34

8. 9. 10. II. 12. 13.

JOLLEY.

W.

C.

HEAD

M. N.: SALVATI, E. A.: and BROWN. G. C.: Early Results and Complications of Surface Replacement of the Hip. J. Bone and Joint 64.A: 366-377, March 1982. MA. S. M. : KAISO, J. M. : and AM5TUTz. H. C. : Frictional Torque in Surface and Conventional Hip Replacement. J. Bone and Joint Surg.. 65-A: 366-370, March 1983. MALLORY. T. H. and DANi. JOHN: Conservative Total Hip Replacement. A Comparison of Wagner Resurfacing Arthroplasty and Total Articular Replacement Arthroplasty. Orthopedics. 5: 10 1 2- 1 (1 1 5 . 1982. SEW HOY. A. L.: HEDLE, A. K.: CLARKE. I. C.: GRUEN. T. A. W.: AMSTUTZ, H. C.: COSTER. I.: and MORELAND. J. R.: The Acetabular Cement-Bone Interface in Experimental Arthroplasties in Dogs. Clin. Orthop.. 155: 231-243. 1981. T0wNLE\-. C. 0.: Hemi and Total Articular Replacement Arthroplasty of the Hip with the Fixed Femoral Cup. Orthop. Clin. North America, 13: 869-894. 1982. TRENTANI, C. and VACCARINO. F.: Italian Experience. Resurfacing Arthroplasty Using the Paltrinieri-Trentani Resurfacing Arthroplasty, 8 Year Assessment. Orthop. Trans., 5: 374. 1981. Surg.
.

(up

right

I M4

flu

Journal

o/ Bone

ii,id

Joint

.5ur,ri

incorporatt-d

The

Role

of Computerized

Tomographic Pelvic
MD.I, Science Health

Scanning Fractures
DALLAS, Center TEXAS at Dallas. Dallas

in the Evaluation
BY From KEVIN GILL. M.D.t, AND Surgery. the Division of Orthopaedic

of Major
ROBERT Unis-ersirsW. of Texas

BUCHOLZ,

ABSTRACT:

Twenty-five

patients

with

double

ver-

tical fractures of the pelvic ring had evaluations plain radiography and computed-tomography of the pelvis. interpretation graphs, based In eight of the twenty-five that was made from the on the classification of

by both scanning

conventional treatments has stimulated a new interest double vertical fracture-dislocations of the hemipelvis. In order essential that in turn logical pelvic depends to make the pelvic on the correct therapeutic injury be properly precise determination decisions classified,

in

patients, the plain radioPennal et al.,

it is which

of its patho-

changed when additional anatomical information was provided by the computed-tomography scan. We recommend that computed tomography be used for: (1) double vertical fracture-dislocations of the pelvic ring in which plain radiographs are inadequate to judge pelvic stability, (2) fractures of the pelvic ring with extension into the acetabulum, and (3) major injuries to the hemipelvis that are to be treated by open reduction and internal fixation. However, due to the increased cost and radiation exposure, routine computed-tomography scanfling is not justified for all injuries to the pelvic ring.

anatomy. Accurate restoration of the anatomy of the ring is the surest way to minimize future morbidity.

Most classification systems rely on a clinical judgment of the probable mechanism of injury, and are based on the interpretation of standard anteroposterior, inlet, and tilt radiographs of the pelvis6. The quality of these routine radiographs varies with the position of the injured patient, overlying soft-tissue and gas shadows, and radiographic resolution. osseous sential A precise determination of the extent of the and ligamentous injury to the for correct therapeutic decisions, pelvis, which is therefore is esoften

impossible. The computer-assisted delineation fractures

purpose of this study was to ascertain if tomographic scans significantly aid in the anatomy of double vertical

Vertical fractures that are on the same side of the pelvic ring. and are both anterior and posterior to the acetabulum (Malgaigne pattern), may result in an unstable hemipelvis. Such injuries are a leading cause in the multiply injured patient. peutic techniques associated pelvic viously high fatality directed visceral rates, of morbidity and mortality Although improved thera-

of the pathological of the pelvic ring. Materials and with

Methods double with vertical both fracture anteroof

Twenty-five the pelvic ring

patients were

at intrapelvic hemorrhage and injuries have diminished the prelittle progress has been made in that often follows these highof symptomatic limb-length sacro-iliac arthritis low-back of the Iumbosacral plexus rewith the long-term results of
.

