Pelvic fractures

Dr SHAMMAS B M
Dept of Orthopedics
Calicut Medical College
• Fractures of the adult pelvis, generally are
either
• (1) stable fractures resulting from low-
energy trauma, such as falls in elderly
patients or
• (2) fractures caused by high-energy trauma
that result in significant morbidity and
mortality
• The potential complications include injuries
to the major vessels and nerves of the pelvis
and the major viscera, such as the intestines,
the bladder, and the urethra
• Immediately after injury, mortality can result
from severe intrapelvic hemorrhage.
• Hemorrhage frequently results from fracture
surfaces and small vessels in the
retroperitoneum.
• ANATOMY
• The pelvis is composed anteriorly of the ring of
the pubic and ischial rami connected with the
symphysis pubis.
• A fibrocartilaginous disc separates the two pubic
bodies.
• The sacrum and the two innominate bones are
joined at the sacroiliac joint by the
• interosseous sacroiliac ligaments
• the sacrotuberous ligaments
• the anterior and posterior sacroiliac ligaments,
• the sacrospinous ligaments,
• iliolumbar ligaments
• This ligamentous complex provides stability to the
posterior sacroiliac complex because the sacroiliac
joint itself has no inherent bony stability
• Pelvic stability is determined by
ligamentous structures in various planes.
• The primary restraints to external rotation
of the hemipelvis are the ligaments of the
symphysis, the sacrospinous ligament, and
the anterior sacroiliac ligament.
• Rotation in the sagittal plane is resisted by
the sacrotuberous ligament..
• Vertical displacement of the hemipelvis is
controlled by all the mentioned
ligamentous structures,
• but if other ligaments are absent, it may
be controlled by intact interosseous
sacroiliac and posterior sacroiliac
ligaments, along with the iliolumbar
ligament.
CLASSIFICATION

