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- 1. Pelvic Ring Injury Moderator: Dr Samuel Hailu Presenter: Yasin Awil (OSR)
- 2. Outline • Anatomy • Biomechanics • Mechanism of Injury • Classification • Approach to patient • Imaging • Management
- 4. Ligaments
- 6. Perineum and genitourinary anatomy Common site of urethral injury: • Membranous Urethra ( males) • Near bladder neck ( females)
- 7. Biomechanics • “Reverse Keystone” on inlet • “Keystone” on outlet
- 8. • Posterior SI: • works almost constantly; • most powerful; • ‘Suspension Bridge’
- 10. Patho-anatomy • Most important determinant is its ring structure • A ring fails in two locations (at least) • The degree of pelvic instability • Correlates with the energy of the trauma • Overall physiological status of the patient • Guides definite management
- 11. MOI • Pelvic ring may fail through the bone, ligaments, or both. • First described by George F. Pennal, 1950s • APC, LC, VS • In clinical practice commonly is a combination of these forces.
- 14. • Complete unstable (vertical shear)
- 15. CLASSIFICATION • Anatomic • Young-Burgess (Mechanism of injury) • Tile (Stability) • AO/OTA • Comprehensive Classification ( Modified Tile AO Müller classification)
- 16. • The Letournel and Judet classification of pelvic fractures is anatomic.
- 17. YOUNG AND BURGESS CLASSIFICATION: • Based on the mechanism of injury. • most likely potential associated injuries • resuscitation requirements • among the most favored classifications
- 20. Tile classification combines: • mechanism of injury • degree of pelvic stability • site of injury
- 22. Subclassification of Crescent # dislocation Day Classification: • Type I -a large crescent fragment, and less than one-third of the sacroiliac joint dislocation. • Type II - an intermediate-sized crescent fragment and the dislocation comprises between one-third and two-thirds of the sacroiliac joint. • Type III fractures are linked to a small crescent fragment where the dislocation comprises most of the joint.
- 23. Nakatani classification of superior ramus fractures • Type I: medially to the medial border of the foramen. • Type II: within the foramen. • Type III: lateral to the lateral border of the foramen.
- 24. Clinical assessment Primary survey: ABCDE • Multiply injured patients require: • careful history regarding the mechanism of injury • Proper physical exam: • Lower limb deformity or shortening • Evaluation of peripheral perfusion,
- 25. P/E: • Evaluation of motor function and sensation, • Rectal examination to evaluate for: • Sacral root injury • Presence of an open fracture, • stability testing of the pelvic ring
- 26. • Stability test
- 29. Associated Injuries • Chest injuries (63%) • Long bone fractures (50%) • Head injury (40%), • Solid organ injury (40%), • Spinal fracture (25%). • Intestinal injuries (14%)
- 30. • APC are associated with higher blood loss • Type III - 67% risk of shock • LC associated with high incidence of head injury (50%) • Type III- 20% risk of bowel injury, 40% extremity # • VS high risk of hypovolemic shock (63%), mortality (25%), head injury (56.2%), lung injury (23%), and splenic injury (25%)
- 31. Genitourinary Tract injuries • Bladder and Urethral injuries – 6% to15% • Vaginal Injury • 0 to 5% • Urethral injury • Male > Female • Posterior >anterior
- 32. Dynamic Retrograde Urethrogram • In posterior urethral injury: • 10 to 20% risk of associated bladder rapture • Bladder rupture: • 60% EPBR, 30% IPBR, and 10% both • 22%-34% mortality
- 33. Management IPBR: • Exploratory laparotomy + bladder repair + Foley or suprapubic catheter • Anterior fixation or ex-fix in same setting EPBR: • Non-OP [Foley catheter + Antibiotics] - strong consideration for ex-fix as definitive management • If ORIF anterior pelvis necessary – bladder repair can be done in same setting
- 34. Urethral Injury: • Endoscopic realignment vs acute suprapubic drainage followed by delayed reconstruction • Clear communication between the orthopedic trauma team and the urologic team
