Pelvic fracturesPelvic fractures

Dr SHAMMAS B MDr SHAMMAS B M

Dept of Dept of Orthopedics Orthopedics

Calicut Medical Calicut Medical CollegeCollege

• Fractures of the adult pelvis, Fractures of the adult pelvis, generally are either generally are either

• (1) stable fractures resulting from (1) stable fractures resulting from low-energy trauma, such as falls in low-energy trauma, such as falls in elderly patients or elderly patients or

• (2) fractures caused by high-energy (2) fractures caused by high-energy trauma that result in significant trauma that result in significant morbidity and mortality morbidity and mortality

• The potential complications include injuries The potential complications include injuries to the major vessels and nerves of the to the major vessels and nerves of the pelvis and the major viscera, such as the pelvis and the major viscera, such as the intestines, the bladder, and the urethra intestines, the bladder, and the urethra

• Immediately after injury, mortality can Immediately after injury, mortality can result from severe intrapelvic hemorrhage. result from severe intrapelvic hemorrhage.

• Hemorrhage frequently results from fracture Hemorrhage frequently results from fracture surfaces and small vessels in the surfaces and small vessels in the retroperitoneum. retroperitoneum.

• ANATOMY ANATOMY • The pelvis is composed anteriorly of the The pelvis is composed anteriorly of the

ring of the pubic and ischial rami ring of the pubic and ischial rami connected with the symphysis pubis. connected with the symphysis pubis.

• A fibrocartilaginous disc separates the two A fibrocartilaginous disc separates the two pubic bodies. pubic bodies.

• The sacrum and the two innominate bones The sacrum and the two innominate bones are joined at the sacroiliac joint by theare joined at the sacroiliac joint by the

• interosseous sacroiliac ligamentsinterosseous sacroiliac ligaments

• the sacrotuberous ligamentsthe sacrotuberous ligaments

• the anterior and posterior sacroiliac ligaments, the anterior and posterior sacroiliac ligaments,

• the sacrospinous ligaments,the sacrospinous ligaments,

• iliolumbar ligaments iliolumbar ligaments

• This ligamentous complex provides stability to This ligamentous complex provides stability to the posterior sacroiliac complex because the the posterior sacroiliac complex because the sacroiliac joint itself has no inherent bony sacroiliac joint itself has no inherent bony stabilitystability

• Pelvic stability is determined by Pelvic stability is determined by ligamentous structures in various planes.ligamentous structures in various planes.

• The primary restraints to external The primary restraints to external rotation of the hemipelvis are the rotation of the hemipelvis are the ligaments of the symphysis, the ligaments of the symphysis, the sacrospinous ligament, and the anterior sacrospinous ligament, and the anterior sacroiliac ligament. sacroiliac ligament.

• Rotation in the sagittal plane is resisted Rotation in the sagittal plane is resisted by the sacrotuberous ligament.. by the sacrotuberous ligament..

• Vertical displacement of the Vertical displacement of the hemipelvis is controlled by all the hemipelvis is controlled by all the mentioned ligamentous structures,mentioned ligamentous structures,

• but if other ligaments are absent, it but if other ligaments are absent, it may be controlled by intact may be controlled by intact interosseous sacroiliac and posterior interosseous sacroiliac and posterior sacroiliac ligaments, along with the sacroiliac ligaments, along with the iliolumbar ligament. iliolumbar ligament.

CLASSIFICATION CLASSIFICATION

• Pennal et al. developed a Pennal et al. developed a mechanistic classification in which mechanistic classification in which pelvic fractures are described as pelvic fractures are described as

• anteroposterior compression anteroposterior compression injuries,injuries,

• lateral compression injuries, lateral compression injuries,

• vertical shear injuries. vertical shear injuries.

• Tile modified the Pennal system to Tile modified the Pennal system to make it an alphanumeric system make it an alphanumeric system involving three groups based on the involving three groups based on the concept of pelvic stability concept of pelvic stability – A (stable), A (stable), – B (rotationally unstable but vertically B (rotationally unstable but vertically

stable),stable),– C (rotationally and vertically unstable). C (rotationally and vertically unstable).

