pelvis fracture dislocation with related anatomy, mechanism of injury, classification, investigation with surgical and non-surgical management.

1. PELVIC FRACTURE
DISLOCATION
DR. PRATIK AGARWAL

2. Anatomy of
pelvis
• Comprises of 3 bones:
 Sacrum &
 2 hemipelvis
• Hemipelvis also known as
innominate bone form by
fusion of-
 Ilium
 Ischium
 Pubis
• Fusion occurs at triradiate
cartilage where acetabulum
develops.

3. Stability of
pelvis
Conferred by ligamentous
structures.
Sacrum to ilium:
 Sacroiliac ligamentous complex-
anterior and posterior.
 Sacrotuberous ligament- for vertical
stability.
 Sacrospinous ligament- for rotational
stability.

4. Stability of
pelvis
Pubis to pubis:
 Symphyseal ligament.
Additional stability:
 Iliolumbar ligaments
 Lumbosacral ligaments
Lumbosacral
ligament
Anterior longitudinal
ligament
Iliolumbar ligament
Ilium
Anterior sacroiliac
ligament
Intervertebral
disc

5. Stability of pelvis
Ligaments resisting rotational forces-
 short posterior sacroiliac
 anterior sacroiliac
 iliolumbar
 sacrospinous ligament.
Ligaments resisting shear forces-
 long posterior sacroiliac
 Sacrotuberous ligament
 lateral lumbosacral ligaments.

6. Biomechanics
• Pelvis allow transfer of weight from
L5 to upper 3 segment of sacrum, SI
joint, to thick strut of ilium then to
roof of acetabulum in standing
position and ischial tuberosity in
sitting position.
• Anterior pubic rami acts as strut to
prevent anterior collapse of pelvic
ring during weight bearing.

7. Mechanism of injury
• Result of high energy injury like motorcycle
accident, motor vehicle pedestrian accident, fall
from height or crush mechanism.
• Impact injuries.
• The Young and Bugress classified into 4 groups
i.e. LC, APC, VS, and Combined injury was
based on mechanism of injury.
• APC injury- mostly due to motor cycle crash,
result in external rotation of hemipelvis.
• LC injury- fall onto side, T-bone in motor
vehicle crash.

8. Classification of pelvis fracture
 Tile Classification- based on the degree of instability and more specifically on the
integrity of the posterior sacroiliac complex.
 Young and Burgess Classification- is a mechanistic classification system.
 Bucholz classification –
 Classification of fragility fracture of pelvis
 AO classification
 Denis classification - for sacral fracture.

9. Tile classification
A. Stable injuries: Posterior arch intact.
 A1: Avulsion fractures of puberty not concerning the
pelvic girdle
 A2: Iliac wing or pubic rami fractures not concerning
the posterior wall
 A3: Transverse fractures of the sacrum or the coccyx

10. Tile classification
B. Rotationally unstable but vertically stable: Forces
resulting in partial disruption of the posterior arch.
 B1: Open book injury (external rotation)
 B2: Lateral compression injury (internal rotation)
 B2-1: Ipsilateral anterior and posterior injuries
 B2-2: Contralateral injuries (Bucket handle)
 B3: Bilateral injuries.

11. Tile classification
C. Rotationally and vertically unstable: Complete
disruption of the posterior sacroiliac complex.
 C1: unilateral
 C2: bilateral
 C3: involving acetabular fracture

12. Young and Burgess Classification
 The Young and Burgess system classifies pelvic fractures by vector of force–
anteroposterior compression (APC), lateral compression (LC), vertical shear
(VS) types and combined mechanism injuries.

13. Lateral compression injuries
 LC: anterior injury = rami fracture
 LC-I: Sacral fracture on side of impact. Most of them considered as stable
 LC-II: Crescent fracture on side of impact. Unstable internal rotation
 LC-III: As per type I or II with contralateral external rotation. Bilateral posterior instability. Typical due to sever
crush/roll over injuries - windswept pelvis.

14. Antero-Posterior Compression Injuries
 APC- anterior injury = symphysis diastasis/rami fracture (open book pelvis)
 APC-I: diastasis of the symphysis without posterior disruption;
 APC-II: >2.5cm of diastasis of the symphysis with disruption of the sacrospinous sacrotuberous and anterior
sacroiliac ligaments
 APC-III: complete disruption of the symphysis and the posterior sacroiliac ligamentous complex

15. Young and Burgess Classification
 Vertical Shear Injuries- Vertical shear completely
unstable injury (rotationally and vertically). Vertical
orientation of rami fractures, disruption of
sacroiliac joint/s and vertical displacement of the
hemipelvis - Malgaigne fracture.
 Combined Mechanism Injuries- any combination
of LC, APC and VS injuries.

