25. management of pelvic ring injuries

Pelvic Ring

Injuries

Muhammad Abdelghani

Epidemiology

• The overall incidence of pelvic ring injuries is estimated at about 3% of all fractures (AO).– Among the polytrauma patients, the

incidence has risen to 25%.

Epidemiology

• Severity of fracture depends on mechanism of injury– Minor pelvic fractures (fractures of individual bones or

single breaks in the pelvic ring; lower energy) – elderly patients after simple falls

– Complex pelvic fractures (higher energy) – younger patients, M:F = 3:1

• Severe pelvic injury usually due to high-velocity MVA, industrial accidents, falls off a significant distance

Anatomy

• The pelvic ring is composed of the sacrum and 2 innominate bones joined anteriorly at the symphysis and posteriorly at the paired sacroiliac joints.

Anatomy

• The innominate bone is formed at maturity by the fusion of 3 ossification centers: the ilium, the ischium, and the pubis through the triradiate cartilage at the dome of the acetabulum.

Anatomy

• 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 represents the inferior aspect of the abdominal cavity.

AnatomyPelvic Ligaments

• Pelvic stability is conferred by ligamentous structures. • These may be divided into 2 groups according to the

ligamentous attachments:– Sacrum to ilium: The strongest and most important

- Sacroiliac ligamentous complex: posterior (short and long) and anterior

- Sacrotuberous ligament

- Sacrospinous ligament

– Pubis to pubis: The symphysis pubis.

• The sacrospinous and sacrotuberous ligaments form part of the pelvic floor.


• Sacroiliac ligamentous complex: - Divided into posterior (short and long) and anterior

ligaments.

- The posterior sacroiliac ligaments, described as the strongest in the body, provide most of the stability.


• Sacrotuberous ligament: – Runs from posterolateral

aspect of sacrum and dorsal aspect of posterior iliac spine to the ischial tuberosity.

– Positioned in the vertical plane– Resists vertical shearing

forces applied to the hemipelvis


• Sacrospinous ligament: – It runs vertically from the

lateral margins of sacrum and coccyx and inserts on the ischial spine.

– It resists external rotation of the pelvic ring.

• The entire ligamentous complex looks and functions like a suspension bridge.


• Additional stability is conferred by ligamentous attachments between the lumbar spine and the pelvic ring.

1. The iliolumbar ligaments originate from L4 and L5 transverse processes and insert on the posterior iliac crest.

2. The lumbosacral ligaments originate from the transverse process of L5 to the ala of the sacrum.


• The transversely placed ligaments – Resist rotational

forces

– Include the short posterior sacroiliac, anterior sacroiliac, iliolumbar, and sacrospinous ligaments.

• The vertically placed ligaments – Resist vertical shear

(VS) – Include the long

posterior sacroiliac, sacrotuberous, and lateral lumbosacral ligaments.

AnatomyRing structure of the pelvis

• The pelvis is a true ring structure.

• It is self-evident that if the ring is broken in one area and displaced, then there must be a fracture or dislocation in another portion of the ring.

Pelvic Stability

• Definition of pelvic stability:– The ability of the pelvis to withstand

physiological forces without significant displacement.

• An unstable injury may be characterized by the type of displacement as: – Rotationally unstable (open and externally

rotated, or compressed and internally rotated).– Vertically unstable

Pelvic Stability

• The pelvic bones themselves have no inherent stability and therefore the integrity of the ligamentous structures is crucial to the preservation or the loss of stability.

• If the ligamentous structures are removed, the pelvis falls into its 3 component parts.

Neurovascular structures

• The iliac arterial and venous trunks pass near the ventral aspect of the SI joints bilaterally.

• Disruption of the SI joints and associated ligaments increases the risk of vascular injury and resultant hemorrhage, which usually arises from the anterior and posterior divisions of the internal iliac vessels.

Pelvic Viscera

• The bladder and urethra are located immediately posterior to the pubic symphysis and the rectum lies immediately ventral to the sacrum.

• The intimate association of these viscera with the pelvic skeleton increases the risk of injury when pelvic fracture occurs.

Mechanism of Injury

• Low-energy injuries – Typically resulting in fractures of individual bones.

