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PELVIC RING FACTURES
DR.K.VINOTHKUMAR
OGH,HYDERABAD
LEARNING OBJCTIVES
• ANATOMY OF PELVIS
• IMAGING
• CLASSIFICATION OF PELVIC FRACTURES
• APPROACHES
• TREATMENT
• NON OPREATIVE
• OPERATIVE
ANATOMY
LIGAMENTS
ANOMALIES
SACRLISATION OF LUMBAR VERTEBRA LUMARISATION OF SACRAL VERTEBRA
IMAGING
• UNLIKE OTHER LONG BONES PELVIS IS A COMPLEX 3 DIMENSIONAL
STRUCTURE
INLET VIEW
• INTERNAL OR EXTERNAL RETOATION OF
HEMIPELVIS
• OPENING OF SI JOINT
• IMPACTION # OF SACRAL ALA
• AP DISPLACEMENT OF POSTERIOR RING
OUTLET VIEW
• SACRAL FRACTURES WITH RESPECT TO
FORAMINA.
XRAY POSITIONING
25° CAUDAL 60° CEPHALAD
CT
• CT SCAN CAN AID IN THE RECOGNITION OF MANY OF THESE INJURIES
THAT GO UNDETECTED ON PLAIN RADIOGRAPHS
• THE 3D AND OTHER RECONSTRUCTED IMAGES CAN ASSIST IN
DETERMINATION OF THE SURGICAL APPROACH
STRESS VIEWS : TAKEN UNDER ANEASTHESIA MAY REVEAL
SOME INSTABILITY WHICH IS NOT SEEN IN NORMAL XRAYS
CLASSIFICATION
STABLE FRACTURES
ROTATIONALLY UNSTABLE
VERTICALLY STABLE
ROTATIONALLY UNSTABLE
VERTICALLY UNSTABLE
YOUNG BURGESS CLASSIFICAITON
• BASED ON MECHANISM OF INJURY
Vertical Shear
LATERAL COMPRESSION (LC I)
ANTERIOR INJURY: PUBIC RAMI #
POST INJURY: SACRAL # ON SIDE
OF IMAPACT
LATERAL COMPRESSION - II
ANTERIOR INJURY: RAMI #
POSTERIOR INJURY:
CRESCENT# (FRACTURE
DISLOCATION OF ILIUM
THROUGH SI JOINT)
LATERAL COMPRESSION III (WIND SWEPT PELVIS)
TYPE I OR II INJURY ON SIDE OF IMPACT +
CONTRALATERAL OPEN BOOK INJURY
ANTERO POSTERIOR COMPRESSION (APC I)
[ANTERIOR INJURY= SYMPHYSIS DIASTASIS/ RAMI #]
MODE OF INJURY: SEVERE EXTERNAL
ROTATION OF ONE HEMIPELVIS
ANTERIOR INJURY: PUBIC DIASTASIS < 2.5 CM
POSTERIOR INJURY: MILD ANTERIOR
OPENING OF SI JOINT
APC II ANT. INJURY: PUBIC DIASTSIS >2.5 CM
POST. INJURY:OPENING OF ANTERIOR SI
JOINT, INACT POSTERIOR SI
LIGAMENTS,RUPTURE OF ANTERIOR SI
LIGAMENTS
(SACROTUBEROUS,
SACROSPINOUS,ANTERIOR SACROILIAC)
APC III – COMPLETE SI JOINT DISRUPTION
DISRUPTION OF
INTRAARTICULAR AND
POSTERIOR SI LIGAMENTS .
VERTICAL SHEAR
• PRIMARY FORCE VECTOR IS DIRECTED CEPHALAD.
