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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:
● Force vector
● Position of femoral head at time of injury
● Bone quality (e.g., age)
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 :
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
❏ 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
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
○ Examination under anesthesia (EUA) under fluoroscopic control
○ Operative fixation if unstable via Kocher-Langenbeck approach
● 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
Investigations
Radiographs :
1. AP x-ray
2. Inlet, outlet, and flamingo views ⇒ Pelvic ring fractures
3. Judet ⇒
a. Obturator oblique
b. Iliac oblique
4. CT scan : the gold standard in the management
❏ Findings :
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:
Bed rest and traction are rarely used as a definitive treatment nowadays (due to problems associated
with prolonged immobility).
Patients are mobilized with partial weight-bearing on the affected side for 6 weeks.
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.
Surgical approach
The two ‘work-horse’ approaches in acetabular surgery
Approach.
The iliofemoral approach is now very rarely used due to the high complication rate of heterotopic
ossification, gluteal muscle dysfunction postoperatively and infection
ILIOINGUINAL APPROACH
It is performed with the patient supine, and provides access to
the entire anterior column, symphysis pubis, quadrilateral plate, ilium and
sacroiliac joint
This approach is now used less commonly than previously. The Stoppa
approach (medial window of the ilioinguinal approach via a rectus abdominis
split) is now generally preferred and access through this approach can be
gained right the way back to the sacroiliac joint if required. If there is iliac
extension of a fracture, the lateral window of the ilioinguinal approach can
also be opened up simultaneously
The Kocher-Langenbeck approach
Surface Landmarks:
G. Trochanter
F. Shaft
• Skin incision:
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)
● Heterotopic ossification
● Osteonecrosis
● DVT and PE
● Infection
● Bleeding
● Neurovascular injury
Image Citation
1. https://orthoinfo.aaos.org/contentassets/6a8179492380455fa5f294f3c533bcdd/a00520f05_ap-
compression_lateral_gwi-compressor.jpg
2. https://orthoinfo.aaos.org/contentassets/bb9ebd0e871a4c6382278eef8abc7d39/a00511f04_an
terior-wall-05-compressor.jpg
3. https://www.researchgate.net/profile/Matthew-Deren-2/publication/258189226/figure/fig8/AS:
392700781187084@1470638570983/Pelvic-stress-fracture-arrow-in-a-40-year-old-distance-ru
nner.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/