Pelvic Injuries

By / Salem Mohammed, Saleh Yousef, & Masoud Alsinan

Supervisor / Dr. Osman

Objectives
Types of Pelvic Fractures
Isolated Pelvic fractures
1. Avulsion fracture:
● An avulsion fracture occurs when a small piece of bone attached to a tendon or ligament gets
pulled away from the main part of the bone
● The most common avulsion injuries seen around the pelvis are of the anterior inferior iliac spine
and the ischial tuberosity
● Mechanism of injury :
○ These fractures are relatively common in the adolescent athlete, due to the relative weakness of the
apophysis compared with the tendon. They can occur when an explosive muscular contraction, such as
sprinting, kicking or jumping causes the tendon to pull at the apophysis and cause a separation of the
apophysis from the bone. Males are affected more often than females.
Isolated Pelvic fractures

2. Stress fractures :
● Stress fractures are injuries to the bone caused by repetitive microtrauma
● Fractures of the pubic rami are fairly common in osteoporotic bone
● Also seen in the superior and inferior pubic rami in slim individuals and long-distance runners
● Patients may present with groin pain lasting a few weeks or months and radiographs will reveal
the fracture, which becomes more apparent when callus formation occurs during healing
Pelvic Ring Fractures

● Pelvic ring fractures are high energy fractures of the pelvic ring which typically occur due to blunt
trauma
● Think of the pelvis as a ‘polo mint’. It is impossible to break a polo mint in one place ,the same
principle applies to the normal bony pelvic ring
● If there is an anterior ring injury, always look for the associated posterior fracture or joint
disruption. Anteriorly the symphysis pubis or pubic rami will be disrupted, and posteriorly there
will either be a sacroiliac joint displacement or sacral fracture
Pathophysiology & Etiology :

● The Young and Burgess is a classification of pelvic ring injuries based on the mechanism of injury
● Most commonly result from trauma, such as motor vehicle accidents (60% of cases), falls from a
height (30% of cases), and crush injuries (10% of cases)
Acetabular Fractures
Acetabular Fractures
● Acetabulum fractures are pelvis fractures that involve the articular surface of the hip joint and may
involve one or two columns, one or two walls, or the roof within the pelvis
● Incidence: 4 per 100,000 per year
Pathophysiology & Etiology :
Pathophysiology:

Fracture pattern predominantly determined by:

● Force vector
● Position of femoral head at time of injury
● Bone quality (e.g., age)

Fractures occur in a bimodal distribution:

High energy trauma in younger patients (e.g., motor vehicle accidents)

Low energy trauma in elderly patients (e.g., fall from standing height)
Risk Factors :
● Risk factors are similar to those of osteoporosis :
○ Advanced age
○ Prior pelvic fracture
○ Glucocorticoid therapy
○ Low body weight
○ Smoking
○ Excess alcohol intake
Clinical Features :

● Pain in the groin, hip and/or lower back

● Swelling
● More intense pain when walking or moving the legs
● Numbness or tingling in your groin area or legs
● Difficulty in time walking or standing
Investigations
Laboratory :

● CBC (Hb, Platelets)

● Coagulation profile (PT, aPTT)
● Liver function, renal function, electrolytes
● Toxicology panel
● Pregnancy test (Female)
Radiographs :

1. AP x-ray
2. Inlet & outlet views ⇒ Pelvic ring fractures
3. Judet ⇒
I. Obturator oblique Acetabular fractures
II. Iliac oblique

4. CT scan : the gold standard in the management

● 3D CT reconstruction
● Contrast ?
Classification of Pelvic Fractures
Young & Burgess Classification

1. Anteroposterior Compression (APC) : ( open book injury )

a. APC Ⅰ ⇒ Less than 2.5cm of widening at the pubic symphysis
b. APC Ⅱ ⇒ more than 2.5cm of widening at the pubic symphysis with anterior widening of sacroiliac joint, and
intact posterior ligaments
c. APC Ⅲ ⇒ more than 2.5cm of widening at the pubic symphysis with a dislocation of sacroiliac joint
Young & Burgess Classification