• HEMI PELVIS SHIFTED VERTICALLY
• AVULSION # OF L5 INDICATES UNSTABLE # (ILIO LUMBAR LIGAMENT DISRUPTION)
COMBINED MECHANISM
• RESULT OF MULTIPLE FORCE VECTORS
DENIS CLASSIFICATION OF SACRAL FRACTURES
• BASED ON FRACTURE LINE IN RELATION WITH
SACRAL FORAMINA
• ZONE I – FRACTURE LINE LATERAL TO FORAMINA
• ZONE II – FRACTURE LINE THROUGH THE
FORAMINA, HIGH CHANCE OF SACRAL NERVE
INJURY
• ZONE III – FRACTURE MEDIAL TO FORAMINA, HIGH
RISK OF INJURY TO SPINAL CANAL
MANAGEMENT
NON OPERATIVE TRATMENT: INDICATIONS :-
• STABLE PELVIC RING INJURIES (LC – I)
• STABLE SACRAL INJURIES. (RISK OF LATE DISPLACEMENT)
• COMORBIDITIES PRECLUDING SURGICAL INTERVENTION
• POOR BONE QUALITY WHERE SCREW PURCHASE MAY BE
PROBLEMATIC
• THE LOW-ENERGY OSTEOPOROTIC PELVIC RING FRACTURE
OPERATIVE MANAGEMENT - GENERAL PRINCIPLES:
• POSTERIOR INJURY IS REGARDED AS THE MORE CRITICAL ONE REQUIRING AN
ACCURATE REDUCTION AND STABLE FIXATION.
• ANTERIOR FIXATION CAN NEITHER MAINTAIN POSTERIOR REDUCTION NOR
RESTORE STABILITY
• IN CEPHALAD DISPLACEMENT OF THE HEMIPELVIS WITH COMPLETE INSTABILITY
OF THE POSTERIOR RING, POSTERIOR FIXATION SHOULD ALWAYS BE
SUPPLEMENTED WITH ANTERIOR STABILIZATION
• POSTERIOR PELVIC RING SHOULD BE REDUCED AND STABILIZED FIRST, FOLLOWED
BY ANTERIOR PELVIC RING
ANTERIOR RING
• EXTERNAL FIXATION
• PUBIC SYMPHYSIS
PLATING
• PUBIC RAMI PLATING
• PUBIC RAMI PC SCREW
FIXATION
POSTERIOR RING
• SACROILIAC SCREW
FIXATION
• SI JOINT PLATING
• ILIAC WING PLATE/SREW
EXTERNAL FIXATION:
INDICATIONS:
• AS AN EMERGENCY PROCEDURE
• TO REDUCE THE POSTERIOR LESION PRIOR TO POSTERIOR
STABILIZATION.
• DEFINITIVE FIXATION: WHEN INTERNAL FIXATION CANNOT BE DONE
( WOUNDS, SPC, TO AVOID MORBIDITY OF OPEN PROCEDURE)
• COMMUNITED FRACTURES
TYPES
ILIAC CREST PIN FIXATION SUPRA ACETABULAR PIN FIXATION
ILIAC CREST PIN FIXATION
• SITE: 2 CM POSTERIOR TO ASIS. AVOID INJURY TO LATERAL FEMORAL
CUTANEOUS NERVE
• STARTING POINT: INNER 1/3RD MIDDLE 1/3RD JUNCTION.
• PIN DIRECTION: 25 - 40° MEDIALLY 10-15 ° CAUDAL.
• PIN THICKNESS: 5 MM
• UNICORTICAL DRILL HOLE . NOT MORE THAN 2CM DEEP.
• SECOND PIN 2 CM POTERIOR TO FIRST ONE . PINS APPEARS TO
CONVERGE
PROCEDURE
ASIS
AIIS
INCISION OVER ILIAC CREST 2 CM BEHIND THE ASIS
DRILLING THE FIRST CORTEX ADVANCING THE PIN BETWEEN TWO TABLES OF ILIAC BONE
GUIDING PIN WHICH INSERTED
BETWEEN THE ILIACUS AND
INNER TABLE
ILIAC CREST PIN
SUPRA ACETABULAR PIN TECHNIQUE:
• BIOMECHANICALLY STRONGER.
• PATIENT CAN SIT.
• FLUROSCOPY DEPENDENT
• SITE: 4-6 CM INFERIOR, 3-4 CM MEDIAL TO ASIS.
• STARTING POINT: AIIS .
• PIN DIRECTION: 10-20 CRANIALLY, 20-30 MEDIALLY. TOWARDS PIIS
• SECOND PIN: 2CM SUPERIOR
PELVIC INFIX
• DONE BY ADAPTING SPINAL INSTRUMENTS TO PELVIS
• INSERTION OF PEDICLE SCREW AS SUPRA ACETABULAR PIN
• SPINAL ROD CONTURED, CUT AND PASSED BETWEEN ABDOMINAL
FAT LAYER AND RECTUS.
