This document discusses the management of pelvic fractures. It begins with an introduction on the epidemiology and anatomy of pelvic fractures. It then describes various classification systems for pelvic fractures based on the site involved and stability. The document outlines the management of pelvic fractures, including resuscitation, history and examination, investigations, and treatment approaches depending on the stability of the fracture. Both non-operative and operative treatment options are discussed. Complications and prognostic factors are also reviewed. The document concludes with perspectives on pelvic fractures from West Africa.

1. By
Dr Salihi Abdulmalik
National Orthopaedic Hospital, Dala-Kano
22nd of August, 2020

2.  Introduction
◦ Epidemiology
◦ Statement of surgical importance
◦ Anatomy
 Classifications
◦ Site involved (ring, sacral)
◦ open
 Jones classification
◦ Tile
◦ Young and Burgess

3.  Management
◦ Resuscitation
◦ History
◦ Examination
◦ Investigations
◦ Treatment
 Associated injuries
 Pelvic injury
◦ Non operative treatment
 Indications
 Options
 Operative treatment
 Indications (absolute and relative)
 Options
◦ Special considerations

4.  Prognosis
 Complications
 West African perspectives
 References

5.  Pelvic fracture < 5% of skeletal injuries
 <35 years? Male, >35 years? Females
 High energy in young, low energy in elderly
 2/3 following RTA
 10% will have visceral injuries, with mortality
in excess of 10%

6.  High incidence of;
◦ Associated soft tissue injuries
◦ High risk of severe blood loss
◦ Shock
◦ ARDS

8.  Based on site involved
◦ Pelvic ring fracture
 Open/close
 Young and Burgess
 Tiles
◦ Sacral fractures
 Denis

9.  Open pelvic classification by Jones
Class 1: stable open pelvic ring fracture
Class 2: open
unstable (vertical or rotational)
no rectal or perineal wound
Class 3: open
unstable
rectal or perineal wound with risk of
contamination
Risk of osteomylitis, deep pelvic infection and
mortality

10.  Based on mechanism of injury
 AP compression (APC)
◦ Type 1: < 2.5cm symphysis diastasis
vertical fractures of 1 or both rami
intact posterior elements
Type 2: > 2.5cm diastasis
widening SI joints
anterior elements affected
posterior elements intact

11. ◦ Type 3: both anterior and posterior
elements disruption
rotationally and vertically unstable

12.  Lateral compression (LC)
◦ Type 1: oblique or transverse ramus fracture
and ipsilateral anterior sacral ala
compression fracture
◦ Type 2 rami fracture and ipsilateral
posterior ilium fracture dislocation
(crescent fracture)
◦ Type 3 ipsilateral compression and
contralateral APC (windswept
pelvis)

13.  Vertical shear
◦ Posterior and superior directed force
◦ High risk of hypovolemic shock
◦ mortality

14.  A: stable
◦ A1: # not involving ring
◦ A2: stable or minimally displaced fracture of the
ring
◦ A3: transverse sacral fracture
 B: rotationally unstable, vertically stable
◦ B1: open book injury (external rotation)
◦ B2: lateral compression injury (internal rotation)
◦ B3: bilateral

15.  C: rotationally and vertically unstable
◦ C1: unilateral
◦ C2: bilateral, one B and C
◦ C3: bilateral both C

16.  Combination injury

19.  Multidisciplinary
 ATLS
Airway
Breathing
Blood loss (venous plexus, iliac vessels, fracture)
 Pelvic binder/ Sheet of cloth
 Military antishock trousers (MAST)
 Anterior external fixator
 ????Laparotomy/ORIF with persistent shock
 Open packing of the retroperitoneum
 Angiography/embolization if despite closing pelvic
volume

