pelvic ring fractures by dr. hardik pawar

1. Pelvis fracture
by
Dr hardik pawar

2. • Introduction
• Anatomy
• Clinical evaluation
• Investigation
• Classification
• Treatment

3. Introduction
• Pelvic injuries are a major cause of
mortality and morbidity in multiple
injured patients.
• The close proximity of osteoligamentous
structures to pelvic
organs, neurovascular, hollow
viscera, and urogenital structures may
lead to wide range of severe complications
and late sequel if not diagnosed and
treated early
• Fatalities are due to uncontrolled
retroperitoneal hemorrhage.

4. • Disabilities are due to anatomic
disruption the pelvic ring. ( low back
pain, leg-length
discrepancies, dyspareunia, impotence,
difficulties with child bearing).
• Pelvic fractures can be particularly
lethal when occur in combination with
significant injuries to other major organ
systems.

5. Anatomy
• bones,
• ligaments,
• muscles,
• vessels,
• nerves,
• and viscera

8. Joints of Pelvis

9. • Pelvic ring formed by connection of the
sacrum to innominate bones at sacroiliac
joints and symphysis pubis.

10. Divisions of Pelvis

11. • The bony pelvis is divided into the so-
called true and false pelvises, with the line
of demarcation formed by the pelvic brim
• The true pelvis contains the pelvic organs
the bladder, urethra, and rectum, and the
uterus and vagina in females, and the
prostate gland in men whereas the false
pelvis forms the lower part of the
abdominal cavity.

12. Ligaments
• Transversely oriented ligaments resist
transverse rotational instability.
• These include:
• iliolumbar,
• short posterior SI,
• anterior SI,
• sacrospinous ligements.
• Sumphysis pubis liga.

14. • Vertically oriented ligaments resist
vertical displacement of the pelvis.
• These include:
• long posterior SI,
• sacrotuberous,
• lateral lumbosacral ligaments.
• (The strongest of these and the most
important with regard to pelvic stability
are the short and long posterior SI
ligaments).

19. • The Greater Sciatic Foramen
• Seven Nerves Three Vessel Sets
Sciatic nerve Superior gluteal artery/vein
Superior gluteal nerve Inferior gluteal artery/vein
Inferior gluteal nerve Internal pudendal artery/vein
Internal pudendal nerve
Posterior femoral cutaneous nerve One Muscle
Nerve to quadratus femoris Piriformis
Nerve to obturator externus

20. •The obturator foramen:
separating pubis from
ischium, is covered by a
membrane, deficient only on
top to allow the obturator
vessels and nerves to escape
from the pelvis. At this point
they are vulnerable and may
be torn in pelvic trauma.

21. Muscles

24. Structures at risk in pelvis
fractures
• Soft tissue – perineum
• Genitourinary
• Gastro intestinal
• Vascular
• Nerves

25. Perineum
• Diamond shaped space b/w inf. Pubic rami
And sacrotuberous liga.
Anterior half is urogenital triangle
Contains – deep perineal muscles
• the urethral sphincter muscle, and (in
women) the vaginal orifice.
• Deep to this lie the muscles of the pelvic
diaphragm,
pubococcygeus, iliococcygeus, and
ischiococcygeus
• The anterior two, pubococcygeus and
iliococcygeus, wrap around the rectum to
form a kind of sling, and are termed levator
ani.
• posterior to the pelvic diaphragm muscles
lie the obturator internus and piriformis

26. Soft tissue

27. Genitourinary • The bladder lies posterior to the pubis Its
proximity to the rami puts it at risk for
damage, because fractured rami may
spear the bladder at the time of injury.
• In males - the urethra
the prostate
The intrapelvic male sex
organs, the seminal vesicles and
ejaculatory and deferent ducts just above
the prostate.
• In females - the urethra
vagina
uterus lies between the bladder
and rectum
• fallopian tubes
• ovaries, which are connected to the
uterine body through the ovarian

28. Gastroinestinal
• final segment of the large intestine
• rectum
• anal canal
• anus.

35. Principal Sites of Hemorrhage
after a Pelvic Fracture

36. •The floor of the pelvis
comprises the coccygeal
and levator ani muscles.
•The urethra, rectum and
vagina transverse the floor
of the pelvis & can be
traumatized significantly
during pelvic ring
disruption.

37. •Clinical assessment:
•History:
1- Age:
(Age affects bone structure)
(Pelvic fracture occurs in elderly with less violent force, and associated
with less soft tissue disruptions than young patients).
2- Gender:
( Males: more associated injuries to the urethra compared to females).
( Females: vaginal tear).

38. 3- Mechanism of injury:
Low energy - domestic falls , avulsion injury ,post menopausal , steroid induced,
metabolic bone diz
High energy - MVA, FALL from height , crush injury , sport injury , gun shots
projectile ,industrial accidents
4- Associated injuries:
( Is important to determine the amount of trauma on the pelvis).

