SEMINAR ON

PELVIC FRACTURES

DR ABHISHEK CHAUDHARY
TRAINEE IN ORTHOPAEDIC SURGERY SGITO
BANGALORE
 In this presentation
• Introduction
• Relevant anatomy
• History /mechanism of injury
• Clinical examination
• Radiological examination
• Emergency management
• Definitive treatment options
• Complications
• Prognosis
 Introduction
• 3 -4 % of all fractures .
• Mechanism typically high energy blunt trauma.
• Mortality rate 15-25% for closed fractures, as much as 50% for
open fractures
– hemorrhage is leading cause of death overall
• closed head injury is the most common for lateral compression injuries
– increased mortality associated with
• systolic BP <90 on presentation
• age >60 years
• increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
• need for transfusion > 4 units
• Associated injuries
– chest injury in up to 63%
– long bone fractures in 50%
– sexual dysfunction up to 50%
– head and abdominal/pelvic organs injury in 40%
– spine fractures in 25%
 Introduction
• Prognosis :- high morbidity
– high prevalence of poor functional outcome and chronic
pain.
– poor outcome associated with
• SI joint incongruity of > 1 cm
• high degree initial displacement
• malunion or residual displacement
• leg length discrepancy > 2 cm
• nonunion
• neurologic injury
• urethral injury

• Pediatric pelvic ring fractures

– children with open triradiate cartilage have different
fracture patterns. (elasticity of ligaments > pelvic bones)
 Relevant anatomy
• BONES :-Pelvis AKA Basin formed of the haunch-bone or
ossa innominata (ilium, ischium, and pubis together,) along
with the sacrum (the holy bone ) and other vertebrae.
Pelvic inlet /pelvic ring/pelvic brim
(egde of the inlet)
Pelvic outlet
 True vs false pelvis
1.The true pelvis
contains the pelvic
organs”the bladder,
urethra, and rectum,
and the uterus and
vagina in females, and
the prostate gland in
Pelvic brim men”
2.whereas the false
pelvis forms the lower
part of the abdominal
cavity.
2.Ligaments

Anterior ligaments
Symphyseal ligaments
(resist external rotation)

pelvic floor
1.sacrospinous ligaments
(resist external rotation)
2.sacrotuberous ligaments
( resist shear and flexion)
 Ligaments contd.
• posterior sacroiliac complex (posterior tension
band)
– strongest ligaments in the body
– more important than anterior structures for pelvic ring
stability
– anterior sacroiliac ligaments
• resist external rotation after failure of pelvic floor and anterior
structures
– interosseous sacroiliac
• resist anterior-posterior translation of pelvis
– posterior sacroiliac
• resist cephalic-caudal displacement of pelvis
– iliolumbar
• resist rotation and augment posterior SI ligaments
3.Other Soft tissues
 History/mechanism of injury
• Requires significant force (high energy vs low
energy)
• Ilicit H/O LOC ,head injury and rule out
polytrauma.
• Most commely MVA (upto 85 %) ,fall (8-
10%),crush injuries (3-6%)
 Forces leading to #
• Anterior posterior compression – secondary to a direct or
indirect force in an AP direction leading to diastasis of the
symphysis pubis, with or without obvious diastasis of the sacroiliac
joint or fracture of the iliac bone.

• Lateral compression – lateral compression force, which cause

rotation of the pelvis inwards, leading to fractures in the sacroiliac
region and pubic rami.

• Vertical shear – an axial shear force with disruption of the iliac

or sacroiliac junction, combined with cephalic displacement of the
fracture component from the main pelvis.

• Combined mechanism – a combination of two of the above

vectors, which leads to a pattern of pelvic fracture that is a
combination of one or more of the above fracture types
 Physical Examination
• Primary survey :-
• Begins with the ABCs (airway, breathing, and circulation), that is,
hemodynamic status.
• The goal of this primary survey is to identify and begin treatment of
immediately life-threatening injuries.

• Secondary survey :-
• PELVIC COMPRESSION/DISTRACTION test
• Examination of perineum.
• Flanks,lower back ,scrotam and labial hematoma.
• Rectal and vaginal examination.
• Urethral injury.
• Sensory and reflexes (The bulbocavernosus and cremaster reflexes)
• Examination of lower limbs.
 Radiological examination
• Plain X-Rays
• initial x-ray is simply a snapshot of one moment in time. The
deformation at the instant of injury was likely far greater than that seen
on films obtained in the emergency department.

• The pelvis has a remarkable ability to recoil to a near-normal alignment

after trauma. This elastic recoil can mask severe instability.

• Fractures noted on the AP x-ray should prompt further investigation of

the pelvis with inlet and outlet views.

• Radiographic signs of instability include:

– Sacroiliac displacement of 5 mm in any plane.
– Posterior fracture gap (rather than impaction).
– Avulsion of the fifth lumbar transverse process, the lateral border of the
sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous
ligament).
AP view
Pelvic inlet view
• INLET VIEW shows
• 1.fractures of the
sacrum
• 2.AP displacement of
injured portions of the
ring, and
• 3.the degree and
severity of rotational
displacement of the
injured hemipelvis.
• 4. Widening of the
sacroiliac or symphysis
pubis joint is clearly
visible on the inlet
view.
• 5.fractures of the
pubic rami are usually
well visualized.
Normal pelvic inlet radiograph
Pelvic outlet view

Outlet view shows

1.fractures of the sacrum.