• Type B1 fractures include "open book" Type B1 fractures include "open book" fractures or anterior compression injuries fractures or anterior compression injuries in which the anterior pelvis opens through in which the anterior pelvis opens through a diastasis of the symphysisa diastasis of the symphysis

• or through a fracture of the anterior pelvic or through a fracture of the anterior pelvic ring. The posterior sacroiliac and ring. The posterior sacroiliac and interosseous ligaments remain intact. interosseous ligaments remain intact.

• In the first stage, the symphysis In the first stage, the symphysis separation is less than 2.5 cm, and the separation is less than 2.5 cm, and the sacrospinous ligament remains intact.sacrospinous ligament remains intact.

• In the second stage, the diastasis is more In the second stage, the diastasis is more than 2.5 cm with rupture of the sacrospinous than 2.5 cm with rupture of the sacrospinous ligament and the anterior sacroiliac ligament.. ligament and the anterior sacroiliac ligament..

• In the third stage, the lesions are bilateral, In the third stage, the lesions are bilateral, creating a B3 injurycreating a B3 injury

• Young and Burgess proposed a different Young and Burgess proposed a different modification of the original Pennal modification of the original Pennal classification, adding a new category for classification, adding a new category for combined mechanical injuries combined mechanical injuries

• Sacral fractures have been classified separately Sacral fractures have been classified separately classification used is by Denis, Davis, and classification used is by Denis, Davis, and Comfort Comfort

• type 1 fractures occur lateral to the neural type 1 fractures occur lateral to the neural foramina through the sacral ala; foramina through the sacral ala;

• type 2 fractures are transforaminal;type 2 fractures are transforaminal;• type 3 fractures occur medial or central to the type 3 fractures occur medial or central to the

neural foramina. neural foramina. • Transverse fractures of the sacrum are classified Transverse fractures of the sacrum are classified

as type 3 injuries because they involve the spinal as type 3 injuries because they involve the spinal canal. canal.

ROENTGENOGRAPHIC ROENTGENOGRAPHIC EVALUATION EVALUATION

• The standard roentgenographic The standard roentgenographic projections required for evaluation of projections required for evaluation of pelvic fractures are an pelvic fractures are an

• anteroposterior view of the pelvis andanteroposterior view of the pelvis and

• 40-degree caudad inlet and 40-degree caudad inlet and

• 40-degree cephalad outlet views 40-degree cephalad outlet views described by Pennal et al.. described by Pennal et al..

• The inlet view demonstrates rotational The inlet view demonstrates rotational deformity or anteroposterior deformity or anteroposterior displacement of the hemipelvis. displacement of the hemipelvis.

• The outlet view demonstrates vertical The outlet view demonstrates vertical displacement of the hemipelvis, sacral displacement of the hemipelvis, sacral fractures, and widening or fracture of fractures, and widening or fracture of the anterior pelvisthe anterior pelvis

• Computed tomography is an Computed tomography is an essential part of the evaluation of essential part of the evaluation of any significant pelvic injury, allowing any significant pelvic injury, allowing evaluation of the posterior portion of evaluation of the posterior portion of the pelvic ring that may be poorly the pelvic ring that may be poorly seen on standard roentgenographs. seen on standard roentgenographs.

• Widening of the symphysis of more than 2.5 cm Widening of the symphysis of more than 2.5 cm has been correlated with rupture of the has been correlated with rupture of the sacrospinous ligament and a rotationally unstable sacrospinous ligament and a rotationally unstable pelvis.pelvis.

• Avulsion fractures of the lateral sacrum and Avulsion fractures of the lateral sacrum and ischial spine also are signs of rotational ischial spine also are signs of rotational instability.instability.

• Widening of the anterior pelvis causes rupture of Widening of the anterior pelvis causes rupture of the anterior sacroiliac ligament, making the the anterior sacroiliac ligament, making the sacroiliac joint appear widened on the sacroiliac joint appear widened on the anteroposterior view.anteroposterior view.

•

• However, as demonstrated by axial CT However, as demonstrated by axial CT images, the posterior ligaments of the images, the posterior ligaments of the sacroiliac joint may remain intact, maintaining sacroiliac joint may remain intact, maintaining the vertical stability of the pelvis. the vertical stability of the pelvis.

