Pelvic fractures

Dr SHAMMAS B M
Dept of
Orthopedics
Calicut Medical
College
• Fractures of the adult pelvis,
generally are either
• (1) stable fractures resulting from
low-energy trauma, such as falls in
elderly patients or
• (2) fractures caused by high-energy
trauma that result in significant
morbidity and mortality
• The potential complications include
injuries to the major vessels and
nerves of the pelvis and the major
viscera, such as the intestines, the
bladder, and the urethra
• Immediately after injury, mortality
can result from severe intrapelvic
hemorrhage.
• Hemorrhage frequently results from
fracture surfaces and small vessels in
• ANATOMY
• The pelvis is composed anteriorly of the
ring of the pubic and ischial rami
connected with the symphysis pubis.
• A fibrocartilaginous disc separates the two
pubic bodies.
• The sacrum and the two innominate bones
are joined at the sacroiliac joint by the
• interosseous sacroiliac ligaments
• the sacrotuberous ligaments
• the anterior and posterior sacroiliac
ligaments,
• the sacrospinous ligaments,
• iliolumbar ligaments
• This ligamentous complex provides
stability to the posterior sacroiliac complex
because the sacroiliac joint itself has no
inherent bony stability
• Pelvic stability is determined by
ligamentous structures in various
planes.
• The primary restraints to external
rotation of the hemipelvis are the
ligaments of the symphysis, the
sacrospinous ligament, and the
anterior sacroiliac ligament.
• Rotation in the sagittal plane is
• Vertical displacement of the
hemipelvis is controlled by all the
mentioned ligamentous structures,
• but if other ligaments are absent, it
may be controlled by intact
interosseous sacroiliac and posterior
sacroiliac ligaments, along with the
iliolumbar ligament.
CLASSIFICATION

• Pennal et al. developed a

mechanistic classification in which
pelvic fractures are described as
• anteroposterior compression
injuries,
• lateral compression injuries,
• vertical shear injuries.
• Tile modified the Pennal system to
make it an alphanumeric system
involving three groups based on the
concept of pelvic stability
– A (stable),
– B (rotationally unstable but vertically
stable),
– C (rotationally and vertically unstable).
• Type B1 fractures include "open book"
fractures or anterior compression injuries
in which the anterior pelvis opens through
a diastasis of the symphysis
• or through a fracture of the anterior pelvic
ring. The posterior sacroiliac and
interosseous ligaments remain intact.
• In the first stage, the symphysis
separation is less than 2.5 cm, and the
sacrospinous ligament remains intact.
• In the second stage, the diastasis is more
than 2.5 cm with rupture of the
sacrospinous ligament and the anterior
sacroiliac ligament..
• In the third stage, the lesions are bilateral,
creating a B3 injury
• Young and Burgess proposed a different
modification of the original Pennal
classification, adding a new category for
combined mechanical injuries
• Sacral fractures have been classified separately
classification used is by Denis, Davis, and
Comfort
• type 1 fractures occur lateral to the neural
foramina through the sacral ala;
• type 2 fractures are transforaminal;
• type 3 fractures occur medial or central to the
neural foramina.
• Transverse fractures of the sacrum are classified
as type 3 injuries because they involve the spinal
canal.
ROENTGENOGRAPHIC
EVALUATION
• The standard roentgenographic
projections required for evaluation of
pelvic fractures are an
• anteroposterior view of the pelvis
and
• 40-degree caudad inlet and
• 40-degree cephalad outlet views
described by Pennal et al..
• The inlet view demonstrates
rotational deformity or
anteroposterior displacement of the
hemipelvis.
• The outlet view demonstrates
vertical displacement of the
hemipelvis, sacral fractures, and
widening or fracture of the anterior
pelvis
• Computed tomography is an
essential part of the evaluation of
any significant pelvic injury, allowing
evaluation of the posterior portion of
the pelvic ring that may be poorly
seen on standard roentgenographs.
• Widening of the symphysis of more than 2.5 cm
has been correlated with rupture of the
sacrospinous ligament and a rotationally unstable
pelvis.
• Avulsion fractures of the lateral sacrum and
ischial spine also are signs of rotational
instability.
• Widening of the anterior pelvis causes rupture of
the anterior sacroiliac ligament, making the
sacroiliac joint appear widened on the
anteroposterior view.
•
• However, as demonstrated by axial CT
images, the posterior ligaments of the
sacroiliac joint may remain intact,
maintaining the vertical stability of the
pelvis.
• Impacted fractures of the anterior cortex
of the sacrum are common with lateral
compression injuries and generally are
stable,
• but a sacral fracture with a gap usually
indicates vertical instability.
