mode of injury, classifications and its management

1. Pelvic Fractures
Presenter – Dr. Madhukar

2. Introduction
• Fracture of the pelvis account for about <5% of all
skeletal injuries.
• Men are more affected then women 56%vs48%.
• The incidence is about 0.82 per 100,000
population.
• About 2/3rds of these occur in road traffic
accidents.
• 10% of these will have visceral injuries and in this
group the mortality is probably in excess of 10%.

3. Anatomy
• The pelvic ring is composed of the sacrum and
two innominate bones joined anteriorly at the
symphysis and posteriorly at the paired
sacroiliac joints.
• The innominate bone is formed at maturity by
fusion a 3 ossification centers; the ilium,
ischium and pubis through the triradiate
cartilage at the dome of the acetabulum.

5. • The pelvic brim is formed by the arcuate lines
that join the sacral promontory posteriorly
and the superior pubis anteriorly.
• Below this is the True or lesser pelvis in which
are contained the pelvic viscera.
• Above this is the False or greater pelvis that
represent the inferior aspect of the abdominal
cavity.

7. Pelvic stability
• The stability of the pelvic ring depends upon
the rigidity of the bony parts and the strong
ligaments that bind the three segments
together across the symphysis pubis and the
sacroiliac joints.
• These may be divided into two groups
according to the ligamentous attachments.

8. Sacrum to ilium
1. sacroiliac ligamentous complex which is again
divide into posterior (short) and anterior (long)
ligaments.
2. sacrotuberous ligament which runs from the
posterolateral aspect of the sacrum and dorsal aspect
of posterior iliac spine to ischial tuberosity. Helps
mainly in vertical stability.
3. sacrospinous ligament is triangular, running from
lateral margins of sacrum and coccyx and inserting on
the ischial spine. Helps in roataional stability

9. • Pubis to pubis : symphyseal ligaments.
• These provide additional stability by attaching
between lumbar spine and pelvic ring.
1. iliolumbar ligaments- originate from L4-L5
transverse process and insert on the posterior
iliac crest.
2. lumbosacral ligaments originate from the
transeverse process of L5 to ala of sacrum.

11. Mechanism of injury
These may be divided into 2 types-
• Low-energy injuries may result from sudden
muscular contractions in young athletes that
cause an avulsion injury, a low energy fall, or a
straddle-type injury (motorcycle or horse).
• High-energy injuries typically result from a
motor vehicle accident, pedestrian-struck
mechanism, motorcycle accident, fall from
heights, or crush mechanism.

12. • Specific injury patterns vary by the direction of
force application. Such as-
1. Lateral compression
2. Anteroposterior compression
3. Vertical shear

13. LATERAL COMPRESSION
• lateral compression is the most common
mode of violence.
• The force can be directed to the pelvis
through the posterior ilium, anterior iliac wing
or greater trochanter
a. When lateral compression (LC) force is
directed to the posterior ilium a sacral
impaction fracture (stable injury) with pubic
rami fracture is seen.

14. b. When LC force is applied to anterior iliac wing
in addition to sacral impaction, the hemi
pelvis will be pushed into the contralateral
side (pushing the opposite hemi pelvis out
into external rotation) producing a lateral
compression injury on the ipsilateral side and
an external rotation injury on the contralateral
side (bucket handle injury).

15. c. When LC force is applied to the greater
trochanter an acetabular fracture is seen.

16. ANTEROPOSRTERIOR COMPRESSION
• Results in the classical open book injury.
• Force is a direct anterior force applied to the
pelvis.
• There is external rotation of both hemipelvis.
• Pubic symphysis diastasis is present.
• Each hemipelvis goes into external rotation with
the posterior ligaments as the hinge.
• No cephaloposterior displacement of sacroiliac
joints.

17. VERTICAL SHEAR
• Mainly from longitudinal forces applied to an
extended extremity.
• Cephaloposterior displacement of the
sacroiliac joints is characteristic. There is
complete injury of the symphysis,
sacrotuberous, sacrospinous and sacroiliac
ligaments.

18. CLASSIFICATIONS

19. TILE CLASSIFICATION

20. CLINICAL EVALUATION
• Perform patient primary assessment (ABCDE):
airway, breathing, circulation, disability, and
exposure.
• Identify all injuries to extremities and pelvis, with
careful assessment of distal neurovascular status.
• Look for other injuries, especially abdomen, spine
and chest injuries
• Apparent shortening of the lower limb may be
present.

