For BPT students

1. PELVIC FRACTURES
Dr. Dibyendunarayan Bid

2. Introduction
• Pelvic fractures are potentially life threatening
injuries with an increased incidence due to
high velocity RTAs.
• Survivors are at a significant risk for morbidities
like chronic pain, LLD, Sexual dysfunction etc
• 3-4 % of all fractures usually associated with
significant trauma

3. Introduction
• Adult mortality 10-15%
• Mortality is ~50% if hypotensive on initial
presentation.
• Mortality is ~30% in open fractures
• Significant decrease in mortality and morbidity
if prompt stabilization of an unstable #

4. ANATOMY

6. The bony pelvis lies in close proximity to various vascular
neural and soft tissue structures making these structures
vulnerable in the event of pelvic ring disruptions

7. Historical perspective
• These #s were historically managed conservatively
and many authors reported poor results.
• Holdsworth (1948) in first described that pts with
pure SI dislocations fared worse than
Illium/sacrum#.
• Slattis reported mortality as high as 17%
• Several publications popularized use of external
fixators.
• But later it became clear that Ex-Fix may be
adequate for anterior/lateral injuries but not for
posterior injuries.

8. Clinical Evaluation
SUSPECT
Start with ABCDs
Evaluate for other injuries to head,
chest, abdomen and spine
INSPECTION
• Skin around the perineum
• Bleeding PV/PR/PU
• LLD and abnormal extremity rotation
• Neuro-vascular status

9. Associated signs:
- Roux's sign:
- a decrease in the distance from the
greater trochanter to the pubic crest on the
affected side in lateral compression frx;
- Earle's sign:
- a bony prominence or large hematoma
as well as tenderness on rectal examination;

10. Destot Sign
Moral Lavale Lesion

11. Palpation
• Post---Haematoma/defect---SIJ or post #
• ASIS: Pushed towards- IR stability, Apart- ER
stabiity
• Lower extremity pushed for vertical stability

12. Imaging Pelvic Fractures
• Plain Radiographs- AP view

13. Imaging Pelvic Fractures
• Plain Radiographs- AP view
Pubic Rami #
Symphyseal Displacement
SIJ and Sacrum
Illiac #
L5 transverse process
Asso acet/proximal femur

14. 2. Plain Radiographs- Inlet view

15. Anterior/posterior Displacement
of Sacrum, SIJ, Illium, symphysis
Rotational deformities of illium
Impacted sacral fractures

16. 3. Plain Radiography Outlet view
Adequate image when pubic
symphysis overlies S2 body

17. Imaging
CT scan
Gold standard for pelvic fractures. Detailed
information about anterior and posterior ring
MRI
Limited role.
GU and Vascular structures

18. CLASSIFICATION of pelvic fractures
Young and Burgess Classification
Most common classification used
Based on the mechanism of injury

23. Tile/AO Classification

24. Tile/AO Classification
Type A: STABLE

25. Tile/AO Classification
Type B: Rotationally unstable, Vertically
stable

26. Tile/AO Classification
Type C: Rotation and vertically
unstable

27. Sacral Fracture-Denis Classification

28. Miscellaneous Fractures
MALGAIGNE’s #
STRADDLE #

29. Principles of Initial Management
• Suspect if high velocity RTA(car vs pedestrian;
Motorcycle) or a fall from height(usually
>15feet)
• Pelvis has no inherent stability and relies on
ligamentous supports.
• Vascular structures are intimately associated
with ligaments and are often injured.

30. German registry
reported a drop
in mortality from
11% to 6% after a
protocol was
established.

31. Circumferential Pelvic wrapping
• First patient; teague 1993,CA
• CORR 1995
• ATLS provider manual in 1997
• Can be done with a bedsheet or a Pelvic
binder.