– May result from sudden muscular contractions in young athletes that cause an avulsion injury, a low-energy fall, or a straddle-type injury.

• High-energy fractures– May result in pelvic ring disruption.

– Typically due to MVA, pedestrian-struck, motorcycle accident, fall from heights, or crush mechanism.

Mechanism of Injury

• Impact injuries result when a moving victim strikes a stationary object or vice versa. – Direction, magnitude, and nature of the

force all contribute to the type of fracture.

• Crush injuries occur when a victim is trapped between the injurious force, such as motor vehicle, and an unyielding environment, such as the ground or pavement.

Mechanism of Injury

Direction of Force

Specific injury patterns vary by the direction of force application

• Anteroposterior (AP) force– This results in external rotation of the hemipelvis.– The pelvis springs open, hinging on the intact posterior ligaments.

• Lateral compression (LC) force: – Results in impaction of cancellous bone through the sacroiliac joint

and sacrum. – The injury pattern depends on location of force application.

• Vertical shear force: – Forces are directed perpendicularly through the sacrum or ilium.– Severe disruptions of the sacroiliac joint, ilium and sacrum may

occur, leading to significant pelvic instability.

Clinical Evaluation

• Primary assessment (ABCDE): airway, breathing, circulation, disability, and exposure. – This should include a full trauma evaluation.

• Initiate resuscitation: Address life-threatening injuries.

Clinical Evaluation

• Evaluate injuries to head, chest, abdomen, and spine.– The focused abdominal ultrasound for trauma (FAST) can

detect intraperitoneal fluid.

– Diagnostic peritoneal lavage (DPL) may be helpful where ongoing bleeding is suspected and the FAST is equivocal.

• If the DPL is grossly positive (>8 mL of blood aspirated on entry into the peritoneum), operative exploration is indicated.

Clinical Evaluation

• Identify all injuries to extremities and pelvis, with careful assessment of distal neurovascular status.

Clinical Evaluation

• Pelvic instability may result in a leg-length discrepancy involving shortening on the involved side or a markedly internally or externally rotated lower extremity.– External rotation and shortening of one of the

lower extremities is a sign of “open-book” or vertical shear (VS) injury

Clinical Evaluation

• AP-LC test for pelvic instability should be performed once only and involves rotating the pelvis internally and externally.– This test can document pelvic instability when AP and lateral

compression on the iliac wings produces pain or rotational instability.

– “The first clot is the best clot”.

– Once disrupted, subsequent thrombus formation of a retroperitoneal hemorrhage is difficult because of hemodilution by administered IV fluid and exhaustion of the body’s coagulation factors by the original thrombus.

– The pelvic rock manoeuvre can demonstrate clinical instability of the pelvic ring, especially when the instability is gross, but an apparently normal examination does not exclude severe pelvic injury.

• Therefore, an AP view of the pelvic ring should be included in the primary survey in all patients with blunt trauma who have signs of hypovolaemic shock.

Clinical Evaluation

• Massive flank or buttock contusions and swelling with hemorrhage are indicative of significant bleeding.

Clinical Evaluation

• Palpation of the posterior aspect of the pelvis may reveal a large hematoma, a defect (representing the fracture), or a dislocation of the sacroiliac joint.

• Palpation of the symphysis may also reveal a defect.

Clinical Evaluation

• The perineum must be carefully inspected for the presence of a lesion representing an open fracture.

• Inspect the patient for bleeding from the urethral meatus, vagina, or rectum. – If these latter 2 areas are not carefully inspected,

occult lacerations may be overlooked, with dire consequences, since these lacerations always mean an open fracture of the pelvis.

Haemodynamic Status

• Attention must be paid to signs of hypovolaemic shock. – This can be a silent killer, as 30% of the blood

volume (up to 1500 ml in a 75 kg adult) will be lost before hypotension is noted.

• Loss of up to this volume from bleeding may only cause tachycardia.

• If there is hypotension with a systolic blood pressure of 90 mmHg or less, at least 1500-2000 ml of blood loss has occurred.

Haemodynamic Status

• Adequate access to the venous system for transfusion and fluid replacement must be achieved in the first hour of management.

