Imaging of pelvic ring fractures

Poster No.: C-2165

Congress: ECR 2010
Type: Educational Exhibit
Topic: Musculoskeletal
Authors: A. Leone, A. M. Costantini, N. Magarelli, L. Bonomo; Rome/IT
Keywords: Pelvic ring fractures, Pelvic ring, CT, Pelvic ring, radiography
DOI: 10.1594/ecr2010/C-2165

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Learning objectives

1. To emphasize the significance of ligament anatomy to pelvic stability

2. To show the patterns of pelvic fractures and their associated mechanisms of
injury

Background

BACKGROUND

The pelvis is a ring like structure which includes the sacrum posteriorly and the two
innominate bones. The sacrum and innominate bones meet at the sacro-iliac (SI) joints,
the pubic bones at the symphysis pubis. Pelvic ring fractures are a common consequence
of high energy blunt trauma such as motor-vehicle or occupational accidents. The
importance of these fractures lies in the high rate of morbidity and mortality due to
associated injuries to different organs and systems, particularly pelvic viscera and
vascular structures (1). Since the pelvis is a ring like structure, any injury to any part of
the pelvic ring is always associated with an injury to an opposite site. Thus, disruption
of the pelvic ring always occurs in two locations: anteriorly and posteriorly (Fig. 1) (2).
Exceptions to this rule include the insuffìciency fractures, and avulsion fractures.

Mechanics

The anterior pelvic arch acts as a supporting strut to maintain the shape of the pelvic ring.
Thus weight is essentially transmitted from the spine to the femura, through the posterior
weight bearing arch; specifically, the posterior SI complex (Fig. 2) (3).

Pelvic Stability

Since there is no inherent stability in the unattached bones, the stability must be
due to the soft tissue, mostly, the ligaments. The posterior horizontal ligaments, such
as the ilio-lumbar, the anterior SI, and the sacro-spinous ligaments, oppose external
rotation of the iliac wings; thus, rotational stability depends on "horizontal" ligaments. The
"vertical" ligaments such as the sacro-tuberous and the longitudinal component of the
posterior SI ligaments oppose vertical and multidirectional displacements. Thus, vertical
and antero-posterior (AP) stability depend on "vertical" ligaments. All these ligaments
may be considered as the so called "posterior tension band". Following trauma, if the
posterior tension band is retained, stability is maintained (3). However, since the degree
of ligaments disruption may vary from case to case, so must the degree of instability of
the pelvic ring. Thus, the concept of stability cannot be "black or white" that is, "stable

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or unstable" because there is a spectrum of instability, and all pelvic ring fractures fall
into a scale of instability (3).

Radiological Signs of Instability

From a radiological point of view, there are three signs of instability (3):

1. Displacement of the posterior SI complex greater than 0.5 cm (Fig. 3).

2. Posterior fracture gap or dislocation of the SI joint (Fig. 4).
3. Avulsion fracture of the fifth lumbar transverse process, the sacral or ischial
ends of the sacro-spinous or sacro-tuberous ligaments. Avulsion fracture of
the fifth lumbar transverse process is a sign of instability because it, almost
always, results from cranial displacement of the underlying hemipelvis (Fig.
5).

Radiological Assessment

The radiological assessment of pelvic ring fractures includes: AP, inlet and outlet views
and CT examination. However, CT examination, with multiplanar and 3D-reconstructions,
has essentially eliminated the requirement for inlet and outlet views (4). CT is more
sensitive and specific than Radiography and better defines: posterior injury, amount
of displacement versus impaction, rotation of fragments, amount of comminution,
retroperitoneal hematoma (5, 6).

Classification Systems

Management of pelvic disruption will depend on analysis of the force which produced the
injury and on the degree of instability of the hemipelvis. Pennal and Tile (7) first proposed
a classification system based on force vectors identifying three primary vectors: AP
compression, Lateral compression and Vertical Shear which are responsible of specific
patterns of pelvic fractures. Yet, since force vectors are not always pure, a fourth group
of fractures should be considered, "the complex fractures" which result from combined
multidirectional forces. Young & Burgess (8) refined this classification system identifying
a constant progression to pelvic injury within AP and lateral compression vector groups.
Thus, AP and Lateral compression injuries are stratified into one of three types reflecting
increasing severity and instability.

Images for this section:

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Fig. 1: Fig. 1 Inlet view. Example of anterior (white arrow) and posterior (yellow arrow)
location of pelvic ring injuries.

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Fig. 2: Fig. 2 3D volume-rendered CT image showing the posterior SI complex which
includes the posterior aspect of the sacrum, the posterior aspect of the iliac wings and
the interosseous SI ligaments (yellow circle).

