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Anatomy, Radiographic

Evaluation, and Classification


of Pelvic Ring Injuries
Robert M. Harris MD
Medical Director of Orthopaedic Trauma
Mountain States Health Alliance
East Tenn State University Quillen School of Medicine
Revised November 2010
Created March 2004
Revised April 2007
By Kyle Dickson MD

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

References

Surgeon variability in the treatment of pelvic ring injuries.


Furey AJ, O'Toole RV, Nascone JW, Copeland CE, Turen C, Sciadini MF. Orthopedics. 2010 Oct 11;33(10)

. Classification of pelvic fractures: analysis of inter- and intraobserver variability using the Young-Burgess and
Tile classification systems.
Furey AJ, O'Toole RV, Nascone JW, Sciadini MF, Copeland CE, Turen C. Orthopedics. 2009 Jun;32(6):401

Interobserver reliability of the young-burgess and tile classification systems for fractures of the pelvic ring.
Koo H, Leveridge M, Thompson C, Zdero R, Bhandari M, Kreder HJ, Stephen D, McKee MD, Schemitsch EH.
Division of Orthopaedic Surgery; and daggerMartin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto,
Ontario, Canada. J Orthop Trauma. 2008 Jul;22(6):379-84

Fracture of the pelvis: current concepts of classification.Young JW, Resnik CS.Department of Radiology,
University of Maryland Medical System/Hospital, Baltimore 21201. AJR Am J Roentgenol. 1990 Dec;155(6):1169-75.

Do initial radiographs agree with crash site mechanism of injury in pelvic ring disruptions? A pilot study.
Linnau KF, Blackmore CC, Kaufman R, Nguyen TN, Routt ML Jr, Stambaugh LE 3rd, Jurkovich GJ,
Mock CN.Department of Radiology, Harborview Medical Center, Seattle, Washington 98104-2499, USA. J
Orthop Trauma. 2007 Jul;21(6):375-80.

References

How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in
blunt trauma patients? Shlamovitz GZ, Mower WR, Bergman J, Chuang KR, Crisp J, Hardy D, Sargent M,
Shroff SD, Snyder E, Morgan MT. Department of Emergency Medicine and Traumatology, Hartford Hospital, UCONN
School of Medicine, University of Connecticut, Hartford, Connecticut, USA. J Trauma. 2009 Mar;66(3):815-20

What constitutes a Young and Burgess lateral compression-I (OTA 61-B2) pelvic ring disruption? A description
of computed tomography-based fracture anatomy and associated injuries. Lefaivre KA, Padalecki JR, Starr AJ.
Department of Orthopaedics Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA. J Orthop
Trauma. 2009 Jan;23(1):16-21.

Predicting blood loss in isolated pelvic and acetabular high-energy trauma. Magnussen RA, Tressler MA,
Obremskey WT, Kregor PJ. Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Nashville, Tennessee
37232-8774, USA. Orthop Trauma. 2007 Oct;21(9):603-7

Pelvic disruption: assessment and classification. Pennal GF, Tile M, Waddell JP, Garside H. Clin Orthop Relat Res.
1980 Sep;(151):12-21

Pelvic fractures: value of plain radiography in early assessment and management. Young JW, Burgess AR,
Brumback RJ, Poka A. Radiology. 1986 Aug;160(2):445-51

Pelvic ring disruptions: effective classification system and treatment protocols.


Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ.
Shock Trauma Center, Maryland Institute for Emergency Medical Services Systems, Baltimore J Trauma. 1990
Jul;30(7):848-56

See Emergent Management of


Pelvic Injuries for Application of
Classification to Treatment

Acknowledgment
Andy Burgess and Kyle Dickson for
the use of their slides

If you would like to volunteer as an author for


the Resident Slide Project or recommend updates
to any of the following slides, please send an email to ota@aaos.org

E-mail OTA
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Questions/Comments

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