23.  Intra-abdominal injury
 Bladder/urethral injury
 Stable/unstable pelvic injury

24.  Stable patient
◦ Splint fractures
◦ Trauma series
◦ Blood samples

25.  Age
 Duration of injury
 Mechanism of injury
 Injury elsewhere

27.  Skin
◦ Flank, pelvic or perineal ecchymosis or abrassions
◦ Scrotal odema
◦ Open wound (groin/buttocks/perineum)
◦ Degloving injuries (Morel-Lavellee lesion)
 Pelvic
◦ LLD
◦ Internal/external rotation
◦ compression/distraction tenderness

28.  Neurological exam
◦ Lumbosacral plexus injury (L5 and S1 are most
common)
◦ Perirectal sensation and sphincteric tone
 Urogenital exams
 Vaginal and rectal exams

29.  Plain radiographs
 CT scan
 MRI
 RUG
 DPL
 FAST

30.  Pelvic AP view:
◦ Pubic rami fracture
◦ Symphysis
displacement
◦ SI joint and sacral #
◦ Iliac fracture
◦ L5 transverse process
#

31.  Inlet view
◦ Anterior or posterior
displacement of SI
joint, sacrum or iliac
wing
◦ Internal rotation of
ilium
◦ Sacral impaction

32.  Outlet view:
◦ Vertical displacement
of hemipelvis
◦ Slight SI joint
widening
◦ Discontinuity of
sacral border
◦ Non displaced sacral
#s
◦ Disruption of sacral
foramina

33.  Iliac oblique:
◦ Posterior column
(Ilioischila line)
◦ Anterior wall of
acetabulum
◦ Iliac wing

34.  Obturator oblique:
◦ Anterior column
◦ Posterior wall

35.  Stress views done under anaesthesia to
determine vertical stability with > 0.5cm
displacement
 Instability
◦ Sacroiliac displacement of >0.5cm in any plane
◦ Posterior fracture gap
◦ Avulsion fracture;
 L5 transverse process
 Sacral spine
 Lateral border of the sacrum

36.  Non operative
◦ Stable ring fractures
 Isolated fractures
 APC 1
 LC 1
◦ Stable sacral fractures
◦ Comorbidities precluding surgical intervention
◦ Poor bone quality
◦ Low energy osteoporotic bone ring fracture

37.  Options
◦ Bed rest
◦ Traction
◦ Pelvic binder
Anti DVT
Analgesics

38.  Operative
◦ Absolute
 Open fractures
 Associated visceral injuries requiring intervention
 Open book or vertically unstable with heamodynamic
instability
◦ Relative
 Symphyseal diasthesis >2.5cm
 LLD > 1.5cm
 Sacral displacement >1cm
 Rotational deformity
 Intractable pain

39.  Options
◦ Ex fix (resuscitation and open book)
◦ Internal fixation
 Iliac wing #s – lag screw and neutralization plate
 Symphyseal diasthesis – plating
 SI dislocation – screws or anterior sacroiliac plating
 Unstable posterior disruption – pelvis fixation to sacral
body
◦ Colostomy maybe required in open fractures

43.  Analgesics
 Anti DVT
 Antibiotics
 Ambulation
◦ FWB in contralateral side after few days
◦ PWB on affected side after 6 weeks (WBAT)
◦ FWB 12 weeks
◦ Bilateral unastable? Wheelchair, PWB at 12 weeks on
less injured side

44.  Options
◦ Sacral decompression in progressive loss of neural
function
◦ Denis I: 6% injury
◦ Denis II: 28% injury
◦ Denis III: 57% injury

45.  Bladder
 Urethra
 Bowel

46.  Infection
 Malunion
 Non union
 Thromboembolism
 Parturition problems
 Urethral stricture
 Importence
 Mortality

47.  High injury severity score
 Associated injuries
 Elderly
 Requirement for large quantity of blood
 Severity
 Shock
 Open fractures
 Perineal lacerations

48.  West African perspectives
 Conclusion
 References
◦ Rockwood
◦ Koval
◦ Orthobullet
◦ Apley

49.  Thank you for listening