Haemodynamic Status

• The primary assessment must focus on possible sources of bleeding, such as external blood loss and internal bleeding in the thorax, abdomen or retroperitoneal space, including disruption of the pelvic ring and multiple long-bone fractures, especially of the femoral shaft.

• Retroperitoneal hemorrhage may be associated with massive intravascular volume loss.

Haemodynamic StatusCauses of retroperitoneal hemorrhage

secondary to pelvic fracture

• Disruption of the venous plexus in the posterior pelvis (the usual cause)

• Large-vessel injury (e.g. external or internal iliac disruption) – 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.

Haemodynamic StatusCauses of retroperitoneal hemorrhage

secondary to pelvic fracture

• Pelvic fracture hemorrhage results most frequently from the venous structures and bleeding bone edges. – This hemorrhage stops in most patients secondary to tamponade from

increasing tissue pressure in the pelvic retroperitoneal space.

• However, in patients who died of pelvic fracture hemorrhage, single or multiple arterial lacerations were more likely to be present. – Arterial bleeding can overcome the tamponade effect of the

retroperitoneal tissues, leading to shock; this is the most common cause of death related to the pelvic fracture itself.

• Arterial bleeding usually arises from branches of the internal iliac system with the superior gluteal and pudendal arteries being the most commonly identified source.

Haemodynamic StatusResuscitation

• Hemorrhage in pelvic trauma may be life-threatening.

• The site of bleeding is determined by peritoneal lavage, portable ultrasound, or CT.

• In the resuscitative phase, control of hemorrhage must be rapid and may be lifesaving.


• After exclusion or control of the intra-abdominal bleeding, it must be determined whether the pelvic bleeding is located in the anterior or the posterior part of the ring, whether it is mainly from the fracture site and whether it is venous or arterial.


• Patients with an unstable pelvic disruption are at much greater general risk than those with a stable pelvis.

• Such patients require massive fluid replacement, as outlined in the ATLS protocol.


• Pelvic stabilization should be performed early, in the resuscitative phase of management.

• Provisional stabilization is required only for those fractures that potentially increase the volume of the pelvis, i.e., the wide open book injury (B1, B3.1) or the unstable pelvic fracture (C). – It is rarely required for lateral compression injuries

(B2), which make up a large percentage of the total number of pelvic disruptions.

Haemodynamic Status Options for immediate hemorrhage control

• Military antishock trousers (MAST): Typically applied in the field.– No impact on survival

rate.– Severe complications

reported (compartment syndrome, extremity loss)


• Anterior external fixator: – In the acute phase many advocate

external fixation as a temporary device to achieve stabilization of the fracture and a positive effect on haemorrhage.

– Placing the pins in the supra-acetabular bone improves stability and is safe if insertion is carried out under fluoroscopic guidance.


Pelvic binder (pelvic wrap): • This is wrapped circumferentially

around the pelvis.• In an incomplete unstable type of

fracture (e.g. an open book injury), internal rotation of the legs, if intact, will reduce the volume of the pelvic cavity and significantly improve the clinical condition.


• A sheet can be used if a binder is not available.


• Pelvic C-clamp– The pelvic C-clamp acts like a simple carpenter’s clamp

and can exert transverse compression directly across the sacroiliac joint.

– The C-clamp is generally applied in the emergency department, if possible with the aid of an image intensifier.

– The typical site for pin placement is at the point of intersection of a line from the posterior to the anterior superior iliac spine, with the extension of the longitudinal axis of the dorsal border of femur.

– C-clamp application can not only be difficult but dangerous in cases of comminuted sacral fractures: neurovascular injury can occur due to crushing of the sacrum.

Pelvic C-clamp


• 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.


• Consider angiography or embolization if hemorrhage continues despite closing of the pelvic volume.– Arterial lesions only represent

10-20% of cases.


• Angiographic embolization may be more time-consuming or delayed and surgical haemostasis may be available more rapidly.

• In some European trauma centers, pelvic packing has been advocated as an additional damage control procedure in posttraumatic pelvic bleeding

• Pelvic packing aims to directly tamponade sources of bleeding within the pelvis.

• Packs can be placed in the preperitoneal and retroperitoneal spaces.

• The method is invasive and the packs must be subsequently removed, usually 48 hours after insertion.

• Packing may be combined with concurrent external fixation.

