Pelvic fractures

1. PELVIC FRACTURES
Dr Sanjay K
Junior resident
Orthopaedics
KMCT Medical College

2. • SURGICAL ANATOMY
• CLINICAL ASSESMENT
• IMAGING
• MECHANISM OF INJURY
• CLASSIFICATION
• TREATMENT
• COMPLICATIONS

3. • account for less than 5% of all skeletal injuries
• important due to the potential risk of severe blood loss.
• 10% - associated visceral injuries : mortality rate - 10%
• < 35 years : males sustain more pelvic fracures thaan
females
• > 35 years : females sustain more pelvic fractures than
males

4. SURGICAL ANATOMY
• The pelvic ring is made up
of the two innominate bones
and the sacrum, articulating in
front at the symphysis pubis and
posteriorly at the sacroiliac joints.
• This structure transmits weight
from the trunk to the lower limbs
• provides protection for the
pelvic viscera, vessels
and nerves.

5. PELVIC STABILITY
• anterior stability –
sacroiliac ligaments
and the iliolumbar ligaments
• posterior stability -
posterior sacroiliac ligaments,
sacrococcygeal ligaments,
sacrotuberous and
sacrospinous ligaments

6. • The superior pubic ligament and the arcuate pubic
ligament give rise to stability at the symphysis pubis..
• The major branches of the common iliac arteries and
veins arise within the pelvis between the level of the
sacroiliac joint and the greater sciatic notch

7. CLINICAL ASSESSMENT
• A fracture of the pelvis should be suspected in any multiply
injured patient.
• swelling and bruising of the lower abdomen, the thighs, the
perineum, the scrotum or the vulva.
• Guarding or tenderness over abdomen suggests the
possibility of intraperitoneal bleeding.
• Repeated assessment of an unstable pelvis will lead to
disruption of any clot formed; this may worsen haemorrhage.

8. • A ruptured bladder should be suspected in patients who
do not void or in whom a bladder is not palpable after
adequate fluid replacement.
• Bladder rupture may be intraperitoneal or extraperitoneal.
• Intraperitoneal rupture may be associated with massive
haemorrhage.
• Neurological examination is done to look for any damage
to the lumbosacral plexus

9. IMAGING
• An AP radiograph of the pelvis should be carefully
inspected, systematically looking in each of the five zones
of injury:
1. The sacroiliac joint area is inspected for any diastasis
or sacral fracture.
2. The ilium is inspected for any fracture.

10. 3. The teardrop is inspected – a radiological feature
which correlates to the non-articular floor of the
acetabulum,
• close inspection in this area will reveal any acetabular
fracture.

11. • 4. The obturator foramen is inspected for any fracture of
the superior or inferior pubic ramus.
• 5. The symphysis pubis is examined for any fracture or
diastasis.

12. A. Inlet view : provides an axial view of the sacrum and
sacroiliac joints
B. outlet view : provides a true anteroposterior view of the
sacrum and pubic symphysis areas.

14. • Judet views (taken at 30 degrees obliquely) comprise an
obturator and iliac oblique view .
• The obturator oblique view shows the anterior column of
the acetabulum
• Iliac oblique view shows the posterior column and anterior
wall of the acetabulum

15. • There are six lines that aid the diagnosis and
classification of acetabular fractures :
1. anterior wall of the acetabulum
2. posterior wall of the acetabulum
3. roof or dome of the acetabulum
4. iliopectineal line – corresponds
to the anterior column of the
acetabulum
5. Ischiopectineal line
6. Tear drop

16. MECHANISM OF INJURY
Divided into 2 types :
• Low energy injuries – result from sudden muscular
contractions in young athletes causing avulsion injury, low
energy fall or saddle-type injury (motorcycle or horse)
• High-energy injuries – result from a motor vehicle
accident, pedestrian-struck mechanism, motorcycle
accident, fall from heights or crush mechanism.

17. Stress fractures
• Fractures of the pubic rami are common in osteoporotic
bone.
• MRI helpful for the diagnosis of posterior insufficiency
fractures.
• Seen in the superior and inferior pubic rami in slim
individuals and long-distance runners.
• Patients may present with groin pain lasting a few weeks
or months

18. • radiographs will reveal the fracture, which becomes more
apparent when callus formation occurs during healing.
• Consideration should be given to checking vitamin D
levels in these patients to exclude deficiency.
• Patients usually heal with rest
• Rarely a painful
non-union may persist
which requires surgery.