21. • Pelvic compression tests should be performed
only once, because once the clot that is formed is
disrupted uncontrollable retroperitoneal
haemorrhage may ensue.
• Flank or buttock contusions herald the presence
of an underlying major haemorrhage.
• Bleeding in pelvic fractures is mainly from the
fractured surfaces
• Anteriorly a defect may be felt if the symphysis
pubis is disrupted

22. • Posteriorly, sacroiliac joint subluxations may
be palpable.
• Per rectal examination: This may reveal bone
fragments if an associated sacral fracture is
present. Rarely, the femoral head may be
palpable if there is a central dislocation of the
hip.

23. HEMODYNAMIC STATUS
• Retroperitoneal hemorrhage may be
associated with massive intravascular volume
loss.
• The usual cause of retroperitoneal
hemorrhage secondary to pelvic fracture is a
disruption of the venous plexus in the
posterior pelvis.
• It may also be caused by a large-vessel injury,
such as external or internal iliac disruption.

24. • Large-vessel injury causes rapid, massive
hemorrhage with frequent loss of the distal pulse
and marked hemodynamic instability.
• This often necessitates immediate surgical
exploration to gain proximal control of the vessel
before repair
• The superior gluteal artery is occasionally injured
and can be managed with rapid fluid
resuscitation, appropriate stabilization of the
pelvic ring, and embolization.

26. • Options for immediate hemorrhage control
include:
1. Application of military antishock trousers
(MAST). This is typically performed in the field.
2. Wrapping of a pelvic binder circumferentially
around the pelvis (or sheet if a binder is not
available). This should be applied at the level
of the trochanters to provide access to the
abdomen.

28. 3. Consider angiography or embolization if the
hemorrhage continues despite closing of the
pelvic volume.
4. Consider application of a pelvic C-clamp
(posterior).
5. Consider an anterior external fixator.

29. 6. Open reduction and internal fixation (ORIF): This
may be undertaken if the patient is undergoing
emergency laparotomy for other indications; it is
frequently contraindicated by itself because loss
of the tamponade effect may encourage further
hemorrhage.
7. Open packing of the retroperitoneum is an
option in the unstable patient who is brought to
the operating room for laparotomy and
exploration.

30. NEUROLOGIC INJURY
• Lumbosacral plexus and nerve root injuries may be
present, but they may not be apparent in an
unconscious patient.
• Higher incidence with more medial sacral fractures.
• Sacral fractures: neurologic injury
• Lateral to foramen (Denis I): 6% injury
• Through foramen (Denis II): 28% injury
• Medial to foramen (Denis III): 57% injury
• Decompression of sacral foramen may be indicated if
progressive loss of neural function occurs.
• It may take up to 3 years for recovery

32. GENITOURINARY AND
GASTROINTESTINAL INJURY
• Bladder injury: 20% incidence occurs with pelvic trauma.
• Extraperitoneal: treated with a Foley or suprapubic tube if
unable to pass.
• Intraperitoneal: requires repair.
• Urethral injury: 10% incidence occurs with pelvic fractures,
in male patients much more frequently than in female
patients.
• Examine for blood at the urethral meatus or blood on
catheterization.
• Examine for a high-riding or “floating” prostate on rectal
examination.
• Clinical suspicion should be followed by a retrograde
urethrogram.

33. Bowel Injury
• Perforations in the rectum or anus owing to
osseous fragments are technically open
injuries and should be treated as such.
Infrequently, entrapment of bowel in the
fracture site with gastrointestinal obstruction
may occur. If either is present, the patient
should undergo diverting colostomy.

34. Radiological evaluation
X RAYS
1. AP view of Pelvis
2. lnlet view of the pelvis:
• Here the beam is directed 60° caudally perpendicular to the pelvic
brim with the patient in supine position.
• Helps to identify anterior and posterior displacements of the sacroiliac
joint, sacrum.
3. Outlet view of the Pelvis:
• Here the beam is directed 45° cephalad.
• This is useful for determination of vertical displacement of the
hemipelvis.
• It may allow for visualization of subtle signs of pelvic disruption, such
as a slightly widened sacroiliac joint, discontinuity of the sacral
borders, nondisplaced sacral fractures, or disruption of the sacral
foramina.