Neurologic Injury

• An accurate neurologic examination is often difficult to obtain secondary to the patient’s inability to cooperate with the examination.

• Because the sciatic nerve and the branches of the sacral plexus are subject to injury with pelvic fracture, it is important to document neurologic function if possible.

• Recording the presence of rectal tone and the bulbocavernosus reflex is important.

• Distal motor and sensory function at the foot and ankle should be assessed where possible.

Genitourinary and Gastrointestinal Injury

• Bladder injury: – The clinical finding most observed after bladder injury is gross

hematuria, which is present in 95% of patients. • The remaining 5% of patients will have microscopic hematuria.

– The presence of a pelvic fracture, particularly combined with penile and scrotal ecchymosis, should raise suspicion for a bladder and/or urethral injury.

– When bladder injury is suspected, contrast cystography is performed in stable patients following placement of a Foley catheter.

– Treatment:• Extraperitoneal bladder injury: treatment is usually with Foley catheter

drainage. • Intraperitoneal bladder rupture: exploration and suture closure.

Suprapubic catheterization is not usually necessary, but when indicated, placement of the catheter must take into account the potential for contamination of anterior internal fixation. The suprapubic catheter may prevent the use of a suprapubic incision approach for skeletal fixation of the pelvic fracture. Where this approach to skeletal fixation is contemplated, another option for bladder drainage such as endoscopic placement of a transurethral catheter should be considered.


• Urethral injury: 10% incidence with pelvic fractures; much more frequently in male 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.


• Clinical examination and pelvic x-rays are obtained and, based on these, a decision to attempt bladder catheterization is made.

• When pelvic fracture is present, catheterization should be attempted by a clinician experienced in passing catheters in patients with urethral injury.

• Unless there is easy and unobstructed passage of the catheter into the bladder, efforts at passing the catheter are stopped and a contrast urethrogram is obtained by inflating the Foley catheter balloon in the penile urethra with 2-3 mL of saline and instilling 10-15 mL of water-soluble contrast material and obtaining an oblique film of the pelvis.


• 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.

Radiographic Evaluation

• Standard trauma radiographs:– AP view of the chest, – lateral view of the

cervical spine– AP view of the pelvis

• If possible, the AP pelvis film is obtained prior to bladder catheterization and cystography to avoid obscuring landmarks.


• AP of the pelvis:– Anterior lesions: pubic

rami fractures and symphysis displacement

– Sacroiliac joint and sacral fractures

– Iliac fractures

– L5 transverse process fractures


Special views of the pelvis:• Obturator and iliac oblique views: may be utilized in

suspected acetabular fractures.• Inlet radiograph• Outlet radiograph


Inlet Radiograph

• Taken with the patient supine with the tube directed 60° caudally, perpendicular to the pelvic brim.

• Useful for determining anterior or posterior displacement of the sacroiliac joint, sacrum, or iliac wing.

• It may determine internal rotation deformities of the ilium and sacral impaction injuries.


Outlet Radiograph

• Taken with the patient supine with the tube directed 45° cephalad.

• 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.

Computed Tomography

• CT is excellent for assessing the posterior pelvis, including the sacrum and sacroiliac joints.

• CT is not a method of emergency evaluation and can in most cases be delayed until the general condition of the patient stabilizes.

• The presence of a contrast blush seen on CT, strongly suggests, even in stable patients, ongoing bleeding and the need for therapeutic angiography.

Magnetic Resonance Imaging

• MRI has limited clinical utility owing to restricted access to a critically injured patient, prolonged duration of imaging, and equipment constraints.

• However, it may provide superior imaging of genitourinary and pelvic vascular structures.

Stress views

• Push-pull radiographs are performed under general anesthesia to assess vertical stability.– Tile defined instability as ≥0.5 cm of motion.

– Bucholz, Kellam, and Browner consider ≥1 cm of vertical displacement unstable.

Radiographic Signs of Instability

• Sacroiliac displacement of 5 mm in any plane.

• Posterior fracture gap (rather than impaction).

• Avulsion of the 5th lumbar transverse process, the lateral border of the sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous ligament).