16. Denis classification
of sacral fracture
• Zone 1 – fracture lateral
neural foramina through the
sacral ala.
• Zone 2 – transforaminal
fractures.
• Zones 3 – fractures medial to
neural foramina & transverse
fracture of sacrum.

17. Bucholz classification
• Group 1 – minimally displaced anterior ring injuries, stable sacral fracture
and partial disruption of anterior sacroiliac ligament.
• Group 2 – anterior injuries associated with rotational opening of SI joint,
sparing posterior sacroiliac ligament.
• Group 3 – complete disruption of anterior and posterior hemipelvis.

18. Classification of fragility
fracture of pelvis
Rommens and Hoffman published this
classification
• FF I - involves anterior ring only.
• FF II – nondisplaced posterior injury with
varying degree of anterior involvement.
• FF III – unilateral displaced posterior injury
• FF IV – bilateral displaced posterior injury

19. AO classification

28. Initial management
 Mechanism of injury – key component in diagnosis, classification & management.
 Primary survey – evaluation and management of airway, breathing, circulation along with stabilization of spine
using cervical spine & spine board.
 Secondary survey – after stabilization of patient assess for any fractures, and associated injuries like head,
thoracic, abdominal and spine injuries.
 Look for sign associated with pelvic fracture-
 Destot’s sign – superficial hematoma beneath inguinal ligament or in scrotum.
 Roux’s sign – decreased distance between GT to pubis in lateral compression injury.
 Earle’s sign – bony prominence or large hematoma and tenderness on rectal examination.
 Pelvic compression test - painful

29. Pelvic ring fracture clinical examination
 Open wound of groin, buttock & perineum.
 Blood at urethral meatus, vagina or around
rectus.
 Pelvic, flank or perineal contusion, ecchymosis
& abrasion.
 Neurologic deficit involving lumbosacral plexus.
 Leg length inequality.
 High riding prostate (urethral injury)
 Abnormal pelvic motion on anteroposterior or
lateral compression of anterior iliac spine & iliac
crest.
 External or internal rotation deformity of
hemipelvis.
 Scrotal edema.
 Pain on palpation of posterior pelvis.

30. Investigation
 Plain X-ray of pelvis with both hip.
 Plain X-ray of chest.
 Focused assessment with sonography
for trauma (FAST).
 CT brain with cervical spine screening.
 Abdominal and pelvic CT scan
 Arteriography
 Diagnostic peritoneal lavage.
 CT scan of pelvis

31. X-ray of pelvis
• Exact injury can be clarified by -
Anteroposterior view
Inlet view
Outlet view
Judet view
• What to see in X-ray of pelvis?
 Three rings
 Joint spaces
 Acetabulum
 Sacral foramina
 Proximal femur

32. X-ray of pelvis
• Three rings-
 Main pelvic ring
 2 obturator foramen
• Disruption of ring +
H/O trauma -->
Fracture

34. X-ray of pelvis
• Sacroiliac joint space ⩽
4mm
• Symphysis pubis joint
space ⩽ 5mm
• Widening of joint +
H/O trauma = Fracture

36. X-ray of pelvis
Trace Letournel’s line –
1.Posterior wall of
acetabulum
2.Anteriror wall of
acetabulum
3.Roof (dome or tectum)
4.Teardrop
5.Ilioischial line (posterior
column)
6.Iliopectineal line (anterior
column)

38. X-ray of pelvis
Sacral foramina
• Arcuate lines are composed
of inferior surfaces of costal
elements that form roof of
anterior sacral canals
(foramina) &neural grooves;
• Should be smooth and
symmetrical
Lines angulates → fracture

40. X-ray of pelvis
Shenton’s line-
• Imaginary line drawn
along superior border
of obturator foramen
and along on
femoromedial border
of neck of femur.
Discontinuity in line →
Fracture

42. Inlet view
Directing X-ray beam 45* caudally
Allow assessment of-
• External and internal rotation of
each hemipelvis.
• Opening of SI joint.
• Anterior and posterior
displacement.

44. Outlet view
Directing X-ray beam 45*
cephalad
Allow assessment of-
• Sacral fracture with
respect to foramina.
• Vertical displacement

46. CT scan
• Has become integral in
management of pelvic ring
injuries and can aid in
classification of injuries.
• Useful in patient not able to
position properly.
• Three dimensional images
gives most accurate picture of
the injury.