- 35. Morel-Lavallé lesion: • Internal degloving which occur when the skin and subcutaneous tissue separate from the underlying fascia
- 36. Open Fractures • 5% of all PRI • Jones classification: • Class 1 - Stable open PRF. • Class 2 - Rotationally or vertically unstable, and there is no rectal or perineal wound. • Class 3- Rotationally or vertically unstable, and a rectal or perineal wound with potential for fecal contamination is present • Careful digital rectal and Vaginal examination
- 37. Faringer et al Classification: • Zone I consists of the perineum, anterior pubis, median buttocks, and posterior sacrum. • Zone II consists of the thigh or groin crease. • Zone III consists of the iliac crest and more lateral buttocks
- 38. Packing and I&D
- 39. Pelvic ring disruption in women: genitourinary and obstetrical implications • Urinary complaints • Sexual function • Dyspareunia • Infertility • Mode of delivery
- 41. IMAGING Plain Radiographs: AP • Overview of complete pelvis • Rami • Symphysis
- 42. Outlet: • SI joint • Sacral foramina • Sympysis
- 43. INLET View: • Pelvic brim • Pubic rami • SI joint • Sacral ala • Iliac wing
- 44. Radiographic Signs of Instability • SI displacement of 5 mm in any plane. post/vertical • Posterior fracture gap (rather than impaction). • Avulsion of the 5th lumbar transverse process, the lateral border of the sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous ligament)
- 46. CT: • Integral in the management of PRI. • Aids in the classification of injuries • CT scan with contrast and CTA evaluate: • life threatening hemorrhage in high energy PRI
- 47. MRI and Scintigraphy: • Occult fractures • Persistent posterior pelvic pain after trauma despite the absence of an obvious fracture on CT scan
- 49. Acute Management The ladder of resuscitation for hemodynamic instability: • Fluid resuscitation • Blood transfusion • Emergent stabilization of the unstable pelvis • Pelvic binder • External fixator ( a shock that doesn’t respond for binder may not respond for the ex-fix ) • Pelvic packing • Angiographic embolization
- 52. Specific Treatments of Pelvic Ring Disruption Closed reduction No posterior and Vertical Displacement: • Both legs are slightly flexed at the hips and knees and internally rotated and tapped. • Pelvic sheet or binder is applied Posterior and Vertical displacement: • Skeletal traction • Pelvic sheet or binder
- 54. Pelvic binder: • Applied at the level of the greater trochanters • Should be flat against the skin to maximize surface area • 24-48 hours
- 56. Anterior external fixation Indication: • Temporary stabilization of unstable fracture • Definitive stabilization of pelvic ring # • Undergoing laparotomy – pelvic packing or Urologic and abdominal procedures. Should be done before laparotomy • An open pelvic ring injury or associated injury of genitourinary organs
- 57. Techniques of Pelvic Ex-fix Application • A)Iliac crest
- 59. Pelvic C- Clamp • Posterior ring stabilization through pins placed in posterior ilium lateral to SI joint • Mechanically superior to any anterior frame, especially in the case of completely unstable (type C) injuries • C/I – presence of iliac wing fracture • Complications - vascular and nerve injuries or displacement of the unstable hemipelvis into the true pelvis ( rare)
- 60. Pelvic Packing • Midline infraumbilical incision from 1 to 2 cm inferior to the umbilicus to the pubic symphysis. • Gently remove the blood clots. • Retract the bladder to one side • Place a laparotomy sponge below pelvic brim • Place a second and third sponge anterior to the first. • Repeat the same on the contralateral side
- 62. Angiography Diagnostic vs Therapeutic • Indication • Hemodynamic instability despite adequate resuscitation and application of external pelvic compression device • There should be no evidence of intraabdominal bleeding.
- 63. DEFINITIVE MANAGEMENT • Recommendations for therapy are based primarily on two factors: • Fracture pattern (including pelvic stability) • Patient factors (e.g., associated injuries, soft tissue conditions within and around the zone of injury, and comorbidities).
