HEGAZY SURGERY

1. Pelvic Ring Fractures
Abdelfattah Saoud MSc, MD, PhD
Professor of Orthopaedic & Spine Surgery
Head of Ranking & Accreditation office
Ain Shams University
Head of International Scientific Relations office
School of Medicine,Ain Shams University
President, World Spinal Column Society
Educational Faculty, Cleveland Clinic Spine
Institute

2. High energy fractures of the pelvis are a challenging
problems both in the immediate post-injury phase and
later when definitive management is undertaken

3.  No single management algorithm can be applied
 Fracture stabilization for unstable fractures
should be performed (as soon as possible), and it
should be considered as part of the resuscitation
procedure

4.  Pelvic ring is formed of two
innominate bones and the
sacrum .
 Articulation is mostly
ligamentous stable
 Another factor in stability is
Interdigitating and matching
contours of the iliac and sacral
articulating surfaces
March 21st

6.  The most important ligaments are:
-Sacroiliac ligaments
(Ant.,Post.,Interosseous.),
-Symphysis pubis
-Sacro-Spinous ligament
-Sacro-Tuberous ligament
- & ilio-lumbar ligament.

7. Diagnosis
 Clinical:
-High energy trauma,
-pain related to the fractured
area,
-symptoms and signs of
complication:
1-Shock(Internal iliac Art.
Branches injury in relation to
S.I joint ,injury of accessory
obturator vessels in relation
to the back of symphysis
pubis (pubic branches of
obturator artery of internal
iliac origin and inferior
epigastric artery which
originates from the external
iliac artery
(Corona Mortis)
2-Urological injury: Urethra ,

8. Radiographic diagnosis
1- of the fracture itself:
A.P view : not a true A.P
due to pelvic inclination
ant. 45 deg.
So true A.P comes by
inclinig the beam of x
ray 45 deg. Caudad=
Outlet view which is very
important to detect
vertical Shear.

9.  If we incline the beam 45
deg. Cephalad= inlet view
which is important to
denote ant. Post.
Displacement of hemi-
pelvis.
 C.T to plan for surgery
,some times we do it in 3
dimensional reformat.

10. Pelvic instability

11. Classification of pelvic fractures
 The two most popular scheme in use
today are the Young-Burgess
system

12. Tile system
February 20

13. Young and Burgess
classification

15. LC Transverse fracture of pubic rami, ipsilateral or
contralateral to posterior injury
I Sacral compression on side of impact
II Crescent (iliac wing) fracture on side of
impact
III LC-1 or LC-II injury on side of impact;
contralateral open-book (APC)

16. APC Symphyseal diastasis or
longitudinal rami fractures
I Slight widening of pubic symphysis or anterior SI
Joint; stretched but intact anterior SI, sacrotuberous, and
sacrospinous ligaments; intact posterior SI ligaments
II Widened anterior SI joint; disrupted anterior SI,
sacrotuberous, and sacrospinous ligaments; intact posterior
SI ligaments
III Complete SI joint disruption with lateral displacement,
disrupted anterior SI, sacrotuberous, and sacrospinous
ligaments; disrupted posterior SI ligaments

17. VS
Symphyseal diastasis or vertical
displacement anteriorly and
posteriorly, usually through the SI
joint, occasionally through the iliac
wing or sacrum

18. CM
Combination of other injury
patterns, LC/VS being the
most common

19. Denis classification of Sacral
fractures
Zone 1 - ala of the sacrum to lateral
border of the neural foramen
Zone 2 - neural foramen
Zone 3 - central portion of the sacrum and
canal

20. Algorithm for
management
(No consensus)

21. This is what our
Invention has
changed

22. Diagnosis of complication
 Urological injury: Ascending urethrography is the
most useful.
 Haemorrhage: Angiography(Arterial): Both for
diagnosis and treatmant by selective embolization.

23. Complication Cont’d
 Neurological injury:
Lumbo-sacral plexus
injury.
 Pelvic D.V .T with fatal
pulmonary embolism.
Late complication:
 Malunion :with leg length
discripency ,or if ant.
With bladder irritation
 Non union with pain
especially in relation to
S.I. joint .Rare and occurs
more in pure ligamentous
injuries

24. Anterior injury

25. Anterior injury
 Ex Fixator.

26. Anterior injury
 Symphyseal plate
February 20

27. February 20

28. Pfannenstiel incision

29. Anterior injury
 Antegrade or retrograde Pubic
screw
February 20

30. Anterior injury
 Other methods…
Wiring
Tension band
February 20

31. Posterior injury
Sacral Fractures
Sacroiliac Fracture Dislocations
Crescent fracture
Indications of intervention:
1-Unstable fracture:e.g Gr. III
APC, VS
2- SIJ gap of more than 5-10
mm
3- Neurologic injury related to
post. Injury: LS trunk lesions
4- Retroperitoneal
haemorrhagae : Tamponade

