PELVIC FRACTURE

Prepared by : Nur Adiibah

Binti Jamil
Supervised by : Dr Faried
• Introduction
• Anatomy
• Etiology
• Classification
• Physical findings
• Diagnostic procedures
• Treatment
• Complication
• prognosis
 Introduction
• pelvic fracture is a disruption of the bony structures of
the pelvis
• can occur by low-energy mechanism or by high-energy impact
• can range in severity from relatively mild injuries to life-
threatening injuries
• High-energy pelvic fractures arise commonly after motor
vehicle crashes, motorcycle crashes, motor vehicles striking
pedestrians and falls. Those high-energy pelvic fractures are
one of the major injuries that lead to death. The presence of
coma, shock, and head and chest injuries are predictors of
death
• The appearance of pelvic fractures is the greatest
in people aged between 15 and 28

• In persons, younger than 35, pelvic fractures occur

more in males than in females. It occur mostly as a
result of high-energy mechanisms

• In persons, older than 35, pelvic fractures are more

likely to happen to females than males. It occur
from minimal trauma, such as a low fall. Elderly
people with osteoporosis have a higher risk factor.
 Anatomy
• The bony pelvis formed by the two hip bones, the sacrum, and the coccyx.
Each adult hip bone is formed by three separate bones (ilium, ischium and
pubis) that fuse together during the late teenage years.
• The SI joint (between sacrum and ilium) transmits forces from the upper limbs
and spine to the hip joints and lower limbs and vice versa. This joint also acts
as a shock absorber. Several muscles influence the movement and the stability
of the SI joint either through attachment to the sacrum or the ilium, or
ligamentous attachment to the strong anterior and posterior SI-joint
ligaments. Two thirds of the joint includes the posterior superior ligamentous
section and one third of the joint includes the anterior inferior synovial
component.
• The pelvis contains sliding, tilting and rotation movement components.
• Major nerves, blood vessels, and portions of the bowel, bladder, and
reproductive organs all pass through the pelvic ring. The pelvis protects these
important structures from injury. It also serves as an anchor for the muscles of
the hip, thigh and abdomen.
 Etiology
• High-impact events
pelvis is a very stable bone structure, most pelvic fractures are caused by
high-impact events such as a car accident or falling from a significant height.
High-impact events usually cause unstable pelvic fractures.
• Bone-weakening diseases
Bone-weakening diseases such as osteoporosis can contribute to pelvic
fractures. Someone who have a bone-weakening disease could get a pelvic
fracture from doing a routine activity or from a minor fall. Pelvic fractures
that are caused by bone-weakening diseases are usually stable fractures.
• Athletic activities
Although it’s not as common, someone who is playing a sport could get a
pelvic fracture known as an avulsion fracture. This happens when a tendon or
ligament tears away from the bone to which it’s attached. When the tendon
or ligament tears away, it takes a small piece of bone with it. A pelvic avulsion
fracture is usually a stable fracture.
 Classification

• Tile classification

• Young-Burgess classification
 Tile classification
• Type A: rotationally and vertically stable, the sacroiliac complex is intact. Type A fractures are
mostly managed non-operatively.
o A1: avulsion fractures
o A2: stable iliac wing fractures or minimally displaced pelvic ring fractures
o A3: transverse sacral or coccyx fractures
• Type B: rotationally unstable and vertically stable, caused by external or internal rotational forces,
results in partial disruption of the posterior sacroiliac complex.
o B1: open-book injuries
o B2: lateral compression injuries
o B3: bilateral rotational instability
• Type C: rotationally unstable and vertically unstable, complete disruption of the posterior
sacroiliac complex.
o C1: unilateral injury
o C2: bilateral injuries in which one side is rotationally unstable and the controlateral side is
vertically unstable
o C3: bilateral injury in which both sides are vertically unstable
 Young-Burgess classification
• based on mechanism of injury
 anteroposterior compression
 lateral compression
 vertical shear
 complex / combination other forces.
• Lateral compression fractures involve transverse fractures of the pubic rami,
either ipsilateral or contralateral to a posterior injury. The most common force
type, lateral compression (LC) forces, from side-impact automobile accidents
and pedestrian injuries, can result in an internal rotation. The superior and
inferior pubic rami may fracture anteriorly, for example.
• Injuries from shear forces, like falls from above, can result in disruption of
ligaments or bones.
• However, this classification is limited as it provides little guidance for
treatment
 Physical Findings
• history of a significant trauma
• tenderness, pain, bruising, swelling and crepitus of the pubis, iliac bones, hips
and sacrum
• haematuria
• rectal bleeding
• haematoma and neurological and vascular abnormalities in the legs
• abnormal position of the lower limbs and pelvic deformity or pelvic instability.
• scrotal, labial or perineal hematoma, swelling or ecchymosis
• flank hematoma
• lacerations of perineum
• degloving injuries (Morel-Lavallee lesion)
• Patients with unstable fractures are usually unable to stand, in contrast to
patients with stable fractures who can often walk unaided.
 Diagnostic procedures
• The diagnosis of a pelvic fracture mostly will be made by medical imaging
which can determine the location of a fracture, how many bones are
affected and whether an injury has damaged surrounding soft tissues,
such as tendons, ligaments, blood vessels or nerves
 X-rays: antero-posterior view, inlet view and outlet view
 CT scan
 Ultrasound

• The severity and correlated injuries can be investigated by

 Urinalysis
 Measurement of haemoglobin and hematocrit: to measure blood loss
 Retrograde urethrography
 Arteriography
 Cystography
 Treatment
• depends on certain factors, including

 How mild or severe your fracture is.

