Successfully reported this slideshow.

Pelvic fracture classification

118

Share

Upcoming SlideShare
Pelvic fracture
Pelvic fracture
Loading in …3
×
1 of 64
1 of 64

More Related Content

Related Books

Free with a 14 day trial from Scribd

See all

Related Audiobooks

Free with a 14 day trial from Scribd

See all

Pelvic fracture classification

  1. 1. Classification of Pelvic Fractures Zahid Askar FCPS(Ortho), FRCS (Ortho) Prof of Orthopaedics & Trauma Khyber Medical College, Peshawer
  2. 2. Value Of classification • Mechanism of injury • Treatment options • Prognosis • Records/communications It should also be :- Easily Reproducible Have good Intra- & Interobservor reliability Easily remembered/applied
  3. 3. Historical Background • First attempt by Malgaigne in 1859 – Described without radiographs of the so-called “double vertical fracture” Malgaigne I. F.: Traite des Fractures et des Luxations, Paris, J. B. Bailliere, 1855.
  4. 4. Historical classification • Watson-Jones • Connolly & Hedberg • Huttinen & Slatis • Trunkey • Looser & Crombie
  5. 5. • Present classification systems started with the ground-breaking work by Pennal • Classified Injuries as APC/LC/VS Pennal GF, Sutherland GO. Fractures of the Pelvis. Park Ridge, IL: American Academy of Orthopedic Surgeons, 1961. Pennal, G. F., and Sutherland, G. 0.: Fractures of the Pelvis. Motion picture in AAOS film library, 1961.
  6. 6. Classification Systems • Letournel • Bucholz, • Tile • Young & Burgess • OTA/AO -research Commonly used Classification systems:- Tile Classification Young & Burgess Classification
  7. 7. Tile classification • Modification of Pennal Idea • Tile et al added the concept of stability The Tile classification system is mainly based on the integrity of the posterior sacroiliac complex Which Tile ???
  8. 8. Original Tile Classification Pennal GF, Tile M, Waddell JP, et al. Pelvic disruption: assessment and classification. Clin Orthop Relat Res 1980;151:12-22. Type A: Pelvic Ring Stable A1: fractures not involving the ring (i.e., avulsions, iliac wing, or crest fractures) A2: stable minimally displaced fractures of the pelvic ring Type B: Pelvic Ring Rotationally Unstable, Vertically Stable B1: open book B2: lateral compression, ipsilateral B3: lateral compression, contralateral, or bucket-handle-type injury Type C: Pelvic Ring Rotationally and Vertically Unstable: C1: unilateral C2: bilateral C3: associated with acetabular fracture
  9. 9. C1: Unilateral C1-1: iliac fracture C1-2: sacroiliac fracture-dislocation C1-3: sacral fracture C2: Bilateral with one side type B and one side type C C3: Bilateral with both sides type C B - Rotationally unstable, vertically stable B1: Open book injury (external rotation) B2: Lateral compression injury (internal rotation) B2-1: Ipsilateral ant. and post. Injuries B2-2: Contralateral ant. and post. Injuries (bucket-handle injury) B3: Bilateral A: stable A1: fracture not involving the ring (avulsion or iliac wing fracture) A2: stable or minimally displaced fracture of the ring A3: transverse sacral fracture (Denis zone III sacral fracture) Modified Tile Classification Tile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg Br 1988;70:1-12.
  10. 10. • Comprehensive Classification
  11. 11. Type A: Stable (Posterior Arch Intact) A1 Avulsion injury A1.1—Iliac spine A1.2—Iliac crest A1.3—Ischial tuberosity A2 Iliac wing or anterior arch fracture caused by a direct blow A2.1—Iliac wing fractures A2.2—Unilateral fracture of anterior arch A2.3—Bifocal fracture of anterior arch A3 Transverse sacrococcygeal fracture A3.1—Sacrococcygeal dislocation A3.2—Sacrum undisplaced A3.3—Sacrum displaced Type B: Partially Stable (Incomplete Disruption of Posterior Arch) B1 Open book injury (external rotation) B1.1—Sacroiliac joint, anterior disruption B1.2—Sacral fracture B2 Lateral compression injury (internal rotation) B2-1 Ipsilateral anterior and posterior injuries B2-2 Contralateral (bucket-handle) injuries B3 Bilateral B3.1—Bilateral open book B3.2—Open book, lateral compression B3.3—Bilateral lateral compression Type C: Unstable (Complete Disruption of Posterior Arch) C1 Unilateral C1.1 Iliac fracture C1.2 Sacroiliac fracture-dislocation C1.3 Sacral fracture C2 Bilateral, with one side type B, one side type C C3 Bilateral
  12. 12. Modified Tile Classification Tile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg Br 1988; 70:1-12.
