POINT:

58. INLET VIEW OUTLET VIEW

59. BILATERAL SI JOINT
FIXATION

60. SI SCREW FOR SACRAL FRACTURE
FOR COMPLETE FRACTURE
WITHOUT DISPLACEMENT AND
NEUROLOGICAL INJURY

61. APPROACHES-ANTERIOR APPROACH

63. • FRACTURES FIXED:ILIAC WING FRACTURE
CRESCENT FRACTURE
SI JOINT DISLOCATION

64. POSTERIOR MIDLINE APPROACH
• COMMUNITED SACRAL
FRACTURES
• WHEN LAMINECTOMY
NEEDED

65. POSTERIOR APPROACH TO SI JOINT

66. ZONE I – SACROILIAC SCREW, PARTIALLY THREADED
ZONE II – 1)UNDISPLACED,NON COMMUNITED-
PARTIALLY THREADED SCREW
2)COMMUNITED FRACTURE- FULLY THREADED
3)WITH NERVE INJURY – OPEN REDUCTION
AND DECOMPRESSION
ZONE III – UNDISPLACED – SI SCREW PARTIALLY
THREADED

67. CRESCENT FRACTURES
TYPE I – TREATED LIKE ILIAC WING
FRACTURE
ANTERIOR APPROACH
LAG SCREWS
TYPE II – POSTERIOR APPROACH
LAG SCREW FIXATION
TYPE III – POSTERIOR APPPROACH
LAG SCREW/ SI SCREW

69. THANK YOU