 The pattern and type of fracture.
 Which bones are displaced and how much they
are displaced.
 Overall health conditions and if you have other
injuries
• mild and stable fractures usually doesn’t involve surgery

 Rest: rest as much as possible to avoid put extra stress

and pressure on pelvic fracture.
 Walking aids: such as crutches, a walker or a
wheelchair to avoid bearing weight on the leg(s). may
have to use the walking aid up to three months or until
the pelvis fully heals.
 Medications:
analgesics : to relieve pain
blood thinner medication (anticoagulant) : to
reduce risk of having blood clots form in the veins of
the legs and pelvis
• severe or unstable pelvic fracture usually requires one or more surgeries

 External fixation
 to stabilize your pelvic area after a pelvic fracture. In this surgery, metal
pins or screws are inserted into the bones through small incisions (surgical
cuts) into the skin and muscle. The pins and screws stick out of skin on
both sides of pelvis, and are attached to bars outside the body. The
resulting system acts as a stabilizing frame to hold the broken bones in
their proper position while the fracture(s) heals.
 Skeletal traction
 Skeletal traction is a pulley system outside of the body that helps realign
the pieces of broken bone(s). During skeletal traction, a surgeon implants
metal pins in thighbone or shinbone that stick out of the skin to help
position of the leg. Weights attached to the pins gently pull the leg,
keeping the broken pelvic bone fragments in a more normal position.
 Open reduction and internal fixation
 During open reduction and internal fixation surgery, the displaced pelvic
bone fragments are first repositioned into their normal alignment. The
fragments are then held together with screws or metal plates that are
attached to the outer surface of the bone.
• people who experience a severe pelvic
fracture from a high-impact accident often
have other injuries or internal injuries
caused by the pelvic fracture that will also
need to be treated. In these cases, the
success in treating the pelvic fracture
often depends on the success of treating
the related injuries
 Complications
• Urogenital Injuries
higher incidence in males (21%)
includes
posterior urethral tear : most common urogenital injury with pelvic ring fracture
bladder rupture
diagnosis : retrograde urethrocystogram
sign
blood at meatus
high riding or excessively mobile prostate
hematuria
treatment
suprapubic catheter placement : relative contraindication to anterior ring plating
surgical repair : rupture should be repaired at the same time or prior to definitive fixation in order to minimize
infection risk
complications
long-term complications common
urethral stricture - most common
impotence
anterior pelvic ring infection
incontinence
parturition sequelae (i.e. caesarean section)
• Neurologic injury

• DVT and PE

• Chronic instability
 rare complication; can be seen in nonoperative cases
 presents with subjective instability and mechanical symptoms
 diagnosed with alternating single-leg-stance pelvic radiographs (flamingo views)

• Infection
 risk factors include:
 obesity
 diabetes
 prolonged operation time
 prolonged ICU stay
 larger amount of packed red blood cell transfusions,
 associated genitourinary and abdominal trauma
 open fractures
 preoperative angioembolization is controversial
 Prognosis
• High prevalence of poor functional outcome and chronic pain

• Poor outcome associated with

 SI joint incongruity of > 1 cm
 high degree initial displacement
 malunion or residual displacement
 leg length discrepancy > 2 cm
 nonunion
 neurologic injury
 urethral injury

• Mortality rate 1-15% for closed fractures, as much as 50% for open fractures
 hemorrhage is leading cause of death overall
 closed head injury is the most common for lateral compression injuries
 increased mortality associated with
 systolic BP <90 on presentation
 age >60 years
 increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
 need for transfusion > 4 units
 APC III injury
Open Book
Fracture
• often the result of a heavy impact to the groin (pubis), a
common motorcycling accident injury. In this kind of injury,
the left and right halves of the pelvis are separated at front
and rear, the front opening more than the rear, i.e. like an
open book that falls to the ground and splits in the middle.

• depending on the severity, this may require surgical

reconstruction before rehabilitation. Forces from an
anterior or posterior direction, like head-on car accidents,
usually cause external rotation of the hemipelvis, an
“open-book” injury

• increased risk of infection and hemorrhaging from vessel

injury, leading to higher mortality
 Q1
• A 26-year-old male with a BMI of 37 is involved in a motor vehicle
collision and requires extrication. During evaluation in the trauma bay,
he becomes hemodynamically unstable and is found to have the injury
shown in Figure A, as well as an associated bladder injury. Which of the
following statements regarding the patient's injury is true?

A. His male gender places him at a lower risk for post-operative

infection
B. His BMI places him at a higher risk for post-operative infection
C. The mechanism of his injury was likely a lateral compression force
D. The internal pudendal artery is the most likely source of arterial
hemorrhage
E. Pelvic binder placement is contraindicated in this patient given his
bladder injury
 Q2
• A 72-year-old woman falls down the stairs and is now unable to bear
weight secondary to right groin pain. Injury radiograph and CT scans
are seen in Figures A through C. What is the Young-Burgess
classification of this injury and the most appropriate treatment plan?

A. Bilateral weight bearing as tolerated for Anterior Posterior

Compression Type I injury
B. Touchdown weight bearing on the right for Lateral Compression
Type I injury
C. Bilateral weight bearing as tolerated for Lateral Compression
Type I injury
D. Posterior sacroiliac screw, followed by non-weight bearing for
Lateral Compression Type II injury
E. Posterior sacral plate, followed by non-weight bearing for Lateral
Compression Type III injury
 Q3

• Alternating single-leg-stance radiographs are most

helpful for evaluation of which of the following
diagnoses?

A. Leg length discrepancy

B. Pelvic ring instability
C. Femoroacetabular impingement
D. Hip abductor weakness
E. Lumbosacral instability
 REFERENCES
• [Link]
1030/pelvic-ring-fractures
• [Link]
diseases/22176-pelvic-fractures
• [Link]
Pelvic_fracture#Diagnosis
• [Link]
Pelvic_Fractures