INTERNAL FIXATION TECHNIQUES
ANTERIOR FIXATION:
INDICATIONS:
• PUBIC DIASTASIS >2.5 CM
• AUGMENTATION OF POSTERIOR FIXATION IN UNSTABLE PELVIC RING
INJURIES
• SIGNIFICANTLY DISPLACED RAMI FRACTURES
• LOCKED SYMPHYSIS
• STRADDLE FRACTURES (BILATERAL SUPERIOR AND INFERIOR RAMI
FRACTURES)
• PAIN AND INABILITY TO MOBILIZE (RELATIVE INDICATION)
CONTRAINDICATIONS:
• BLADDER RUPTURE
• COLOSTOMY
• SUPRAPUBIC CATHETER
• APPROACHES:STOPPA APPROACH
PFANNENSTIEL INCISION
SKIN INCISION WITH EXPOSED FASCIA
LINEA ALBA EXPOSED
FIXATION OF RAMI FRACTURES
• MANY FRACTURES CAN BE TREATED CONSERVATIVELY
• USED FOR GROSSLY DISPLACED RAMI # OR AUGMENT POSTERIOR
FIXATION
• APPROACH: EXTENSION OF STOPPA OR ILIOINGUINAL APPROACH
PERCUTANEOUS SCREW FIXATION
• AVOIDS EXTENSIVE DISSECTION OF OPEN REDUCTION.
ANTEROGRADE SCREW (RIGHT)
• THE STARTING POIN MIDPOINT ON A
LINE BETWEEN THE TIP OF THE
GREATER TROCHANTER AND A SPOT
ABOUT 4 CM POSTERIOR TO THE ASIS
RETROGRADE SCREW (LEFT)
• ENTER JUST LATERAL TO PUBIC
TUBERCLE
POSTERIOR RING FIXATION
INDICATION
• SI DISLOCATION
• DISPLACED CRESCENT FRACTURES
• SACRAL FRACTURES
• LUMBOPELVIC DISASSOCIATION
PERCUTANEOUS VS OPEN
OPEN SI JOINT REDUCTION
• COMBINED ACETABULUM FRACTURE
• PERCUTANEOUS REDUCTION NOT
ADEQUATE
• NO LINEAR REDUCTION VECTOR
PERCUTANEOUS
• LESS INVASIVE
• AVOID WOUND COMPLICATIONS
• LINEAR REDUCTION VECTOR AVAILABLE
ILIOSACRAL SCREW FIXATION
• INDICATIONS: SI JOINT
DISLOCATIONS, CRESCENT
FRACTURE,SACRAL BODY
FRACTURE
• POSITION : SUPINE/ PRONE
• SITE: INTRSECTION OF LINE
DRAWN FROM GT AND ASIS
• STARTING POINT:
INLET VIEW OUTLET VIEW
BILATERAL SI JOINT
FIXATION
SI SCREW FOR SACRAL FRACTURE
FOR COMPLETE FRACTURE
WITHOUT DISPLACEMENT AND
NEUROLOGICAL INJURY
APPROACHES-ANTERIOR APPROACH
• FRACTURES FIXED:ILIAC WING FRACTURE
CRESCENT FRACTURE
SI JOINT DISLOCATION
POSTERIOR MIDLINE APPROACH
• COMMUNITED SACRAL
FRACTURES
• WHEN LAMINECTOMY
NEEDED
POSTERIOR APPROACH TO SI JOINT
ZONE I – SACROILIAC SCREW, PARTIALLY THREADED
ZONE II – 1)UNDISPLACED,NON COMMUNITED-
PARTIALLY THREADED SCREW
2)COMMUNITED FRACTURE- FULLY THREADED
3)WITH NERVE INJURY – OPEN REDUCTION
AND DECOMPRESSION
ZONE III – UNDISPLACED – SI SCREW PARTIALLY
THREADED
CRESCENT FRACTURES
TYPE I – TREATED LIKE ILIAC WING
FRACTURE
ANTERIOR APPROACH
LAG SCREWS
TYPE II – POSTERIOR APPROACH
LAG SCREW FIXATION
TYPE III – POSTERIOR APPPROACH
LAG SCREW/ SI SCREW
THANK YOU

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PELVIC RING FRACTURES

  • 2.
