Pelvic Ring Injury

Clinical Imaging Evaluation

Tommy Suharso
Objectives
• To review an essential clinical evaluation of
pelvic ring injury
• To analyze pelvic radiograph systemically
Clinical Assessment
• History
– Patient profile
– Injury profile
• Physical Examination
– Look
– Feel
– Move
Clinical Assessment - Look

•Wounds
•Contusions
•Bleeding Genitalia
•Displacement of pelvis or lower extremities
Clinical Assessment - Look
Clinical Assessment - Look
Clinical Assessment - Look

Morel-Lavalle lesion
Clinical Assessment – Feel&move
• Palpation
• Traction
• Rectal and Vaginal Examination
• Neurological Examination – L5 root
Clinical Assessment - Feel
Clinical Assessment - Move
Clinical Assessment - Move
Clinical Assessment - Move
Clinical Assessment
• Clinical signs of instability
– Severe displacement
– Marked posterior disruption – bruising
– Gross instability on manual palpation
– Severe associated injury to viscera
– Associated open wound
Radiological Assessment

A single AP radiograph is often

sufficient in the acute situation
to determine the presence of
pelvic ring instability
 Radiological Assessment
Anterior lesions
: Separation of pubic
symphysis
: Fracture close to pubic
symphysis
: Fracture of pubic ramus
: Fracture of ipsi or
contralateral side
: Lock of pubic symphysis
: All 4 rami fractures
 Radiological Assessment
Posterior lesions
:Separation of SI joint
: Fracture of iliac crest
(Crescent Fx)
: Fracture of sacrum
: Impacted fracture of ilium
: Avulsion of transverse
process L5
Radiological Assessment

Inlet
 Radiological Assessment
Inlet view
: Roundness of pelvic cavity
: Ischial spine
: Fracture of pubic ramus
: Sacrogluteal line
: Fracture of sacrum

Inlet
Radiological Assessment

Outlet
 Radiological Assessment
Outlet view
: Fracture of iliac wing
: Level of ischial tuberosity
: Fracture of pubic ramus
: Outline of obturator foramen
: Fracture of sacrum

Outlet
Radiological Assessment
Radiological Assessment
Radiological Assessment
Radiological Assessment

Symmetry of pelvic ring

Radiological Assessment
CT scan

?
CT scan
Radiology of the Inominate Bone
and Acetabulum
 Imaging

• Plain radiography

• Computed tomography
– 2D
– 3D
• Other modalities
 Plain radiography is the
basis for most treatment
decisions
 Plain Radiography

• Complex 3 D anatomy

• Composite Images
Osteology
2 Column Schematic
 Complex Landmarks

• Tear drop

• Ilio-ischial line

• Roof
• Ilio-pectineal line
Teardrop
Teardrop
Ilio-ischial Line
Ilio-ischial Line
Ilio-ischial Line
Ilio-pectineal Line
Ilio-pectineal Line
Roof
Roof
 AP Pelvis

• Contralateral hemi-pelvis

• Posterior ring

• Anterior ring

• LS junction

• Proximal femur
 AP Hip

1 Ilio-pectineal line
2 Ilio-ischial line
3 Teardrop
4 Roof
5 Anterior Wall
6 Posterior Wall
 Obturator Oblique

1 Pelvic brim
2 Posterior wall
3 Mid ant. column
4 Spur sign (BC fx)
5 Obturator foramen
BC – “spur” sign
 Iliac Oblique

1 Sciatic notch
2 Anterior wall
3 Posterior column
4 Iliac crest
5 Posterior wall
 Imaging

• Plain radiography

• Computed tomography
– 2D
– 3D
• Other modalities
 2 D CT

• Posterior ring
• Femoral head
• Loose bodies
 2 D CT

• Marginal impaction

• Size / orientation wall /column

– Wall, column, transverse

• Unrecognized T component
 3D CT

• Problems
– Manpower costs
– “smoothing” algorithms
• Most useful
– Late reconstructions
– Transitional patterns
– Educational aid
Future Modalities
 Imaging

• Plain radiography

• Computed tomography
– 2D
– 3D
• Other modalities
Lower GU Tract Evaluation

• Anterior ring injuries

• Acetabular fractures
– Low anterior column
– Displacment criteria
• Males – RUG -> cysto
• Females - cysto
Angiography
 Summary

• Knowledge plain radiology essential

• Other modalities adjunctive