39. Associated injuries
Neurologic impairment

40. Visceral injuries

41. Physical examination:
• Evaluation should begin eith ABC
• Initiate resucitation
• Evaluate injuries to head , chest , abdomen and spine
• * Unexplained hypotension may be the only initial indication of
major pelvic disruption with instability in the posterior
ligamentous complex

42. •Inspection:
( The patient must be completely
undressed).
1- Wounds:
Open wounds , abrasions , ecchymosis
Hematoma
2- Contusions:
( Position of contusions and abrasions
may indicate direction of the injurious
force).

43. Cutaneous Manifestations of
Pelvic Trauma

44. 3- Bleeding genitalia:
(In men, blood from urethra suggests a
urethral rupture;
in women, blood from urethra or vagina
suggests an occult open fracture of the
pelvis).

45. 4- Displacement of pelvis or lower
extremities:
(If there is no other fracture in the
leg, its degree of rotation and shortening
suggest what type of pelvic fracture is
present).
( Shortening appreciated as leg length
discrepancy happens as a result of
muscular pull on the unstable hemipelvis).

46. - If the extremity is obviously
shortened, internally rotated, and
displaced at the posterior iliac spine, it is
mostly a lateral compression injury with
posterior impaction.
- If the extremity is externally rotated and
shortened, it indicates mostly a severe
unstable vertical shear type

47. •Palpation:
( Careful manual palpation of the pelvis
may reveal crepitus or abnormal motion
in the hemipelvis, either one indicative of
instability).
( Repeated examination for pelvic
instability should be avoided in unstable
situations to prevent further induction of
blood loss).

48. •Palpation of posterior aspect may reveal
large hematoma
•Maneuvers:
1- Test for anterior defects:
Direct palpation of symphysis pubis may
reveal a gap or ecchymosis, indicating a
symphysis disruption.
2- Test for rotational instability:
Grasping the iliac crests and pushing
the unstable hemipelvis inward and
outward (compression – distraction
maneuver).

49. 3- Test for vertical instability:
Can be appreciated when movement of
the hemipelvis is detected as manual
compression and traction are applied
through an extended uninjured lower
extremity.
(Palpating the posterior iliac spine &
tubercle while pushing and pulling the
unstable pelvis)

51. •Rectal & Vaginal examination:
( Both are essential for complete
patient assessment).
- Very often the fracture can be palpated
by either of these routes to further assess
the stability of the pelvic ring.
- Presence or absence of vaginal or
rectal lacerations.
- High riding prostate gland.

52. • Neurological examination
- Injury to lumbosacral
plexus, especially L5 root is
common, therefore, a careful
neurological examination is mandatory.
- Nerve injuries of all types are much
more common in shear type fractures.

53. •Radiological examination:
- AP pelvic view is mandatory and can
provide a reliable working diagnosis in
about 90% of the cases.
- For 3 dimensional analysis, oblique
views (inlet and outlet films) are included
to evaluate anterior, posterior, cranicaudal
and rotational displacement).
- The inlet view is the best view for
disclosing posterior displacement.

55. Pelvis inlet

56. • inlet view
• X-ray beam angled ~45 degrees
caudad
• adequate image when S1 overlaps
S2 body
• ideal for visualizing:
• anterior or posterior translation of
the hemipelvis
• internal or external rotation of the
hemipelvis
• widening of the SI joint
• sacral ala impaction

57. Pelvis outlet

58. • outlet view
• X-ray beam angled ~45 degrees
cephalad
• adequate image when pubic
symphysis overlies S2 body
• ideal for visualizing:
• vertical translation of the hemipelvis
• flexion/extension of the hemipelvis
• disruption of sacral foramina and
location of sacral fractures

59. • radiographic signs of instability
• > 5 mm displacement of posterior
sacroiliac complex
• presence of posterior sacral fracture
gap
• avulsion fractures (ischial spine, ischial
tuberosity, sacrum, transverse process
of 5th lumbar vertebrae)

60. Other investigation
• C T scan
• routine part of pelvic ring injury
evaluation
• better characterization of posterior ring
injuries
• helps define comminution and fragment
rotation
• visualize position of fracture lines
relative to sacral foramina
• MRI
• Fluroscopy
• Angiography
• Indications:
• nonresponders who have been
mechanically stabilized

61. Classifications

62. Classification
• The Young-Burgess (1986; 1987)
system is as follows:
1. APC injury
• The hallmark of the AP compression
injury is pubic diastasis with or without
disruption of the SI joints. The location
and degree of diastasis is correlated
with the magnitude of force imparted to
the pelvis and with the amount of
resulting instability. The AP
compression causes the pelvis to open:
one or both hemipelves undergo
external rotation. According to the
Young-Burgess classification system, 3
degrees of AP compression injury are
identified.