32. • Where to wrap??
At the level of the Greater Trochanters
•How much force????
150-170N

33. Pneumatic Anti-shock Garment
• Inflatable device traditionally used by the
armed forces.
• Great value in transport and initial
stabilization of patient; acts as a air splint

34. Disadvantages of PASG
• Risk of displacement in LC injuries
• Restricts access to patient
• Increased risk of compartment syndrome

35. External Fixation
• Indications
– pelvic ring injuries with an external rotation
component (APC, VS, CM)
– unstable ring injury with ongoing blood loss
• Contraindications
– ilium fracture that precludes safe application
– acetabular fracture

36. Technique
– theoretically works by decreasing pelvic volume
– stability of bleeding bone surfaces and venous
plexus in order to form clot
– pins inserted into ilium
• single pin in column of supracetabular bone from AIIS
towards PSIS
– obturator outlet or "teepee" view to visualize this column of
bone
– AIIS pins can place the lateral femoral cutaneous nerve at risk
• multiple half pins in the superior iliac crest
– place in thickest portion of anterior ilium, gluteus medius
tubercle or gluteal pillar
– should be placed before emergent laparotomy

38. Angiography / Embolization
• Indications
– controversial and based on multiple variables
including:
– protocol of institution, stability of patient,
proximity of angiography suite , availability and
experience of staff
– CT angiography useful for determining presence or
absence of ongoing arterial hemorrhage (98-100%
negative predictive value)

39. Non-Operative Management
• Lateral impaction type injuries with minimal
(< 1.5 cm) displacement
• Pubic rami fractures with no posterior
displacement
• Minimal gapping of pubic symphysis
– Without associated SI injury
– 2.5 cm or less, assuming no motion with stress or
mobilization
– This number is not absolute, so other evidence of
instability (like SI injury) must be ruled out

40. Non-Operative Management
• X-rays are static picture of dynamic situation
– It may be that the deformity is worse than seen on
X-rays taken
– Stress radiographs may be helpful
– Other evidence of instability should be sought
• Lumbar transverse process fractures
• Avulsions of sacrotuberous/sacrospinous ligaments

41. Non-Operative Treatment
• Tile A (stable) injuries can generally bear
weight as tolerated
• Walker/crutches/cane often helpful in early
mobilization
• Serial radiographs followed during healing
• Displacement requires reassessment of
stability and consideration given to operative
treatment

42. Non-Operative Treatment
• Tile B (partially stable) injuries can be treated
non-operatively if deformity is minimal
• Weight bearing should be restricted (toe-
touch only) on side of posterior ring injury
• Serial radiographs followed during healing
• Displacement requires reassessment of
stability and consideration given to operative
treatment

43. Principles of Operative Treatment
• Posterior ring structure is important
• Goal is restoration of anatomy and enough
stability to maintain reduction during healing
• Most injuries involve multiple sites of injury
– In general, more points of fixation lead to greater
stability
– This does NOT mean that all sites of injury need
fixation

44. Principles of Operative Treatment
• Anterior ring fixation may provide structural
protection of posterior fixation
• If combined open and percutaneus techniques
are used, the open portion is often done first to
aid in reduction of the percutaneusly treated
injury
• LETOURNEL’s Golden rule: Posterior stabilization
to be done before anterior as posterior is the
main weight bearing part.

45. Anterior Pelvic Ring Injuries
Indications for ORIF
• Symphyseal dislocation >2.5cm(static or
dynamic)
• Toaugment posterior fixation in vertically
dislaced fractures.
• Locked symphysis.

46. Surgical Approach to the
Anterior Pelvic Ring
Pfannenstiel Approach
•Supine Position
•8 cm incision
•A Foley catheter and
nasogastric tube are inserted

48. •The cut edges of the
rectus abdominal
muscles superiorly to
reveal the symphysis
and pubic crest.
•If access to the back of
the symphysis is
required, use the
fingers to push the
bladder gently off the
back of the bone

49. Symphyseal Dislocations
• Ant Ex Fix = Internal Fixation for controlling
rotation but Internal fixation >>> for resisting
vertical displacements
• Ex fix particularly useful in open injuries or pts
requiring GI/GU procedures.

