Fractures of pelvis

ANATOMY
ANATOMIE
ANATOMY
Vascularization
VASCULARIZATION
Nerves
 MECHANISM
- Low energy – Isolated fractures of the pelvic bones

- High energy – Fractures of the pelvic ring

 Low energy trauma
- Iliopubic and / or ischiopubic rami
- Avulsion of: antero-superior iliac spine
antero-inferior iliac spine
ischiatic tuberosity
- Isolated (transversal) fracture of sacrum
- Iliac wing
 High energy trauma
- Vehicles - antero-posterior impact
- lateral impact
- dashboard
- Motorcycle - arse impact
- knee impact
- Pedestrian - impact with vehicle
- frontal
- lateral
 High energy trauma

- Fall from heights

- on feet
- on a side
- Penetrating mechanism
- firearms
- blade weapons
- Crushing
- mine accidents, avalanches, wheel passes on
the pelvis, building collapses/earthquake, etc.
 Classification
- Anatomical classification
- depending on lesion site

- Anatomo-pathological classification
- depending on the number of interruptions of the
pelvic ring

- Depending of the mechanism:

antero-posterior compression
lateral compression
vertical (axial) shear
 TILE Classification
TYPE A
• Stable
• A1—Fractures of the pelvis not involving the ring
• A2—Stable, minimally displaced fractures of the ring
• A3—Transverse sacral fracture
• TYPE B
• Rotationally unstable, vertically stable
• B1—Open book
• B2—Lateral compression: ipsilateral
• B3—Lateral compression: contralateral
(bucket-handle)
• TYPE C
• Rotationally and vertically unstable
• C1—Unilateral rotationally and vertically unstable
• C2—Bilateral
• C3—Associated with an acetabular fracture
Rotational instability
Vertical and rotational instability
 Clinical examination
- Inspection
- hematoma over the ipsilateral flank, inguinal
ligament, proximal thigh or in the perineum
- hematuria
- rectal bleeding
- vaginal bleeding
- abnormal positions
- lower limb length discrepancy
 Clinical examination
- Palpation of pubic symphysis, pubic rami, iliac
crests, sacroiliac joints

- Bimanual compression & distraction of the iliac

wings and abduction & adduction of the hip should
be done to detect instability - risk to increase
bleeding

- Manual traction of the lower limb can aid in the

determination of vertical instability
 Clinical examination
- Digital vaginal +/- rectal examination
- Bladder outlet obstruction - acute urinary
retention
- Neurological examination
- Motility and sensibility – pelvis + lower linbs
- Vascular examination
- Arterial pulse, temperature and color of
the lower limb teguments
Radiological examination

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Radiological examination

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Radiological examination

Fractures of the iliopubic and ischiopubic rami

(superior and inferior pubic rami)

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 Radiological examination

Acetabular fracture and fracture of the ischiopubic rami

(inferior pubic rami)

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Radiological examination

Pubic diastasis and right sacro-iliac diastasis

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Radiological examination

Avulsion fracture of the antero-superior iliac spine

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 Radiological examination

Left sacro-iliac joint and pubic symphysis diastasis with ascension

of the left hemipelvis
Radiological examination

Inlet view of the pelvis

Outlet view of the pelvis

Radiological examination
Obturatory Alar incidence
incidence
 Radiological examination
Right alar incidence

Fractures of iliac wing, ilion body, ilio-pubic and ischio-pubic rami

 Diagnosis
CT-scan
- three-dimensional reconstruction
- for bones
MRI
- for soft tissues and organs lesions
- to detect fractures not visible on X-ray
 Associated lesions
Haemorrhage
- Most dangerous complication
- Source: fracture site
local arterial and/or venous lesions
lesions of the great vessels
- Treatment: -laparotomy and haemostasis
-arteriography + embolization
-external fixation
 Associated lesions
Urinary tract
Bladder
- Extraperitoneal: anterolateral wall
- Intraperitoneal: superior wall - dome
Uretra
- Membranous or the initial bulbocavernous uretra
Diagnosis
- Bleeding / urinary meatus
- Bladder drainage - catheterization to drain urine
- Uretrography and cistography
- Cystoscopy
- MRI
 Associated lesions