19. CLASSIFICATION
• The Young and Burgess is a classification of pelvic ring
injuries based on the mechanism of injury
• The Tile classification provides an assessment of stability
of the pelvis.
• The mechanism of injury (Young and Burgess) is
predictive of the severity of the injury (blood loss) and also
guides the surgeon on how to correct any deformity or
displacement of the fracture,
• STABILITY (Tile) guides the surgeon as to whether an
injury needs operative fixation.

20. YOUNG AND BURGESS
CLASSIFICATION
1. ANTEROPOSTERIOR COMPRESSION (APC)
• Open book injury
• Results from a front-on force transmitted through the
pelvis.
• Initially the anterior structures open up (symphysis pubis)
and, as the energy increases, the posterior structures
(sacroiliac joint) are injured.
• Commonly seen in motorcyclists who straddle the bike
and horse riders.
• There is external rotation of both hemipelvis

21. • APC I – less than 2.5 cm of widening at the pubic
symphysis
• APC II – symphysis widening of more than 2.5 cm
with an anterior widening of a sacroiliac joint; the
posterior ligaments are intact
• APC III – widening of the
symphysis of more than
2.5 cm with a dislocation
of a sacroiliac joint

22. APC III

23. 2. LATERAL COMPRESSION (LC)
• Most common mode
• Result from the force applied to and transmitted from the
side of the pelvis.
• Commonly seen in pedestrians hit by an automobile, or
from a side-on impact where an automobile is hit.
• In the milder form one side of the hemipelvis is affected
and, as the energy increases, the injury is transmitted to
and affects the opposite side.

24. • LC I – rami fracture and ipsilateral anterior sacral alar
fracture (Figures)
• LC II – rami fracture and ipsilateral posterior ilium fracture
dislocation
• LC III – ipsilateral lateral compression and contralateral
APC pattern injury (windswept pelvis).

28. 3.VERTICAL SHEAR (VS)
• usually seen after a fall from height, landing on one leg
leading to one hemi pelvis being driven up.
• Complete disruption of symphysis, sacrotuberous,
sacrospinous and sacroiliac ligaments, cephaloposterior
displacement of sacroiliac joints.

30. TILE CLASSIFICATION
• Gives an accurate assessment of pelvic stability.
• Guides whether the patient may require surgery and
whether the patient can safely mobilize with their injury.
• Fractures are stable (type A), partially stable (type B) or
unstable (type C).

32. TREATMENT

34. PELVIC BINDERS
• The binder should be applied at the
level of greater trochanters of the hips
(not the iliac crest).
• Effective in closing the pelvic volume
and providing temporary stability
• Ideally, it should not be left on
for more than 24 hours as pressure
sores can develop.

35. ANGIOGRAPHY AND EMBOLIZATION
• Immediate transfer to the angiography suite for targeted
embolization is undertaken
• controls arterial bleeding only – the major vessels are the
internal iliac artery and superior gluteal artery.

36. PRE-PERITONEAL PACKING –
• An external fixator is swiftly applied, and the pelvis is
opened via the Stoppa approach
• the rectus abdominis muscle is divided in the midline.
• At least six large abdominal packs are inserted, three
either side of the midline: one posteriorly, one in the mid-
pelvis, and another anteriorly

37. NON- OPERATIVE
INDICATIONS:
• Most LC-1 and APC-1 fractures
• Gaping of pubic symphysis < 2.5 cm
• Pubic rami fractures with no posterior displacement

38. • Bed rest or traction is not favoured for the treatment of
pelvic injuries due to the complications of being immobile
in hospital for prolonged periods
• venous thromboembolism, chest sepsis, pressure sores
• Early mobilization with the use of walking aids is favoured
• patients may partially weight-bear as tolerated on the
affected side

39. OPERATIVE
Absolute Indications :
• Open pelvis fractures or those in which there is
associated visceral perforation requiring operative
intervention
• Open- book fractures or vertically unstable fractures with
associated patient hemodynamic instability

40. Relative Indications :
• Symphyseal diastasis > 2.5 cm (loss of mechanical
stability)
• Leg length discrepancy > 1.5 cm
• Rotational deformity
• Sacral displacement > 1 cm
• Intractable pin

41. EXTERNAL FIXATION
• Usually a temporary stabilising option
• Used as a definitive fixation in anterior pelvis fractures
• Two to three 5 mm pins spaced 1 mm apart along the
anterior iliac crest
• Use of single pins placed in the supraacetabular area in
an AP direction (Hanover frame )
• Acetabular and iliac wing fractures are contraindications
to external fixation
• Vertically unstable fractures treated with ipsilateral distal
femoral skeletal traction