examined

routine

posterior radiographs and pelvic computed-tomography scans. All patients had sustained at least one fracture anterior and one posterior to either patients ranged from eleven thirty years). patients. All such There injuries acetabulum. to sixty-three The ages of the years (median, male impact

reducing the chronic disability energy injuries. The incidence discrepancy, pelvic obliquity pain, and permanent deficits mains high35. Dissatisfaction
5

were eight female and seventeen were caused by a high-energy

Read

at the

Annual

Meeting

of The

American

Academy

of OrthoHealth Sci-

paedic
ence

Surgeons. t Division
Center,

Anaheim. of Orthopaedic
5323 Harry

California. Surgery.
Boulevard,

March I I . 1983. University ot Texas

Dallas. Texas

Hines

75235.

as a motor-vehicle accident or a fall from a height. Each injury was classified by the schema of Pennal et al. , using the information obtained from plain anteropostenor radiographs. Inlet and tilt radiographs of the pelvis were not made routinely, in order to minimize the total
THE JOURNAL OF BONE
AND JOINT SURGERY

COMPUTERIZED

TOMOGRAPHIC

SCANNING

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EVALUATION I
THOSE MADF.

OF

MAJOR

PELVIC

FRACTURES

35

TABLE
DIAGNOSES Initial MADE Classification. FROM

Pt..;iN

RADIOGRAPHS

CoSIPARI:D

ViTH

FROSt

CoslPtTF:n-TosiouRxPH\

S-sNs

Based

on Anteropostertor Radiographs

Fttial (lassittcation. Computed-Totitographv

Based on Scans

Anteroposterior

conipression

injury

3-l

Anteroposterior

compression

injury

Lateral

compression

injury

.:c::%.4

I.ateral

compression

injury

2 Vertical Total
*

I7 Vertical 25 Total compression lesions, and two of fifteen apparent shear injury

shear

injury

I5 25

In two

of three

apparent

anteroposterior of diagnosis of Pennal

compression was made. et al.

injuries,

four

of seven

apparent

lateral

vertical-shear 1 Based

injuries, a change on the classification

!:iI
FIG. 1-A

In this

eighteen-year-old

patient

the

anteroposterior

radiograph

is suggestive

of a stable

lateral

compression

injury

of the

pelvis.

FIG.

I-B with comminution of the sacro-iliac joint and posterior displacement

The of the

computed-tomography hemipelvis.

scan,

however.

demonstrates

an unstable

fracture

36

KEVIN

GILL

AND

R.

W.

BUCHOLZ

1!

FIG.

2-A comminution of the sacral pars lateralis and diastasis of the pubic symphysis

This preoperative plain with cephalad displacement

radiograph of the

of a seventeen-year-old left hemipelvis.

patient

shows

radiation exposure of the patient. The three major categories in the classification of Pennal et al are: ( 1 ) anteroposterior compression injury, (2) lateral compression injury (stable
.

or unstable),

and

(3)

vertical

shear

injury. of the pelvis were also within one week of the from the scans

Computed-tomography made for all twenty-five

scans patients

The gantry also could be tilted to as much as 20 degrees off the vertical, thus altering the plane of tomography to improve visualization of any fracture fragments. Five-millimeter contiguous cross-sectional images were made every twenty-two seconds, with a radiation dose of approximately one rad per axial cut. An average of eight to ten axial cuts was necessary to evaluate the posterior elements of the pelvic ring. An entire pelvic study was completed in less than ten minutes. The scanned, anterior thus part minimizing underwent of the pelvic ring radiation was not dose routinely the total surgical

time of injury. The anatomical were then used to reclassify

data obtained each injury.

The General Electric 8800 scanner was used for all patients. in the doughnut-shaped gantry be varied in diameter from

high-resolution whole-body The patient was positioned of the scanner, which could to forty-five centimeters.

twenty

to the patient. Twelve of the patients

procedures

The

postoperative

radiograph

in the same

patient

shows

screw

fixation

of the

left

sacro-iliac

joint

and

plate

fixation

of the

pubis.

THE

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37 role. Cornosseous or hemipelvic rupture of the

and the

had result.

follow-up

computed-tomography

scans

to evaluate

plex plays an especially important supporting plete disruption of one or more of these ligarnentous components results in an unstable fragment. Lesser injuries, such as an isolated

Results In eight
injury, made

patients
from plain

the

initial
radiographs,

classification
was

of the pelvic
changed because

of the

additional

anatomical
.

information

provided

by the had had antero-

anterior sacro-iliac ligament or a hairline fracture through the sacral forarnen, are minimally displaced and essentially stable. With complete posteriordisruption ofthe pelvic ring, however, displacement patterns rotatory
pelvic

computed-tomography the complete plain posterior, tilt, in classification were

scan Four radiographic

of these patients study, including

of the hernipelvis

may

occur

in three

and inlet radiographs. Table I lists the changes according to specific mechanism of injury. that originally as unstable In two joint
two and

planes. Most and external

criteria for

of injury involve cephalad. posterior, displacement While no quantitative

.