Genitals:
Vagina
Uterus

Digestive tract:
Rectum – iliac anus in emergency
to redirect feces from the lesions
(diverting colostomy)
 Open fractures
- Rare
- Open in: rectum, vagina, bladder,
exterior (iliac wing, perineum)

- Treatment
- Stop haemorrhage
- Debridement and closure of wound if possible
- Iliac anus if necessary (diverting colostomy)
- Fractures stabilization
 Treatment
Traction:
- Only as temporary immobilization
- Many complications

Pneumatic splints
- Emergency treatment
- Prevents shock (hipotension - initial redistribution of
blood from the limb to the trunk and restrict the expansion of a
pelvic hematoma)
- Like a pneumatic cast immobilization
pneumatic antishock garment (PASG) or
medical antishock trouser (MAST)
 Treatment
Pelvic hammock
- Indicated in open book fractures
- The patient is placed in a canvas sling or hammock that is
suspended by a tension spring to an overhead frame bar. The
pelvis is suspended so that it is just off the mattress.

- The body weight force is converted to lateral compression

(it can “close” an open book fracture and maintain the reduction till union)
 Surgical treatment
External fixation
- Good in emergency
- Controls haemorrhage
- Can be maintained as definitive
treatment
- Problems
- Obese patients
- Infections at the pins level
- It doesn’t stabilize the posterior complex
– if injured – requires traction or
posterior osteosynthesis
 External fixation

Pins
Connecting rods
Clamps
 Internal fixation
Mini-invasive sacro-iliac fixation with screws under
C-arm control
 Internal fixation

Open anterior fixation with plate and screws

of the sacro-iliac joint
 Internal fixation
Osteosynthesis for pubic symphysis
 Internal fixation

Osteosynthesis

Acetabulum and iliac wing Ilion, ilio-pubic rami, iliac wing

 Internal fixation
Transiliac fixation for
fractures of the sacrum
- screws and/or plates
 Internal fixation
Sacrum Back
- screws and/or plates
Sacro-iliac joint
- screws and/or plates
Iliac wing
- nothing (if isolated) or plates
Pubic rami (ilio-pubic or ischio-pubic)
- nothing (if isolated) or plates
Pubic symphysis Front

- nothing (if isolated and minimal displacement) or plates

 Complications

Infection - 0-25%

Thrombosis and thromboembolism

Malunion – gait and osteoarthritis

Nonunion
Acetabulum
fractures
 Anatomy
The acetabulum is supported by two columns
in the shape on an inverted “Y.”
These are in turn linked to the sacrum by the sciatic buttress.
Anatomy
 Mechanism
The femoral head strikes the acetabular wall

Vehicle crashes – dashboard strikes the

knee and the femoral head strikes the
posterior wall

Lower part

The fracture location depends on the

Medium part position of the lower limb:
flexion/extension,
abduction/adduction
Upper part internal/external rotation
AO foundation
 Causes

Car accidents

Sport accidents

Falls on the hip

 Anatomy

The anterior or iliopubic column is composed of the entire pubis and a large portion of
the ilium, extending from the iliac crest down the iliac wing and through the superior
obturator (pubic) ramus towards the pubic symphysis. Isolated injuries to the anterior
column result from forces applied to the hip in external rotation.