  • 3. LEARNING OBJCTIVES • ANATOMY OF PELVIS • IMAGING • CLASSIFICATION OF PELVIC FRACTURES • APPROACHES • TREATMENT • NON OPREATIVE • OPERATIVE
  • 5.
  • 7.
  • 8. ANOMALIES SACRLISATION OF LUMBAR VERTEBRA LUMARISATION OF SACRAL VERTEBRA
  • 9.
  • 10. IMAGING • UNLIKE OTHER LONG BONES PELVIS IS A COMPLEX 3 DIMENSIONAL STRUCTURE
  • 11. INLET VIEW • INTERNAL OR EXTERNAL RETOATION OF HEMIPELVIS • OPENING OF SI JOINT • IMPACTION # OF SACRAL ALA • AP DISPLACEMENT OF POSTERIOR RING OUTLET VIEW • SACRAL FRACTURES WITH RESPECT TO FORAMINA.
  • 13.
  • 14. CT • CT SCAN CAN AID IN THE RECOGNITION OF MANY OF THESE INJURIES THAT GO UNDETECTED ON PLAIN RADIOGRAPHS • THE 3D AND OTHER RECONSTRUCTED IMAGES CAN ASSIST IN DETERMINATION OF THE SURGICAL APPROACH STRESS VIEWS : TAKEN UNDER ANEASTHESIA MAY REVEAL SOME INSTABILITY WHICH IS NOT SEEN IN NORMAL XRAYS
  • 15. CLASSIFICATION STABLE FRACTURES ROTATIONALLY UNSTABLE VERTICALLY STABLE ROTATIONALLY UNSTABLE VERTICALLY UNSTABLE
  • 16. YOUNG BURGESS CLASSIFICAITON • BASED ON MECHANISM OF INJURY
  • 18. LATERAL COMPRESSION (LC I) ANTERIOR INJURY: PUBIC RAMI # POST INJURY: SACRAL # ON SIDE OF IMAPACT
  • 19. LATERAL COMPRESSION - II ANTERIOR INJURY: RAMI # POSTERIOR INJURY: CRESCENT# (FRACTURE DISLOCATION OF ILIUM THROUGH SI JOINT)
  • 20. LATERAL COMPRESSION III (WIND SWEPT PELVIS) TYPE I OR II INJURY ON SIDE OF IMPACT + CONTRALATERAL OPEN BOOK INJURY
  • 21.
  • 22.
  • 23. ANTERO POSTERIOR COMPRESSION (APC I) [ANTERIOR INJURY= SYMPHYSIS DIASTASIS/ RAMI #] MODE OF INJURY: SEVERE EXTERNAL ROTATION OF ONE HEMIPELVIS ANTERIOR INJURY: PUBIC DIASTASIS < 2.5 CM POSTERIOR INJURY: MILD ANTERIOR OPENING OF SI JOINT
  • 24. APC II ANT. INJURY: PUBIC DIASTSIS >2.5 CM POST. INJURY:OPENING OF ANTERIOR SI JOINT, INACT POSTERIOR SI LIGAMENTS,RUPTURE OF ANTERIOR SI LIGAMENTS (SACROTUBEROUS, SACROSPINOUS,ANTERIOR SACROILIAC)
  • 25. APC III – COMPLETE SI JOINT DISRUPTION DISRUPTION OF INTRAARTICULAR AND POSTERIOR SI LIGAMENTS .
  • 26. VERTICAL SHEAR • PRIMARY FORCE VECTOR IS DIRECTED CEPHALAD. • HEMI PELVIS SHIFTED VERTICALLY • AVULSION # OF L5 INDICATES UNSTABLE # (ILIO LUMBAR LIGAMENT DISRUPTION)
  • 27. COMBINED MECHANISM • RESULT OF MULTIPLE FORCE VECTORS
  • 28. DENIS CLASSIFICATION OF SACRAL FRACTURES • BASED ON FRACTURE LINE IN RELATION WITH SACRAL FORAMINA • ZONE I – FRACTURE LINE LATERAL TO FORAMINA • ZONE II – FRACTURE LINE THROUGH THE FORAMINA, HIGH CHANCE OF SACRAL NERVE INJURY • ZONE III – FRACTURE MEDIAL TO FORAMINA, HIGH RISK OF INJURY TO SPINAL CANAL
  • 29.