Other Diagnostic Techniques

• Additional diagnostic techniques (e.g. ultrasonography, cystourethrography, EMG, etc) must be included in the early or late phase if a specific lesion is suspected.

Classification of Pelvic Fractures

• Classification of pelvic fractures and dislocations requires adequate plain radiography (AP, inlet, and outlet x-rays) and thin-cut (3-mm) CT scanning.

Classification

Young and Burgess

• This system is based on the mechanism of injury:– Lateral Compression (LC)

– AP Compression (APC)

– Vertical Shear (VS)

– Combined Mechanism (CM)

ClassificationYoung and Burgess

Lateral Compression (LC)

• Transverse fracture of pubic rami, ipsilateral or contralateral to posterior injury– LC-I: Sacral compression on side of impact (Stable because

ligaments remain intact)

– LC-II: Crescent (iliac wing) fracture on side of impact. Lateral force delivered more anteriorly than the LC-I pattern

– LC-III: LC-I or LC-II injury on side of impact; contralateral open-book (APC) injury


AP Compression (APC)

• Symphyseal diastasis or longitudinal rami fractures– APC-I: Slight widening of symphysis (<2.5 cm), but the posterior pelvic

ligaments are intact – APC-II: Widening of the symphysis > 2.5 cm with anterior opening of

the sacroiliac joint. The posterior sacroiliac ligaments are intact, but the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments are torn

– APC-III: Complete disruption of the ipsilateral ligaments, including the posterior sacroiliac ligaments, which results in rotational and vertical instability of the hemipelvis.


Vertical Shear (VS)

• Vertically applied forces caused by falls onto an extended lower extremity, impacts from above, or MVA with an extended lower extremity against the floorboard or dashboard.

• Typically associated with complete disruption of the symphysis, sacrotuberous, sacrospinous, and sacroiliac ligaments and result in extreme instability.

• Highly associated with neurovascular injury and hemorrhage.


Combined Mechanisms (CM)

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

Classification

Tile

• This classification combines a patient’s mechanism of injury and pelvic stability.

• It classifies pelvic fractures into 3 groups: – Type A: Stable fractures– Type B: Rotationally unstable, vertically stable– Type C: Rotationally and vertically unstable (i.e.

complete disruption of the anterior and posterior pelvic rings).

ClassificationTile

Type AStable

• A1: Fractures of the pelvis not involving the ring; avulsion injuries

• A2: Non-displaced or minimally displaced pelvic ring fracture (eg, superior & inferior pubic ramus fracture)

• A3: Transverse fractures of the inferior sacrum or coccyx with no disruption of the pelvic ring

ClassificationTile

Type BRotationally unstable, vertically stable

• B1: External rotation instability; open-book injury

• B2: LC injury affecting only one side of the pelvis, ipsilateral anterior and posterior ring involvement with instability in internal rotation

• B3: LC injury affecting both sides of the pelvis; bilateral rotational instability (‘bucket handle’ fracture)

ClassificationTile

Type CRotationally and vertically unstable

• C1: Ipsilateral anterior and posterior injury resulting in rotational and vertical instability of the hemipelvis

• C2: Bilateral injury resulting in rotational instability on one side and vertical instability on the other side

• C3: Bilateral pelvic injury in which both sides are rotationally and vertically unstable with an associated acetabular fracture

Factors increasing mortality

• Type of pelvic ring injury: Posterior disruption is associated with higher mortality (APC III, VS, LC III)

• High Injury Severity Score• Associated injuries: Head and abdominal, 50%

mortality• Hemorrhagic shock on admission• Requirement for large quantities of blood• Perineal lacerations, open fractures• Increased age

Morel-Lavallé lesion(Skin Degloving Injury)

• A Morel-Lavallée lesion is a closed degloving injury associated with severe trauma to the pelvis.

• It presents as a hemolymphatic mass located over the external aspect of the thigh.

• Since Morel-Lavallée first described the lesion in the 19th century, the term has been used to describe similar lesions in other anatomic sites such as the lumbar area and over the scapula.

Morel-Lavallé lesion(Skin Degloving Injury)

• Infected in one-third of cases

• Requires thorough debridement before definitive surgery

Open pelvic fractures

• Open pelvic fractures occur when there is communication between a fracture fragment and the skin or a pelvic visceral cavity.