51. ORIF of Symphyseal disruptions
• Apply circumferential wrap at the level of the
GT.
• Internally rotate the legs and tape them.
• Ant approach to pubic symphysis.
• Place reduction forceps anteriorly so that
plate can be put on the superior surface.

54. • Inlet view: judge the alignment of the plate;
• Outlet view judge the length of screws;screws
should have a bicortical purchase.

55. Fractures of the Pubic ramus
• Fractures medial to insertion of inguinal
ligament should be treated like symphyseal
dislocations.
• Comminuted fractures: ORIF
• Minimal comminution: Ramus screw (ante
vs retro)

56. Fractures of the Pubic ramus
• Reduction technique
Secure a precontoured plate in the supra-
acetabular bone.
One tine of the reduction forceps on the medial
fragment and another on the most medial hole
of the plate.

59. Posterior Pelvic Ring Injuries
• Indications for ORIF:-
1. Displaced illiac wing fractures that enter and exit
both the crest and GSN/SIJ.
2. Multiplanar instability(disruption of ligaments)
3. Non impacted comminuted displaced sacral
fractures.
4. Vertical or cephalad displacement.
5. U shaped fractures with spino-pelvic
dissociation

60. Approaches to posterior pelvic ring
Posterior approach to SIJ
• Pt is placed prone with logitunal traction.
• In severely displaced fractures we can rigidly fix the
contralateral pelvis

61. Approaches to posterior pelvic ring
Posterior approach to SIJ

63. Anterior Approach to the Sacroiliac Joint
• Make a curved incision over
the iliac crest, beginning 7 cm
posterior to the anterior
superior iliac spine. Curve the
incision anteriorly and
medially along the line of the
inguinal ligament for 5 cm.

64. • Subperiosteally dissect the illiacus muscle and
retract medially to reach the anterior part of
the SIJ.
• Care should be taken not to injure L5 nerve
root.

65. Posterior approach to Sacrum

67. Sacroilliac Joint Dislocations
• Posterior approach----Only inferior joint
visualised
• Anterior approach----Superior Ala visualized
• Longitunal traction is the single most
important maneuvre.
• Important to let the pelvis hang free as
pressure on ASIS will lead to ext rotation

68. • Two reduction forceps

69. Illio-Sacral screw Placement
• Inlet projection—screw
towards anterior aspect
of promontory
• Outlet ---screw is above
the S1 foramen
• Screw to be directed
anteriorly; superiorly
and medially. Lateral Projection

70. Be aware of sacral dysmorphism

71. Illiac wing fractures and fracture
dislocations( Crescent fractures)
• Illiac wing fractures exiting through the SIJ are crescent #.
• Crescent fragment is the variable sized that contains the
PSIS and PIIS and remains attached to the sacrum.
• Smaller the “CRESCENT” fragment > damage to posterior
structures

72. Crescent fractures
• Always approched posteriorly

73. SACRAL Fractures
• Can be regarded as a pelvic injury, spinal injury
or both.
Indications for fixation:-
 Ant and post ring disruption with vertical sheer
sacrum fracture.
 Comminuted # with rotation
 Spinal-pelvic dissociation
 Rarely in impacted # with Internal rotation
deformity

74. Illiosacral screw
Plate fixation

75. Spinal-Pelvic fixation
1. Spinal point of fixation- L5(usually)
2. Illiac screw just inf to PSIS
3. Illiac screw is connected to pedicle screw with appropriate
rods and screw-rod clamps
This bypasses the lines of force transmission from spine to illium
through the construct instead of the sacrum

76. Post-Operative Care
• Mobized to chair 1st day post-op
• Toe touch weight bearing upto 10 weeks
(unstable injuries)
• Stable injuries immediate post-op FWB.
• DVT prophylaxis.
• Prophylaxis for hetereropic ossification.

