pelvic fractures

1. PELVIC INJURIES
Dr. HARSHA NANDINI TALASILA
M.S. ORTHO

2. ANATOMY
• Pelvic ring is composed of
1. Sacrum
2. 2 innominate bones
• These are joined together
Anteriorly at the symphysis
Posteriorly at the paired
sacroiliac joints

3. • The innominate bone is formed at
maturity by the fusion of 3 ossification
centres
• ILIUM ISCHIUM and PUBIS through
triradiate cartilage at the dome of
acetabulum.
• The pelvic brim is formed by the arcuate
lines that join the sacral promontory
posteriorly and superior pubis anteriorly.
• Below this is the true or lesser pelvis
contains the pelvic viscera
• Above this is the false or greater pelvis
represents the inferior aspect of the
abdominal cavity.

5. LIGAMENTS
• SACRUM TO ILIUM
1. Sacroiliac ligaments
a) Anterior
b) Posterior –long and short
2. Sacro tuberous ligament: runs from the posterolateral aspect of the
sacrum and the dorsal aspect of the posterior iliac spine to the ischial
tuberosity
3. Sacrospinous ligament: lateral margins of the sacrum and coccyx
and inserts on the ischial spine.

6. • Lumbar spine to pelvic ring:
1. Iliolumbar ligaments : originate from L4-L5 transverse processes and
insert on the posterior iliac crest
2. Lumbosacral ligaments: transverse process of L5 to the ala of the
sacrum.

9. MECHANISM OF INJURY
• Low energy Injuries : fractures of individual bones
• High energy injuries : pelvic ring disruption

10. LATERAL COMPRESSION
• Most common mode of violence
• When lateral compression force
is directed to the posterior ilium
a sacral impaction fracture (
stable fracture ) with pubic rami
fracture.
• When the LC force is applied to
the greater trochanter a
transverse acetabular fracture is
the result.

11. • When LC force is directed to
anterior iliac wing, in addition to
sacral impaction, the hemipelvis
will be pushed into the
contralateral side (pushing the
opposite hemipelvis out into
external rotation) producing a
lateral compression injury on the
ipsilateral side and external
rotation injury on the
contralateral side ( BUCKET
HANDLE INJURY).

12. ANTEROPOSTERIOR COMPRESSION
• Anteriorly applied force from
direct impact or indirectly
transferred via the lower
extremities or ischial
tuberosities resulting in external
rotation injuries, symphysis
diastasis or longitudinal rami
fractures.

13. SHEAR FORCE
• This leads to a completely unstable fracture with triplanar instability
secondary to disruption of the sacrospinous,sacrotuberous and
sacroiliac ligament

14. Clinical evaluation
ATLS PROTOCOL
• AIRWAY
• BREATHING
• CIRCULATION – hypovolaemic shock
• DISABILITY
• EXPOSURE
CONTINUOUS RE-EVALUATION
Evaluate for other injuries to head, chest, abdomen and spine and limbs

15. INSPECTION
•Skin around the perineum
•Bleeding PV/PR/PU
•Deformity of lower limbs
•Abnormal extremity rotation

16. PALPATION
• Pelvic compression test
•Posteriorly :Hematoma---SIJ disruption
•Distal neurovascular deficits

17. • ROUX’S Sign: distance measured from the greater trochanter to the
pubic crest is diminished on one side, as compared with the other, as
might result from an overlapping anterior ring fracture.
• EARLE'S SIGN—occurs when a large hematoma, an abnormal palpable
bony prominence, or a tender fracture line is detected on a rectal
examination

18. Measures for emergency haemorrhage
control
• Military antishock trousers
• Wrapping of a pelvic binder circumferentially around the pelvis
• Pelvic C- Clamp: a posteriorly applied device that may offer greater
stability to vertically unstable fractures.
• Anterior external fixator
• ORIF can be done if the patient is undergoing emergency laparotomy
for other indications

19. Pelvic Sheet : Circumferential compression
Using a sheet around trochanteric area

20. Role of External Pelvic Fixation
• Tamponade effect
• Stabilizes clots
• Required for unstable fracture in
unstable patient
• Patients with unstable fractures
undergoing laparotomy

21. NEUROLOGICAL INJURY
• Lumbosacral plexus and nerve root injuries may be present
• High incidence with sacral fractueres