2.Fractures of the posterior iliac

wing are visible on the outlet view,
as are fractures of the pubic rami.

3.Widening of the sacroiliac joint can

be noted.

4.The outlet view also demonstrates

cephalad or caudad displacement of
the injured hemipelvis
Flouroscopy
Other x ray
views..
 CT SCAN
• CT is the modality of choice for accurately
depicting complex acetabular or pelvic ring
fractures. After an initial plain radiograph, a CT is
often required to make an accurate assessment
of the fracture.

• Although CT does not reveal ligament injury

directly, ligament disruption can be inferred by
examination of joint disruption. For example,
external rotation of the iliac wing will first disrupt
the anterior sacroiliac ligaments .
 Role of MRI in pelvic fractures
• It has limited clinical utility owing to restricted access to a
critically injured patient, prolonged duration of imaging,
and equipment constraints. However, it may provide
superior imaging of genitourinary and pelvic vascular
structures.

• Magnetic resonance imaging (MRI) allows direct inspection

of the critical ligaments in the posterior pelvis. Ligament
disruption, avulsion, and fracture hematoma are all visible
using MRI (Fig. 41-36). However, definitive assessment of
an entire ligament can be difficult because of the nature of
MRI. Edema and fluid can obscure ligamentous detail, and
the true extent of ligament injury can be difficult to
appreciate
A.Normal magnetic resonance
imaging (MRI) of SI joints and
posterior ligaments.

B. Plain x-ray and CT scan of

transforaminal sacral fracture.

C. Injury MRI showing hematoma

(solid arrow) and disrupted
posterior sacral ligaments
(broken arrow).

D. Postoperative x-ray showing

fixation with a retrograde ramus
screw and an iliosacral screw
entering the S2 body.
 Other investigations
• CBC ,BLOOD GROUPING AND CROSSMATCHING
• FAST
• DIAGNOSTIC PERITONEAL LAVAGE
• CT ANGIO
• RETROGRADE URETHROGRAM
Classification of pelvic #
Tiles system
Young-Burgess system

(crescent #)
Young-Burgess system
Young-Burgess system
Young-Burgess system
Sacral #
Sacral fractures:
neurologic injury

1.Lateral to foramen
(Denis I): 6% injury

2.Through foramen
(Denis II): 28% injury

3.Medial to foramen
(Denis III): 57% injury
 Sacral # contd..

• Jumpers #
Examples of complex
Denis zone III sacral
fractures.
A. H•type.
B. Sacral U type.
C. Sacral lambda fracture.
D. Sacral T fracture.
DAMAGE CONTROL in pelvic #
Treatment algorithm by O’Brien and
Dickson
Iliac external fixator
1.provide temporary pelvic
stability and allow access to the
abdomen and perineum. It also
can be used as definitive
fixation in some patients or as an
adjunct to internal fixation
in others.

2.Fractures that involve the iliac

wing, the acetabulum,
or both usually are
contraindications to pelvic
external
fixation.
Supraacetabular exfix
Insertion of these pins
requires fluoroscopic
guidance and an
understanding of the
pelvic anatomy.

use this construct when

the abdominal
protuberance
is significant

The main advantage is an

excellent pin purchase in
the pelvis; a disadvantage
is limited hip flexion in
some patients.
Pelvic clamps
Because in vertically unstable
fractures an anteriorly applied
external fixator does not control
motion in the posterior sacroiliac
complex, two pelvic clamps have
been developed to
help control the posterior pelvis
in the resuscitation phase:
the Ganz C-clamp and the pelvic
stabilizer developed
by Browner et al.
Ganz fixator application
• Imaginary line from
ASIS TO PSIS

• Insert the nail on this

line 3 to 4 finger
breadths anterolateral
to the posterior
superior iliac spine .

• Do not make the entry

point too distal to avoid
endangering the gluteal
vessels or thesciatic
nerve.

• CI in iliac wing # close

to SI joint
 Definitive treatment of pelvic #
• Stable, nondisplaced pelvic fractures (Tile type A, Young and
Burgess types LC I and AP I) early mobilization and analgesics.

• The significant morbidity associated with nonoperative

treatment of displaced, unstable pelvic fractures has led to a
more aggressive operative approach.

• Indications for pelvic # fixation

• 1.rotationally unstable but vertically stable (Tile type B, Young
and Burgess type AP II) fractures with a pubic symphysis
diastasis of more than 2.5 cm.

