For residents orthopaedic

1. PELVIS RING FRACTURE
FACILITATOR:DR SWETALA STEPHEN (MD, MMED, FELLOW- PELVIS &
ACETABULAR)
PRESENTER:DR CYNTHIA A.BISHAIJA

2. CONTENTS
• Pelvis osteology
• Pelvis muscle
• Blood supply
• Epidemiology
• Classification
• Mechanism of injury
• Radiological imaging
• Emergency care
• Definitive care
• Post reconstruction

3. PELVIS OSTEOLOGY

6. PELVIC LIGAMENTS

7. PELVIC MUSCLES

8. BLOOD SUPPLY

10. FUNCTION OF PELVIC LIGAMENTS

11. EPIDEMIOLOGY
• Pelvic ring fractures can affect all ages but the predominant age group was
in the 18 to 44 age group with an overall mean age of 45.
• The geriatric - 22% of the overall number. Men are affected slightly more
than women (56% vs. 44%).
• The incidence of pelvic ring fractures was reported to be 0.82 per 100,000
people.
• Multiple injured patients with pelvic ring fractures have morbidity and
mortality rates that range from 10% to 50%

12. CLASSIFICATION
1.YOUNG AND BURGESS
mech
anism
Description Treatment
APC1 Symphysis widening <2.5cm Non operative, protected
weight bearing
APC II o Symphysis widening > 2.5cm, Anterior SI Joint
diastasis, disruption of the sacrospinous and
Sacro tuberous ligament
o Posterior SI joint Intact,
o Anterior symphyseal
plate o ex fix ± Posterior
fixation
APC
III
o Disruption of Anterior and posterior SI joint,
o Disruption of sacrospinous and sacrotuberous
ligaments
o APCIII A/C with vascular injury
o Anterior symphyseal
mult-hole plate or ex fix
and posterior
stabilization with SI
screws or plate/screws

13. mecha
nism
Description Treatment
LC I o Oblique/ transverse ramus fracture and
ipsilateral anterior sacral ala compression
fracture.
o Non operative,
o Protected weight bearing
LC II o Rami fracture and ipsilateral posterior ilium
fracture dislocation (crescent fracture)
o ORIF illium
LCIII o Ipsilateral lateral compression and
contralateral APC, (windswept pelvis)
o Common mechanism is rollover car accident
or pedestrianVS Auto
o Posterior stabilization with
plate or SI screw as needed
o Percutaneous or open based
on injury pattern and surgeon
preferences

14. Mech
anism
Decreption Treatment
Vertic
al
shea
o Posterior and superior directed force.
o Associated with highest risk of
hypovolemic shock (63%, ) mortality
rate up to 25%
o Posterior
stabilization with
plate or SI screws as
needed
o Percutaneous or
open based on injury
pattern and surgeon
preferences

16. 2.TILES CLASSIFICATION

18. MECHANISM OF INJURY
MTA
• speed of vehicle i.e 30mph (50kmp)
• Collision type; Risk is highest in side impact collisions on
the same side as the victim followed by head-on collisions
• Pedestrians, bicyclists, and motorcyclists have twice the
risk of sustaining a pelvic fracture

19. Fall from height,
•> 4m – high energy trauma,
•<7m – Fractures of pelvis, upper limbs, lower limbs, and
blunt thoracic trauma - most common in
•>7m –TBI and Spine cord injury are most common

20. Osteoporosis
• More to elderly than young generation
• Women on menopause
• Other risks eg steroids use

22. RADIOLOGICAL IMAGING
1.APVIEW
Provides details on
• Rami fractures, Sacrospinous disruptions, Sacral injuries and the arcuate
lines
• Can properly evaluate the injuries of iliac wings.
The patient in supine with symmetrical positioning of the legs and subtle
abduction and internal rotation of the hips.
The beam is directed at the midpelvis, about 2 finger breadths above the
pubic symphysis and the radiologic plate

24. INLETVIEW
• Patient lied as above, the craniocaudal beam is directed at the
level of the ASIS and the middle of the radiographic plate at an
angle of approximately 40 degrees relative to the horizontal
plane.
• It evaluate; the pelvic brim, the pubic rami, the SI joints, the
sacral ala, and the body of the sacrum as well as the posterior
iliac spine.
• The inlet view allows for assessment of an internal or external
rotation of each hemipelvis

26. OUTLETVIEW
• The caudocranial beam is focused 2 to 3 fingerbreadths
below the pubic symphysis
• S1&S2 vertebra bodies are clearly visualized
• This view can evaluate;
othe symmetry of the SI joints a
oSymphysis Pubis,
oDisplacement of hemipelvis