• These injuries are observed in 4-5% of patients with pelvic fracture.

• The incidences of pelvic infection including soft tissue infection and osteomyelitis, as well as high mortality and long-term disability, are raised in patients with open pelvic fracture.


• During the acute evaluation of genitourinary injury in the patient with a pelvic fracture, a careful digital rectal is mandatory and a vaginal examination, if the patient can be comfortably positioned, is highly desirable.

• Palpable vaginal lacerations indicate open pelvic fracture.

• Occasionally, rectal lacerations can also be palpated but, in the majority, the most consistent finding indicating rectal injury in the patient with pelvic fracture is the finding of blood in the rectal lumen.


• Vaginal speculum examination and proctoscopic examination are postponed until it is safe to place the patient in the lithotomy or lateral decubitus position.

• Evaluation for fecal continence is not an emergency diagnostic procedure for patients with pelvic fracture.

• Damage to the anal sphincter with a perineal laceration suggests the need for diverting colostomy.

• When fecal soilage of an open wound is possible, diversion is performed to reduce the chance of pelvic wound infection.

TREATMENT

Decision making

• Decision making can be divided into 2 phases:– Detection and treatment of life-threatening

situations (Emergency algorithm)

– Diagnosis and detailed classification of the osteoligamentous injury and operative planning and surgery, if required.

Decision making

• Possible posterior ring injuries are iliac wing fractures, SI dislocations, and sacral fractures.

• Possible anterior ring injuries are rami fractures and symphyseal disruptions. – Pelvic injuries can include any combination of anterior and

posterior injuries, unilateral or bilateral.

Non-operative Treatment

• Fractures amenable to nonoperative treatment include:– Lateral impaction injuries with minimal (<1.5 cm)

displacement.– Pubic rami fractures with no posterior

displacement.– Gapping of pubic symphysis <2.5 cm.

Non-operative Treatment

• Rehabilitation:– Protect weight bearing typically with a walker or

crutches initially.– Serial radiographs are required after mobilization

has begun to monitor for subsequent displacement.– If displacement of the posterior ring >1 cm is

noted, weight bearing should be stopped. Operative treatment should be considered for gross displacement.

Principles of Definitive Fixation of Pelvic Fractures

1. With complete instability of the posterior ring (i.e., the posterior SI ligaments are disrupted), anterior fixation alone is inadequate.

2. With complete instability of the posterior ring and vertical instability, any posterior fixation should be supplemented with some form of anterior stabilization.

3. With partial instability of the pelvic ring (i.e., the posterior SI ligaments are intact), anterior fixation alone is adequate and full weight-bearing may be permitted.

Definitive Fixation of Pelvic Fractures

Disruptions of the Pubic Symphysis

• Options for stabilizing symphyseal disruptions:– Anterior external fixators – Internal fixation with plate and screws



• Advantages of external fixations:– They can be easily applied to pubic rami fractures as well as symphysis

disruption

– They can be applied in the emergency room, ICU, or operating room.

– External fixators can be applied when contamination from abdominal and genitourinary injuries makes internal fixation approaches hazardous.

– External fixation devices can be removed in the clinic or office setting.

• Disadvantages of external fixation: – Interference with positioning, sitting, and clothing.

– Pin site care and infection can be problematic, particularly with obese patients.

– It is more difficult to obtain and maintain an anatomic reduction of the anterior pelvic ring with external fixation devices.



• Advantages of Internal Fixation:– Absence of interference with positioning, sitting, or with

clothing

– No attendant problems of pin site care.

• Disadvantages of Internal Fixation:– It cannot be employed when there is contamination of the

operative field

– Formal reoperation is necessary if the fixation hardware must be removed

– Internal fixation potentially limits pelvic relaxation in women during childbirth.



• Fixation options are essentially the same for pubic ramus fractures as for pubic symphysis diastasis. – However, internal fixation with

plating does not carry the same long-term obstetrical or hardware failure sequelae.


Fixation of Posterior Pelvic Fractures

• Usually, a single pelvic reconstruction plate or lag screw along the crest supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim or sciatic buttress will suffice in neutralizing deforming forces until healing has occurred.