• Pennal et al. developed a mechanistic

classification in which pelvic fractures are
described as
• anteroposterior compression injuries,
• lateral compression injuries,
• vertical shear injuries.
• Tile modified the Pennal system to make it
an alphanumeric system involving three
groups based on the concept of pelvic
stability
– A (stable),
– B (rotationally unstable but vertically stable),
– C (rotationally and vertically unstable).
• Type B1 fractures include "open book" fractures
or anterior compression injuries in which the
anterior pelvis opens through a diastasis of the
symphysis
• or through a fracture of the anterior pelvic ring.
The posterior sacroiliac and interosseous
ligaments remain intact.
• In the first stage, the symphysis separation is
less than 2.5 cm, and the sacrospinous ligament
remains intact.
• In the second stage, the diastasis is more than
2.5 cm with rupture of the sacrospinous ligament
and the anterior sacroiliac ligament..
• In the third stage, the lesions are bilateral,
creating a B3 injury
• Young and Burgess proposed a different
modification of the original Pennal classification,
adding a new category for combined mechanical
injuries
• Sacral fractures have been classified separately
classification used is by Denis, Davis, and Comfort
• type 1 fractures occur lateral to the neural foramina
through the sacral ala;
• type 2 fractures are transforaminal;
• type 3 fractures occur medial or central to the neural
foramina.
• Transverse fractures of the sacrum are classified as type
3 injuries because they involve the spinal canal.
ROENTGENOGRAPHIC
EVALUATION
• The standard roentgenographic
projections required for evaluation of
pelvic fractures are an
• anteroposterior view of the pelvis and
• 40-degree caudad inlet and
• 40-degree cephalad outlet views described
by Pennal et al..
• The inlet view demonstrates rotational
deformity or anteroposterior displacement
of the hemipelvis.
• The outlet view demonstrates vertical
displacement of the hemipelvis, sacral
fractures, and widening or fracture of the
anterior pelvis
• Computed tomography is an essential part
of the evaluation of any significant pelvic
injury, allowing evaluation of the posterior
portion of the pelvic ring that may be
poorly seen on standard roentgenographs.
• Widening of the symphysis of more than 2.5 cm has
been correlated with rupture of the sacrospinous
ligament and a rotationally unstable pelvis.
• Avulsion fractures of the lateral sacrum and ischial spine
also are signs of rotational instability.
• Widening of the anterior pelvis causes rupture of the
anterior sacroiliac ligament, making the sacroiliac joint
appear widened on the anteroposterior view.
•
• However, as demonstrated by axial CT images,
the posterior ligaments of the sacroiliac joint
may remain intact, maintaining the vertical
stability of the pelvis.
• Impacted fractures of the anterior cortex of the
sacrum are common with lateral compression
injuries and generally are stable,
• but a sacral fracture with a gap usually indicates
vertical instability.
• An avulsion fracture of the tip of the L5
transverse process at the attachment of the
iliolumbar ligament is another indication of
vertical instability
• Vertical instability usually is defined as 1 cm or
more of cephalad migration of one hemipelvis.
• if vertical stability is questionable, stress testing
can be beneficial.
• Bucholz recommended a push-pull test in
which, under roentgenographic control,
the examiner pushes up on one extremity
while pulling down on the other.
TREATMENT: RESUSCITATION
PHASE
• During acute resuscitation, management of
patients with pelvic fractures should follow one of
the existing trauma protocols
• The MAST suit (military antishock trousers) has
proved beneficial during patient transport but is
not used routinely in the evaluation/resuscitation
phase
• A deflatable bean bag has been suggested to
stabilize the pelvis temporarily in the initial
resuscitation phase.
 External Fixation
• In patients with an unstable pelvic fracture who
demonstrate hemodynamic instability after an
initial fluid bolus, emergency external fixation
should be performed early in the resuscitation
effort.
• Reported benefits are
• (1) a tamponade effect on the retroperitoneal
hematoma, effected by reducing the
retroperitoneal volume;
• (2) less motion of the fracture surfaces, which
allows more effective clot formation; and
• (3) greater patient mobility during transport and
for CT scanning and other evaluations
• Moreno et al., Burgess et al., and others noted a
reduction in the transfusion requirements of
patients with unstable pelvic fractures who were
treated with immediate external fixation
compared with those who did not undergo
immediate fixation.
• Many variations of pelvic external fixators
are available.
• simple anterior frame with two 5-mm pins
in each iliac wing is used commonly.
• Vertically unstable fractures usually also
are treated with ipsilateral distal femoral
skeletal traction until definitive internal
fixation can be done.
• In the emergent application of a pelvic external
fixator, the following basic technical principles
must be observed:
• adequate soft tissue protection via guide
sleeves for drilling and pin insertion;
• skin incisions at 90 degrees to the iliac crest
and large enough to accommodate guide
sleeves;
• 5 mm or larger blunt half-pins,
• 180 mm in length or longer
• 2 or 3 pin clusters per hemipelvis;.
• converging pin placement into the anterior
third of the iliac wing;
• a frame construct that provides clearance
from and access to the abdomen;
• and dual frame construct to allow
independent free manipulation without
loss of pelvic reduction.
• Pins can be placed
• percutaneously or
• via an open technique.
• If the pins are placed percutaneously,
• Pin is placed 2 cm posterior to the
anterosuperior iliac spine. aiming the pin toward
the greater trochanter and allowing it to find its
way between the tables of the hemipelvis.
• Frame Construction and Fracture
Reduction/Stabilization.
• Apply two upright bars to each pin cluster and
connect them to cross bars, thereby creating a
dual Slatis-type rectangular frame construct.
• Each independent frame can be loosened
subsequently and manipulated, thereby allowing
access to the abdomen.
• Once the pins are in position and the frame is
constructed, before tightening, reduce the
displaced pelvic ring injury.
• Open book types require "closure of the book;"
• lateral compression injuries require "opening the
book."
• Tile C injuries are unstable posteriorly, and
simple "book-closing" maneuvers can further
displace the disrupted posterior pelvic anatomy.
Therefore, apply bilateral compressive forces to
the pelvic ring posteriorly.
• If used for the definitive treatment of the pelvic
fracture, the frame is left in place for 8 to 12
weeks, depending on the fracture type and
reduction.
• Pin site care must be meticulous, with peroxide
swabs used twice daily to clean away the
crusted transudate that often forms.
Pelvic Clamps

