detailed description of pelvic fractures and management

1. PELVIC FRACTURES – ANATOMY, TYPES,
MANAGEMENT &OUTCOME - EVIDENCE
BASED ANALYSIS
MODERATOR – Dr. SANDEEP
NEMA
PRESENTER – Dr. ADITYA.G

2. CONTENTS
EPIDEMIOLOGY
MECHANISM OF INJURY
CLASSIFICATION
TREATMENT

3. EPIDEMIOLOGY
Incidence of pelvic ring fractures - 0.82 per 100,000
people
Predominant age group -18 to 44 yr
The geriatric population - 22% of the overall number
Yoshihara H, Yoneoka D. Demographic epidemiology of unstable pelvic fracture in the United
States from 2000 to 2009: Trends and in-hospital mortality. J Trauma Acute Care Surg. 2014

4. CLINICAL ANATOMY
MAJOR – POSTERIOR
MINOR – ANTERIOR

8. SUSPENSION BRIDGE
KEY-STONE

9. Pennal and Sutherland – trauma mechanism produces
specific types of injuries
(magnitude and directon)

10. MECHANISMS OF INJURY
THREE TYPES –
ANTEROPOSTERIOR COMPRESSION
LATERAL COMPRESSION
VERTICAL SHEAR

11. APC

12. LC

13. VS

14. ANTERIOR INJURIES
PUBIS/ SYMPHYSIS
Anterior ring injuries can occur through:
a The symphysis.
b The rami.
c A combination of both the symphysis or rami

16. POSTERIOR INJURIES
OSSEOUS
LIGAMENTOUS
BOTH

18. CLASSIFICATION

19. YOUNG-BURGESS

20. APC1
APC
3
APC
2

21. LC1
LC 3
LC 2

22. VS

23. NAKATANI – PUBIC RAMI #

24. STABILITY CLASSIFICATION (TILE)

26. AO/OTA
STABLE
PARTIALLY
STABLE
UNSTABLE

27. AO/OTA

30. GENERAL ASSESSMENT AND
MANAGEMENT OF THE
POLYTRAUMA PATIENT
-Injury Severity Score (ISS) of > 17 points
-Most deaths occur either at the scene, during the first
24 hours after admission, or in
the second and third week (“trimodal mortality”).

31. Polytrauma patients – outcome is more related to organ injuries w.c.t
pelvic #
(Poole GV, Ward EF, Muakkassa FF, et al. Pelvic fracture from major blunt trauma.
Outcome is determined by associated injuries. Ann Surg. 1991 Jun;213(6):532–538;
discussion 538–539.
Poole GV, Ward EF. Causes of mortality in patients with pelvic fractures. Orthopedics.
1994 Aug;17(8):691–696.)

33. ATLS PROTOCOL
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE
CONTINUOUS RE-EVALUATION

35. Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus
conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of
Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of
Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and
Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of
Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and

36. IMAGING
PLAIN XRAYS –
ANTERO-POSTERIOR
INLET (60DEG CC)
OUTLET (45DEG CC)

40. IMAGING
Computed tomography
The current standard for rapid, high-resolution CT imaging - 64-
slice helical scanner.
Helical images are obtained from the diaphragm and include the
pubic symphysis and ischium.
Advantages

41. MPR
3D – VOLUME/SURFACE RENDER

43. METHODS OF PELVIC FIXATION
EARLY RESUSCITATION-
Bed sheet
Pelvic binder
Sling
Traction
Pelvic clamp
Emergency ex-fix
MAST
TEMPORARY
MAY CAUSE PRESSURE ULCERS

44. ACUTE MX
4 SCENARIOS

45. POSTERIOR PELVIC CLAMP
OUTER TABLES OF THE ILIAC BONE – PINS ARE HAMMERED,
COMPRESSION IS GIVEN THROUGH THE PINS.
DISPLACED SACRO-ILIAC INJURIES

46. DAHNERS LE, JACOBS RR, JAYARAMAN G, ET AL. A STUDY OF EXTERNAL SKELETAL FIXATION SYSTEMS FOR
UNSTABLE PELVIC FRACTURES.
J TRAUMA. 1984 OCT;24(10):876–881.
MCBROOM R, TILE M. DISRUPTION OF THE PELVIC RING. ORTHOP TRANS. 1982; 6(3):493.
 DAHNERS, MCBROOM
AND TILE – DESIGN OF
FIXATOR AFFECTS
STABILITY