47. Treatment
Goal-
1) Restoration of bony anatomy
2) Prevention of deformity
3) Minimizing discomfort & facilitating return of function

48. Early treatment
Resuscitation as per A.T.L.S.
A. Airway maintenance and cervical
spine protection.
B. Breathing and ventilation
C. Circulation and hemorrhage control
D. Disability i.e. neurological status
E. Exposure / environmental control.

49. Hemorrhage control
Aim-
• Reduce pelvic volume and allow for
tamponade effect.
• Stabilize pelvic injury & allow clot
formation.
• Allow autotransfusion
Modalities-
• Pelvic binder
• Bed sheet with artery clamp
• Pneumatic anti shock garment
• Ganz clamp / external fixator

50. Pelvic binder
Advantage-
• Non invasive
• Simple to apply
• Inexpensive
Contraindication-
• Lateral compression fracture
• Skin necrosis
• Associated visceral/neural injury

51. Pneumatic ant shock
garment / medical anti
shock trouser
It redistribute blood from limb to the
trunk and restrict expansion of pelvic
hematoma.
Complication-
Compartment syndrome
Extensive skin necrosis
Delay in assessment of limb and
abdomen.

52. External fixation
Allow stabilization of anterior ring disruption
Types-
• Anterior external fixator
• Supraacetabular external fixation
• Pelvic clamp
Complication-
• Pin site infection
• Aseptic pin loosening
• Serosanguineous discharge
• Adjacent skin necrosis
• Visceral injury

53. Anterior external
fixator
• Used for rotationally unstable injuries.
• Two pins of 5mm passed 2cm
proximal to ASIS within iliac cortex on
each side.
• Connect pin clusters and crossbars.
• In vertically unstable fractures, frame
is used as definitive fracture fixation
for 8-12 weeks

54. Supraacetabular
external fixation
• Anterior inferior iliac spine staring
point on iliac oblique view.
• Drill 2-3 cm using self tapping pins,
taking not to slide medially or
laterally.
• Advance pin just to sciatic notch.
• Connect the pin to the crossbar.

55. Pelvic clamp
• Used to control motion in posterior
sacroiliac complex.
• Percutaneous pins placed over region
of sacroiliac joint posteriorly.
• Used only as temporary stabilizing
device that should be removed within
5 days.
• Contraindication-
 Iliac wing fracture close to sacroiliac
joint.

56. Ganz fixation
• Used for hemodynamically unstable
patient with type C injuries until definitive
fixation possible.
• Steinmann pin inserted 3-4 finger breadth
from PSIS on imaginary line between ASIS
and PSIS.
• This closes the diastasis and stabilizes the
posterior pelvic ring.
• Once clamp is placed, diagnostic or
therapeutic procedures can be performed.

57. Nonoperative treatment
Following injuries amenable to nonsurgical management are-
 Stable pelvic ring injuries
 Stable sacral injuries
 Comorbidities precluding surgical intervention
 Poor bone quality
 Pubic rami fractures with no posterior displacement
 Gaping of pubic symphysis <2.5 cm
 Lateral impaction type injuries with minimal <1.5 cm displacement.

58. Operative treatment
Absolute indication Relative indication
• Open pelvic fractures
• Open book fracture or
unstable fracture associated
with hemodynamic instability
• Symphysis diastasis >2.5 cm
• Leg length discrepancy >1.5
• Rotational deformity
• Sacral displacement
• Intractable pain

59. Surgical approaches
Anterior approach-
• For anterior ring injuries and sometimes
posrterior ring injuries also.
Pfannensteil incision-
• Curvilinear incision 2cm cephalad to
superior pubic ramus.
• Incise external oblique aponeurosis parallel
to inguinal ligament.
• Identify spermatic cord and ilioinguinal
nerves.
• Release insertion of rectus abdominis from
superior pubic ramus.
• Expose subperiosteally superior, anterior
and posterior surface of both rami.

60. Anterior approach
for sacroiliac joint
• Useful for open reduction and plating
for sacroiliac joint dislocation.
• 10-12 cm incision, 1.5 cm proximal and
parallel to iliac crest, starting at anterior
superior iliac spine.
• Detach abdominal muscle without
disturbing origin of gluteus muscles.
• Incise periosteum and strip the iliacus
muscle subperiosteally.
• Retract iliacus muscle up to lateral
attachment of anterior sacroiliac
ligament.
• Expose anterior aspect of joint.