77. Complictaions
• Intra-operative haemorrhage
• Inability to achieve reduction
• Wound infection.
• Newly recognized post-op neurologic deficits
• Loss of fixation and reduction
• Sexual dysfunction

78. Physiotherapy Management
 PT is an important part of the rehabilitation in both, low-
energy and high-energy pelvic fractures.
 Low-energy injuries are usually managed with conservative
care.
 This includes bed rest, pain control and PT.
 High-energy injuries, especially the unstable fractures must be
reduced by surgical treatment.
 Afterwards PT includes the same treatment as in low-energy
fractures.
 Early mobilisation is very important because prolonged
immobilisation can lead to many complications, including
respiratory and circulatory dysfunctions.
 PT helps the patient to get out of bed as soon as possible.

79.  The goals of the PT program should provide the patient with
an optimal return of function by improving functional skills,
self-care skills and safety awareness.
 The main goals are to improve the pain level, strength,
flexibility, speed of healing, and the motion of the hip, spine
and leg.
 Another important goal is to shorten the time needed to
return to activity and sport.
 The intensity of the rehabilitation depends on whether the
fracture was stable or unstable.

80.  In people with surgical treatment, PT starts after 1
or 2 days of bed rest.
 It is initiated with training of small movements,
transfers and exercise training.
 The following exercises can start immediately after
surgery and should be done at least four times a day
(unless told otherwise).
 The number of repetitions are guidelines and can
vary with every patient.

81. Plantar flexion and
dorsiflexion of the feet
Sit up or lie down. Keep your
legs straight and move your
feet up and down at the ankles,
pointing your toes and then
relaxing.
Repeat 10 – 15 times every
hour.

82. Abduction of the hip
Move your leg out to the
side and then back to the
middle.
Repeat both sides 10
times.

83. Contraction of the
quadriceps
Keep your legs flat on the
bed. Push the knee down
so that your leg is straight
and then tighten your thigh
muscle and hold for five
seconds.
Repeat 5 – 10 times.

84. Extension of the knee:
lying
Lie on your back. Put a rolled
towel under your knee.
Tighten your thigh muscles and
straighten your knee, lifting
your heel off the bed. Hold your
leg straight for five seconds and
lower it gently.
Repeat both sides 10 times.

85. Extension of the knee: In
sitting
Once you can sit in a chair or
wheelchair comfortably: Pull
your foot up towards you,
tighten your thigh muscle and
straighten your knee. Hold this
position for five seconds.
Repeat 10 – 15 times every
hour.

86. Short-term goals for patients after surgery are:
 independence with transfers and wheelchair
mobility.
 Depending on the medical status of the patient
these goals can be achieved in 2 to 6 weeks.
 The physical therapy program can be continued in
the hospital or at home.
 The home-based program includes basic range of
motion, stabilising and strengthening exercises
intended to prevent contracture and reduce
atrophy.

87.  During the non-weight bearing status the
patient performs isometric exercises of
the gluteal muscle and quadriceps femoris
muscle, range of motion exercises and upper-
extremity resistive exercises (for
example shoulder and elbow flexion and
extension) until fatigued.
 The number of repetitions can vary with the
patient.

88.  Once weight-bearing is resumed, PT consists of gait
training and resistive exercises for the trunk and
extremities, along with cardiovascular exercises (for
example treadmill).
 Stabilisation exercises and mobility training should
also be remained in the program.
 Aquatherapy is also good and helpful when
available.

89.  Mobility training is useful to regain the range of motion in
the hip, knee and ankle after immobilisation.
 Gait training should start with walking between parallel bars.
 Afterwards the patient should learn how to walk with a
walker or with a cane.
 Balance and proprioception training should also be included
in the rehabilitation.
 Resistive training should be progressive to improve the
muscle strength in the hip and leg.
 In the final stage functional exercises should be included to
provide the patient with an optimal return of function.

90.  In pelvic fractures in the elderly population, the
rehabilitation process will be focused on optimising
their quality of life.
 Rapid mobilisation and sufficient pain relief are the
main objectives of treatment and appointment of
the home to assess the need for eg rails, ramps,
increased lighting, removal of loose mats.
 Appropriate walking aids should also be supplied.
A falls prevention outpatient program could be of
benefit.