22. GENITO URINARY AND GASTROINTESTINAL
INJURY
• 1) Bladder injury: 20% incidence with pelvic trauma
Extraperitoneal : treated with foley’s or suprapubic catheterization
Intraperitoneal : requires repair
• 2) Urethral injury: 10% incidence
Male>Female
Examine for blood at meatus or blood on catheterization
Examine for high riding or floating prostate on rectal examination.
Clinical suspiscion should be followed by a retrograde urethrogram.
• 3) BOWEL INJURY

23. RADIOGRAPHIC EVALUATION

24. 1 .Plain Radiographs-APview

25. • Symphyseal displacement
• Pelvic ring
• L5 transverse process
• Associated acetabular and
proximal femur
PlainRadiographs-APview

26. 2. PlainRadiographs-Inletview

27. Anterior/posterior Displacement of Sacrum, SIJ, Ilium,
symphysis
Rotational deformities of ilium
Impacted sacral fractures

28. 3. PlainRadiography-Outletview
•Adequate image when
pubic symphysis overlies
S2 body
•Sacrum
•Cephalad Displacement
•Sacral Foramina

29. CT Scan
• Better defines posterior injury
• Amount of displacement versus impaction
• Rotation of fragments
• Amount of comminution
• Assess neural foramina

30. 3D CT

31. MRI
• Limitedrole.
• GUandVascularstructures

32. Young and Burgess
Classification
Based on the mechanism of the injury

33. LATERAL COMPRESSION
• TYPE I: sacral impaction on the side of impact

34. • TYPE II:crescent or iliac wing fracture on the side of the impact.

35. • Type III:LC-I or LC-II on the side of impact, force is continued to
contralateral hemipelvis to produce an external rotation injury(
WINDSWEPT PELVIS)

36. ANTEROPOSTERIOR COMPRESSION INJURIES

37. ANTERO-POSTERIOR COMPRESSION INJURY
• TYPE I: less than 2.5cm of symphysis diastasis. Vertical fractures of
one or both pubic rami occur with intact posterior ligaments.
• TYPE II: more than 2.5cm of symphysis diastasis. Widening of
sacroiliac joints, caused by anterior sacroiliac,sacrotuberous and
sacrospinous ligaments disruption. Intact posterior sacroiliac
ligaments
• TYPE III: complete sacroiliac joint disruption with lateral
displacement. Disrupted anterior sacroiliac,sacrotuberous and
sacrospinous, posterior sacroiliac ligaments.

38. AP - II

39. AP III

40. Vertical shear
• Symphyseal diastasis or vertical
displacement anteriorly and
posteriorly usually through the
sacroiliac joints, sometimes
through the iliac wing or sacrum.

41. COMBINATION MECHANICAL
• Combination of injuries often resulting from crush injuries
• Most common are VS and LC.

42. STRADDLE INJURY

43. ILIAC WING FRACTURE- DUVERNEY’S
FRACTURE
• Mechanism of Injury
• These fractures are usually the
result of a medially directed
force.
• A Duverney fracture may be due
to a high-energy force and,
therefore, may serve to alert the
clinician to other injuries.
• The iliac wing may at times
demonstrate medial
displacement

44. TILES CLASSIFICATION
Based on stability

45. Type A : Stable
A1: fractures of the pelvis not involving the ring; avulsion injuries
A2: stable, minimal displacement of the ring

46. TYPE B: rotationally unstable but vertically
stable
• TYPE B1: external rotation instability; open book injury
• TYPE B2: lateral compression injury; internal rotation instability;
ipsilateral only
• TYPE B3: lateral compression injury; bilateral rotational instability(
bucket handle)

47. TYPE C: rotationally and vertically unstable
• Type C1: unilateral injury
• Type C2: bilateral injury, one side rotationally unstable with
contralateral side vertically unstable
• Type C3: bilateral injury, both sides rotationally and vertically unstable
with associated acetabular fracture

48. RADIOLOGICAL EVIDENCES OF INSTABILITY
1. Sacrospinous ligaments avulsions( ischial spine or sacral border
fractures)
2. Iliolumbar ligament avulsion(L5 transverse process fracture)
3. Sacral fractures or sacroiliac joint displacement

