2. Combination of bones
2 part –false and true
Function :
Transmit weight
Protection for vital organs
3.
4. Pelvic ring stability depends on :
Rigidity of bony parts
Strong ligaments binds the segments together
across symphysis pubis and sacroiliac joint
5. Pelvic fractures accounts for 3% of all skeletal
fractures
95% of pelvic injuries -> minor trauma
Severe trauma have high mortality rate due to
hemorrhage or multiple injuries
Hemorrhage is 80-90% venous in origin
6. Radiographic lines :
1. Iliopectineal
2. Ilioischial
3. Radiographic
tear drop /
acetabulum
4. Acetabular roof
5. Acetabulum rim
/ wall : anterior
and posterior
6. Shenton
7. Arcuate
7. Iliac = unaffected hip 45 Obturator = affected 45
Inlet = caudal 45 to inf Outlet = cephalad 45 to sup
8.
9. Generally injuries of the pelvis is classified into 4
groups :
Isolated fractures with an intact pelvic ring
Sacrococcygeal fractures
Fractures of acetabulum
Fractures with broken ring – stable or unstable
10. Isolated fractures with intact pelvic ring
Ramus Pubic Fractures Duverney Fractures
• In general these injuries do not require
surgical treatment, unless injuries to
bladder, vagina, perineum are present
• NSAID / Pain killer, walker / stabilizer
11. Fractures of acetabulum
Acetabular fracture may cause disruption in hip joint
integrity and dislocation / subluxation of hip joint
When dislocation occur, emergency relocation /
reduction of the dislocation is necessary to prevent
necrosis of bone (avascular necrosis)
13. Pediatic Acetabular Fractures Classification
Watts Classification
1. Type A – Small fragments occuring with hip
dislocation
2. Type B – Stable linear fractures without
displacement in association with pelvic
fractures
3. Type C – Linear fractures with hip joint
instability
4. Type D – Fractures secondary to central
fracture-dislocation of the hip
16. Treatment :
Non – operative
Protected weight bearing 6-8 weeks
minimally displaced fracture (< 2mm)
< 20% posterior wall fractures
femoral head remains congruent with weight bearing roof
(out of traction)
both column fracture with secondary congruence (out of
traction)
displaced fracture with roof arcs > 45 degrees in AP and
Judet views
relative contraindications to surgery :
Morbid obesity
Open contaminated wound
DVT
17. Operative
ORIF
displacement of roof (>2mm)
posterior wall fracture involving > 40-50%
marginal impaction
intra-articular loose bodies
irreducible fracture-dislocation
pregnancy is not contraindication to surgical fixation
ORIF – Hip Arthroplasty
significant osteopenia and/or significant comminution
Percutaneous Fixation with column screws
18. Complication
Post-traumatic DJD
most common complication
anatomic reduction essential to prevent
treat with hip fusion or THA
Heterotopic Ossification
treat with
indomethacin x 5 weeks post-op
low dose external radiation (no difference shown in direct comparison)
Osteonecrosis
6-7% of all acetabular fractures
18% of posterior fracture patterns
DVT and PE
Infection
Bleeding
Neurovascular injury
Intraarticular hardware placement
Abductor muscle weakness
19. Sacrococcygeal fractures
Common in pelvic ring injury (30-45%) or after
repetitive stress / insuficiency fracture in old
age
Fractures may damage Sacral Plexus – loss of
neurological function
Sacrum contain :
Lumbar Plexus (L4-S1)
Sacral Plexus (S2-S4)
S2-S5 controls sexual, bowel and bladder function
(parasymphatethic pathway)
presence of a neurologic deficit is the most
important factor in predicting outcome
20. Denis classification
Comprised of 3 zones
Lateral to neuroforamina
50% of patient, neurological injuries
in 6% cases, affecting L4-L5 nerve
In neuroforamina, excluding spinal
canal
34% of patient, neurological injuries
in 28% cases, affecting L5-S1-S2 nerve
Extend into spinal canal
16% of patient, neurological injuries
in 57% cases
Highest prevalence and severity of
injuries
21. Transverse sacral fractures
High incidence of nerve
dysfunction
U-type sacral fractures
Result from axial loading
High incidence of neurologic
complication
22. Treatment :
Operative
Surgical fixation w/w/out
decompression
displaced fractures >1 cm
soft tissue compromise
persistent pain and/or
displacement of fracture after non-
operative management
Neurological deficit
Non – operative
Progressive weight bearing and
orthosis
<1 cm displacement and no
neurologic deficit
insufficiency fractures
Physical examination reveal :
Soft tissue trauma around pelvis
Pelvic ring instability
Rectal / vaginal touche
Radiograph : AP, Inlet, Outlet, Cross-table view, CT, MRI
23. Complication
Venous thromboembolism
often as a result of immobility
Iatrogenic nerve injury
may result from
overcompression of fracture
improper hardware placement
Malreduction
more common with vertically displaced fractures
24. Fractures with broken ring – stable or unstable
Pelvic ring injury are categorized into 3
classification :
Letournel and Judet’s classification
Young and Burgess’ Classification
Tile Classification
Mortality rate 15-20% for closed fractures, up to
50% for open fractures
Hemorrhage is the leading cause of death
25. The Letournel and Judet classification of pelvic
fractures is anatomic
A : Iliac wing fractures
B : Ilium fractures with extension to the sacroiliac joint
C : Trans-sacral fractures
D : Unilateral sacral fractures
E : Sacroiliac joint fracture–dislocation
F : Acetabular fractures
G : Pubic ramus fractures
H : Ischial fractures
I : Pubic symphysis separation
26. Young and Burgess’ Classification is based on the mechanism
of injury
Anterior-posterior Compression (APC)
I. Symphysis widening < 2.5 cm
II. Symphysis widening > 2.5 cm. Sacrospinous and
sacrotuberous disruption
III. Sacroilium dislocation with vascular injury
Lateral Compression (LC)
I. Ipsilateral ramus pubis and sacral ala fracture
II. Ipsilateral ramus pubis and ilium posterior fracture; also
known as crescent fracture
III. Ipsilateral compression and contralateral APC. Ex : Run
over by car
Vertical Shear (VS)
27.