• An avulsion fracture of the tip of the L5
transverse process at the attachment of
the iliolumbar ligament is another
indication of vertical instability
• Vertical instability usually is defined as 1
cm or more of cephalad migration of one
hemipelvis.
• if vertical stability is questionable, stress
testing can be beneficial.
• Bucholz recommended a push-pull
test in which, under
roentgenographic control, the
examiner pushes up on one
extremity while pulling down on the
other.
TREATMENT: RESUSCITATION
PHASE
• During acute resuscitation, management
of patients with pelvic fractures should
follow one of the existing trauma protocols
• The MAST suit (military antishock
trousers) has proved beneficial during
patient transport but is not used routinely
in the evaluation/resuscitation phase
• A deflatable bean bag has been
suggested to stabilize the pelvis
temporarily in the initial resuscitation
phase.
 External Fixation
• In patients with an unstable pelvic fracture
who demonstrate hemodynamic instability
after an initial fluid bolus, emergency
external fixation should be performed
early in the resuscitation effort.
• Reported benefits are
• (1) a tamponade effect on the
retroperitoneal hematoma, effected by
reducing the retroperitoneal volume;
• (2) less motion of the fracture surfaces,
which allows more effective clot formation;
and
• (3) greater patient mobility during
transport and for CT scanning and other
evaluations
• Moreno et al., Burgess et al., and others
noted a reduction in the transfusion
requirements of patients with unstable
pelvic fractures who were treated with
immediate external fixation compared
with those who did not undergo immediate
fixation.
• Many variations of pelvic external
fixators are available.
• simple anterior frame with two 5-
mm pins in each iliac wing is used
commonly.
• Vertically unstable fractures usually
also are treated with ipsilateral distal
femoral skeletal traction until
definitive internal fixation can be
done.
• In the emergent application of a pelvic
external fixator, the following basic
technical principles must be observed:
• adequate soft tissue protection via guide
sleeves for drilling and pin insertion;
• skin incisions at 90 degrees to the iliac
crest and large enough to accommodate
guide sleeves;
• 5 mm or larger blunt half-pins,
• 180 mm in length or longer
• 2 or 3 pin clusters per hemipelvis;.
• converging pin placement into the
anterior third of the iliac wing;
• a frame construct that provides
clearance from and access to the
abdomen;
• and dual frame construct to allow
independent free manipulation
without loss of pelvic reduction.
• Pins can be placed
• percutaneously or
• via an open technique.
• If the pins are placed percutaneously,
• Pin is placed 2 cm posterior to the
anterosuperior iliac spine. aiming the pin
toward the greater trochanter and
allowing it to find its way between the
tables of the hemipelvis.
• Frame Construction and Fracture
Reduction/Stabilization.
• Apply two upright bars to each pin cluster
and connect them to cross bars, thereby
creating a dual Slatis-type rectangular
frame construct.
• Each independent frame can be loosened
subsequently and manipulated, thereby
allowing access to the abdomen.
• Once the pins are in position and the
frame is constructed, before tightening,
reduce the displaced pelvic ring injury.
• Open book types require "closure of the
book;"
• lateral compression injuries require
"opening the book."
• Tile C injuries are unstable posteriorly,
and simple "book-closing" maneuvers can
further displace the disrupted posterior
pelvic anatomy. Therefore, apply bilateral
compressive forces to the pelvic ring
posteriorly.
• If used for the definitive treatment of the
pelvic fracture, the frame is left in place
for 8 to 12 weeks, depending on the
fracture type and reduction.
• Pin site care must be meticulous, with
peroxide swabs used twice daily to clean
away the crusted transudate that often
forms.
Pelvic Clamps
• Because in vertically unstable fractures an
anteriorly applied external fixator does not
control motion in the posterior sacroiliac
complex,
• the Ganz C-clamp and
• the pelvic stabilizer developed by Browner
and associates.
• Used only as a temporary stabilizing
device that should be removed within 5
days if possible.
TREATMENT:
RECONSTRUCTIVE PHASE
• Stable, nondisplaced pelvic fractures (Tile
type A) do not require operative
stabilization and can be adequately
managed with early mobilization and
analgesics.
• Operative reduction and stabilization have
been advocated for rotationally unstable
but vertically stable (Tile type B) fractures
with a
• pubic symphysis diastasis of more than
2.5 cm,
• pubic rami fractures with more than 2 cm
displacement, or
• other rotationally unstable pelvic
injuries with significant limb-length
discrepancy of more than 1.5 cm or
• unacceptable pelvic rotational
deformity.
