2. Introduction
• Incidence – 8-9% of all blunt injuries
• Challenging – requires multidisciplinary approach
• High morbidity and mortality
• High velocity pelvic injury – mortality ranges from 10-16%
3. Clinical anatomy
• Pelvis is made up of 3 bones – 2 innominate bone and sacrum
• It is divided into
• False pelvis – portion from iliac crests superiorly to the pelvic brim
inferiorly
• True pelvis – from the pelvic brim to the pelvic floor
• It is a strong ligamentous complex
4.
5.
6.
7. .
• iliac crest
• anterior superior iliac spine
• anterior inferior iliac spine
• acetabulum
• obturator foramen
• ischiopubic ramus
• pubic tubercle
• pectineal line of the pubis
• pubic crest
• pubic symphysis
• pelvic brim (separates the true from the
false pelvis)
• iliac fossa
• sacral promontory
• sacrum
• anterior sacral foramen
• ala of sacrum
• coccyx
• ischial spine
• pelvic brim extends from promontory of
the sacrum, arcuate line of the ilium,
pectineal line (pectin of pubis) and pubic
crest
Greater (false ) pelvis is located
above the pelvic brim and the lesser (
true ) pelvis below the brim.
9. Stability of the pelvic
• Depends on both bony and ligamentous structures
• Anterior portion of the pelvic ring neither participates in normal
weight bearing nor it is essential for maintenance of pelvic stability .
• Weight bearing portion : SI joints and ilia
• Posteriorsuperior SI ligaments provide most of the ligamentous
stability of the SI joints
10. Mechanism of injury
• Low velocity injury
Fall from height/ sports related injury
Adolscents and elderly
Avulsion fractures – adolscents
Pubic rami fractures - elderly
• High velocity injury
Motor vehicle accidents
young age
Hemodynamically unstable
Associated with pelvic visceral injury
11. Presentation
• History of high velocity injury
• Unable to stand and weight bear
• Bruising and contusion in perineal area
• Restricted and painful movement of lower limb
• Labial/scrotal hematoma
• Bleeding per urethra
• Neurological deficit – foot drop
12. Associated injury
• Head injury
• Chest injury
• Abdominal injury
• Pelvic visceral organ injury
• Genito-urinary injury
• Spine injury
• Long bone fracture
13. Milch signs
• Destot`s sign -------- large haematoma above inguinal ligament or
scrotum
• Roux`s sign --------- distance from greater trochanter to pubic spine is
increased on the affected side
• Earle`s sign -------- on per rectal examination , the bony prominence
or a large haematoma can be palpated
15. Computed tomography:
• for assessing the posterior pelvis, including the sacrum and sacroiliac
joints.
Magnetic resonance imaging:
• critically injured patient,
• provide superior imaging of genitourinary and pelvic vascular
structures
19. Classification of pelvic fractures
• Tiles classification – based on stability
• Young and Burgess – based on direction of force and associated
injuries
20.
21. Tile’s Classification
• TYPE A - Stable
A1—Fractures of the pelvis not involving the ring
A2—Stable, minimally displaced fractures of the ring
• TYPE B - Rotationally unstable, vertically stable
B1—Open book
B2—Lateral compression: ipsilateral
B3—Lateral compression: contralateral (bucket-handle)
• TYPE C - Rotationally and vertically unstable
C1—Rotationally and vertically unstable
C2—Bilateral
C3—Associated with an acetabular fracture
22.
23. AP Compression (APC) : - direct anterior force
AP1
• symphysis <2cm & ant. SI lig.
stretched
• low- to moderate-energy forces
(sports)
24. AP2
• symphysis >2cm & ant. SI lig. torn (+
the ligaments of the floor of the pelvis
- sacrotuberous and sacrospinous)
• High energy - 'Open book'
25. AP3
• Symphysis & ant & post SI lig.
torn
• High energy - pelvis rotates
externally
• Very Unstable
26. Lateral Compression (LC): unilateral pubic rami fractures, with
or without symphysis injury, and bilateral rami fractures, with or without pubic symphysis
injury.
LC1
• unilateral ramii & ipsilat
sacral compression.
• lateral force compressing
sacrum
Young and Burgess system
31. Stable pelvic fracture
• # do not involve the pelvic
ring and they are
minimally displaced
Unstable pelvic # :
• Involve the pelvic ring and
are widely displaced
34. • Hemodyanamically unstable pelvic injuries
• Early recognition of lethal traid of death
Metabolic acidosis
Hypothermia
Coagulopathy
35. Why do they bleed to death?
• No tamponade effect to prevent bleeding
• Volume of cylinder 4/3 pie R3
36. Hemorrhage control methods
• Pelvic containment
Sheet as a pelvic binder
Commercial pelvic binder
MAST
External fixator
All these reduce R
- Angiography
- Pelvic packing
65. Operative management
• APC II
Anterior ring fixation with or without posterior ring fixation
Pubic symphysis plating
- APC III
Anterior(Pubic symphysis plating)
+ posterior ring fixation(SI screw/plate)
66. • LC II
ORIF plating
May or may not require SI screw fixation
- LC III
ORIF plating with SI screw fixation
67. • VS
ORIF with plating SI joint fixation
May require ilio lumbar fixation
68. .
HOW SOON SHOULD A
PATIENT WITH A FRACTURED
PELVIS BEAR WEIGHT? His
weight is transmitted from his
spine to his sacrum, then
through his acetabulae to his
femora. If this weight bearing
column is fractured, he should
be in bed for at least 3 weeks,
and not bear weight until 6
weeks. But if the weight
bearing parts of his pelvis are
intact, he can start weight
bearing in a few days, if his
other injuries allow it