• Impacted fractures of the anterior cortex of Impacted fractures of the anterior cortex of the sacrum are common with lateral the sacrum are common with lateral compression injuries and generally are stable, compression injuries and generally are stable,

• but a sacral fracture with a gap usually but a sacral fracture with a gap usually indicates vertical instability. indicates vertical instability.

• An avulsion fracture of the tip of the L5 An avulsion fracture of the tip of the L5 transverse process at the attachment of transverse process at the attachment of the iliolumbar ligament is another the iliolumbar ligament is another indication of vertical instabilityindication of vertical instability

• Vertical instability usually is defined as 1 Vertical instability usually is defined as 1 cm or more of cephalad migration of one cm or more of cephalad migration of one hemipelvis.hemipelvis.

• if vertical stability is questionable, stress if vertical stability is questionable, stress testing can be beneficial.testing can be beneficial.

• Bucholz recommended a push-pull Bucholz recommended a push-pull test in which, under test in which, under roentgenographic control, the roentgenographic control, the examiner pushes up on one examiner pushes up on one extremity while pulling down on the extremity while pulling down on the other.other.

TREATMENT: RESUSCITATION TREATMENT: RESUSCITATION PHASE PHASE

• During acute resuscitation, management During acute resuscitation, management of patients with pelvic fractures should of patients with pelvic fractures should follow one of the existing trauma protocols follow one of the existing trauma protocols

• The MAST suit (military antishock The MAST suit (military antishock trousers) has proved beneficial during trousers) has proved beneficial during patient transport but is not used routinely patient transport but is not used routinely in the evaluation/resuscitation phasein the evaluation/resuscitation phase

• A deflatable bean bag has been suggested A deflatable bean bag has been suggested to stabilize the pelvis temporarily in the to stabilize the pelvis temporarily in the initial resuscitation phase. initial resuscitation phase.

External Fixation External Fixation

• In patients with an unstable pelvic fracture In patients with an unstable pelvic fracture who demonstrate hemodynamic instability who demonstrate hemodynamic instability after an initial fluid bolus, emergency after an initial fluid bolus, emergency external fixation should be performed early external fixation should be performed early in the resuscitation effort. in the resuscitation effort.

• Reported benefits are Reported benefits are • (1) a tamponade effect on the (1) a tamponade effect on the

retroperitoneal hematoma, effected by retroperitoneal hematoma, effected by reducing the retroperitoneal volume; reducing the retroperitoneal volume;

• (2) less motion of the fracture surfaces, (2) less motion of the fracture surfaces, which allows more effective clot formation; which allows more effective clot formation; and and

• (3) greater patient mobility during transport (3) greater patient mobility during transport and for CT scanning and other evaluations and for CT scanning and other evaluations

• Moreno et al., Burgess et al., and others Moreno et al., Burgess et al., and others noted a reduction in the transfusion noted a reduction in the transfusion requirements of patients with unstable requirements of patients with unstable pelvic fractures who were treated with pelvic fractures who were treated with immediate external fixation compared with immediate external fixation compared with those who did not undergo immediate those who did not undergo immediate fixation. fixation.

• Many variations of pelvic external Many variations of pelvic external fixators are available. fixators are available.

• simple anterior frame with two 5-mm simple anterior frame with two 5-mm pins in each iliac wing is used pins in each iliac wing is used commonly. commonly.

• Vertically unstable fractures usually Vertically unstable fractures usually also are treated with ipsilateral distal also are treated with ipsilateral distal femoral skeletal traction until definitive femoral skeletal traction until definitive internal fixation can be done. internal fixation can be done.

• In the emergent application of a pelvic In the emergent application of a pelvic external fixator, the following basic external fixator, the following basic technical principles must be observed:technical principles must be observed:

• adequate soft tissue protection via guide adequate soft tissue protection via guide sleeves for drilling and pin insertion;sleeves for drilling and pin insertion;

• skin incisions at 90 degrees to the iliac skin incisions at 90 degrees to the iliac crest and large enough to accommodate crest and large enough to accommodate guide sleeves; guide sleeves;

• 5 mm or larger blunt half-pins, 5 mm or larger blunt half-pins, • 180 mm in length or longer180 mm in length or longer

• 2 or 3 pin clusters per hemipelvis;. 2 or 3 pin clusters per hemipelvis;. • converging pin placement into the converging pin placement into the

anterior third of the iliac wing;anterior third of the iliac wing;• a frame construct that provides a frame construct that provides

clearance from and access to the clearance from and access to the abdomen; abdomen;

• and dual frame construct to allow and dual frame construct to allow independent free manipulation independent free manipulation without loss of pelvic reduction. without loss of pelvic reduction.