• 2.pubic rami fractures with more than 2 cm displacement,

• 3.other rotationally unstable pelvic injuries with significant

limb-length discrepancy of more than 1.5 cm or unacceptable
pelvic rotational deformity.
 Our options
• ANTERIOR RING FIXATION
• 1.The mainstay of treatment for types APC-II or APC-III injuries is
ORIF of the pubic symphysis when the clinical situation allows.
• 2. External fixator as definitive fixation

• INDICATIONS FOR POSTERIOR RING FIXATION

• 1.Tile type C (Young and Burgess types AP III, LC III), AND
• 2.vertical shear pelvic injuries require posterior fixation to
regain vertical stability.

• External fixation alone is not recommended as definitive

treatment of vertically unstable pelvic fractures because the
posterior instability cannot be controlled by this treatment
method
 Options contd..
• OPTIONS FOR POSTERIOR FIXATION :
• Posterior treatment generally is determined by the portion of the
posterior ring disrupted.

1.For sacral fractures and sacroiliac joint disruptions, image

intensifier–directed screw fixation from the ilium posteriorly into
the sacral body .
2.Transiliac rod.
3.Tension band plating.
4.Anterior plating of the sacroiliac joint can be done through an
anterior retroperitoneal approach.
5.For iliac wing fractures, open reduction and pelvic reconstruction
plate fixation techniques, as well as lag screw fixation through the
pelvic tables, are used.
• Use a Pfannenstiel incision.
• Indications :-
ORIF with plate of Pubic symphysis
POSTERIOR fixation of SI joint diastasis

Use a standard
posterior vertical
incision, 2 cm lateral to
the posterior superior
iliac spine for sacroiliac
dislocations,
fracture-dislocations, or
sacral fractures.
 Root relationship to alar slope
1.Anterior to the sacral ala
in this region run the
L5 nerve root and the iliac
vessels.

2.The cortex of the alar

slope forms the anterior
boundary of the “safe
zone” for passage of
iliosacral screws into the
body of S1. The posterior
boundary of the safe zone
is formed by the foramen
of the S1 nerve root.
 ICD as guide
1.In 94% of nondysplastic upper sacral
segments, the ICD coincided with the alar slope as seen on
True lateral view the preoperative CT scan.

2.It a useful radiographic landmark for determining the

anterior border of the safe zone

3. 6% nondysplastic are recessed sacral ala .(slope is

posterior)
1.Routt et al. emphasized that the posterior pelvis must be accurately reduced to
allow superimposition of the greater sciatic notches and both ICDs on the true
lateral image.

2.With this as a necessary criterion for screw passage, using the ICD as the anterior
marker for the safe zone and being aware of anterior sacral recession, no screw
placement errors were noted in 51 consecutive patients.
The problems in finding the safe zone
Upto 30 % cases have neurological
complications
Percutaneous SI screw fixation
ORIF with ANTERIOR SI plating
 COMPLICATIONS
• HAEMORRHAGE
• Any pattern stable unstable can cause fatal haemorrhage.
• External rotation or vertical displacements (APC OR VS TYPE ) of the injured hemipelvis are
associated with a greater risk of hemorrhage than internal rotation displacement.

• DVT/PE
• When assessed with magnetic resonance venography, the reported rate of proximal deep vein
thrombosis in patients with pelvic or acetabular fractures is 35% .
• The reported rate of pulmonary embolism after pelvic fracture ranges from 2% to 12% , and
fatal pulmonary embolism ranges from 0.5% to 10% .

• use of low molecular weight heparins has increased in trauma centers. However, low
molecular weight heparins carry a slightly increased risk of bleeding, and so prophylaxis is
normally delayed until 36 hours after injury (CI in CNS trauma)

• combination of elastic stockings, sequential compression devices, and chemoprophylaxis if

hemodynamic status allows. Repeated Duplex ultrasound examinations ,coagulation profile and
D dimer assays may be necessary. Thrombus formation may necessitate anticoagulation and/or
vena caval filter placement.
 Complications contd..
• Infection: The incidence is variable, ranging from 0% to
25%, although the presence of wound infection does not
preclude a successful result.

• Malunion: Significant disability may result, with

complications including chronic pain, limb length
inequalities, gait disturbances, sitting difficulties, low back
pain, and pelvic outlet obstruction.

• Neurological

• Soft tissue complications

 Rehabilitation/mobilization
• Full weight bearing on the uninvolved lower extremity occurs
within several days.

• Partial weight bearing on the involved lower extremity is

recommended for at least 6 weeks.

• Full weight bearing on the affected extremity without crutches is

indicated by 12 weeks.

• Patients with bilateral unstable pelvic fractures should be

mobilized from bed to chair with aggressive pulmonary toilet
until radiographic evidence of fracture healing is noted. Partial
weight bearing on the less injured side is generally tolerated by
12 weeks.
 References
• Rockwood and Green's Fractures in Adults (2-
Volume Set), 6th ed_0781746361
• Campbell's Operative Orthopaedics 12th
• Atlas of Human Anatomy, Sixth Edition- Frank H.
Netter, M.D
• Gray's Anatomy for Students 3rd Ed. (2015)
• http://eradiology.bidmc.harvard.edu/LearningLab
/musculo/Boulton.pdf
• Rockwood and Wilkins' Fractures in Children 6th
• Pubmed central