63. Classification
• APC- I injuries: Less than
2.5 cm of the pubic
diastasis is noted, either at
the symphysis or through
vertically oriented rami
fractures. The SI joints and
posterior ligaments remain
intact, and stability is
maintained.

65. Classification
• APC- II injuries: The
amount of anterior diastasis
exceeds 2.5 cm. In
addition, diastasis occurs in
1 or both of the SI joints.
This incomplete posterior
arch disruption results in
rotational instability. The
posterior ligaments are not
injured; therefore, vertical
stability is preserved.

67. Classification
• APC- III injuries: These injuries extend to
the posterior SI ligaments, which are
disrupted. Consequently, the pelvis is
vertically and rotationally unstable.

69. Classification
2. Lateral compression (LC) injury
• Lateral compression injury results in
internal rotation of the affected
hemipelvis. This internal rotation
decreases rather than increases the
pelvic volume. Consequently, pelvic
vascular injuries and resulting
hemorrhage are less common with this
injury than with other injuries. Lateral
compression injuries are associated
with brain and intra-abdominal injuries.

70. Classification
• The hallmarks of a lateral compression
injury include sacral buckle fractures
and horizontal pubic rami fractures. The
Young-Burgess classification system
describes 3 types of injuries.

71. Classification
• LC- I injuries: These involve a force
directed posteriorly to the lateral
aspect of the hemipelvis, which
results in an ipsilateral sacral buckle
fractures; ipsilateral horizontal pubic
rami fractures; or, less
commonly, disruption of the pubic
symphysis with overlap of the pubic
bones. The posterior ligaments
remain intact; therefore, the pelvis is
stable.

73. Classification
• LC- II injuries: These involve more
internal rotation of the hemipelvis.
As in type I injuries, ipsilateral sacral
buckle fractures and horizontal pubic
rami fractures are associated with
fracture of the ipsilateral iliac wing or
disruption of the ipsilateral posterior
SI joint. The pelvis is rotationally
unstable, but its vertical stability is
maintained.

75. Classification
• LC- III injuries: The force continues
from the ipsilateral side across the
midline to affect the contralateral
hemipelvis. The ipsilateral
hemipelvis sustains either a type I or
type II injury with associated internal
rotation. The contralateral pelvis
undergoes external rotation.
Contralateral vertical pubic rami
fractures or disruption of the
ligaments may occur. As in type II
injuries, the pelvis is rotationally
unstable but vertically stable.

77. Classification
3. Vertical shear injury
• A vertically oriented force applied to a
hemipelvis, usually by the
femur, results in a vertical shear injury.
At the anterior aspect, vertically
oriented fractures of the pubic rami
occur. Posteriorly, the ipsilateral SI joint
(or occasionally the contralateral SI
joint) and its associated ligaments are
disrupted.

78. Classification
• The affected hemipelvis is displaced in
a cranial direction. Complete disruption
of the posterior ligaments yields a
rotationally and vertically unstable
pelvis.
• Associated injuries seen in the vertical
shear pattern are similar to those
encountered in type III AP compression
injuries.

81. Combined mechanism

82. Miscellaneous fractures
• Straddle fracture
• Malgaigne fracture
• Jumper’s fracture

83. Denis classification of sacral
fractures

84. Denis zone 3
H
U
Lamda
T

87. Management
1. Early management
• Treatment should not await for full and
detailed diagnosis.
• Doctor should move according to the
priority of life saving measures with the
already available information.
• ATLS PROTOCOL
• ABCDE
• Airway , breathing , circulation , disability
, exposure

88. • The system is based on a three-stage
approach:
• 1. Primary survey and simultaneous
resuscitation – a rapid assessment and
treatment of life-threatening injuries.
• 2. Secondary survey – a detailed, head-to-
to evaluation to identify all other injuries.
• 3. Definitive care – specialist treatment of
identified injuries.

89. Management of severe bleeding
1. resuscitation
Treatment of shock.
2. Pelvic binder
3. External fixation to close the book.
Management of genito urinary injury
Management of GI injuries

91. •Reduction and stabilization of the pelvis can
be achieved by a variety of mechanical
means:
- Bind the pelvis by
a rolled sheet.
- Apply pneumatic
antishock garments
(PASGs).
- Pelvic c – clamps.
- External fixator.
Stabilization

92. • pelvic binder/sheet
• risk of over-rotation of hemipelvis
and hollow viscus injury (bladder) in
pelvic fractures with internal rotation
component (LC)
• technique
• centered over greater trochanters to
effect indirect reduction
• do not place over iliac
crest/abdomen
• prolonged pressure from binder
or sheet may cause skin necrosis

93. •Pneumatic antishock garments (PASGs).
(It functions by compressing the pelvis, and if applied it should not
be deflated until the patient is actively being resuscitated in the trauma
room).
Advantages: reduce displacement of APC INJURY
- Easy to use, applicable in the field, & reusable.
Disadvantage: Increase displacement of LC INJURY
- It blocks access to the patient and restricts excursion of the
diaphragm.
- Gluteal & thigh compartment syndromes after its extended use in
hypotensive patients.