- 64. Cont… ORIF of pubic symphysis: • Ex fix • Plating • Cerclage wiring Strength • Two plates >> one plate • Box plates – Allow Biplanar screw insertion • Plates >> Ex fix Ramus fracture location further from mid line • Plating becomes less significant
- 65. SI dislocation: • SI screw • Long thread (32 mm) • First sacral body • Ant Platting • Trans-iliac bars • Trans-iliac plating
- 67. References • TILE.M (2015). Fractures of the Pelvis and Acetabulum: Principles and Methods of Management, 4th ed., Switzerland: AO Foundation. • BROWNER B.D.( 2020). Skeletal Trauma. Basic Science, Management and Reconstruction, 6th edition., Philadelphia, USA • COURT-BROWN C.M. (2015). Rockwood’s and Green’s Fractures in Adults, 8th ed., Philadelphia: Lippincott Williams & Wilkins • MOORE K.L. (2014). Moore clinically oriented anatomy, 7th ed., Philadelphia: Lippincott Williams & Wilkins • journal homepage: www.elsevier.com/locate/injuryJames A.C. Fagga,b,, Mehool R. Acharyaa, Tim J.S. Chessera, Anthony J. Warda
Editor's Notes
- Most normal forces applied to the pelvis tend to push the sacrum anteriorly and the innominate bones posteriorly. The shapes of the pelvic bones affect the way that they interact. On the inlet view, the sacrum appears wider anteriorly and is held in position by tension in the ligaments, with the strongest ligaments located posteriorly. On the outlet view, the sacrum appears as a classic “keystone” in which applied forces create compression between the bones, contributing to stability of the ring
- The suspension bridge-like appearance of the posterior sacroiliac complex. Note the posterior sacroiliac ligaments, the strongest in the body, which function like suspension cables. Note that the posterior superior iliac spines act as towers, and the sacrum acts as the bridge deck. Computed tomographic scan shows the appearance of the sacroiliac arch. Professor JCB Grant at the University of Toronto described the posterior sacroiliac ligament as the most powerful ligament in the body. When its function is understood, the reason for its strength becomes obvious. The posterior sacroiliac ligaments work almost constantly to resist anterior displacement of the sacrum and axial skeleton relative to the innominate bones.
- Load should be applied through the top of S1, preferably through L5, which remains attached to the sacrum by its ligaments. The injured pelvis model also acts differently in response to loading in single-leg stance compared with bilateral stance (Fig 1.2-4). When loaded vertically, the sacroiliac joints are subjected primarily to shear. However, in single-leg stance there is compression inferiorly and distraction superiorly, whereas in bilateral stance there is greater compression across the sacroiliac joint, with distraction inferiorly (Table 1.2-1). In upright stance, relatively small shearing forces occur across the pubic symphysis, generally in combination with compression when loaded in single-leg stance and distraction when loaded in bilateral stance.
- The term APC is generally used to describe forces that open the pelvis like a book may be applied to the pelvis by several mechanisms. Fig. A) A direct blow to the posterior superior iliac spine can externally rotate one or both ilia, causing disruption of the anterior part of the pelvic ring B) External rotation of the femora or direct compression against the anterior superior spines also causes disruption of the symphysis pubis, or equivalent fractures of the public rami. With further force, the ligaments of the pelvic floor (sacrotuberous and sacrospinous ligaments) are disrupted along with the anterior sacroiliac ligaments. Further force will sequentially rupture the posterior sacroiliac ligaments. When the force overcomes the posterior sacroiliac ligaments the pelvis will also become completely unstable. LC Anterior iliac wing- anterolateral portion of sacrum adjacent to SI joint sustains impaction fracture. Injury to Posterior SI ligament complex may follow Posterior ilium- Crescent fracture Ramus fracture (oblique, horizontal), fracture dislocation through sympysis Greater trochanter – associated acetabular # Posterior SI complex – force parallel to sacral trabeculae compression or impaction of cancellous bone of sacrum VS Force perpendicular to bony trabeculae Fracture pattern depends on amount of force and strength of bone in relation to ligament Strength of Bone << ligament – Vertically oriented sacral and Rami # Bone >> ligament- Sympysis and SI dislocations
- Many systems have been used for classification of pelvic ring fractures. The main themes of pelvic ring fracture classification have concentrated on anatomy, mechanism of injury, or stability. Example of anatomic classification of pelvic fracture: Letournel’s anatomical classification system; Denis classification of sacral fractures; Subclassification of crescent fractures of the posterior ilium; Nakatani classification of superior ramus fractures Understanding the exact anatomy of a pelvic ring fracture is essential for the treating surgeons. However, an anatomical classification by itself does not provide enough information to be useful either in modern clinical practice or in research. he Letournel and Judet classification of pelvic fractures is anatomic. A, Iliac wing fractures. B, Ilium fractures with extension to the sacroiliac (SI) joint. C, Transsacral fractures. D, Unilateral sacral fractures. E, SI joint fracture-dislocation. F, Acetabular fractures. G, Pubic ramus fractures. H, Ischial fractures. I, Pubic symphysis separation. Combinations of all of these injuries can occur.