32. Lumbosacral Pivot point
 Described by McCord et al in
1992.
 It is the axis of flix. Exten. at
the lumbo-sacral junction.
 Lies in the intersection of
middle osteoligamentous
column and L5-S1 disc.
 For constructs that cross the
Lumbosacral junction: Only
those devices that pass
ventral to this point provide a
significant biomechanical
advantage regarding the
rigidity of fixation.

33. Posterior injury
 Iliosacral screw

34. Iliosacral screw
February 20

35.  Iliosacral screw
February 20

36. Iliosacral screw
February 20

37. Iliosacral screw
February 20

38.  Iliosacral screw
February 20

39. Transiliac sacral bars:
- utilizes threaded
rods, compression
achieved by tightening
of threaded nuts;
- advantages
include technical ease of
insertion and limited
soft tissue dissection;
-Biomechanically
ineffective according to
McCord point and is a
real obstacle of flexion
and extension
February 20

40. Posterior injury
 Iliosacral plates(anterior or posterior)

41. Ilio inguinal aproach

43. Our modification
 No need to expose vessels
 Only Pfannensteil and the lateral iliac
window
 we pass plates and do indirect
reduction under ilio posoas muscle
with hip flexion

44.  Lumbopelvic Fixation
Lumbopelvic fixation
consists of pedicle screws
placed in L5 and or L4 that
are connected to fixation
placed into the ilium from
posterior to anterior just
cephalad to the sciatic notch

46. MW technique
iliac screws
(7 mm) inserted
in a Galveston
manner, and
iliosacral screws
(7 mm) to
maximize
construct
strength

47. Disadvantages of lumbo-sacral
stabilisation
techniques are the restriction
of waist movements and the
need a second operation to
remove the fixation due to
painful hardware.
February 20

48. The New Internal Fixator
Saoud & Reda Technique:
WSCJ Vol 2 issue 1, 2011
-Application of Iliac screw(polyaxial)60-100 mm, 7 mm
width on each side
-Submuscular channel connecting the two incisions
-Rod applied between the two polyaxial screw heads.

51. Advantages

52. It is a very fast & safe
technique that doesn’t
need
much experience or
fluoroscopy thus it is
suitable for
polytrauma and critically
sick patients.

53. Safety of application
doesn’t depend on
accurate
reduction of the sacral
fracture.

54. After application of the
screws they can be used
as
joysticks to manipulate
the fracture by
distraction and
compression

55. Very small skin incisions and the absence of any
major dissection would spare the patient any
further jeopardy to the possibly contused or
devitalized skin of this area which is a huge
advantage especially with suspected or diagnosed
Morel-Lavallée skin lesions

56.  May nullify need for Ext. Fixator

57. Treatment of Complications of
pelvic fractures

58. Treatment of complication
 Urological injury: Suprapubic cystostomy
 Haemorrhage: Angiography(Arterial): Both for
diagnosis and treatmant by selective embolization.

59. Complication Cont’d
 Neurological injury:
Treatment of Lumbo-sacral
plexus injury is by fracture
fixation and expectancy for
12-24 mns with
EMG.Results of grafting are
bad
 Pelvic D.V .T Prevention,
IVC filter
Late complication:
 Malunion :innominate
osteotomy
 Non union with pain
especially in relation to S.I.
joint .For SI fusion

60.  Open pelvic fractures especially with
bowel injury are emergencies.
Fixation is by Ext Fix. Or S&R
technique, may be supplemented
when patient is more stable

61. Anatomy - Pelvis
 Iliac bone with iliac apophysis
 Ischium with apophysis
 Pubic bones – physeal connection at
ischiopubic junction
 Sacrum – SI joint 2/3 synchondrosis,
1/3 synovial joint
 Pubic symphysis - synchondrosis

62. The Child’s Pelvis
 Fundamental Differences:
• Bones more malleable
• Cartilage capable of absorbing more
energy
• Joints more elastic
• Triradiate Cartilage

63. Ossification centers

64.  3 Primary Ossification Centers:
• Pubis
• Ischium
• Ilium

65. Anatomy
 Other Secondary Ossification Centers
of the Pelvis
• iliac crest
• ischial apophysis
• anterior inferior iliac spine
• pubic tubercle
• angle of the pubis
• ischial spine
• lateral wing of the sacrum