94. •Pelvic C- clamps:
(recently developed devices that
can be rapidly applied to reduce and
provisionally stabilize the pelvis in
the emergency department).
- The design allows for
compression of the pelvis through
percutaneously inserted pins applied
to the outer surface of the ilium. Care
must be taken because serious
complications can result from
misplacement of the pins.

95. Definitive Pelvic Fracture
Management
objectives

96. Treatment
• General guidelines
• MINIMALLY DISPLACED LC 1 AND APC 1 –
PROTCATED WEIGHT BEARING AND
SYMPTOMATIC TREATMENT
•
• DICRUPTION OF ANT. RING WITHOUT COMPELETE
POST. RING DISRUPTION
APC 2 , LC 1 WITH DISPLACEMENT –
REDUCTION AND STABILIZATION
• COMPLETE DISRUPTION OF POST RING
LC 2 , LC 3 , APC 3 , VS - STABILIZATION OF BOTH
ANT AND POST PELVIC RING

97. Non operative treatment
• Indication
• Pubic rami fractures with no post.
Displacement
• Gapping of pubic symphysis < 2.5 cm
• Lateral impaction type with minimal
displacement
Options :
Tractions ,
Protected weight bearing
Pelvic binders

98. Operative treatment
INDICATIONS :
• Open pelvic fractures associated with
visceral injuries
• Open book and verticaly unstable fractures
• Symphyseal diastasis > 2.5 cm
• SI joint displacement > 1 cm
• Leg length discrepancy > 1.5 cm
• Rotational deformity
• Sacral fracture displacement > 1 cm

99. Surgical techniques
• External fixation – ant. Ex fix
• Ganz fixation
• ORIF of pubic symphysis with plates
• Posterior ring fixation with plates
or screws
• Posterior SI "tension" plating
• Percutaneous iliosacral screw fixation for
sacroiliac disruptions
• Percutaneous fixation of sup. Pubic rami
• Transiliac rod fixation of sacral fractures

103. •Management of open pelvic
fractures:
- Isolated iliac wing fractures
are managed like open fractures
in other areas of the body with
aggressive debridement &
stabilization of fractured
components.
- Aggressive debridement and
packing of the wound to prevent
continuous bleeding and possible
sepsis.

104. - Perineal lacerations and wounds that communicate with
the rectum or colon require early diverting colostomy
(preferably at transverse colon to provide uncontaminated
skin around the pelvis).
- Early detection and repair of vaginal lacerations to
minimize subsequent pelvic abscesses.
• Other advisable damage control
procedures at an early stage
include suprapubic urine catheter
drainage, insertion of a
transurethral catheter, and suture of
the bladder after urological injuries.

105. •Anterior external fixator:
( The standard method for
controlling pelvic hemorrhage).
- Proper application should
provide stability to the pelvis and
hematoma, while allowing
access to the abdomen for
surgical procedures.
- Although it can be applied in
the emergency department, it is
frequently deferred until O.T.

106. APC TYPE 2

107. LATERAL COMPRESSION
TYPE 2

108. APC TYPE 3

109. LATERAL COMPRESSION
TYPE 3

110. Right VS injury

111. APC 2 INJURY

112. Pr e o p e r a t i v e ( A ) a n d p o st o p e r a t i v e
( B) x - r a y s d e m o n st r a t i n g o p e n
r e d u c t i o n a n d i n t e r n a l
f i x a t i o n o f t h e a n t e r i o r r i n g o f t h e
p e l v i s.

113. Ri g h t i l i a c w i n g f r a ct u r e . B.
Ma n a g e d co n se r v a t i v e l y .
Fr a ct u r e ca l l u s i s p r e se n t a t
6 WEEKS

114. St a b i l i za t i o n t e ch n i q u e i n ce n t r a l
a n d / o r b i l a t e r a l sa cr u m f r a ct u r e s:

115. JUMPER ‘S FRACTURE

117. Teatment

118. Pelvic Surgical Approaches

119. COMPLICATIONS
• EARLY :
• Heammorhage
• GI tract injury
• GU injury
• Neurologic injury
• Vascular injury
• Infection
• Thromboembolism

120. • LATE
• Fixation failure
• Mal union
• Chronic persistent pain
• Non union
• Sexual dysfunction

121. THANK YOU