  13. 13. Tile Type A fractures • The SI Joint is completely stable( Rotationally & vertically) • Fractures are outside the pelvic ring !!A: stable A1: fracture not involving the ring (avulsion or iliac wing fracture) A2: stable or minimally displaced fracture of the ring A3: transverse sacral fracture (Denis zone III sacral fracture)
  14. 14. Tile Type B Fractures • Partial Instability of the SI Joint Complex • Rotationally Unstable while Vertically stable B - Rotationally unstable, vertically stable B1: Open book injury (external rotation) B2: Lateral compression injury (internal rotation) B2-1: with anterior ring rotation/displacement through ipsilateral rami B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury) B3: Bilateral
  15. 15. Tile type B1- Open Book Injury (External Rotation Injury)
  16. 16. APC
  17. 17. B2- Lateral Compression Injury B2: lateral compression injury (internal rotation) B2-1: with anterior ring rotation/displacement through ipsilateral rami B2-2: with anterior ring rotation/displacement through contralateral rami (bucket- handle injury)
  18. 18. B2: lateral compression injury (internal rotation) B2-1: Ipsilateral Ant/Post Injuries B2-2-Contralateral Ant/Post Injuries (bucket-handle injury) B2.1 B2.2
  19. 19. B2.2- Contralateral injuries
  20. 20. B3- Bilateral The B3 bilateral injuries can be bilateral open book type One side B1 and one side B2 or Bilateral B2 .
  21. 21. Type C Injuries- Unstable C1: Unilateral C1-1: iliac fracture C1-2: sacroiliac fracture-dislocation C1-3: sacral fracture C2: Bilateral with one side type B and one side type C C3: Bilateral with both sides type C
  22. 22. C1- Unilateral Injuries C1: Unilateral C1-1: iliac fracture C1-2: sacroiliac fracture-dislocation C1-3: sacral fracture
  23. 23. Tile- Type C2 Injuries Bilateral with one side type B and one side type C
  24. 24. C3 Injuries Bilateral with both sides type C
  25. 25. Young and Burgess Classification • Based on the direction of forces causing fracture, associated instability of pelvis • Original Work of Pennal Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: Value of plain radiography in early assessment and management. Radiology 1986;160:445-51. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. Jul 1990;30(7):848-56.
  26. 26. Young and Burgess classification • Four Injury Patterns • Lateral compression (LC) • Anteroposterior compression (APC) (external rotation) • Vertical shear (VS) • Combined Mechanism (CM)
  27. 27. LC-1
  28. 28. LC-2 Crescent Fracture
  29. 29. LC-3 Windswept Injury
  30. 30. APC
  31. 31. APC-1 Symphysis widening < 2.5 cm
  32. 32. APC-2 Symphysis widening > 2.5 cm. Anterior SI joint diastasis . Posterior SI ligaments intact. Disruption of sacrospinous and sacrotuberous lig
  33. 33. APC-3 Disruption of anterior and posterior SI ligaments (SI dislocation). Disruption of sacrospinous and sacrotuberous ligaments.
  34. 34. C-Vertical Shear Injuries
  35. 35. CM- Combined Mechanism • Combined VS & LC • LC &APC
  36. 36. Pelvic ring disruptions: effective classification system and treatment protocols. Burgess AR, et al J Trauma. 1990 Jul;30(7):848-56.
  37. 37. Which one is better ??? • Easily reproducible • Inter observor Agreement • Relationship to prognosis/treatment
  38. 38. Kappa values ( Agreement grades) Poor ======= =0 to 0.20 , Fair =========0.21 to 0.40 , Moderate ====0.41 to 0.60 Substantial ===0.61 to 0.80 Perfect ====== >0.80 Intraobserver agreement SUBSTANTIAL---- for the full Young-Burgess system , Average kappa value = 0.61 (95% CI 0.53, 0.69). SUBSTANTIAL ---- without the subclasses of the Young-Burgess system , Average kappa value = 0.72 (95% CI 0.66, 0.78) MODERATE ------- for the Tile system is Average kappa value = 0.47 (95% CI 0.31, 0.64) Andrew et al: Classification of Pelvic Fractures: Analysis of Inter- and Intraobserver Variability Using the Young-Burgess and Tile Classification Systems :Orthopedics June 2009 - Volume 32 · Issue 6 Interobserver Agreement MODERATE for full Young-Burgess system Average kappa value = 0.46 (95% CI 0.39, 0.52 MODERATE for only the 4 main fracture types Average kappa value= 0.58 (95% CI 0.45, 0.72),. MODERATE for Tile system, Average kappa value = 0.47 (95% CI 0.42, 0.52).
  39. 39. Koo et al : Interobserver reliability of the Young-Burgess and Tile classification systems for fractures of the pelvic ring. J Orthop Trauma. 2008 Jul;22(6):379-84. CONCLUSIONS: The CT scan can improve the reliability of assessment of pelvic stability (Pre-CT and post-CT = 0.59 and 0.93) Investigation (Xrays/CT scan) Classification Type of Surgeon Average kappa score Xrays Young-Burgess All 0.72( Substantial) Xrays/CT scan All 0.63(Substantial) Xrays Tile All 0.30( Fair) Xrays/CT scan All 0.33(Fair) “The Young-Burgess system may be optimal for the learning surgeon. The Tile classification system is more beneficial for specialists”