43. • Temporary external fixators like Glanz c clamp and
Browner’s fixator help control the posterior pelvis in
vertically unstable fractures in resuscitation phase

44. INTERNAL FIXATION
• Diastasis of pubic symphysis : plate fixation used if no
open injury or cystostomy tube is present
• Sacral fractures : plate fixation or sacroiliac screw fixation

45. • Iliac wing fractures : ORIF using lag screws and
neutralization plates
• Unilateral sacroiliac dislocation : direct fixation with
cancellous screws or anterior sacroiliac plate fixation is
used
• Bilateral posterior unstable disruptions : Fixation of the
displaced portion of the pelvis to the sacral body by
posterior screw fixation

46. Specific fracture Treatment
Tile: Stabilisation Options
1. Stable (A1, A2): Protected weight bearing and
symptomatic treatment
2. Open book (B1)
Symphyseal diastasis <2 cm: protected weight
bearing
Symphyseal diastasis >2 cm: external fixation or
symphyseal plate

47. 3. Lateral compression (B2, B3)
Ipsilateral only: No stabilisation necessary
Contralateral (bucket handle):
• Leg-length discrepancy <1.5 cm: no stabilisation
necessary
• Leg-length discrepancy >1.5 cm: external fixation or open
reduction and internal fixation (ORIF)
4. Rotationally and vertically unstable (C1, C2, C3):
• external fixation with or without skeletal traction or ORIF.

48. GENITOURINARYAND
GASTROINTESTINAL INJURY
• Bladder injury: 20% incidence occurs with pelvic trauma.
• Extraperitoneal: treated with a Foley or suprapubic tube if
unable to pass.
• Intraperitoneal: requires repair.
• Urethral injury: 10% incidence occurs with pelvic
fractures, in male patients much more frequently than in
female patients.
• Examine for blood at the urethral meatus or blood on
catheterization.
• Examine for a high-riding or "floating" prostate on rectal
examination.
• Clinical suspicion should be followed by a retrograde
urethrogram.

49. NEUROLOGIC INJURY
• Lumbosacral plexus and nerve root injuries may be
present, but they may not be apparent in an unconscious
patient.
• Higher incidence with more medial sacral fractures
• Sacral fractures: neurologic injury
• Lateral to foramen (Denis 1): 6% injury
• Through foramen (Denis lI): 28% injury
• Medial to foramen (Denis Il|): 57% injury
• Decompression of sacral foramen may be indicated if
progressive loss of neural function occurs.
• It may take up to 3 years for recovery

50. BOWEL INJURY
• Perforations in the rectum or anus owing to osseous
fragments are technically open injuries and should be
treated as such.
• Infrequently, entrapment of bowel in the fracture site with
gastrointestinal obstruction may occur.
• If either is present, the patient should undergo diverting
colostomy.

51. Post operative care
• Aggressive pulmonary toilet should be pursued with
incentive spirometry, early mobilization.
• Prophylaxis against thromboembolic phenomena should
be undertaken, with a combination of elastic stockings,
sequential compression devices, and chemoprophylaxis if
hemodynamic and injury status allows.

52. Weight-bearing status may be advanced
as follows:
• Full weight bearing on the uninvolved lower extremity/sacral side
occurs within several days.
• Partial weight bearing on the involved side is recommended for at
least 6 weeks.
• Recently, weight-bearing as tolerated (WBAT) has been supported
in low-energy LC1 fractures.
• Full weight bearing on the affected side without crutches is
indicated by 12 weeks
• Patients with bilateral unstable pelvic fractures should be mobilized
from bed to chair with aggressive pulmonary toilet until
radiographic evidence of fracture healing is noted.
• Partial weight bearing on the "less" injured side is generally
tolerated by 12 weeks

53. Complications
1. Infections : 0-25%
2. Thromboembolism
3. Malunion - rare
4. Nonunion - rare, seen in young
5. Mortality
• Hemodynamically stable patients: 3%
• Hemodynamically unstable patients: 38%
• LC: head injury major cause of death
• APC: pelvic and visceral injury major cause of death
• VS: 25% death

54. REFERENCES
• Rockwood and Greens fractures in adults 8th edition
• Campbell’s operative orthopaedics 13th edition
• Apley and Solomon’s system of orthopaedics and trauma
10th edition
• Kenneth and koval handbook of fractures 6th edition

55. THANK YOU