49. MANAGEMENT

51. Non operative treatment-INDICATIONS
• Lateral impaction type injuries with minimal displacement<1.5cms
• Pubic rami fractures with no posterior displacement
• Pubic diastasis <2.5cms

52. Specific fracture treatment
1. Stable ( A1,A2) :protected weight bearing and symptomatic
treatment
2. Open book (B1) : symphyseal diastasis <2cm: protected weight
bearing
symphyseal diastasis >2cm: external fixation or symphyseal plate

53. 3. Lateral compression (B2,B3) :
• Ipsilateral only: no stabilization required
• Contralateral ( bucket handle)
Leg-length discrepancy <1.5cms: no stabilization required
Leg-length discrepancy >1.5cms: external fixation versus open
reduction and internal fixation.

54. 4. Rotationally and vertically unstable : (C1,C2,C3) external fixation
with or without skeletal traction or ORIF

55. Operative treatment
• External fixation
• Internal fixation

56. External fixation
• Pelvic clamp or fast assembling external fixator with pins may
be applied in emergency.
In acute phase it gives:
• A tamponade effect on the retroperitoneal hematoma,
effected by reducing the retroperitoneal volume
• Less motion of the fracture surfaces, which allows more
effective clot formation
• Greater patient mobility during transport and for CT scanning
and other evaluations.
• Same may be continued in some of the fractures types as
definitive treatment for 8 to 12 weeks.

57. Pin Placement
• 5 mm diameter pins with 16 to 22 mm lengths are required.
Pin positions proposed are:
-In iliac crest 2 to 3 cm posterior to ASIS.
-2 to 3 pins convergent towards central part of iliac bone widely
spaced.

58. Biplanar: one pin in crest.
another in the region of anterior inferior iliac spine.
-One or two pairs in supra-acetabular part of acetabulum.

59. -Choice has to be made according to how fast it is required to be
done and how long it is to be kept.
-Skin around entry site should be free of tension to prevent
necrosis which may end up in pin tract infection.
-These are hardly useful in maintaining posterior instability.
-Use of external fixator is limited in acute phase and as a
definitive treatment in open book injuries.

60. Pelvic clamp

61. Internal fixation
• Closed methods
Iliosacral screws
The screws should pass from posterior part of
iliac bone to 1st segment of sacrum not hitting
sacral first root.

62. • Rami fixations with screws: It is possible to fix rami with stab near pubic tubercle
and passing cannulated screw on a guide wire. Avoid injuring spermatic cord in
male patients

63. • ORIF of ramus with plate: Superior pubic ramus is usually
fixed with direct exposure from front. Care must be taken to
avoid injuries to femoral vessels and spermatic cord. This
may be necessary in vertical shear injuries or bad overriding
lateral compression injuries after open reduction.
Open reduction methods

64. • ORIF of iliac wing: Fractured iliac wing is exposed by incision along iliac crest and
after open reduction may be fixed with plate and/or screws.

65. ORIF of sacroiliac joint or adjacent iliac bone:
• Anterosuperior part of sacroiliac joint is exposed by incision along
crest on it anterior two third and dissecting on inner aspect of iliac
wing. Avoid injuring lumber fifth root as it passed on sacral ala.
Reduction is carried out by clamp which can catch hold temporary
screws. Two plates at right angles is placed on anterosuperior part
of sacroiliac joint.

66. • Transiliac plate fixation: Ten to twelve hole strong plate is little
over contoured to achieve compression and reduction, Plate
contoured in C shape is fixed with posterior parts of iliac bones
with screws some may be added on sacrum avoiding sacral
formina hit with screws.

67. • Iliolumbar fixation: This a very useful method in vertical shear
injuries with gross comminution at posterior part of pelvis
ring, Spinal instrumentation with fixation of lumber fifth and
fourth vertebra is achieved with transpedicular screws. This
which is stabilized with a rod to iliac bone screw after
reduction

68. COMPLICATIONS
• Thromboembolism : disruption of the pelvic venous vasculature and
immobilization constitute major risk factors for the development of deep
venous thromobosis
• Mortality :
1. Hemodynamically stable patients: 3%
2. Hemodynamically unstable patients : 38%
3. Lateral compression injury: head injury is the major cause of death
4. Anteroposterior compression injury : pelvic and visceral injury major
cause of death.
5. AP 3: 37%
6. Vertical shear : 25%

69. THANKYOU