• Because in vertically unstable fractures an

anteriorly applied external fixator does not
control motion in the posterior sacroiliac complex,
• the Ganz C-clamp and
• the pelvic stabilizer developed by Browner and
associates.
• Used only as a temporary stabilizing device that
should be removed within 5 days if possible.
TREATMENT: RECONSTRUCTIVE
PHASE
• Stable, nondisplaced pelvic fractures (Tile type
A) do not require operative stabilization and can
be adequately managed with early mobilization
and analgesics.
• Operative reduction and stabilization have been
advocated for rotationally unstable but vertically
stable (Tile type B) fractures with a
• pubic symphysis diastasis of more than 2.5 cm,
• pubic rami fractures with more than 2 cm
displacement, or
• other rotationally unstable pelvic injuries
with significant limb-length discrepancy of
more than 1.5 cm or
• unacceptable pelvic rotational deformity.
• Operative treatment of rotationally unstable
pelvic fractures can be accomplished by
• an anterior external fixator used for definitive
treatment or
• open reduction and internal fixation with anterior
plating.
• Retrograde pubic ramus screws placed
percutaneously or with an open technique also
have been described
• External fixator ay be especially useful in
patients with associated genitourinary or
gastrointestinal injuries with significant
contamination or other soft tissue problems that
might preclude anterior open reduction and
internal fixation.
• Some authorsadvocate the use of a single four-
or six-hole 3.5-mm reconstruction plate.
Anterior Internal Fixation of Tile
Types B and C Pelvic Fractures
• Approach the symphysis through a Pfannenstiel
incision
• for reduction of the symphysis, place a Weber
clamp anterior to the rectus muscles onto the
body of the pubis bilaterally.
• a curved, 3.5-mm reconstruction plate on the
superior surface of the symphysis is used for
fixation
• Double plating is used only in type C injuries
when it is not certain that posterior fixation is
possible during the initial procedure, as in a
patient undergoing emergency laparotomy
• If internal fixation of a pubic ramus fracture is
indicated in a type B or C pelvic fracture, it is
performed through an ilioinguinal incision .
• Tile type C pelvic injuries require posterior
fixation to regain vertical stability.
• External fixation alone is not
recommended as definitive treatment for
vertically unstable pelvic fractures,
• because the posterior instability cannot be
controlled by this treatment method.
• For Tile type C fractures the anterior ring can be fixed
with either an external fixator or an anterior plate as
described above.
• Posterior treatment generally is determined by the
portion of the posterior ring disrupted.
• For sacral fractures and sacroiliac joint disruptions some
authors have described image intensifier–directed screw
fixation from the ilium posteriorly into the sacral body .
• This technique risks damage to the L5 nerve root and
iliac vessels anterior to the body of the sacrum and to
the sacral nerve roots within its bony confines
• Because neurological injury occurs with 30% of
transforaminal sacral fractures (Denis zone II fractures),
• some authors advocate open reduction and internal
fixation of such fractures with decompression of the
involved neural foramina.
• Transiliac rod fixation has been reported for sacral
disruptions, although there is a risk of neurological injury
with compression of the sacrum
• . Tension band plating also can be used between the
two posterior iliac crests
• Simpson et al. reported excellent results with the
use of the anterior retroperitoneal approach for
anterior plating of the sacroiliac joint because it
allowed direct observation of the joint .
• If this approach to the sacroiliac joint is used,
the superior gluteal artery, L4 nerve root, and
lumbosacral trunk must be carefully protected,
especially in the inferior third of the joint.
• For iliac wing fractures, open reduction
and pelvic reconstruction plate fixation
techniques are used.
• For fracture-dislocations of the sacroiliac
joint (the so-called crescent fracture), the
fracture can be reduced and fixed
anteriorly or posteriorly, with or without
hardware transfixing the sacroiliac joint.
• Internal Fixation: Posterior Screw Fixation of
Sacral Fractures and Sacroiliac Dislocations
(Prone)
• Use a standard posterior vertical incision, 2 cm
lateral to the posterior superior spine, for
sacroiliac dislocations, fracture-dislocations, or
sacral fractures.
• Reflect the posterior portion of the gluteal
muscles from the posterior iliac wing and the
gluteus maximus origin from the sacrum. Expose
the greater sciatic notch to evaluate reduction.
• Under image intensifier control, insert
screws perpendicular to the iliac wing
across the sacroiliac joint into the sacral
ala, directing the screws toward the S1
vertebral body.
• Percutaneous Iliosacral Screw Fixation of
Sacroiliac Disruptionsand Sacral Fractures
(Supine)
• the normal sacral ala has an inclined
anterosuperior surface, the sacral alar slope, that
extends from proximal-posterior to distal-anterior
.
• Anterior to the sacral ala in this region run the
L5 nerve route and the iliac vessels.
• 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.
• Screws used to fix sacroiliac joint disruptions are
placed perpendicular to the joint, whereas
• screws used to fix sacral fractures are placed
more transversely to allow passage of the screw
into the contralateral ala.
• Anterior Approach and Stabilization of
Sacroiliac Joint
• Upper half of a Smith-Petersen incision
along the anterior iliac crest is used
• initially used staples but now uses
dynamic compression plates,
reconstruction plates, or four-hole plates.