  40. 40. Osterhoff et al : Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess. Injury 2014 Apr;45(4):742-7 Conclusions “In this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.” Predictive Value ???
  41. 41. Guthrie HC, Owens RW, Bircher MD. Fractures of the pelvis: J Bone Joint Surg Br. 2010 Nov;92(11):1481-8 “We recommend using the Young and Burgess classification which is derived from the initial anteroposterior (AP) radiograph and is based predominantly on the mechanism of injury and severity of pelvic fracture.”
  42. 42. Classification of Pelvic Injuries in Children Torode and Zieg modification of Watts classification • Type I – avulsion fractures • Type II - Iliac wing fractures • Type III – stable pelvic ring injuries • Type IV – any fracture pattern creating a free bony fragment (unstable pelvic ring injuries) Torode I, Zieg D. Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84.
  43. 43. Open pelvic fractures Accounting for 2% to 4% of all pelvic ring fractures. High rate of mortality (25–50%) and significant morbidity An open pelvic fracture is defined by a communication to lesions of the integument or the gastrointestinal and urogenital tracts.
  44. 44. Class 1: Stable open pelvic ring fractures (low mortality) Class 2: Unstable open pelvic ring fractures without rectal injury (about 33% mortality) Class 3: Unstable open pelvic ring fractures in combination with rectal injury (upto 50% mortality) Jones Classification for Open Pelvic Fractures Jones AL, Powell JN, Kellam JF, et al. Open pelvic fractures: a multicenter retrospective analysis. Orthop Clin North Am 1997; 28:345–350.
  45. 45. Bircher and Hargrove Classification of Open Pelvic Fractures Soft tissue injury was divided into three main alphanumerical categories, which were assigned to Tile’s classification of pelvic ring fractures. Subsets were defined by the primary skin lesion and associated soft tissue damage. Bircher M, Hargrove R. Is it possible to classify open fractures of the pelvis? Eur J Trauma 2004; 30:74–79.
  46. 46. Bircher and Hargrove Classification of Open Pelvic Fractures Type A1: Penetrating trauma, for example, by a bullet. Tile/AO type A fracture. Type A2: “Outside in” injury of the iliac crest, with minimal soft tissue damage. Tile/AO type A fracture. Type A3: “Outside in” injury of the iliac crest, with extensive soft tissue damage requiring surgery for soft tissue coverage. Tile/AO type A fracture. Type B1: “Inside out” injury caused by lateral compression and showing little external damage but possible injury to the genitourinary system (i.e., tilt fracture). Tile/AO type B2 fracture (LC). Type B2: “Inside out” injury, caused by lateral compression and representing moderate tissue damage. An example would be a rotationally unstable pelvic fracture in combination with extensive degloving (Morel–Lavalle´ syndrome). Tile/AO type B2 fracture (LC). Type B3: “Perineal split” following APC injury. Tile/AO type B1 fracture (“open book”).
  47. 47. Type C1: “Perineal split” and/or “sacral shear/split” injury with moderate to extensive skin loss, complete genitourinary disruption, and rectal lesions with subsequent fecal contamination. Tile/AO type C fracture. Type C2: “Hemipelvic destabilization” injury with severe tissue damage, complete urogenital and bowel injury combined with extensive contamination of all tissue layers. Tile/AO type C fracture. Type C3: “Pelvic crush” with bilateral complex pelvic instability and massive damage to soft tissues and intrapelvic organs. Tile/AO type C fracture. Soft tissue injury was divided into three main alphanumerical categories, which were assigned to Tile’s classification of pelvic ring fractures. Subsets were defined by the primary skin lesion and associated soft tissue damage. Bircher M, Hargrove R. Is it possible to classify open fractures of the pelvis? Eur J Trauma 2004; 30:74–79.
  48. 48. Summary • Tile and Burgess & Young Classifications are the most commonly used classifications • Burgess & Young seems to be more easily remembered and reproduced • The prognostic values of both are comparable • Certain fractures may not be classifiable in either systems
  49. 49. Thanks for your attention !!!

×