Four injuries reclassified 1-B).

had been vertical-shear patients

classified as stable injuries (Figs. comminution

unsuspected

it has been posterior unstable

stability have been universally accepted. generally agreed that any degree of cephalad or of the hemipelvis study is diagnostic of an pelvis

displacement lesion6.

1-A and
raphy

of these was
demonstrated

severe
previously

of the sacro-iliac
scan,

shown

on the computed-tomog-

A standard

radiographic

of a traumatized

posterior displacement In six patients occult joint

of the ilium at the sacro-iliac joint. injuries to the contralateral sacro-iliac

were revealed by the scan. Unexpected extension of the hemipelvic fracture into the acetabulum was made visible by the computed-tomography scan in three patients. Similarly, an unsatisfactory position on the of the plain screws, which was impossible to visualize was shown by the postoperative scans in three patients (Figs. 2-A, 2-B, and 2-C). The scanner can produce sagittal reconstructive images by utilizing the information provided It creates an image in the sagittal plane by the axial images. that is perpendicular radiographs,

includes anteroposterior, inlet (x-ray beam directed 30 to 45 degrees caudad), and tilt radiographs (x-ray beam directed 30 to 45 degrees cephalad). The inlet radiograph visualizes the anterior aspect of the sacral pars lateralis, the sacro-iliac joint, and the adjacent part of the ilium, and can be used to detect anteroposterior displacement pelvis. The tilt radiograph discloses the extent displacement. demonstrate iliac joint, iliac pelvic pelvic
is rarely

of the hemiof cephalad

None ofthese standard radiographs, however. the status of the posterior aspect of the sacrothe amount of comminution of a sacral or sacroor the Thus, is feasible,
from

fracture, fragment. stability

true

amount while
these

of rotation some inference definition

of the of the

hemiinjury

concerning

a precise
standard

to the axial plane. However, these sagittal reconstructions were not found to be as helpful in revealing fracture-dislocations of the pelvic ring as they have been in demonstrating isolated acetabular fractures. Discussion Stability integrity joint.
structures.

attainable

radiographs.

Computerized tomographic scans appear to offer several distinct advantages over routine radiographs. These indude: ( 1 ) an unobstructed cross-sectional image of the severity of the posterior injury to the pelvic ring; (2) a clear display of the spatial orientation and planes of displacement of the hemipelvis; (3) a detailed involvement; and (4) in patients an accurate duction, the way to evaluate of the implants. placement picture of any acetabular treated by internal fixation. adequacy and of the fracture progress reof

ofthe sacrum, The

pelvic the

ring ilium,

is dependent including and the sacro-iliac

on the structural the sacro-iliac ligament cornligament adjoining

of the posterior the

elements,

posterosuperior

The postoperative
position of the screws

computed-totiiography delayed mobilization

scan reveals that of the patient.

the screw

threads

did not gain

adequate

purchase

on the

intact

sacrum.

This

unsatisfactory

VOl.

66-...

NC)

I. JANUARY

1954

38

KEVIN

GILL

AND

R.

W.

BUCHOLZ

This

anteroposterior

radiograph

of a twenty-five-year-old

victim

of a motor-vehicle

accident

shows

a seemingly

intact

pelvic

ring.

FIG.

3-B

The computed-tomography part of the sacrum was

also

scan, noted.

however.

demonstrates

a previously

unsuspected

locked

sacro-iliac

joint.

Extensive

comminution

of the

posterior

healing

of the fracture. The degree of posterior disruption of the pelvic ring is invariably underestimated on plain radiographs (Figs. 3-A and 3-B). While fractures of the sacrum or ilium and subluxations of the sacro-iliac joint are generally detectable, the extent of comminution most joint is often less evident. Fracture comminution occurs pect of the sacro-iliac frequently along the anterior asand through the thinned cortices

scan

The axial transverse cuts of the computed-tomography can provide indisputable evidence of fracture
.

displacement5 are especially vic disruptions, anteroposterior vertical-shear

Anteroposterior and rotational malposition well delineated. In their classification of pelPennal et al. distinguished between stable and lateral compression injuries injuries, based on an evaluation and unstable of the status

along the sacral foramina29. Occasionally the entire sacral pars lateralis will be fragmented. In three patients in our series the comminution was judged on the computed-tomography scans to be too extensive fixation, and external fixation to permit satisfactory internal was chosen as an alternative

of the posterosuperior sacro-iliac relative positions of the hemipelvic twenty-five patients were initially sion injuries graph, but vertical-shear injury seen for definitive accordingly.