Fixation of Posterior Pelvic Fractures

• SI joint fixation options include: – iliosacral screws– anterior SI plating– posterior trans-iliac plating or

compression rods

Treatment according to Tile Classification

Treatment according to Tile Classification Type A

Stable

• A1: Fractures of the pelvis not involving the ring; avulsion injuries

• A2: Non-displaced or minimally displaced pelvic ring fracture (eg, superior & inferior pubic ramus fracture)

• A3: Transverse fractures of the inferior sacrum or coccyx with no disruption of the pelvic ring

• Stable, minimally displaced fractures with minimal disruption of the bony and ligamentous stability of the pelvic ring may successfully be treated with protected weight bearing and symptomatic treatment.

Treatment according to Tile Classification

Type A

Stable

• Virtually all type A fracture can be managed symptomatically with the following exceptions.

• Avulsion fractures (A1) of the iliac crest, esp. in young athletes, can be fixed with lag screws if widely displaced. • Fractures of the iliac wing with wide displacement (A2) may be fixed with standard techniques, especially in young women, as this injury can leave a malalignment of the iliac crest. • Transverse sacral fractures (A3) should be considered spinal injuries; therefore, with wide displacement and a sacral plexus neurological deficit, reduction with or without decompression is usually required.

Treatment according to Tile Classification Type B

Rotationally unstable, vertically stable • B1: External rotation

instability; open-book injury

• B2: LC injury affecting only one side of the pelvis, ipsilateral anterior and posterior ring involvement with instability in internal rotation

• B3: LC injury affecting both sides of the pelvis; bilateral rotational instability (‘bucket handle’ fracture)

• B1: – Symphyseal diastasis <2.5 cm: Protected

weightbearing & symptomatic treatment.– Symphyseal diastasis >2.5 cm: Ext fixation

or symphyseal plate is performed (ORIF preferred if laparotomy for associated injuries and no open injury), with possible fixation for the posterior injury.

• B2: Elastic recoil may improve pelvic anatomy. No stabilization is necessary

• B3 (bucket handle): The posterior sacral complex is commonly compressed.– Leg-length discrepancy <1.5 cm: No

stabilization is necessary.– Leg-length discrepancy >1.5 cm: External

fixation? ORIF?

Treatment according to Tile Classification Type C

Rotationally and vertically unstable

• C1: Ipsilateral anterior and posterior injury resulting in rotational and vertical instability of the hemipelvis

• C2: Bilateral injury resulting in rotational instability on one side and vertical instability on the other side

• C3: Bilateral pelvic injury in which both sides are rotationally and vertically unstable with an associated acetabular fracture

• C1, C2, C3: External fixation ± skeletal traction and ORIF are options.

Treatment according to Young and Burgess Classification

Treatment according to Young & Burgess Classification

LC

• LC-I: Sacral compression on side of impact (Stable)

• LC-II: Crescent (iliac wing) fracture on side of impact. Lateral force delivered more anteriorly than the LC-I pattern

• LC-III: LC-I or LC-II injury on side of impact; contralateral open-book (APC) injury

• LC-I: Protected weight bearing on the side of the posterior ring injury. Repeat x-rays 2-5 days after injury

• LC-II: Anterior and posterior fixation

• LC-III: Anterior and posterior fixation


APC

• Symphyseal diastasis or longitudinal rami fractures– APC-I: Slight widening of

symphysis (<2.5 cm), posterior ligaments intact

– APC-II: Widening of symphysis > 2.5 cm with anterior opening of sacroiliac joint. The posterior sacroiliac ligaments are intact, but the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments are torn

– APC-III: Complete disruption of the ipsilateral ligaments, including the posterior sacroiliac ligaments, which results in rotational and vertical instability of the hemipelvis.

• APC-I: Symptomatic management only

• APC-II: ORIF • APC-III: Control

haemorrhage by fracture reduction and stabilization with external fixation. posterior percutaneous iliosacral screws, either acutely or on a delayed basis depending on the patient's physiologic status


VS

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

• Depends on the posterior fracture location. Reduction with traction, percutaneous iliosacral screw fixation, and anterior stabilization (ORIF or external fixation).

