1) Pelvic fractures can result in severe blood loss due to injury to the internal iliac plexus of arteries and veins. They are commonly caused by road traffic accidents. 2) Pelvic stability is determined by ligamentous structures such as the ligament of the symphysis pubis, sacrospinous ligament, and anterior sacroiliac ligament. 3) Pelvic fractures are classified using either the Young-Burgess classification based on injury mechanism, or the Tile classification based on stability. The classifications help determine treatment approach and predict associated injuries.

1. PELVIC FRACTURE
Dr. Bipul Borthakur,
Professor,
Dept. of Orthopedics, SMCH

2. • Classification
• Evaluation
• Outcome management

3. Introduction
Fracture of pelvis account for less than 5% of skeletal injury
But particularly important due to potential risk of severe blood loss
Majority occur due to RTA and 10% of them associated with visceral injury

4. Anatomy
Internal iliac plexus of arteries and veins

5. Anatomy

6. Anatomy
• Pelvic stability is determined by ligamentous structures
• Primary restraints to external rotation of hemipelvis- ligament
of symphysis, sacrospinous liagament and anterior sacroiliac
ligament.
• Rotation in saggital plane by – sacrotuberous ligament
• Vertical displacement by- all the above ligaments ( if absent
then interosseous sacroiliac, posterior sacroiliac and iliolumbar
helps )

8. Clinical assessment
 Should be suspected in any multiply injured patient
 Multidisciplinary approach with orthopaedic surgeons, general
surgeons, and anesthesiologists is critical to optimizing outcomes.
 Patient should be managed according to ATLS protocol
• Physical examination –
 Vertical shear may present with shortening and external rotation of affected
limb
 Unstable lateral compression – internal rotation

9.  APC injury- scrotal edema in male patient
 Careful neurovascular assessment (lumbosacral injury might associate)
 Careful examination of skin to rule out open fracture
 AP and LC compression test should be done once (as first clot is the best
clot)
 Massive flank or buttock contusions - indication of significant bleeding
 Perineum must be carefully inspected – rule out open fracture
 Digital rectal and vaginal examination in women should be done

10. Possible clinical findings
Suspected pelvic ring fractures initial management are shown on next slide

12. Classification
Among all classifications below mentioned classification provide
valuable information
A. Young and Burgess- based on mechanism of injury (help to
determine associated injury)
B. Tile classification – based on stability of pelvis

13. Young and Burgess
I. Anteroposterior compression (APC)
II. Lateral compression (LC)
III. Vertical Shear(VS)
IV. Combined

15. APC
1.Injury results from front to front force transmission through
pelvis
2.Initially anterior structures open up & as energy increase
posterior structure injured
(anterior- symphysis pubis, posterior- sacroiliac joint )
3. Three types – APC 1, APC2 and APC3

16. 1. APC1- less than 2.5cm widening at pubic symphysis

17. • APC2- widening of symphysis pubis more than 2.5cm with
anterior widening of sacroiliac joint
• Posterior ligaments are intact

18. apc3
• Widening of symphysis pubis more than 2.5cm with
Dislocation of sacroiliac joint

19. Lateral compression
• Injuries results from the force applied and/or transmitted to
side of pelvis
• Types –
1. Lc1
2. Lc2
3. Lc3

20. • LC1- rami fracture and ipsilateral anterior sacral alar fracture

21. • LC2- rami fracture with ipsilateral posterior ilium fracture
disclocation
AP Oblique
inlet outlet

22. • Lc3 – ipsilateral lateral compression and contralateral APC
injury

23. Vertical shear
• Usually seen after fall from height
• Landing on one leg leading to one hemipelvis being driven up
• Complete disruption of all posterior structures

24. Combined
• This injury combined of APC,LC and VS
• Occur when individual ejected from automobile or motorcycle

25. Tile classification
• Gives accurate assessment of pelvic stability
• It decides whether surgery required or not
• Based on stability of posterior arch
• Types –
1) Type A :stable( posterior arch intact)
2) Type B: partially stable ( incomplete disruption of posterior arch)
3) Type C: unstable ( complete disruption of posterior arch )

