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Anatomy, Radiographic

Evaluation, Classification and


Complication of Pelvic Ring
Injuries
IB Aditya Wirakarna

Pelvic Ring Disruption

Marker for severe


injury
Overall mortality 610%
Life threatening

Magnitude of Forces

ACL injury 500-1000N


LC-I pelvic fracture 6000-9000N

Bone Anatomy

Two innominate bones


with sacrum.
Coalesce at triradiate
cartilage.
Ilium, ishium and pubis
have three separate
ossification centers that
fuse at sixteen years.
Gap in symphysis < 5 mm
SI joint 2-4 mm

Ligamentous Anatomy

Ligaments - posterior
ligaments are stronger
than anterior ligaments:

Posterior SI
Anterior SI
Interosseous ligaments
Pubic symphysis
Sacrotuberous
Sacrospinous

ANATOMY
Ligamentous

ASI
ST

PSI

SS
ST

Posterior Ligaments

Ant. SI Joint resist external rotation


Post. SI and Interosseous posterior stability by tension band
(strongest in body)
Iliolumbar ligaments augments posterior complex
Sacrotuberous (sacrum behind sacro-spinous into ischial tuberosily
vertically)Resists shear and flexion of SI joint
Sacrospinous (anterior sacral body to ischial spine horizontally)
resists external rotation

Normal SI Joint Motion with Gait

< 6 mm of translation
< 6 rotation
Intact cadaver resist 5,837 N (1,212 lbs)

ANATOMY
Relationships

Vascular Anatomy

Internal iliac artery


courses medial to the vein,
splits into anterior and
posterior branches.
Posterior branch is more
likely injured (SGA is
largest branch).
Usual bleeding is from
venous plexus.

Potentially Damaged Visceral


Anatomy

Blunt vs. impaled by bony spike


Bladder/urethra
Rectum
Vagina

Pelvic Stability

Strength of ring: 40%


anterior and 60%
posterior.
Vsphere = 4/3r.
Stability ability of
pelvic ring to withstand
physiologic forces
without abnormal
deformation

IDENTIFY THE HIGH RISK


PELVIC DISRUPTION
By Radiography
By Physical Exam

Physical Exam

Physical Exam-poor
sensitivity (8%) for
mechanically unstable
pelvis fractures in
blunt trauma patients

Shlamovitz GZ, Mower WR,


Morgan MT-Journal of Trauma
Mar 09

Radiographs

Anteroposterior (AP)
Inlet (40 caudad)
Outlet (40 cephalad)
CT scan
Judet (acetabular
fractures)

AP VIEW

If evidence of pelvic ring fracture...

INLET VIEW

Inlet (Caudad) View

Horizontal Plane
Rotation
Posterior
Displacement
Sacral ala

OUTLET VIEW

Outlet (Cephalad) View

Sacrum
Cephalad
Displacement
Sacral Foramina

CT Scan

Better defines posterior injury


Amount of displacement versus impaction
Rotation of fragments
Amount of comminution
Assess neural foramina

CT SCAN

3D CT

Radiographic Signs of Instability

Sacroiliac displacement of 5 mm in any


plane
Posterior fracture gap (rather than
impaction)
Avulsion of fifth lumbar transverse process,
lateral border of sacrum (sacrotuberous
ligament), or ischial spine (sacrospinous
ligament)

Translational Deformities

X axis Diastasis or impaction


Y axis Caudad or cephalad displacement
Z axis Anterior or posterior displacement

Rotational Deformities

X axis Flexion or extension


Y axis Internal rotation or external
rotation
Z axis Abduction or adduction

Classification

Aids in predicting hemodynamic instability


Aids in predicting visceral and g.u. injuries
Aids in predicting pelvic instability
Aids in understanding mechanism of injury,
force vector of injury, and surgical tactic for
reduction

Classification Systems

Anatomical (Letournel)
Stability & Deformity (Pennal, Bucholz,
Tile)
Vector force and associated injuries (Young
& Burgess)
OTA-research

Anatomical Classification
(Letournel)

Where The Pelvis Breaks

Anterior

Rami fractures
Symphyseal disruption

Posterior

Iliac wing fracture


Iliac wing/sacroiliac
(SI) joint
(crescent
fracture)
SI joint
Sacrum/SI joint
Sacrum fracture

Pennal, 1961

Magnitude and
direction of forces
Lateral posterior
compression (LC)
Anterior posterior
compression (APC)
Vertical shear (VS)

Bucholz, 1981 Tile, 1988

Added stability to the


classification

Tile Classification

Type A: Stable fracture.


Type B: Rotationally unstable, but vertically stable.
Type C: Rotationally and vertically unstable.