28. JUDATEVIEW
Types:
I. Obturator oblique
II. Iliac oblique
• Oriented 45 degrees to coronal plane
• Obturator ring is perpendicular (orthogonal) to iliac wing
• Iliac oblique of one hip is obturator oblique of contralateral hip

30. i.Obturator oblique
• Injured hemipelvis bumped up, toward Xray beam.
• Iliac cross section is small as possible
• Perfectly displays outline of the obturator ring
• Best demonstrates
1)Anterior column 2) Posterior wall

32. ii.Iliac oblique
• Contralateral (uninjured) hemipelvis bumped up, toward Xray beam
• Exposes surface of the iliac wing
• Obturator foramen not visible, obturator ring as thin as possible
• Best demonstrates
1) Posterior column 2) Anterior wall 3) Iliac wing in profile

34. “FLAMINGO”VIEWS
• Single-leg-stance radiographs, the “Flamingo” views, are
dynamic views that can aid in identifying occult instability that
otherwise may be overlooked.

35. CT SCAN
• Used in the management of pelvic ring injuries and can aid in the
classification of injuries.
• The CT scan can aid in the recognition of injuries that go undetected on
plain radiographs.

36. MRI
• In cases of lumbopelvic dissociation or sacral fractures with
neurologic compromise, MRI is of benefit in determining the
areas of neural canal compromise and nerve root compression.
• MR venography is also useful for the evaluation of deep vein
thrombosis (DVT) in the pelvic veins.

37. SCINTIGRAPHY
• An alternative for MRI, or when contraindicated.
• Identifies occult pelvic ring fractures that cannot be seen on CT,
with a sensitivity that approaches 100% and a positive predictive
value of approximately 92%.
CT- gold standard

38. PHYSICAL SIGNS OF PELVIC INSTABILITY
1. Deformity of Lower Limb ipsilateral to hemipelvis, without an obvious
fracture
2. Gray turner sign; Buttock/flank ecchymosis & swelling – Pos+ for
Retroperitoneal hemorrhage
3. Destot sign; a palpable hematoma over proximal thigh or perineum,
indicate pelvic fracture with hemorrhage
NB check out for other Associated injuries,

40. CLINICAL EXAMINATION

41. EMERGENCY CARE FOR PELVIC RING FRACTURES
Transfussion tequirement in Hemodynamic instability
• Definition; Systolic BP <90mmgh, HR 120 bpm, with evidence of skin
vasoconstriction (cool, clammy, and decreased capillary refill), altered level
of consciousness, and/or shortness of breath. OR
• (SBP) of >90 mmHg but requiring at least 4–6 units of packed red blood cells
within the first 24 h, vasopressor drugs, and/or have an admission base
deficit (BD) >6 mmol/L and/or a shock index (heart rate divided by SBP) >1.

43. BINDERS/MAST(Military Anti ShockTrousers)
• Closing the pelvic diastasis in openbook–type injuries reduces the
pelvic volume available for hemorrhage, thereby improving the
chance of tamponade and clot formation.
• The earliest forms of external compression devices were the
Pneumatic antishock garment (PASG) and the Military (or
medical) antishock trousers (MAST), which were inflatable
garments.

44. • Complications from the use of these devices included compartment
syndrome and extensive skin necrosis, especially in the setting of a
concomitant internal degloving injury.
• In addition, access to the abdomen for examination was precluded and
necessitated device removal to address abdominal issues.

45. • For optimal reduction of the APC injury, a binder should be placed at the
level of the greater trochanters.
• Adduction and internal rotation of the extremities, if uninjured, can also
assist in reducing the pelvic ring fracture.
• Anterior external fixator is excellent for temporary use to aid in resuscitation
in the acute phase.

46. • The purpose of external compression is as follows:
(a)To close the open-book pelvic injury, which reduces the pelvic volume
thereby allowing for a tamponade effect;
(b)To stabilize the pelvic ring injury, which allows for clot formation
(c)Allow for autotransfusion by returning the blood from the lower
extremities to the vascular system.

47. EMERGENT EXTERNAL FIXATION.
• Use of external fixation still an option for the definitive management of
certain pelvic ring injuries as an adjunct to posterior internal fixation,
especially when anterior stabilization is required and precluded by soft
tissue problems or genitourinary injuries.