36. Treatment
• Non-operative
• Operative - 1.External
- 2.Internal

37. Non-operative
• Indications
• Lateral impaction type injuries with minimal (<1.5 em)
displacement. .
• Pubic rami fractures with no posterior displacement.
• Gapping of pubic symphysis <2.5 cm
• Protect weight bearing typically with a walker or crutches
initially.
• Serial radiographs are required after mobilization has
begun to monitor for subsequent displacement.
• If secondary displacement of the posterior ring >1 cm is
noted, weight bearing should be stopped. Operative
treatment should be considered for gross displacement.

38. Operative
• Absolute Indications for Operative Treatment
• Open pelvic fractures or those in which there is an
associated visceral perforation requiring operative
intervention
• Open-book fractures or vertically unstable fractures with
associated patient hemodynamic instability
• Relative Indications for Operative Treatment
• Symphyseal diastasis >2.5 cm (loss of mechanical stability)
• Leg-length discrepancy >1.5 cm
• Rotational deformity
• Sacral displacement >1 cm
• Intractable pain

39. Operative
• External fixation:
• It is usually a temporary stabilizing option. Can be
used as a definitive fixation in anterior pelvic
fractures.
1. Two to three 5-mm pins spaced 1 mm apart
along the anterior iliac crest
- Acetabular and Iliac wing fractures are
contraindications to external fixation.
- Vertically unstable fractures usually also are
treated with ipsilateral distal femoral skeletal
traction.

40. 2. The use of single pins placed in the
supraacetabular area in an AP direction
(Hanover frame), Hip flexion maybe limited
with this frame.
• Ideally, two 5-mm pins are placed in between
the iliac cortical tables.

43. 3. Temporary external fixators like Ganz c clamp
and Browner's fixator help control the
posterior pelvis in vertically unstable fractures
in the resuscitation phase.

46. • lnternal fixation:
• Iliac wing fractures; ORIF using lag screws and
neutralization plates.
• Diastasis of the pubic symphysis: Plate fixation is used if no
open injury or cystostomy tube is present.
• Sacral fractures: plate fixation or sacroiliac screw fixation
• Unilateral sacroiliac dislocation: Direct fixation with
cancellous screws or anterior sacroiliac plate fixation is
used.
• Bilateral posterior unstable disruptions: Fixation of the
displaced portion of the pelvis to the sacral body may be
accomplished by posterior screw fixation

51. • Specific fracture Treatment
• Tile: Stabilisation Options
1. Stable (A1, A2): Protected weight bearing and
symptomatic treatment.
2. Open book (B1)
• Symphyseal diastasis <2 em: protected weight
bearing
• Symphyseal diastasis >2 em: external fixation or
symphyseal plate

52. 3. Lateral compression (B2, B3)
• Ipsilateral only: No stabilisation necessary
• Contralateral (bucket handle}:
• Leg-length discrepancy <1.5 em: no stabilisation
necessary
• Leg-length discrepancy >1.5 em: external fixation
or open reduction and internal fixation (ORIF).
4. Rotationally and vertically unstable {C1, C2, C3):
• external fixation with or without skeletal traction
or ORIF.

54. Post operative care
• Aggressive pulmonary toilet should be
pursued with incentive spirometry, early
mobilization.
• Prophylaxis against thromboembolic
phenomena should be undertaken, with a
combination of elastic stockings, sequential
compression devices, and chemoprophylaxis if
hemodynamic and injury status allows.

55. • Weight-bearing status may be advanced as follows:
• Full weight bearing on the uninvolved lower extremity/sacral side
occurs within several days.
• Partial weight bearing on the involved side is recommended for at
least 6 weeks. Recently,weight-bearing as tolerated (WBAT) has
been supported in low-energy LC1 fractures.
• Full weight bearing on the affected side without crutches is
indicated by 12 weeks.
• Patients with bilateral unstable pelvic fractures should be mobilized
from bed to chair with aggressive pulmonary toilet until
radiographic evidence of fracture healing is noted. Partial weight
bearing on the “less” injured side is generally tolerated by 12
weeks.

56. Complications
1. Infections – 0-25%
2. Thromboembolism
3. Malunion- rare.
4. Nonunion- rare, seen in young.
5. Mortality
• Hemodynamically stable patients: 3%
• Hemodynamically unstable patients: 38%
• LC: head injury major cause of death
• APC: pelvic and visceral injury major cause of death
• AP3 (comprehensive posterior instability): 37% death
• VS: 25% death

57. THANK YOU