61. Surgical approaches
Posterior approach-
• Use for posterior ring injuries only.
• Incision along lateral lip of posterior
third of iliac crest to posterior
superior iliac spine.
• Separate lumbosacral fascia
• Reflect aponeurosis of sacrospinalis
medially.
• Split gluteus maximus in line with its
fibre or incise its origin on iliac crest.
• Ilium is exposed.

62. Approach for both
sacroiliac joint and
sacrum
• Useful in bilateral, unstable sacroiliac disruption or
comminuted vertical fractures of sacrum.
• Modified Mears & Rubash approach
• Transverse straight incision across the midportion of
sacrum 1 cm inferior to PSIS.
• Explore sciatic nerve.
• Expose superior portion of origin of gluteus
maximus on PSIS.
• Elevate paraspinous muscle and perform osteotomy
of spine posterior to sacrum, leaving gluteus
maximus muscle intact.
• Elevate paraspinous muscle subperiosteally to form
tunnel for application of plate.

63. Indication of anterior ring stabilization
 Pubic diastasis > 2.5 cm.
 Augmentation of posterior fixation in vertically displaced unstable or completely
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)

64. Indication of posterior ring stabilization
 Complete disruption of the SI joint and associated with multiplanar instability.
 Any posterior ring injury i.e. SI dislocation, or sacral fracture with vertical
displacement or the propensity to do so.
 Displaced crescent fractures—displaced iliac wing fractures that enter and exit
both the crest and greater sciatic notch or SI joint.
 Displaced sacral fractures
 Lumbopelvic disassociation

65. indications for Sacral Fracture Stabilization
 Vertical shear sacral fracture posteriorly and a concomitant anterior ring injury is
present
 Comminuted sacral alar fractures with external rotation deformity of the
hemipelvis
 Lumbopelvic disassociation injury
 Lateral compression fractures with sacral impaction and excessive internal
rotation

66. ORIF of pubic diastasis
• Use Pfannensteil incision
• Symphyseal specific plate or pelvic
reconstruction plate of 3.5 mm or 4.5
mm (4-8 hole) is used to stabilize bone.
• Screw should exit inferior aspect of each
body.
• Patient should be catheterized before
surgery to prevent bladder injury.

67. ORIF of iliac wing
fracture
• Either anterior or posterior approach.
• Being flat bone reduction is difficult.
• Weber, CMF or pointed reduction clamp
placed across fracture site.
• Plates & screws are placed along the crest
while doing anterior approach or along pelvic
brim just adjacent to SI joint while doing
posterior approach.
• Lag screw useful for both fixation &
compression at fracture site.

68. ORIF of rami fracture
• Pubic rami fracture extending laterally
to pubic root can be fixed using plate.
• Pfannesteil incision or its extension into
Stoppa approach may be needed.
• Care must be taken to avoid
intraarticular screw penetration into
acetabulum.
• Pelvic reconstruction plate or
precontoured plate can be used.

69. Percutaneous fixation of
pubic rami fracture
• Screw is inserted antegrade from lateral aspect or
retrograde from medial side.
• Reduction to be done before guide wire is inserted.
• Advance guide wire to bone. Confirm direction of
guide wire in outlet and inlet view.
• 6.5 mm or 7.3 mm cannulated screw is used to fix
the fracture fragment.
• Note- if guide wire is outside the bone may cause
injury to bladder or corona mortis.

70. Percutaneous fixation
of sacral fractures &
sacroiliac dislocation
• Matta and Saucedo
• Insert screw perpendicular to iliac wing
across SI joint into sacral ala towards S1
vertebral body.
• For sacral fractures, one or two screw into
S1 vertebral body from lateral surface of
iliac wing.

71. Transiliac rod fixation of
sacral fractures
• Insertion of posterior lag screw fixation of
SI joint.
• Place drill holes through posterior
tubercle of ilium just dorsal to sacral
lamina.
• Place two rods posterior to sacrum and 4
cm apart, between two intact posterior
tubercles of iliac wings.
• Avoid entering sacrum

72. Post-operative care
 Toe touch bearing allowed on side of posterior injury.
 Weight bearing as tolerated allowed on side without posterior
injury.
 Non weight bearing in bilateral posterior pelvic injuries.
 Weight bearing advocated after 8-12 weeks after surgery.

73. Complications
Early
 Hemorrhage
 Genitourinary tract injury (20%)
 Gastrointestinal tract injury
 Neurological injury (10-15%)
 Vascular injury
 Infection
 Thromboembolism
Late
 Malunion
 Chronic persistent pain
 Nonunion
 Sexual dysfunction
 Gait disturbance
 Heterotrophic ossification

74. Thank you