Pelvic Fracture

ANATOMY OF PELVIS

INTERPRETATION PELVIC
XRAY

OUTLINE CLINICAL FEATURE

CLASSIFICATION

MANAGEMENT
SURGICAL ANATOMY

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 engaging the audience

Veins form venous plexus and have no valves and adhere closely to pelvic walls - can hemorrhage easily and are not compressible.

Classically venous hemorrhage is said to account for 90% of bleeding from pelvic fractures, and arterial only 10%. However
arterial bleeding is more common than this in patients that have ongoing hemorrhage (e.g. despite pelvic binding or
mechanical stabilisation) or have hemodynamic compromise.

Suzuki et al (2008) point out that:

Haemorrhage from pelvic fracture is essentially bleeding into a free space, potentially capable of accommodating
the patient’s entire blood volume without gaining sufficient pressure-dependent tamponade.
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PATIENT CAN LOSS 9 UP TO 5L OF BLOOD LOSS
• Other structure that can get affected in pelvic fracture

- Lumbsacral plexus , especially in posterior pelvic injury

- Most common is L5, S1 nerve root injury in pelvic ring injuries
- Sciatic nerve injury in acetabular fracture
- Most common urogenital organ to be injured : membranous urethra ( male )
- Pelvic colon is mobile and hence rarely injured

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 CLINICAL ASSESTMENT
• HISTORY : pelvic fracture should be suspected in polytrauma patient , high energy trauma ( Fall from
height , MVA )
• SYMPTOMS : pelvic pain & inability to bear weight , c/o abdominal pain
• SIGN : Tachycardic, Hypotensive
- Inspection : scrotal , labial , perineal hematoma , swelling or echymosis , perineum laceration , flank
hematoma , degloving injuries ( moralle lavalle lesion ) , Limb length discrepancy , one or both limb
externally rotated

- Palpation : place gentle palpation over iliac crest to feel for instability , tenderness , single hand gentle
palpation
- Neurological exam: rectal exam to look for laxity and perianal sensation , rule out lumbar plexus injury 6
How to identify pelvic fracture

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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 dis placement or sacral fracture.
Distruption of lines indicate ?
1. Iliopubic line : anterior pelvic ring injury
2. Ilioischial line : posterior pelvic ring injuty
3. Teardrop : occult acetabular fracture
4. Acetabular roof/ ant and post border : acetabular fracture
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ISOLATED PELVIC FRACTURE – AVULSION FRACTURE
IMAGING
1. Radiograph
- Pelvis AP
- Inlet view ( beam angled 40 degree caudad ) - examining the iliac crest, sacrum, proximal femur,
pubis, ischium and the great pelvic ring. allowing for assessment of any suspected narrowing or
widening of pelvic rim and anterior posterior displacement of rami
- Outlet view ( beam angled 40 degree caudal ) - allows for assessment of the cephalic/caudal
translation and superior migration of the hemipelvis following trauma
- Judet/ oblique view ( beam 45 degree oblique to affected hip ) – to look at ilioischial line of
posterior column , posterior column , acetabular roof, iliac crest
2. CT PELVIS and 3d recon

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 Classification
1. YOUNG BURGESS – BASED ON MECHANISM OF INJURY.
PREDICTIVE OF SEVERITY OF INJURY ( BLOOD LOSS ) AND
GUIDES SURGEON HOW TO FIX THE DISPLACEMENT

2. TILE – PROVIDE ASSESSTMENT OF THE STABILITY OF

FRACTURE, GUIDES SURGEON IF THE FRACTURE REQUIRE
OPERATIVE FIXATION
YOUNG BURGESS CLASSIFICATION
results from a front-on force transmitted through
the pelvis. Initially the anterior structures open up
(symphysis pubis) and, as the energy increases,
the posterior structures (sacroiliac joint) are
injured.
Seen in motorbike subject to sudden deceleration
at point of impact

result from the force applied to and transmitted

from the side of the pelvis. This is commonly
seen in pedestrians hit by an auto mobile

injuries are usually seen after a fall from height,

landing on one leg leading to one hemipelvis
being driven up lead to distruption of whole
posterior structure 15
TILE CLASSIFICATION – to determine stability of #
APC III, LC III, VS and Combined
mechanism injuries that are
associated with massive blood loss. In
all of these cases, the pelvic ring is
completely unstable (type C)
Stable # - LC 1 & Type A
Unstable # - Rest

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 MANAGEMENT
1. Resuscitation
2. Early pelvic binder application –initial management of unstable ring injury, most effective when centered
at GT with legs internally rotated . Use up to 24 hours only , can cause skin necrosis. However in LC
fracture , it may displace the fracture. Hence to apply pelvic binder in all suspected pelvic fracture then
loosen up when LC I/II fracture is confirmed.
The use of pelvic binders has effectively removed the need for external fixators in the emergent period. If the
application of a correctly positioned and tensioned binder fails to improve the hemodynamic status of a patient,
it is unlikely an external fixator will improve matters
3. External fixation – provide anterior stability ( open book )
indications
• pelvic ring injuries with an external rotation component (APC, VS, CM)
• unstable ring injury with ongoing blood loss
4. Skeletal traction
- If the fracture has vertical component , may benefit from vertical skeletal traction + binder
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INDICATION FOR NON OPERATIVE – APC 1 , LC 1, ISOLATED RAMUS #
The pelvic binder can be removed as soon as possible if :

• there is no pelvic fracture, or

• a pelvic fracture is identified as mechanically stable, or
• the binder is not controlling the mechanical stability of the fracture, or
• there is not further bleeding and coagulation is normal

ORIF indications

• symphysis diastasis > 2.5 cm

• SI joint displacement > 1 cm
• sacral fracture with displacement > 1 cm
• displacement or rotation of hemipelvis
• open fracture
• chronic pain and diastasis in parturition-induced diastasis or acute setting >4-6cm
Safe zone for
half pin
insertion in
acetabulum &
pelvis
 REFERENCE
1. ORTHOBULLET

Thank you
2. HTTPS://LITFL.COM/TRAUMA-PELVIC-FR
ACTURES-II/
3. HTTPS://WWW.TAMINGTHESRU.COM/BL
OG/DIAGNOSTICS/PELVIC-XRAYS
4. ORTHOPEDIC APLEY AND SOLOMON
5. AOTRAUMA FRACTURE MANAGEMENT