47. PRACTICAL ASPECTS OF PELVIC
EXTRNAL FIXATION
FIXATOR DESIGN
PIN SELECTION, INSERTION

48. Indications:
• Acute management - severe pelvic injury (control
haemorrhage / provide provisional stability)
• Early management – (polytrauma) – pain relief,
nursing care
• Some patterns of # - definitive management (B1,B2)
• Adjunct to internal fixation

49. Anterior fixator – not stable enough to allow WBW.
To increase Stability of the anterior frame -
Increasing the pin size to 5 mm,
Adding a second set of pins anteriorly
Triangulating the bars

50. TYPES OF CONSTRUCTS IN
EXTERNAL FIXATION

52. ANGLE OF PIN INSERTION

53. TECHNIQUE OF PIN
INSERTION(CONVENTIONAL)FIRST PIN- 2-3CM
POST. TO ASIS
2 OR 3 WIDELY
SPACED PINS
CONVERGE ABOVE
ACETABULUM
5mm SCHANZ PINS

54. WRONG DIRECTION

55. SKIN INCISION – PERPENDICULAR TO ILIAC CREST
TO EXTEND THE INCISION AFTER REDUCTION

56. PINS TO ENGAGE SUPRA-ACETABULAR BONE
REDUCTION OF PELVIS – DIRECT PRESSURE OVER THE BONE
NOT TO USE THE PINS A JOYSTICKS

57. TECHNIQUE OF PIN
INSERTION(HANNOVER)
2 PIN STRUCTURE
ONE PIN IN EACH INNOMINATE - SUPRAACETABULAR

58. Obturator-outlet view of the acetabulum teardrop view
Directly onto the anterior inferior iliac spine (AIIS) angled toward the
sciatic buttress.

60. “IN-FIX”
VAIDYA ET AL.
ADAPTING SPINAL INSTRUMENTATION TO THE PELVIS (OFF-LABEL
USE)
SUPRA-ACETABULAR PEDICLE SCREW
Vaidya R, Colen R, Vigdorchik J, et al. Treatment of unstable pelvic ring injuries with an
internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma. 2012
Jan
Vaidya R, Kubiak EN, Bergin PF, et al. Complications of anterior subcutaneous internal
fixation for unstable pelvis fractures: A multicenter study. Clin Orthop Relat Res.
2012

62. METHODS OF PELVIC FIXATION
DEFINITIVE FIXATION
Anterior external fixation
Open reduction and internal fixation of the pubic symphysis
Posterior pelvis

63. MCBROOM R, TILE M. DISRUPTION OF THE PELVIC RING. ORTHOP TRANS. 1982; 6(3):493

64. HEARN TC, TILE M. THE EFFECTS OF LIGAMENT
SECTIONING AND
INTERNAL FIXATION OF BENDING STIFFNESS OF THE
PELVIC RING. PROCEEDINGS OF THE 13TH
INTERNATIONAL CONFERENCE ON BIOMECHANICS.
DEC 9–13, 1991;
PERTH, AUSTRALIA.

70. DEFINITIVE MX

71. PATIENT IS STABLE –
FULL CLINICAL EXAMINATION –
INSPECTION – LIMB ATTITUDE, LLD, EXTERNAL INJURIES
PALPATION – CREPITUS, GAP IN SYMPHYSIS, MOBILITY

73. SURGICAL APPROACHES
ANTERIOR PELVIC RING –
PFANNENSTIEL – SYMPHYSIS ORIF, PELVIC PACKING IN DCO
MODIFIED STOPPA
LATERAL/EXTRAPELVIC APPROACH TO ILIUM

74. PFANNENSTIEL
SUPINE, URINARY CATHETER
SUPRAPUBIC HORIZONTAL INCISION
VERTICAL DEEPER DISSECTION
MODIFIED STOPPA
SIMILAR, WITH LATERAL DISSECTION FOR MORE LATERAL RAMUS #
USUALLY – FOR ACETABULAR #