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Fig. 3: Fig. 3 Inlet view. Displacement of the posterior SI complex greater than 0.5 cm
(arrow). The inlet view, showing a break of the innominate line (dottled line), is the best
for disclosing this sign. Note also the cranial displacement of the right hemipelvis (black
lines), as well as avulsion fracture of the right fifth transverse process.

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Fig. 4: Fig. 4 AP view showing dislocation of the right SI joint (arrow). This is a sign of
instability, since the interosseous SI ligament must be disrupted.

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Fig. 5: Fig. 5 Outlet view. Avulsion fracture of the right fifth lumbar transverse process
(arrow) resulting from cranial displacement of the underlying hemipelvis (lines).

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Imaging findings OR Procedure details

IMAGING FINDINGS

Anteroposterior Compression Fractures

AP compression fractures are commonly the result of forces applied in the AP plain,
such as a direct blow to the symphysis or to the posterior SI area. The effect of this
force is external rotation of the innominate bone. The hallmarks include diastasis of the
pubis symphysis and vertical fractures of pubic rami. Progressive force will disrupt sacro-
tuberous, sacro-spinous, and SI ligaments and stability will depend on the degree of
ligament disruption. If additional force is applied, disruption of posterior SI ligament results
in complete instability. Thus, AP compression injuries are stratified into one of three types
reflecting increasing severity and instability.

Type 1 is the most common type of AP compression fractures. Posterior ligaments

are intact, thus the fracture is stable and diastasis of the symphysis pubis is less than
2.5 cm since sacro-spinous ligaments remain intact (Fig. 1). Since the force is applied
in the AP plane, the fracture of the pubic rami is characteristically vertically oriented
(Fig. 2). Furthermore, the posterior SI complex is intact, however, CT examination can
demonstrate minor widening of the anterior part of SI joint resulting from stretching, rather
than disruption, of the anterior SI ligaments (Fig. 3).

AP compression type 2 fractures include vertical fractures of pubic rami as described for
type 1, with additional widening of the SI joint because of disruption of the anterior SI
ligament. Moreover, the widening of the pubis symphysis is greater than 2.5 cm since
sacro-spimous and sacro-tuberous ligaments are disrupted (Fig. 4). These injuries are
partially unstable as they are unstable to AP compressive forces.

AP compression type III fractures result in complete SI joint disruption since the posterior
SI ligaments are disrupted (Fig. 5). Obviously, these fractures are totally unstable.

Lateral Compression Fractures

Application of force from the side is the most common mechanism of pelvic injury. Also
these fractures are stratified in one of three types reflecting increasing instability. The
effect of this force is internal rotation of the innominate bone (Fig 6). The hallmark is
represented by horizontal superior pubic ramus fracture on the side of impact. (Fig. 7).

In Type I injuries, the lateral force is applied over the posterior pelvis and this results
in fractures of one or more pubic rami, and posteriorly, in compression fractures of the
sacrum (Fig. 8). Since posterior ligaments remain intact, these fractures are stable.

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The lateral force, in Type II injuries, is usually applied more anteriorly giving rise to a
more evident internal rotation. The pubic rami injuries are as described for Type I, but
progressive internal rotation results in disruption of the posterior SI ligament and thus, in
widening of the posterior aspect of the SI joint. An alternative outcome, if the ligaments
remain intact, is for the ilium to fracture (Fig. 9). These fractures are partially unstable.

Lateral compression Type III injuries, result from internal rotation on the side of impact and
external rotation on the other, and is often the result of roll-over injury. Thus, radiological
features include lateral compression injuries, as described for Type I or II, on one side,
and AP compression injuries on the other. These fractures are completely unstable
because of posterior ligaments disruption (Fig. 10).

Vertical Shear Fractures

These fractures are usually the result of falls or jumps onto the lower limbs. The forces
involved are in the vertical plane and thus are shearing in nature; the result is disruption
of the pelvic ring and soft tissue. The hallmark of this mechanism of injury is cranial
displacement of the affected hemipelvis (Fig. 11). These lesions are extremely unstable
since all ligaments are torn.

Complex Fractures

Are the result of combined multidirectional force vectors, often, it is a combination of

lateral compression and vertical shear or AP compression and vertical shear forces (Fig.
12).

Images for this section:

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Fig. 1: Fig. 1 AP compression type 1 fracture. AP radiograph shows diastasis of the pubis
symphysis (double-head arrow) which is less than 2.5 cm.

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Fig. 2: Fig. 2 AP compression type 1 fracture. AP radiograph shows the characteristically
vertically oriented fracture of the pubic rami (arrows).

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Fig. 3: Fig. 3 AP compression type 1 fracture. 3D volume-rendered CT image showing
minor widening of the anterior part of SI joints (yellow arrows). Diastasis of pubis
symphysis is less than 2.5 cm (white arrow).