2. Lateral Compression (LC) :

a. LC Ⅰ ⇒ rami fracture and ipsilateral anterior sacral alar fracture
b. LC Ⅱ ⇒ rami fracture and ipsilateral posterior ilium fracture dislocation
c. LC Ⅲ ⇒ ipsilateral lateral compression and contralateral APC pattern injury ( windswept pelvis )

3. Vertical Shear (VS) :

a. One hemipelvis is driven up with complete disruption of all the posterior structures.
b. Highest risk of hypovolemic shock

4. Combined :
a. Results from combination of APC, LC, VS.
Tile Classification :
● It gives accurate assessment of pelvic stability.
● It guides whether the patient requires surgery or can safely mobilize with their injuries.
❏ A = fractures are stable :
❏ A1 ⇒ fractures not involving the pelvic ring ( avulsion or iliac wing fracture )
❏ A2 ⇒ iliac wing fracture or anterior rami fractures
❏ A3 ⇒ transverse sacral fracture
❏ B = fractures are partially stable :
❏ B1 ⇒ unilateral anterior disruption of posterior structures ( SIJ widening or sacral fracture )
❏ B2 ⇒ unilateral SIJ joint fracture / subluxation ( anterior ring rotation )
❏ B3 ⇒ bilateral SIJ / sacral fracture / subluxation
❏ C = fractures are unstable :
❏ C1 ⇒ complete unilateral posterior disruption
❏ C2 ⇒ complete unilateral posterior disruption with contralateral partial disruption
❏ C3 ⇒ complete bilateral posterior disruption
Classification of Acetabular Fractures
Letournel Classification

● Two groups :
○ Elemental fractures : ( posterior wall, posterior column, anterior wall, anterior column )
○ Associated fractures
1.Anterior wall of the acetabulum 2. Posterior wall of the acetabulum 3. Roof or dome of the acetabulum 4. Iliopectineal line 5. Ilioischial line 6.
Teardrop
Letournel Classification
Letournel Classification
● Posterior wall fracture ⇒
○ The most common
○ Best visualized on obturator oblique pelvis view ( Gull sign )
○ Check the superior gluteal neurovascular bundle
● Posterior column fracture ⇒
○ There may be medial displacement of the femoral head
● Anterior wall fracture ⇒
○ The least common (rare)
○ Associated with anterior subluxation of the femoral head
● Anterior column fracture ⇒
○ There are subtypes according to the fracture height
Letournel Classification
● Transverse fracture ⇒
○ Relatively common
○ May be associated with sacroiliac joint injury
○ According to height, the transverse fracture can be transtectal, juxtatectal, infratectal which can guide the
surgical approach
● T-shaped fracture ⇒
○ May be associated with sacroiliac joint injury
○ Look at the height of the transverse fracture before deciding the surgical approach
● Transverse posterior wall fracture ⇒
○ May be associated with sacroiliac joint injury
○ The incidence of sciatic nerve injury is very high (70%)
● Posterior wall posterior column fracture ⇒
○ The femoral head is dislocated
○ There may be an associated sciatic nerve injury
Letournel Classification
● Anterior column posterior hemitransverse fracture ⇒
○ Common in elderly
● Associated both column fracture ⇒
○ Spur sign on x-ray
Management of pelvic ring and
Acetabular fractures
 PELVIC BINDERS
The initial management must follow the ATLS protocol to the injured patient.

Appropriate application of the binder is key. The binder should be applied at the level of
greater trochanters of the hips (not the iliac crest).

Ideally, it should not be left on for more than 24 hours as pressure sores can develop.

Patient unstable within 24 hours, the binder should be released and the pressure areas
checked,

Even if the pelvis is over-reduced, the pelvic volume has been reduced, hence limiting
blood loss and therefore this is preferable to a binder not being applied or one being
applied too loosely.
 MANAGEMENT OF THE PATIENT IN
EXTREMIS
If a binder is in situ, and there is persistent haemodynamic instability despite resuscitation with blood products,

immediate haemorrhage control is required. Other causes and sites of haemorrhage must first be excluded (chest,
abdomen,external bleeding). If there is no time for a trauma CT, an AP X-ray of the pelvis should be taken.