ligament complex and the fragments Four of our judged to have compres.

on the basis of a single anteroposterior radiolater the injuries were reclassified as unstable fractures because of the complete posterior on the computed-tomography treatment in these four The results of this and treat pathological all scans. The plans patients were altered study injuries rather of injury.
AND JOINT SURGERY

treatment. Posterior locking of the anterior lip of the ilium behind the sacral portion ofthe sacro-iliacjoint was apparent in three of our twenty-five patients. While such locking may be seen on a standard inlet radiograph of the pelvis, this obscured graphically. portion of the joint is difficult to analyze radio-

comparative pelvic anatomy

have on the than by

prompted us to judge basis of their specific a presumptive diagnosis

THE

of the mechanism
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COMPUTERIZED

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SCANNING

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EVALUATION

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FRACTURES

39 fixation in three

Acetabular
ring

disruptions

frequently

accompany

pelvic is usually scans and ace-

fracture patients also

scans

was thought in our series.

to compromise Callus formation

fracture

injuries. While involvement of the hip joint obvious on plain radiographs, computed-tomography ideally outline the degree of fracture comminution tabular greatly proaches. incongruity47. facilitate the Computerized preoperative

and bone-remodeling

tomographic studies planning of surgical ap-

were clearly visualized on the computed-tomography that were obtained two to six months after injury. Based on the results of this study, we recommend the use of adjunctive computed-tomography scans in the evaluation of major pelvic-ring injuries when there is a double
vertical fracture or subluxation of

Open reduction preferred treatment operative decisions and weight-bearing

and internal fixation is occasionally the for an unstable pelvic-ring injury9. Postconcerning mobilization of the patient must be based on a clinical judgment and time. often easily poof the

the hemipelvis

in which concluthere is

anteroposterior,

sively

demonstrate

inlet, and tilt the stability

radiographs cannot of the injury; when

at the time of operation of the adequacy of the fixation the phase of osseous healing at any given point in The exact location and purchase of screw threads are difficult to determine on plain radiographs, but are seen on computed-tomography scans. An unsatisfactory sition of the screws in the region of comminution

an iliac fracture and when major by open reduction of the pelvic exposure of scanning of justified.

with extension into one injuries of the hemipelvis and internal fixation

or both acetabula; are to be treated of the posterior part

ring. However, due to the cost and radiation pelvic computed-tomography scans, routine all patients with pelvic-ring injuries is not

References
1 . BUCHOLZ, R. W.: The Pathological Anatomy of Malgaigne Fracture-Dislocations of the Pelvis. J. Bone and Joint Surg. . 63-A: 400-404. March 1981. 2. HOLDSWORTH, F. W.: Dislocation and Fracture-Dislocation of the Pelvis. J. Bone and Joint Surg. . 30-B(3): 461-466, 1948. 3. HUNDLEY, J. M. : Ununited Unstable Fractures of the Pelvis. In Proceedings of The American Academy of Orthopaedic Surgeons. J. Bone and Joint Surg. 48-A: 1025, July 1966. 4. LANGE, T. A. . and ALTER, A. J. . JR. : Evaluation of Complex Acetabular Fractures by Computed Tomography. J. Comput. Assist. Tomog. . 4: 849-852, 1980. 5. LAWSON, T. L.; FOLEY. W. D.; CARRERA. G. F.; and BERLAND. L. L.: The Sacroiliac Joints: Anatomic, Plain Roentgenographic and Computed Tomographic Analysis. J. Comput. Assist. Tomog. , 6: 307-314. 1982. 6. PENNAL, G. F.: TILE, MARVIN; WADDELL, J. P.; and GAR5IDE, HENRY: Pelvic Disruption: Assessment and Classification. Clin. Orthop.. 151: 1221, 1980. 7. SHIRKHODA, ALl; BRASHEAR, H. R. ; and STAAB. E. V. : Computed Tomography of Acetabular Fractures. Radiology, 134: 683-688. 1980. 8. SLAT1s. P. , and HUITTINEN, V.-M.: Double Vertical Fractures of the Pelvis. A Report on 163 Patients. Acta Chir. Scandinavica, 138: 799-807,

1972.
9.
TILE, MARVIN:

Pelvic

Fractures:

Operative

Versus

Nonoperative

Treatment.

Orthop.

Clin.

North

America,

11: 423-464,

1980.

VOL.

66-A,

NO.

1, JANUARY

1984