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Fig. 4: Fig. 4 AP compression type 2 fracture. 43-year-old patient involved in a motor-
vehicle accident. a) AP radiograph shows diastasis of the symphysis pubis more than 2.5
cm (double-head arrow), and widening of the anterior part of the left SI joint (arrow). b)
Axial CT scan better defines the anterior widening of the left SI joint (arrow).

Fig. 5: Fig 5 AP compression type III fracture. a) AP view shows wide diastasis of the
pubis symphysis (double-head arrow) and SI joints (arrows). b) Axial CT scan better
defines the diastasis throughout right SI joint (white arrow) since posterior SI ligament is
disrupted, and widening of the anterior part of the left SI joint (yellow arrow), since the
posterior SI ligament remains intact. Note also the crush fracture of the sacrum on the
left (orange arrow).

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Fig. 6: Fig. 6 Lateral compression fracture. AP radiograph shows internal rotation of the
right hemipelvis (lines) with overlapped symphysis (arrow).

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Fig. 7: Fig. 7 Lateral Compression Fracture. AP radiograph showing horizontally oriented
fracture of the superior pubic ramus on the side of impact (yellow arrow) associated with
other pubic fractures (white and orange arrows).

Fig. 8: Fig. 8 Lateral Compression Fracture type I. AP radiograph shows horizontally

oriented fracture of right superior pubic ramus (yellow arrow) associated with another
pubic fracture (orange arrow), and a compression sacral fracture (white arrow). Note the
internal rotation of right hemipelvis (lines).

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Fig. 9: Fig. 9 Lateral Compression Fracture type II. a) AP view shows a horizontal
fracture of the right superior pubic ramus (yellow arrow) associated with another pubic
fracture (white arrow). b) Axial CT scan clearly shows the posterior lesion which includes
a compression sacral fracture (yellow arrow) associated with a fracture of the ilium (white
arrow).

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Fig. 10: Fig. 10 Lateral Compression Fracture type III. 11-year-old boy involved in a
motor-vehicle roll over. AP radiograph shows internal rotation of the right hemipelvis,
complete disruption of the right SI joint (yellow arrow), external rotation of the left
hemipelvis, and widening of the anterior part of the left SI joint (white arrow). Note also
a fracture of the left iliac wing (orange arrow).

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Fig. 11: Fig. 11 Vertical shear fracture. 3D volume-rendered CT image shows cranial
displacement, and disruption of the left SI joint (arrow) associated with avulsion of
ipsilateral fifth lumbar transverse process (small arrow). An "autonomous" fragment of
the right iliac crest as well as a mild diastasis of pubic symphysis are also evident.

Page 19 of 22
Fig. 12: Fig. 12 Combination of AP and vertical shear forces. AP radiograph shows a wide
disruption of the pubis symphysis and a sacral vertical fracture (yellow arrow) passing
cranially medial to the left S1 articular process (AP compression fracture), but a cranial
displacement of the left hemipelvis (lines), indicating a vertical shear component, is also
evident.

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Conclusion

CONCLUSION

Management of pelvic disruption will depend on analysis of the force which produced
the injury and on the degree of instability of the hemipelvis. Radiography represents the
key to mechanism of injury. CT represents the key to severity of injury. Mechanism and
severity of injury represent the keys to appropriate treatment.

Personal Information

Antonio LEONE, MD

Department of Bioimaging and Radiological Sciences

Catholic University, School of Medicine

Largo A. Gemelli, 1

00168 Rome

Italy

Tel: +39-06-30156054

Fax: +39-06-35501928

e-mail: aleonemd@tiscali.it

References

REFERENCES

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2. Chenoweth DR et al. A clinical and experimental investigation of occult injuries of the

pelvic ring. Injury 1980;12: 59-653.

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3. Tile M, Hearn T, Vrahas M. Biomechanics of pelvic ring. In "Fractures of the pelvis and
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4. Hilty MP, Behrendt I, Benneker LM. Pelvic radiography in ATLS algorithms: A

diminishing role? World Journal of Emergency Surgery 2008, 3:11-155.

5. Falchi M, Rollandi GA. CT of pelvic frctures. Eur J Radiol. 2004; 50: 96-105. Review.

6. Koo H, Leveridge M, Thompson C et al. Interobserver reliability of the Young-Burgess

and Tile classification systems for fractures of the pelvic ring. J Orthop Trauma. 2008;
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7. Pennal GF, Tile M, Waddel JP, GarsideH. Pelvic disruption: Assessment and
classification. Clin Orthop 1980; 151:12-21

8. Burgess AR, Eastridge BJ, Young JWR, et al. Pelvic ring disruptions: effective
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