66. Secondary Ossification Center
 Iliac Crest : first seen at age 13 to 15 and
fuses at age 15 to 17 years
 Ischium : first seen at age 15 to 17 and
fuses at age 19 to 25 years
 ASIS : first seen about age 14 and fusing
at age 16
*(Important to know these secondary
ossification centers so they will not
be confused with avulsion fractures)

67. Elasticity of Joints
 Sacroiliac Joint and Pubic Symphysis
more elastic
 Allows significant displacement
 Allows for single break in the ring
 Thick periosteum – apparent
dislocations may have a periosteal
tube that heals like a fracture

68. Weakness of Cartilage
 Avulsion fractures occur more often
in children and adolescents through
apophysis

69. Pelvic ring fractures: Diagnosis
History and Associated Injuries
 Usually high energy injuries for pelvic ring
and acetabular fractures
 Other associated injuries
• Orthopaedic – long bone or spine fractures
• Urologic – bladder rupture
• Vascular – less frequent than in adults

70. Physical Examination
 A, B, C’s
 Trauma evaluation
 Orthopaedic exam all extremities and
spine
 Systematic approach to the Pelvis

71. Examination of the Pelvis
 Areas of contusion, abrasion, laceration,
ecchymosis, or hematoma, especially in
the perineal and pelvic areas, should be
recorded.
 Landmarks such as the anterior superior
iliac spine, crest of the ilium, sacroiliac
joints, and symphysis pubis should be
palpated.
 Carefully evaluate perineum/genital/rectal
areas in fractures with significant
displacement to rule out open fractures

72. Examination of the Pelvis
 Provocative Tests (ie. Compressing the
pelvic ring with anterior-posterior and
lateral compression stress)
 The range of motion of the extremities,
especially of the hip joint, should be
determined
 Neurologic and vascular exam of the lower
extremities

73. Radiographic Evaluation
 Standard AP Pelvis
 Judet views for acetabular involvement
 Inlet/Outlet views for pelvic ring injuries
 Computed tomography
• 2-d and 3-d reconstruction
 Cystography and/or urography if blood at
meatus or on bladder catheterization

74. Pelvic Avulsion Fracture Injuries
 At sites of muscle attachments
through apophyses, caused by
forceful contraction
 Iliac wing – tensor fascia lata
 Anterior superior iliac spine –
sartorius
 Anterior inferior iliac spine – rectus
femoris
 Ischium – hamstrings
 Lesser trochanter - iliopsoas

75. Relative Percentages of Pelvic
Avulsion Fracture Locations

76. ASIS Avulsion Fracture

77. Ischial Avulsion Fracture-
11 year old Sprinting

78. Ischial Avulsion Fracture CT

79. AIIS Avulsion – 13 yo Female
Kicking a Soccer Ball

80. Classification of Pelvic Injuries
in Children
Torode and Zieg modification of Watts
classification
 Type I – avulsion fractures
 Type II - Iliac wing fractures
 Type III – stable pelvic ring
injuries
 Type IV – any fracture pattern
creating a free bony fragment
(unstable pelvic ring injuries)

81. Tile Classification
(applicable to adolescents /
patients near skeletal maturity)
 Type A – stable
 Type B – rotationally unstable,
vertically stable
 Type C – rotationally and vertically
unstable

82. Treatment Options
 Bedrest
 Spica cast
 Mobilization with restricted
weightbearing
 Skeletal traction
 External fixation
 ORIF

83. Treatment Differences
 Pubic symphyseal and SI disruptions may
be able to be treated closed because of
potential for periosteal healing
 Children tolerate
bedrest/traction/immobilization better
than adults
 Operative fixation should spare growth
plates when possible
 When not possible consider temporary (4-
6 weeks) fixation across physes with
smooth pins

84. Treatment
 Most avulsion injuries, Tile A
fractures treated with restricted or
no weight bearing
 Most Tile B fractures treated non
operatively unless major deformity
 Tile C fractures may need
stabilization

85. Treatment Caveats
 Older children and adolescents with
pelvic injuries treated like adults
 Operative treatment in general for
pelvic injuries where posterior ring
disruptions are displaced or
unstable(Theoretically our
Saoud&Reda can be used)
 May be able to stabilize anterior ring
only, and for shorter time period if
using external fixation

86. Pelvic Ring Injuries- Often Crush
Mechanism and Can Have Severe
Soft Tissue Injuries as well

87. Plate Symphysis for Diastasis

88. 13 year old, bilateral pubic rami
fractures with left SI disruption
subtrochanteric femur fracture

89. Thank You