48. • C-Clamps are used in the emergent setting primarily and are not indicated
for the definitive treatment of a pelvic ring injury.
• In cases in which ORIF of the anterior injury is contraindicated, anterior
external fixation is an effective option

49. COMPLICATION:
• Pin-site infection,
• Aseptic pin loosening,
• Serosanguineous discharge
• Adjacent skin necrosis

50. Pelvic c clamp
• Preferably in C type PRI
• A Landmark for surgical access, generally through a 2-cm incision, is the
intersection of a line extending along the longitudinal axis of the femur
and a perpendicular line originating from the ASIS

52. ADVANTAGES
1. Can be applied in OR, ICU, EMD
2.It addresses the site of instability by a direct compressive
force applied to the ilium lateral to the SI joints
DISADVANTAGE
1. Contraindicated inTrans iliac injuries

53. ANGIOGRAPHY
• Used in pelvic ring fractures who are hemodynamically unstable.
• Much of the bleeding occurs from the venous plexus and the cancellous
fracture surfaces

54. PELVIC PACKING
• For pelvic packing to be effective, it is important for the pelvis to be
stabilized either with a C-clamp or external fixation such that a stable wall
exists against which the packing can occur

55. DEFINITIVE MANAGEMENT OF PRI
• Indication for surgery
1. Unstable pelvic fracture
2.Major displacement of Symphysis pubis > 2.5cm
3. Fractures dislocation of SI joints
4.A significant tilt fractures – may lead to significant deformity
5.Patients factors, eg bed ridden, or not

57. 1.ANTERIOR PELVIC RING FIXATION

59. A.Symphyseal Reduction and Stabilization; symphyseal plating
• Use a contoured plate, 3.5mm six holes or more
• No differences in locking vs non locking plating
• The choice of plate depends on the type of associated ring injury as well as
the presence and stability of posterior fixation

60. B.Pubic Ramus; use a plate osteosynthesis technique
C.Superior Ramus Screw Fixation; Are IM Screw and can be
alternative to ORIF or EX Fix,
They are placed Antegrade (starting on the ilium superolateral to
the acetabulum and directed toward the symphysis) /Retrograde
(starting at the symphysis and directed above the acetabulum)

62. 2.POSTERIOR PELVIC RING FIXATION:

64. A.Iliac wing fractures or SI joint injuries can be reduced and fixed both
anteriorly and posteriorly. Fixation is achieved by interfragmentary
compression and the application of neutralization plates.
B. Sacroiliac (Fracture) Dislocations: (Anterior Approach)
• anterolateral approach is common for the anterior access to the SI joint
• Packing to control bleeding may be required at times
• Use a 3.5-4.5mm contoured plate and screw

66. Surgical approaches
ANTERIOR APPROACHES
1. Pfannenstiel Approach
2. Stoppa Approach
3. Anterolateral Approach
POSTERIOR APPROACHES
1. Paramedian Approach

67. POSTOPERATIVE CARE OF PELVIC RING INJURIES
• Drains and SoftTissues. It is discontinued when drainage is, 25 mL per 8-
hour shift. Sutures or staples are left in place for at least 2 weeks.
• Developed Ileus postoperatively, perhaps requiring a nasogastric tube. In
addition, dietary intake should be advanced carefully and only when flatus
and bowel sounds have returned.The use of narcotics postoperatively,
necessary for pain control, can exacerbate the situation. Patients may have
constipation. An aggressive postoperative bowel regimen with stool
softeners is often necessary

68. • In Morel-Lavallee lesions successful management of the internal degloving
can also be performed with percutaneous drainage and irrigation of the
space.
• Concern over open incisional drainage occurs from the fact that the
degloved skin and fat receive their entire blood flow from collaterals in the
adjacent peripheral skin.The underlying fascia no longer is providing blood
flow.Thus if the lesion is large enough, complete full-thickness necrosis with
resultant skin sloughing has been known to occur.

69. Mobilization andWeightbearing
• Early mobilization helps with both pulmonary toilet and bowel/bladder
function
• Pelvic ring injuries with complete disruption of the posterior ring should be
mobilized with nonweightbearing or touchdown weight earing for 12 weeks
followed by progressive weightbearing as tolerated.

70. • Patient factors such as obesity, bone quality, as well as fixation construct
and stability should be considered when determining weightbearing status.
• Stable and incomplete pelvic ring disruptions, stable impacted lateral
compression injuries, or APC I injuries can usually be allowed full
weightbearing immediately

71. REFERENCES
• Rockwood and Green’s Fractures in Adults EIGHTH EDITION
• Campbell’s OPERATIVE ORTHOPAEDICS 14TH EDITION