  • 30. MANAGEMENT NON OPERATIVE TRATMENT: INDICATIONS :- • STABLE PELVIC RING INJURIES (LC – I) • STABLE SACRAL INJURIES. (RISK OF LATE DISPLACEMENT) • COMORBIDITIES PRECLUDING SURGICAL INTERVENTION • POOR BONE QUALITY WHERE SCREW PURCHASE MAY BE PROBLEMATIC • THE LOW-ENERGY OSTEOPOROTIC PELVIC RING FRACTURE
  • 31. OPERATIVE MANAGEMENT - GENERAL PRINCIPLES: • POSTERIOR INJURY IS REGARDED AS THE MORE CRITICAL ONE REQUIRING AN ACCURATE REDUCTION AND STABLE FIXATION. • ANTERIOR FIXATION CAN NEITHER MAINTAIN POSTERIOR REDUCTION NOR RESTORE STABILITY • IN CEPHALAD DISPLACEMENT OF THE HEMIPELVIS WITH COMPLETE INSTABILITY OF THE POSTERIOR RING, POSTERIOR FIXATION SHOULD ALWAYS BE SUPPLEMENTED WITH ANTERIOR STABILIZATION • POSTERIOR PELVIC RING SHOULD BE REDUCED AND STABILIZED FIRST, FOLLOWED BY ANTERIOR PELVIC RING
  • 32. ANTERIOR RING • EXTERNAL FIXATION • PUBIC SYMPHYSIS PLATING • PUBIC RAMI PLATING • PUBIC RAMI PC SCREW FIXATION POSTERIOR RING • SACROILIAC SCREW FIXATION • SI JOINT PLATING • ILIAC WING PLATE/SREW
  • 33. EXTERNAL FIXATION: INDICATIONS: • AS AN EMERGENCY PROCEDURE • TO REDUCE THE POSTERIOR LESION PRIOR TO POSTERIOR STABILIZATION. • DEFINITIVE FIXATION: WHEN INTERNAL FIXATION CANNOT BE DONE ( WOUNDS, SPC, TO AVOID MORBIDITY OF OPEN PROCEDURE) • COMMUNITED FRACTURES
  • 34. TYPES ILIAC CREST PIN FIXATION SUPRA ACETABULAR PIN FIXATION
  • 35. ILIAC CREST PIN FIXATION • SITE: 2 CM POSTERIOR TO ASIS. AVOID INJURY TO LATERAL FEMORAL CUTANEOUS NERVE • STARTING POINT: INNER 1/3RD MIDDLE 1/3RD JUNCTION. • PIN DIRECTION: 25 - 40° MEDIALLY 10-15 ° CAUDAL. • PIN THICKNESS: 5 MM • UNICORTICAL DRILL HOLE . NOT MORE THAN 2CM DEEP. • SECOND PIN 2 CM POTERIOR TO FIRST ONE . PINS APPEARS TO CONVERGE
  • 36. PROCEDURE ASIS AIIS INCISION OVER ILIAC CREST 2 CM BEHIND THE ASIS
  • 37. DRILLING THE FIRST CORTEX ADVANCING THE PIN BETWEEN TWO TABLES OF ILIAC BONE
  • 38. GUIDING PIN WHICH INSERTED BETWEEN THE ILIACUS AND INNER TABLE ILIAC CREST PIN
  • 39. SUPRA ACETABULAR PIN TECHNIQUE: • BIOMECHANICALLY STRONGER. • PATIENT CAN SIT. • FLUROSCOPY DEPENDENT • SITE: 4-6 CM INFERIOR, 3-4 CM MEDIAL TO ASIS. • STARTING POINT: AIIS . • PIN DIRECTION: 10-20 CRANIALLY, 20-30 MEDIALLY. TOWARDS PIIS • SECOND PIN: 2CM SUPERIOR
  • 40.
  • 41.