The posterior or ilioischial column is composed mainly of the ischium and a small part
of the ilium. It extends from the posterior iliac body just below the angle of the greater
sciatic notch down the ischial body into the inferior obturator (ischiopubic) ramus.
Forces applied to the hip while in internal rotation result in posterior column injuries.
 Classification
Anatomic
2 columns - anterior (ilio-pubic)
- posterior (ilio-ischiatic)
2 walls - anterior
- posterior
Types of fractures
- Transversal (2 fragments)
- T fracture (3 fragments)
- Transverse + 1 wall (3 fragments)
- T fracture + 1 wall (4 fragments)
- T fracture with floating acetabulum
Posterior wall - commonest type (25-33%)
 Clinical examination
- Identify the mechanism – low or high energy
- Position of the lower limb at the moment of trauma
- Direction of the impact

- Inspection
- Traumatic marks, hematomas
- Abnormal position of the lower limb
- Lower limb lenght discrepancy

- Associated lesions – fractures of patella, femur fractures,

knee sprains, etc.

- Neurological examination – sciatic and femural nerves

- Vascular examination – iliac and femural arteries and veins
 Radiological examination
Landmarks
1. Iliopectineal line
2. Ilioischiatic line
3. Teardrop – radiological
U
4. Dome – acetabular
ceiling
5. Anterior acetabular lip
6. Posterior acetabular lip
Radiological examination
Iliopectineal line (anterior column)

Ilioischial line (posterior column)

Radiological examination
Anterior lip and teardrop

Posterior lip

Dome
Radiological examination
 Radiological examination
Obturatory and alar views

Alar

Obturatory
Anterior wall acetabular fracture
Posterior wall acetabular fracture

CT-scan

Posterior column acetabular fracture

Anterior column acetabular fracture

 CT-scan 3D reconstruction

Front Back

Right 3/4 Left 3/4

Transverse + posterior wall fracture

 Treatment
Aim

Hip stability and congruency

Ideal – anatomical reduction of the

articular surface
- stable fixation
 Treatment
TILE
1. Polytraumatized patients
- early and concomitant assessment and
resuscitation
- establish adequate ventilation, to maintain the
circulation (intravascular volume and cardiac
function)
2. Reduction of the hip dislocation – emergency
3. Reduction and osteosynthesis of the acetabular
fracture – delayed emergency with exceptions
 Treatment

Indications for emergency surgical treatment

- Irreducible hip dislocation
- Unstable hip reduction
- Associated severe neurological lesions
(ex: paralysis of the sciatic nerve) or
aggravation of the neurological deficit
after reduction
- Associated vascular lesions
- Open fractures
 Treatment
Irreducible hip dislocation
- intra-articular fragments
Unstable hip reduction
- big fragments from the columns – posterior
(often) or anterior (rare) dislocation
- comminuted fracture of the quadrilateral
surface (medial instability – femural head
will dislocate inside the pelvis)
 Treatment
TILE
Indications of surgical treatment – based on:
- General status
- Age
- Bone quality
- Type of fracture
- Surgeons experience

- First 7 days after trauma

 Surgical treatment

Neutralisation plate – Protects lag screws from

bending, shear & rotation
 Surgical treatment
Osteosynthesis with plates

Posterior wall fracture

 Surgical treatment
Osteosynthesis with plates

Posterior column fracture

AO Foundation
 Surgical treatment
Osteosynthesis with plates

Anterior column fracture Anterior wall fracture

AO Foundation
 Surgical treatment
Osteosynthesis with screws

Anterior column fracture Anterior wall fracture

AO Foundation
 Surgical treatment
Osteosynthesis with plates and screws

Both acetabular column fracture

AO Foundation
 Surgical treatment
Impacted fragments

Fill the defect zone with cancellous

Elevate impacted fragments
autograft or a bone substitute
AO Foundation
 Complications
Shock
Hip osteoarthritis – most common
Avascular necrosis of the femural head
Infection
Thrombosis and thromboembolism
Malunion
Necrosis of soft tissues flaps
(in particular in the extended ilio-inguinal
approach)
 Complications
Nervous lesions
- sciatic (knee in flexion to relax the nerve)
- femural (in anterior column fractures)
- gluteus superior
- pudendum
-cutaneus femoris lateralis
Vascular lesions
- femoral artery and vein
- iliac artery and vein
 Complications

Heterotopical ossifications
Posterior approaches
Muscular desinsertions
Diphosphonates
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