76. LATERAL APPROACH TO ILIUM
SIMILAR TO ILIOFEMORALAPPROACH TO ACETABULUM
LATERAL/SEMILATERAL

77. SURGICAL APPROACHES
POSTRIOR PELVIC RING
ANTERIOR (INTRAPELVIC) APPROACH TO THE SACROILIAC
JOINT - sacroiliac dislocations, crescent fractures(iliac wing
fracture that exits into the SI joint with resultant SI
dislocation)
POSTERIOR (EXTRAPELVIC) APPROACH TO THE SACROILIAC
JOINT AND LATERAL SACRUM –
 displaced sacroiliac joint dislocations,
 displaced fractures of the posterior iliac wing (crescent fractures),
 displaced fractures of the sacrum that exit posteriorly within zone I or
II
SACRAL APPROACH - displaced fractures of the central

78. ANTERIOR
SUPINE/LATERAL DECUBITUS
INCISION ABOVE ILIAC CREST
For iliac wing+sacral fracture dislocations
L5 root entrapment in the fracture

79. POSTERIOR
PRONE
INCISION OVER SUPERIOR PART OF SIJ
 midline

80. POSTERIOR
MIDLINE INCISION

81. INTERNAL FIXATION OF STABLE
PELVIC RING FRACTURES (TYPE A)
INDICATIONS
A1 TYPE – IF DISPLACED MORE THAN 2 CM

82. A2.1(BLADE) – DISPLACED – FOR COSMESIS AND PAIN RELIEF
A2.2 – ORIF NOT REQUIRED
A2.3 – IF SIGNIFICANTLY DISPLACED, TO PREVENT NON UNION

83. ORIF WITH DOUBLE PLATING – ANTERIOR APPROACH TO ILIAC WING

84. A3.1, 3.2 – ORIF NOT REQUIRED
A3.3 – IF NEURODEFICIT PRESENT

85. INTERNAL FIXATION OF THE
ANTERIOR PELVIC INJURIES—OPEN
BOOK (TYPE B1)

86. SYMPHYSIS DISRUPTION
SUPINE
PFANNENSTIEL INCISION
INSTRUMENTS
IMPLANTS
POSTERIOR FIXATION +/-
Internal fixation of the anterior pelvis is stronger than external
fixation

88. IMPLANTS AVAILABLE

89. Prior to ORIF-
Taping the feet in internal rotation or binding the
legs
External fixator, or a femoral distractor
Outlet view
TRANS-SYMPHYSEAL SCREWS – UNSTABLE PELVIC
INJURIES WHERE ADDITIONAL STABILIZATION IS
NEEDED
THROUGH THE PLATE OR SEPARATELY

90. RAMI FRACTURES
ORIF WITH RECON PLATES
PERCUTANEOUS SCREW FIXATION – ANTEGRADE/RETROGRADE

91. PERCUTANEOUS-
ANTEGRADE – LATERAL TO MEDIAL
RETROGRADE – MEDIAL TO LATERAL
(THROUGH PUBIS)
CR + GUIDE PIN INSERTION
6.5/7.3MM PARTIALLY THREADED CANNULATED CANCELLOUS
SCREWS

92. TECHNIQUE - PUBIC RAMUS
SCREW

93. oSTOPPA/ ILIOINGUINAL APPROACH
oFIXATION – START LATERALLY AND PROCEED MEDIALLY
oPRE CONTOUR PLATES
oCAN BE EXTENDED BEYOND THE SYMPHYSIS IF SYMPHSEAL INJURY IS
ALSO PRSESNT

94. CRESCENT FRACTURES
# OF ILIAC BLADE WITH SIJ
EXTENSION AND
DISLOCATION
CRESCENT FRAGMENT -
FRAGMENT OF BONE THAT
INCLUDES THE PSIS AND PIIS

96. INTERNAL FIXATION OF LATERAL
COMPRESSION FRACTURES (TYPE
B2)
LC fractures are the most common type of pelvic fractures
Usually can be treated nonoperatively
Operative indication –
Persistent excessive internal rotation –
can cause LLD, asymmetric ischial tuberosities
causing pain on sitting, gait disturbances

98. Reduction – external rotation and abduction of LL
Schanz pin – joystick reduction
Starr frame:

99. TILT FRACTURE
One of the least common variants of LC pelvic injures.
Protrusion of the pubic ramus into the perineum by
displacement of the fragment.
Lateral fracture of the pubic ramus that rotates through the
symphysis pubis and ultimately causes its disruption.
The ramus assumes a vertical orientation distally at the
symphysis and subsequently impinges to some degree
on the perineum or inferior pubic ramus resulting in chronic
pain and dyspareunia in women.