  • 42. PELVIC INFIX • DONE BY ADAPTING SPINAL INSTRUMENTS TO PELVIS • INSERTION OF PEDICLE SCREW AS SUPRA ACETABULAR PIN • SPINAL ROD CONTURED, CUT AND PASSED BETWEEN ABDOMINAL FAT LAYER AND RECTUS.
  • 43.
  • 44. INTERNAL FIXATION TECHNIQUES ANTERIOR FIXATION: INDICATIONS: • PUBIC DIASTASIS >2.5 CM • AUGMENTATION OF POSTERIOR FIXATION IN UNSTABLE PELVIC RING INJURIES • SIGNIFICANTLY DISPLACED RAMI FRACTURES • LOCKED SYMPHYSIS • STRADDLE FRACTURES (BILATERAL SUPERIOR AND INFERIOR RAMI FRACTURES) • PAIN AND INABILITY TO MOBILIZE (RELATIVE INDICATION)
  • 45. CONTRAINDICATIONS: • BLADDER RUPTURE • COLOSTOMY • SUPRAPUBIC CATHETER • APPROACHES:STOPPA APPROACH PFANNENSTIEL INCISION SKIN INCISION WITH EXPOSED FASCIA
  • 47.
  • 48.
  • 49.
  • 50. FIXATION OF RAMI FRACTURES • MANY FRACTURES CAN BE TREATED CONSERVATIVELY • USED FOR GROSSLY DISPLACED RAMI # OR AUGMENT POSTERIOR FIXATION • APPROACH: EXTENSION OF STOPPA OR ILIOINGUINAL APPROACH
  • 51.
  • 52. PERCUTANEOUS SCREW FIXATION • AVOIDS EXTENSIVE DISSECTION OF OPEN REDUCTION. ANTEROGRADE SCREW (RIGHT) • THE STARTING POIN MIDPOINT ON A LINE BETWEEN THE TIP OF THE GREATER TROCHANTER AND A SPOT ABOUT 4 CM POSTERIOR TO THE ASIS RETROGRADE SCREW (LEFT) • ENTER JUST LATERAL TO PUBIC TUBERCLE
  • 53.
  • 54. POSTERIOR RING FIXATION INDICATION • SI DISLOCATION • DISPLACED CRESCENT FRACTURES • SACRAL FRACTURES • LUMBOPELVIC DISASSOCIATION
  • 55. PERCUTANEOUS VS OPEN OPEN SI JOINT REDUCTION • COMBINED ACETABULUM FRACTURE • PERCUTANEOUS REDUCTION NOT ADEQUATE • NO LINEAR REDUCTION VECTOR PERCUTANEOUS • LESS INVASIVE • AVOID WOUND COMPLICATIONS • LINEAR REDUCTION VECTOR AVAILABLE
  • 56.
  • 57. ILIOSACRAL SCREW FIXATION • INDICATIONS: SI JOINT DISLOCATIONS, CRESCENT FRACTURE,SACRAL BODY FRACTURE • POSITION : SUPINE/ PRONE • SITE: INTRSECTION OF LINE DRAWN FROM GT AND ASIS • STARTING POINT:
  • 60. SI SCREW FOR SACRAL FRACTURE FOR COMPLETE FRACTURE WITHOUT DISPLACEMENT AND NEUROLOGICAL INJURY
  • 62.
  • 63. • FRACTURES FIXED:ILIAC WING FRACTURE CRESCENT FRACTURE SI JOINT DISLOCATION
  • 64. POSTERIOR MIDLINE APPROACH • COMMUNITED SACRAL FRACTURES • WHEN LAMINECTOMY NEEDED
  • 66. ZONE I – SACROILIAC SCREW, PARTIALLY THREADED ZONE II – 1)UNDISPLACED,NON COMMUNITED- PARTIALLY THREADED SCREW 2)COMMUNITED FRACTURE- FULLY THREADED 3)WITH NERVE INJURY – OPEN REDUCTION AND DECOMPRESSION ZONE III – UNDISPLACED – SI SCREW PARTIALLY THREADED
  • 67. CRESCENT FRACTURES TYPE I – TREATED LIKE ILIAC WING FRACTURE ANTERIOR APPROACH LAG SCREWS TYPE II – POSTERIOR APPROACH LAG SCREW FIXATION TYPE III – POSTERIOR APPPROACH LAG SCREW/ SI SCREW
  • 68.