28. Tile Classification is based on the integrity of posterior
sacroiliac complex
Type A is stable injuries, outside ring and inside ring
Type B is Rotationally unstable but vertically stable (unilateral)
or Rotationally unstable in 1 part and vertically unstable in
other part
Type C is Rotationally and vertically unstable (Bilateral)
29.
30. Pediatric Pelvic Injury Classification
Watts Classification modified by Torode and Zieg
1. Type I – avulsion fracture
2. Type II – Iliac wing Fractures
3. Type III – Stable pelvic ring injuries
4. Type IV – unstable pelvic ring injuries
31. Radiographic imaging
Cervical Spine – in suspected high-speed MVI
Thorax – in suspected high-speed MVI
AP pelvis
Inlet view
Outlet view
CT
Signs of Instability
> 5 mm displacement of
posterior sacroiliac complex
presence of posterior sacral
fracture gap
Avulsion fractures (ischial
spine, ischial tuberosity,
sacrum, transverse process of
5th lumbar vertebrae)
32. Treatment
Initial treatment :
Primary Survey (ABCDE)
Stabilize patient
Bleeding control, fluid resuscitation
Bleeding source :
Arterial 20%
Venous 80% from Venous plexus just over SI joint
Pelvic Binder for unstable ring injury, placed in
greater trochanter area
Ex : PASG, MAST (Military Anti Shock Trouser)
33. Secondary survey
Open wound in perineum, groin area
Abnormal pelvic mobility
Leg – length discrepancy
Blood in urethral orifice, anus, perineum, vagina
Neurological deficit in lower part of body
34.
35. External Fixation
Indications
pelvic ring injuries with an external rotation component
(APC, VS, CM)
unstable ring injury with ongoing blood loss, to reduce
pelvic volume
Contraindications
ilium fracture that precludes safe application
acetabular fracture
Angiography / Embolization
Indications
CT angiography useful for
determining presence or absence of
ongoing arterial hemorrhage
Can not detect venous hemorrhage
Flush pelvic aortogram, then selected pelvic
angiography
36. Definitive treatment
Nonoperative
weight bearing as tolerated
mechanically stable pelvic ring injuries including
LC1
anterior impaction fracture of sacrum and oblique ramus
fractures with < 1cm of posterior ring displacement
APC1
widening of symphysis < 2.5 cm with intact posterior
pelvic ring
isolated pubic ramus fractures
37. Operative
ORIF
symphysis diastasis > 2.5 cm
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
diverting colostomy
consider in open pelvic fractures, especially with
extensive perineal injury or rectal involvement
40. Complication
Neurologic injury
DVT and PE
Chronic instability – persistent pain
Urogenital injury – Urethral tear, bladder
rupture
Pelvic infection in open fractures
41. Other Disorder of Pelvis
Osteitis Pubis
Inflammation or
degeneration of symphysis
pubis
Repetitive microtrauma or
fracture
Anterior pubic pain, most
commonly after trauma or
sport.
Symphysis pubis is tender
to palpation
Imaging : AP view
with/without inlet and
outlet view
Treatment consist of activity
modification, NSAID and
fusion as last resort
42. Sacroilitis
Inflammation or degeneration of sacroiliac joint
Low back pain
Sacro iliac joint is tender to palpation
Imaging used is X-ray or CT-scan
Lab report necessary is CBC, ESR, CRP if infection
is suspected
Treatment consist of rest, NSAID, corticosteroid
local injection
43. Ischial Bursitis
Inflammation of bursa of ischial tuberosity
Prolonged sitting
Buttock pain on sitting
Ischial tuberosity is tender on palpation.
May mimick hamstring injury, however on phys ex,
hamstring movement is not painful
Imaging used is X-ray or MRI
Treatment consist of Rest, NSAID and activity
modification (either to decrease seating or adding
more cushion)
44.
45. Iliac Crest Contusion / Hip Pointer
Usually from direct trauma to iliac crest
More common in contact sport
There is history of trauma or hip pain
Iliac crest is tender to palpation
Imaging used is X-ray
Treatment consist of rest, NSAID, padding to
Iliac Crest and local corticosteroid injection