27. Type a
• A1 – fracture not involving pelvic ring ( eg- avulsion or iliac
wing fracture)
• A2 – iliac wing fracture or anterior rami fractures
• A3 – transverse sacral fracture

28. Type B
• B1 – open book injury (exteranl rotation)
• B2 – lateral compression injury( internal rotation)
• B2-1 ipsilateral anterior and posterior injuries
• B2 -2 contralateral injuries
• B3 – bilateral SIJ/sacral fractures /subluxation

29. Type c
• C1 – complete unilateral posterior disruption
• C2 – complete unilateral posterior disruption with contralateral
partial disruption
• C3 – complete bilateral posterior disruption

30. Open fracture
• 5% common
• May contaminate with vagina or rectum – complications like
osteomyelitis, deep pelvis infection, mortality
• So careful inspection to perineal area is must and digital rectal and
vaginal should be done
• Fecal contamination – may require diverting colostomy, emergency
irrigation and debridement of fracture
• If not contaminated- regular irrigation and debridement with IV
antibiotics

32. • Ruptured bladder should be suspected if they can’t void urine
• Or bladder is not palpated after adequate fluid replacement
• Rupture may be intraperitoneal or extraperitoneal
• Intraperitoneal rupture associated with massive haemorrhage
• Bowel injury might occur
• Neurological examination is important ( lumbosaccral plexus
injury)

33. Radiorapic evaluation
Standard trauma series – CT chest . Us abdomen , AP view of
pelvis lateral view of CS spine
AP view of pelvis
1. Anterior lesions- pubic rami fractures and symphysis displacement
2. Sacroiliac joint and sacral fractures
3. Iliac fractures

34. Special views
1. Obturator and iliac oblique views- for suspected acetabular
fractures
2. Inlet view- taken wit patient supine wit the tube 6deree
caudally perpendicular to pelvic brim
Provides an axial view of sacrum and sacroiliac joint
3.Outlet view- patient supine wit tube directed 45 degree
cephalhead
Determination of vertical displacement of pelvis
Provides true AP view of sacrum and pubic symphysis

35. • CT scan
 Better defines posterior injury
 Rotation of fragments
 Ammount of comminution
 Assess neural foramina

36. Tretment
Non operative
– Tile A without open fracture
– Ap of pubic symphysis < 2.5 cm
– Rehabilitation – protected weight bearing with crutch supported

37. Operative treatment
• Absolute indication –
1. Open fractures or associated visceral injury
2. Open book fractures or vertically unstable fractures wit
haemodynamic instability
• Relative indication –
1. Symphysis diastasis >2.5 cm
2. LLD>1.5cm
3. Rotational deformity
4. Sacral displacement >1cm

38. Operative tecniques
• Principle- convert an unstable pelvis into stable one
• Initial treatment includes- external fixation and pelvic clamps
1. External fixation – construct mounted on two pins ideally of
5mm size spaced one cm apart along anterior iliac crest
o Or single pins placed in supra-acetabular area in AP direction
o It is resuscitative fixation and can be used definitive for anterior
pelvic injuries

42. Pelvic clamps

43. Internal fixation or reconstructive phase
1. Diastasis of pubic symphysis
– plate fixation is most commonly used

44. • Iliac win fracture – ORIF wit la screws and neutralization plate

45. • Sacral fractures and or sacroiliac dislocation – iliosacral
screw fixation or anterior sacroiliac plating

46. Post operative management
• In general early mobility is desired
• Aggressive pulmonary toilet
• Prophylaxis against thromboembolic phenomena
• Weight bearing –
1. Full weight bearing uninvolved side- within several days
2. Partial weight bearing involved side- after 6 weeks and full after 12
weeks

47. Complications
• Infections- 0-20%
• Thromboembolism – due to disruption of pelvic veins and
immobilazation
• Malunion - rare
• Nonunion – rare
• Moratality –
– APC3 – 37%
– VS-25%
– LC- head injury major cause of death

48. THANK YOU