• Operative treatment of rotationally
unstable pelvic fractures can be
accomplished by
• an anterior external fixator used for
definitive treatment or
• open reduction and internal fixation with
anterior plating.
• Retrograde pubic ramus screws placed
percutaneously or with an open technique
also have been described
• External fixator ay be especially useful in
patients with associated genitourinary or
gastrointestinal injuries with significant
contamination or other soft tissue
problems that might preclude anterior
open reduction and internal fixation.
• Some authorsadvocate the use of a single
four- or six-hole 3.5-mm reconstruction
plate.
Anterior Internal Fixation of
Tile Types B and C Pelvic
Fractures
• Approach the symphysis through a
Pfannenstiel incision
• for reduction of the symphysis, place a
Weber clamp anterior to the rectus
muscles onto the body of the pubis
bilaterally.
• a curved, 3.5-mm reconstruction plate on
the superior surface of the symphysis is
used for fixation
• Double plating is used only in type C
injuries when it is not certain that posterior
fixation is possible during the initial
procedure, as in a patient undergoing
emergency laparotomy
• If internal fixation of a pubic ramus
fracture is indicated in a type B or C pelvic
fracture, it is performed through an
ilioinguinal incision .
• Tile type C pelvic injuries require
posterior fixation to regain vertical
stability.
• External fixation alone is not
recommended as definitive
treatment for vertically unstable
pelvic fractures,
• because the posterior instability
cannot be controlled by this
• For Tile type C fractures the anterior ring can be
fixed with either an external fixator or an anterior
plate as described above.
• Posterior treatment generally is determined by
the portion of the posterior ring disrupted.
• For sacral fractures and sacroiliac joint
disruptions some authors have described image
intensifier–directed screw fixation from the ilium
posteriorly into the sacral body .
• This technique risks damage to the L5 nerve root
and iliac vessels anterior to the body of the
sacrum and to the sacral nerve roots within its
bony confines
• Because neurological injury occurs with 30% of
transforaminal sacral fractures (Denis zone II
fractures),
• some authors advocate open reduction and
internal fixation of such fractures with
decompression of the involved neural foramina.
• Transiliac rod fixation has been reported for
sacral disruptions, although there is a risk of
neurological injury with compression of the
sacrum
• . Tension band plating also can be used between
the two posterior iliac crests
• Simpson et al. reported excellent results
with the use of the anterior retroperitoneal
approach for anterior plating of the
sacroiliac joint because it allowed direct
observation of the joint .
• If this approach to the sacroiliac joint is
used, the superior gluteal artery, L4 nerve
root, and lumbosacral trunk must be
carefully protected, especially in the
inferior third of the joint.
• For iliac wing fractures, open
reduction and pelvic reconstruction
plate fixation techniques are used.
• For fracture-dislocations of the
sacroiliac joint (the so-called
crescent fracture), the fracture can
be reduced and fixed anteriorly or
posteriorly, with or without hardware
transfixing the sacroiliac joint.
• Internal Fixation: Posterior Screw Fixation
of Sacral Fractures and Sacroiliac
Dislocations (Prone)
• Use a standard posterior vertical incision,
2 cm lateral to the posterior superior
spine, for sacroiliac dislocations, fracture-
dislocations, or sacral fractures.
• Reflect the posterior portion of the gluteal
muscles from the posterior iliac wing and
the gluteus maximus origin from the
sacrum. Expose the greater sciatic notch
to evaluate reduction.
• Under image intensifier control,
insert screws perpendicular to the
iliac wing across the sacroiliac joint
into the sacral ala, directing the
screws toward the S1 vertebral body.
• Percutaneous Iliosacral Screw Fixation of
Sacroiliac Disruptionsand Sacral Fractures
(Supine)
• the normal sacral ala has an inclined
anterosuperior surface, the sacral alar
slope, that extends from proximal-
posterior to distal-anterior .
• Anterior to the sacral ala in this region run
the L5 nerve route and the iliac vessels.
• The cortex of the alar slope forms the
anterior boundary of the "safe zone" for
passage of iliosacral screws into the body
of S1. The posterior boundary of the safe
zone is formed by the foramen of the S1
nerve root.
• Screws used to fix sacroiliac joint
disruptions are placed perpendicular to the
joint, whereas
• screws used to fix sacral fractures are
placed more transversely to allow passage
of the screw into the contralateral ala.
• Anterior Approach and Stabilization
of Sacroiliac Joint
• Upper half of a Smith-Petersen
incision along the anterior iliac crest
is used
• initially used staples but now uses
dynamic compression plates,
reconstruction plates, or four-hole
plates.