100. LOCKED SYMPHYSIS
A locked symphysis is defined as a lateral compression injury
of the pelvis, in which the intact pubis is trapped against
the contralateral pubis.
forced hyperextension and adduction of the hip caused by
a lateral compression force to the pelvis.
Pubic symphysis plating

101. INTERNAL FIXATION OF UNSTABLE
FRACTURES
(TYPES B3 AND C)
Displacement of more than 1
cm at the fracture or site of
ligamentous injury indicates
disruption of the surrounding
soft tissues.

103. PRE-OP REALIGNMENT
BINDER
SKELETAL TRACTION
TO AID IN INTRA-OP REDUCTION
Vertically or translationally unstable (type C) injuries cannot be
adequately stabilized by external fixation alone.

104. NON-OPERATIVE – NOT RECOMMENDED DUE TO LONG DURATION OF
IMMOBILIZATION AND ITS ADVERSE EFFECTS
HIGH RATE OF NON UNIONS AND MALUNIONS

105. INJURIES – ROTATORY INSTABILITY,
CRANIO CAUDAL TRANSLATION

106. SACROILIAC JOINT DISLOCATIONS-
ILIOSACRAL SCREW FIXATION
Sacroiliac Joint Dislocations
Iliosacral Screw Fixation
PERCUTANEOUS/ OPEN
PERCUTANEOUS – minimally invasive, either in the supine or prone
positions
OPEN – complex injuries,

107. Unilateral sacroiliac dislocation / fracture dislocation (usually a/w
anterior ring disruption)
iliosacral compression screw fixation
transiliac rod
transiliac plating
anterior sacroiliac plating
most biomechanically stable - iliosacral screw with two symphyseal
plates

108. Closed reduction of the pelvic ring - the
IRTOTLE technique (internal rotation and taping
of the lower extremities) or pelvic sheet with
holes cut inside.

109. ALONG WITH AP/LAT, INLET VIEW IS USED
TO PREVENT ANTERIOR SACRAL CORTEX
PENETRATION

111. SACROILIAC JOINT DISLOCATIONS-
ORIF
ANTERIOR APPROACH

112. PILOT HOLES IN SACRUM AND ILIUM
POINTED REDUCTION CLAMP REDUCTION

113. SCREWS IN SACRUM
AND ILIUM
REDUCTION WITH
JUNGBLUTH CLAMP
REDUCTION WITH
FARABEUF CLAMP

114. SACROILIAC JOINT DISLOCATIONS-
ORIF
POSTERIOR APPROACH

115. OPENING VIA POSTERIOR APPROACH, REDUCTION WITH POINTED REDUCTION
FORCEPS/ PELVIC CLAMP

116. With bilateral posterior pelvic injuries, at least one side of the
posterior injury must be fixed to the axial spine to provide adequate
stability for maintenance of sacral reduction with patient
mobilization.
Best biomechanics – resists SI displacement - Combining iliosacral
screws with transiliac bars or plates.
Kraemer W, Hearn T, Tile M, et al. The effect of thread length and location
on extraction strengths of iliosacral lag screws. Injury. 1994 Jan

117. DENIS – SACRAL (ANATOMIC)
Zone I: lateral to the sacral neural
foramina.
Zone II: transforaminal.
Zone III: medial to the sacral
foramina, involving the spinal
canal.

121. SPINOPELVIC DISSOCIATION
a H-type.
b U-type.
c Y-type.
d T-type.

133. REFERENCES
Rockwood and Green’s Fractures in adults, 8e
Fractures of the Pelvis and Acetabulum Principles and Methods of
Management, 4e