- perianal sensation, • anal sphincter tone, • voluntary perianal contraction, • the presence of anal wink, and • the bulbocavernosus reflex
- 4 Direct palpation of the iliac crest reveals crepitus or abnormal motion, which, if present, is the best indicator of instability of the pelvis With one arm controlling the injured hemipelvis and the second arm applying traction, one can again determine the amount of instability present.
- Fig 1.8.6-3 Bilateral manual compressive pelvic examination with image intensification. The examiner must be in a stable position with both hands located at the iliac crests. In this figure, the examiner’s left arm is adducted against the chest and the elbow is flexed. The examiner’s right upper extremity is positioned away from the imaging beam and provides contralateral resistance during the compressive examination. The C-arm is tilted to an inlet view and centered on the anterior pelvic ring. The inlet tilt demonstrates the instability and avoids superimposition of the examiner’s arms on the image Fig 1.8.6-4a–b Bilateral manual compressive pelvic examination with image intensification. a The unstressed inlet image. b The stressed inlet image revealing right hemipelvic instability
- The majority of patients with a urologic injury will have gross hematuria. All these patients should have a cystogram. In the male patient, a dynamic retrograde urethrogram (RUG) is the best study to evaluate for a urethral injury. A Foley catheter is inserted into the penile urethra and the balloon is inflated with 1 to 2 mL of saline; 25 mL of water-soluble contrast material is then instilled. An anteroposterior (AP) view of the pelvis or a 30- to 45-degree oblique view is obtained under fluoroscopy, if possible. Lack of contrast in the bladder usually indicates a urethral disruption, although the bladder may still fill with contrast (Fig. 46-2). After the RUG is performed, if the urethra is not injured, an attempt is made to pass the catheter into the bladder and a cystogram (either plain radiograph or computerized tomography [CT] scan) is performed by instilling an additional 300 to 400 mL of water-soluble contrast into the bladder. Figure 1. Image from ascending urethrography in a male patient with an “open-book” pelvic fracture from trauma shows the posterior urethra (arrow), which appears stretched but intact (Goldman type I injury), with no evidence of contrast material extravasation. Figure 2. Image from ascending urethrography shows an area of contrast material extravasation (white arrow) indicative of injury to the posterior urethra, with an intact urogenital diaphragm (black arrow). These findings signify a Goldman type II injury.
- The patient is placed supine symmetrical positioning of the legs and subtle abduction and internal rotation of the hips. The beam is directed perpendicular to the midpelvis, about 2 fingerbreadths above the pubic symphysis and the radiologic plate Signs of Instability Displacement of the posterior SI complex > 1 cm Presence of a gap rather than impaction posteriorly Avulsion fractures Vertical fractures through the pubic and ischial rami
- Essentially the true “anterior” view of the pelvis and is orthogonal to the inlet view The caudocranial beam is focused 2 to 3 fingerbreadths below the pubic symphysis. Vertical displacement of the hemipelvis can be identified. Because the obturator foramen is brought into profile, fractures extending into the obturator foramen can be detected more easily than on the AP view
- Displacement of the hemipelvis in the transverse (axial) 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.
- a To begin pin placement, the iliac crest is localized 1–2 cm posterior to the anterior superior iliac spine (ASIS). b The stab wound begins directly over the crest and progresses toward the umbilicus. c Two K-wires are inserted, one on the medial side and one on the lateral side, into the iliac wing to identify both borders of the crest and the plane of the ilium toward the acetabular roof. d A trocar sleeve system is introduced in a lateral-to-medial 45° inclination. e Illustration showing the opposite side after pin placement with the final sizes of the stab wounds. f Straight, double ball-jointed pelvic pin clamps may be used to connect the pins and “prestress” them into a straight configuration.
- a Placement of the trocar sleeve system in the area of the anterior inferior iliac spine. Note the direction of the pin toward the area above the greater sciatic notch, 30–45° toward midline in the frontal plane. The trocar is removed, and the sleeve system must be held firmly against the bone before drilling. b Obturator outlet position of the pelvis. A 5 mm Schanz screw is placed through the external sleeve of the trocar sleeve system. c Schanz screws placed on both sides. d Final assembly of the external fixator placed in the area of the anterior inferior iliac spine.