Operative Techniques

External Fixation

• This can be applied as: – a construct mounted on 2-3 5-mm pins spaced 1 cm apart

along the anterior iliac crest, or

– single pins placed in the supraacetabular area in an AP direction (Hanover frame).

• External fixation is a resuscitative fixation and can only be used for definitive fixation of anterior pelvis injuries.– It cannot be used as definitive fixation of posteriorly

unstable injuries.

Internal Fixation

• This significantly increases the forces resisted by the pelvic ring compared with external fixation.

Internal Fixation

• Iliac wing fractures: Open reduction and stable internal fixation using lag screws and neutralization plates.

Internal Fixation

• Diastasis of the pubic symphysis: Plate fixation (if no open injury or cystostomy tube is present).– If the patient has a visceral injury necessitating a paramedian

midline or Pfannenstiel incision, or if preferred by the surgeon to external fixation, internal fixation using a 4.5-mm plate will restore stability.

• A single four-hole plate placed across the superior surface of the symphysis pubis is used.

• This should be done immediately after the abdominal procedure prior to closure of the skin.

Internal Fixation

• N.B. Plates should not be used in the presence of fecal contamination or the proposed use of a suprapubic tube.– In that situation, external fixation is usually the safer and

preferred option.

Internal Fixation

• Sacral fractures: Trans-iliac bar fixation may be inadequate or may cause compressive neurologic injury; in these cases, plate fixation or sacroiliac screw fixation may be indicated.

Transiliac bar posterior fixation

Internal Fixation

• Unilateral sacroiliac dislocation: Direct fixation with cancellous screws or anterior sacroiliac plate fixation is used.

Internal Fixation

• Bilateral posterior unstable disruptions: Fixation of the displaced portion of the pelvis to the sacral body may be accomplished by posterior screw fixation.

Implants

Plates: • Because of the difficulty in

contouring the standard plates in the several directions required, the 3.5-mm and 4.5-mm reconstruction plates are recommended for pelvic fixation. – In general, the 3.5-mm plates are

used on most women and smaller men, and the 4.5-mm plates on larger men.

Implants

Screws:• The 3.5-mm fully threaded cancellous screws and the

6.5-mm fully threaded cancellous screws are essential components of the fixation system, as well as all the standard lag screws in the two sizes (4.0 mm and 6.5 mm).

• Screws of exceptional length, up to 120 mm, are required in the pelvis.

Implants

Instruments• Since reduction of the pelvic fragments is the most

difficult part of the operation, special pelvic clamps are essential.

• These include the pointed fracture reduction clamps and the large pelvic reduction clamps held in place with 2 screws.

• Other specialized pelvic reduction clamps are also available.

Special Considerations

Average blood replacement

• LC = 3.6 U

• AP = 14.8 U

• VS = 9.2 U

• CM = 8.5 U

Post-operative Management

• Aggressive pulmonary toilet: – Incentive spirometry– Early mobilization– Encouraged deep inspirations and coughing– Suctioning or chest physical therapy if necessary.


• Prophylaxis against thromboembolic phenomena: – Combination of:

• elastic stockings• sequential compression devices• chemoprophylaxis (if hemodynamic status allows)

– Duplex ultrasound examinations may be necessary.– Thrombus formation may necessitate

anticoagulation and/or IVC filter placement.


• Weight-bearing status may be advanced as follows:– Full weight bearing on the uninvolved lower extremity within

several days.

– Partial weight bearing on the involved lower extremity is recommended for at least 6 weeks.

– Full weight bearing on the affected extremity 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.

Complications

• Infection: – Incidence is variable (0%-25%)– Presence of contusion or shear injuries to soft tissues

is a risk factor for infection if a posterior approach is used. • This risk is minimized by a percutaneous

posterior ring fixation.

Complications

• Thromboembolism: Disruption of the pelvic venous vasculature and immobilization constitute major risk factors for the development of DVT.

Complications

• Malunion: Significant disability may result, with complications including chronic pain, limb length inequalities, gait disturbances, sitting difficulties, low back pain, and pelvic outlet obstruction.

Complications

• Nonunion: – Rare, although it tends to occur more in younger

patients (average age 35 years) with possible sequelae of pain, gait abnormalities, and nerve root compression or irritation.

– Stable fixation and bone grafting are usually necessary for union.

Thank You