Two options exist; these depend on the experience of those available and the protocol that your unit follows

in this situation:

1. Angiography and embolization

2.Immediate transfer to the operating theatre for pre-peritoneal packing

3.Pelvic C-Clamp
Permits quick and efficient compression and stabilization of fractures or luxations, and thus control of
haemorrhaging in the unstable posterior pelvic ring.

– Gains time for subsequent diagnostic or therapeutic procedures.

– The patient can be passed through a CT-gantry without removing the device.

– Provides unrestricted access to the abdomen, pelvis or proximal femur.

– The Pelvic C-Clamp can be applied quickly outside the operating room, e.g. in the emergency room or
on the X-ray table.

– MR-safe: made entirely of non-ferrous materials.

 CONSERVATIVE MANAGEMENT
If the pelvic injury is a stable

conservative management is generally indicated unless the injury is open.

Bed rest or traction is not favoured for the treatment of pelvic injuries due

the complications of being immobile in hospital for such prolonged periods

Common fractures treated conservatively include

avulsion fractures and the LC I type fracture.

 OPERATIVE FIXATION

The principle of operative fixation is to convert an

unstable pelvic ring to a stable one.

Pubic symphysis diastasis is treated with open

reduction and internal fixation with plates and screws

External fixation of the pelvis is indicated for temporary or

definitive stabilization of unstable pelvic ring injuries.
Management of Acetabular Fracture
Undisplaced fractures are usually stable and can be managed conservatively.

Bed rest and traction are rarely used as a definitive treatment nowadays (due to problems associated
with prolonged immobility).

If pain is severe, this indicates a lack of fracture stability. Repeat X-rays

If the hip is dislocated, reduction is urgent, followed by the application of skeletal traction until
definitive surgery. This is best achieved via a distal femoral transfixion pin.
open reduction and internal fixation

ILIOINGUINAL The Kocher-Langenbeck approach

APPROACH
Complications Pelvic Fracture
 Complications
Urethral stricture : Due to scar “late” or due to
compression cause narrowing “early”

Impotence: “Neurovascular injury”

Venous thromboembolism (VTE): The risk of VTE

is especially high following pelvic surgery

Nerve injury

Infection

Note:Bladder and urethral injury is the commonest associated injury in pelvic fractures.
Complication of Acetabular Fracture
 ● Post-traumatic degenerative joint disease (DJD)

most common complication

● Heterotopic ossification

● Osteonecrosis

● DVT and PE
● Infection
● Bleeding
● Neurovascular injury
Image Citation
1. https://orthoinfo.aaos.org/contentassets/6a8179492380455fa5f294f3c533bcdd/a00520f05_ap-compression_late
ral_gwi-compressor.jpg
2. https://orthoinfo.aaos.org/contentassets/bb9ebd0e871a4c6382278eef8abc7d39/a00511f04_anterior-wall-05-co
mpressor.jpg
3. https://www.researchgate.net/profile/Matthew-Deren-2/publication/258189226/figure/fig8/AS:3927007811870
84@1470638570983/Pelvic-stress-fracture-arrow-in-a-40-year-old-distance-runner.png
4. https://teachmeanatomy.info/wp-content/uploads/Hip-Bone-of-a-5-year-old-Triradiate-Cartilage-Present.jpg
5. https://traumainternational.co.in/tag/kocher-langenbeck-approach/
6. https://prod-images-static.radiopaedia.org/images/18824661/4fc305d3aeb03968135d2dbe8d32e7_gallery.jpeg
7. https://musculoskeletalkey.com/wp-content/uploads/2016/06/00265.jpeg
8. https://www.researchgate.net/profile/Marilyn-Heng/publication/273280198/figure/fig2/AS:294692991324161@
1447271692083/The-Young-and-Burgess-Classification-of-pelvic-fractures.png
9. https://i.pinimg.com/474x/e8/ab/04/e8ab04da3057e72985021bf19db6bd41.jpg
10. https://i.pinimg.com/1200x/0f/28/1e/0f281ebf5cbdfafd59a7a6d8de13caf5.jpg
11. https://epomedicine.com/wp-content/uploads/2020/11/judet-views.jpg
References :