OTA/AO Pelvic Injury


Classification

61A Lesion sparing (or with no


displacement of ) posterior arch
B Incomplete disruption at posterior arch;
partially stable
C Complete disruption of posterior arch;
unstable

A Fractures Ring Intact

A-1 Fracture of innominate bone;


avulsion
A-2 Fracture of innominate bone; direct
blow
A-3 Transverse fracture of sacrum and
coccyx

B-Ring Injury Partially stable

B-1 Unilateral partial


disruption of posterior
arch, external rotation
(open book injury)
B-2 Unilateral, partial
disruption of posterior
arch, internal rotation
(lateral compression
injury)
B-3 Bilateral, partial
lesion of posterior arch

C Complete Disruption Posterior


Arch, Unstable Pelvis

C-1 Unilateral,
complete disruption of
posterior arch
C-2 Bilateral,
ipsilateral complete,
contralateral
incomplete
C 3 Bilateral,
complete disruption

Young-Burgess Radiology 1986

Based on mechanism of injury


Predictive of associated local & distant injury
Useful for planning acute treatment

MECHANISM OF INJURY (MOI)

Do initial radiographs agree with MOI in


pelvic ring disruptions- Linnau KF, Blackmore
CC, Routt ML, Mock CN-J Ortho Trauma Jul
2007

more reliable for LC than AP mechanisms

MECHANISM OF INJURY

Lateral compression (implosion)

AP compression (external rotation)

Vertical shear

Combined injury

Young-Burgess Classification

LATERAL COMPRESSION
ring plus:

fracture of anterior

LC -I Compression fracture of anterior


sacrum
LC -II Iliac wing fracture posteriorly
(unstable)
LC -III Windswept pelvis (contralateral SI
injury)

ANTERIOR-POSTERIOR COMPRESSION

APC
APC
APC

I Partial disruption
II Posterior sacroiliac ligaments intact
III Posterior sacroiliac ligaments

CLASSIFICATION
Mechanism and direction of injury

DISRUPTED PELVIC RING

Posterior/SI injury is a
marker for associated
vascular injuries

Tamponade efforts and fluid


resuscitation may be rendered
useless

Resuscitation

Young and Burgess


classification:

LC III
APC II
APC III
VS
CM

RESUSCITATION REQUIREMENTS

units blood
1st 24 hours

Mortality

Death
s:

Interobserver Reliability of the


Young/Burgess and Tile classifications

Koo H, Leveridge M, McKee,MD, Schemitsch EH,

J Ortho Trauma

Jul 2008

Young/Burgess Kappa .72-better for the training


surgeon
CT-improved assessment of stability

Furey AJ, OToole RV, Turen C, Ortho June 2009


Interobserver moderate degree of agreement
Intraobserver- moderate for Tile
Substantial for Burgess

LATERAL COMPRESSION
LC I: Sacral compression

Lateral Compression

Most common pattern.


LC1 stable, load to posterior ring.
LC2 load to anterior ring, posterior ligaments
injured, ST and SS intact.
LC3 LC2 + external rotation injury of the
other side.

LC-I

LATERAL COMPRESSION
Common anterior pattern

LATERAL COMPRESSION
LC I: Sacral compression

What Constitutes a LCI

Lefaivre KA, Padalecki JR, Starr AJ- J Ortho Trauma Jan 2009

LC I-Spectrum of injuries

Complete sacral disruptions


Denis classification
Predicted by severity of anterior pelvic ring disruption
Abdominal AIS
Rami fracture location
ISS

LATERAL COMPRESSION
LC II: Iliac wing fracture

LC-II

LC-II

LC III: Windswept pelvis

LC III

LC III

LC III

Anteroposterior Compression

APC1- stable injury, anterior ligament injury.


APC2 SS and anterior SI injury, possibly ST.
APC3 anterior and posterior injury, completely
unstable.

ANTEROPOSTERIOR COMPRESSION

AP I: Hockey player

AP I

Note that the


ligaments are
stretched, and not
torn

ANTEROPOSTERIOR COMPRESSION
APII: Open book pelvis

AP II

APC-2 Sacrotuberous, sacrospinous,


and anterior SI joint ligaments disrupted
(post SI ligaments intact)

Note: pelvic floor ligaments are


violated, as well as anterior SI
ligaments

AP-II

AP II
Ligamentous pathology

AP II
These anterior SI ligaments are disrupted...

But these posterior SI ligaments remain intact

ANTEROPOSTERIOR COMPRESSION
APC III: Complete iliosacral dissociation

APC-3

Complete SI joint disruption


(usually not vertically displaced)

AP III

APC-III

AP III

ASSOCIATED INJURIES
Lateral Compression:

Abdominal visceral injury


Head injury
Few pelvic vascular injuries

AP Compression:

Urologic injury
Hemorrhage/pelvic vascular injury:
APCII-10%, APCIII-22%

Vertical Shear

Always unstable
Ant. symphsis or vertical rami fracturespost. Injury variable
Vertical displacement

VERTICAL SHEAR

Vertically unstable
often due to a unilateral injury.
Similar to APC3.

VERTICAL SHEAR

COMBINED MECHANICAL INJURY

Combined vectors
occasionally 2 separate
injuries
(ejection/landing)

COMBINED MECHANICAL INJURY

CLASSIFY INJURY (Young-Burgess)

LC-I, AP-I
Conservative
Treatment

AP-II

AP-III, VS

Anterior
Stabilization
Anterior and
Posterior Stabilization

Surgeon variability in the treatment


of pelvic ring injuries

Furey AJ, OToole RV, Nascone JW, Sciadini MF- Ortho Oct 2010

Young and Burgess, and Tile Classifications


Kappa Value-

Intraobserver- 0.56 moderate agreement


Interobserver- 0.47 moderate agreement

Consistent treatment for certain patterns

ASSOCIATED INJURIES

Abdominal visceral injury


Head injury
Few pelvic vascular injuries
Urologic injury

Injuries

to the Rectum

Hemorrhage/pelvic vascular injury:


APCII-10%, APCIII-22%

Injuries to the Rectum

Most commonly, injuries to the rectum occur with penetrating rather than blunt
pelvic trauma
Traditionally, rectal trauma had been managed with the principle of the four Ds:
divert, drain, direct repair, and distal washout
Challenging these current principles is difficult as extraperitoneal rectal injuries
are rare, limiting a large-scale study, and the clinical consequences of pelvic
sepsis without proximal diversion of the fecal stream can be a disastrous
scenario in an often already multiply injured patient
Although less common with blunt bony pelvic injury, 25 % of patients with an
open pelvic fracture have an associated rectal laceration (Jones-Powell class III)
In this study, the highest mortality and highest ISS scores were for patients with
a combination of open pelvic fracture and rectal laceration underscoring the
synergistic effect of combined pelvic injuries on mortality

Injuries to the Rectum

Typically, any penetrating injury to the pelvis or


significant pelvic fracture should raise concern for a rectal
injury
As mentioned previously, rectal trauma requiring surgical
intervention is rare with a blunt trauma.
In contrast, when a penetrating injury traverses the pelvis,
the rectum must be evaluated

Injuries to the Rectum

We recommend direct visualization of the rectum with either rigid


proctoscopy or flexible sigmoidoscopy
During both procedures, the rectal mucosa is visualized
circumferentially and assessed for injury
If injury is present, repair will then depend on the degree of injury
(hematoma v. laceration), anatomic location (intra- or
extraperitoneal), and clinical scenario (hemodynamic status)
Noninvasive imaging with CTof the rectum with rectal contrast
should be used with caution as immediate imaging may not
accurately assess highenergy wounds to the rectum that are only a
partial injury to the wall that subsequently convert into a full
thickness wound

Injuries to the Rectum


Management
The extraperitoneal rectum is not easily mobilized, and mobilization,
resection, and anastomosis are difficult in the elective setting and
even more so in trauma
Therefore, diversion of the fecal stream with a proximal colostomy
with or without presacral drainage and primary repair is the current
standard of care.
Presacral drainage had previously been considered to be the standard
of care based on management with the four Ds from the Vietnam War
Several retrospective studies in civilian trauma have shown no
increase in pelvic sepsis or infection with the omission of presacral
drainage when diverting colostomy is performed

Injuries to the Rectum


Management
Therefore, in civilian-penetrating pelvic injuries with a rectal
wound and without massive tissue destruction, presacral
drainage is unnecessary.
Rectal injuries in the proximal two thirds of the rectum could
be managed with primary repair or resection and anastomosis
with proximal diversion at the surgeons discretion.
Those wounds in the distal one third of the rectum could
undergo primary repair if accessible transanally, with proximal
diversion utilized if the injury was not easily accessible, with
presacral drainage

Direct repair of the injury is not necessary


A retrospective study of 30 consecutive patients with
penetrating extraperitoneal rectal injuries who were all
treated with diverting colostomy with or without direct
repair and presacral drainage showed no infectious or
survival benefit for direct repair or presacral drainage

The management of combined bladder and rectal injuries


may require more than just proximal diversion, however.
High rates (24 %) of rectovesical and rectourethral fistula
are associated with combined GU and rectal injuries.
Therefore, in these instances, debridement of necrotic
rectum with primary repair, proximal diversion, and the
placement of an omental pedicle flap between the rectum
and GU injury may reduce fistula formation especially in
cases of combined posterior bladder and anterior rectal
injuries.

Two to 3 months following the injury, the rectum and


distal colon can be evaluated for healing and patency with
a barium enema and, if adequate, the colostomy may be
reversed with high rates of success

In summary, rectal trauma occurs most commonly with


penetrating injuries and is quite often associated with
injuries of the bladder, distal urinary system, and small
bowel.
Any suspicion for rectal trauma should prompt visualization
of the rectum with various endoscopic equipment.
Currently, injuries to the rectum should be managed with
proximal diversion with additional consideration for tissue
debridement and omental flap placement when there is
concomitant GU injury.

Thank You