• Pins can be placedPins can be placed

• percutaneously or percutaneously or

• via an open technique.via an open technique.

• If the pins are placed percutaneously, If the pins are placed percutaneously,

• Pin is placed 2 cm posterior to the Pin is placed 2 cm posterior to the anterosuperior iliac spine. aiming the pin anterosuperior iliac spine. aiming the pin toward the greater trochanter and allowing toward the greater trochanter and allowing it to find its way between the tables of the it to find its way between the tables of the hemipelvis. hemipelvis.

• Frame Construction and Fracture Frame Construction and Fracture Reduction/Stabilization.Reduction/Stabilization.

• Apply two upright bars to each pin cluster Apply two upright bars to each pin cluster and connect them to cross bars, thereby and connect them to cross bars, thereby creating a dual Slatis-type rectangular creating a dual Slatis-type rectangular frame construct.frame construct.

• Each independent frame can be loosened Each independent frame can be loosened subsequently and manipulated, thereby subsequently and manipulated, thereby allowing access to the abdomen. allowing access to the abdomen.

• Once the pins are in position and the frame is Once the pins are in position and the frame is constructed, before tightening, reduce the constructed, before tightening, reduce the displaced pelvic ring injury. displaced pelvic ring injury.

• Open book types require "closure of the book;" Open book types require "closure of the book;" • lateral compression injuries require "opening lateral compression injuries require "opening

the book." the book." • Tile C injuries are unstable posteriorly, and Tile C injuries are unstable posteriorly, and

simple "book-closing" maneuvers can further simple "book-closing" maneuvers can further displace the disrupted posterior pelvic displace the disrupted posterior pelvic anatomy. Therefore, apply bilateral anatomy. Therefore, apply bilateral compressive forces to the pelvic ring compressive forces to the pelvic ring posteriorly. posteriorly.

• If used for the definitive treatment of the If used for the definitive treatment of the pelvic fracture, the frame is left in place pelvic fracture, the frame is left in place for 8 to 12 weeks, depending on the for 8 to 12 weeks, depending on the fracture type and reduction.fracture type and reduction.

• Pin site care must be meticulous, with Pin site care must be meticulous, with peroxide swabs used twice daily to clean peroxide swabs used twice daily to clean away the crusted transudate that often away the crusted transudate that often forms. forms.

Pelvic Clamps Pelvic Clamps

• Because in vertically unstable fractures an Because in vertically unstable fractures an anteriorly applied external fixator does not anteriorly applied external fixator does not control motion in the posterior sacroiliac control motion in the posterior sacroiliac complex,complex,

• the Ganz C-clamp andthe Ganz C-clamp and• the pelvic stabilizer developed by Browner the pelvic stabilizer developed by Browner

and associates. and associates. • Used only as a temporary stabilizing device Used only as a temporary stabilizing device

that should be removed within 5 days if that should be removed within 5 days if possible. possible.

TREATMENT: TREATMENT: RECONSTRUCTIVE PHASE RECONSTRUCTIVE PHASE • Stable, nondisplaced pelvic fractures (Tile Stable, nondisplaced pelvic fractures (Tile

type A) do not require operative stabilization type A) do not require operative stabilization and can be adequately managed with early and can be adequately managed with early mobilization and analgesics. mobilization and analgesics.

• Operative reduction and stabilization have Operative reduction and stabilization have been advocated for rotationally unstable but been advocated for rotationally unstable but vertically stable (Tile type B) fractures with a vertically stable (Tile type B) fractures with a

• pubic symphysis diastasis of more than 2.5 pubic symphysis diastasis of more than 2.5 cm, cm,

• pubic rami fractures with more than 2 cm pubic rami fractures with more than 2 cm displacement, or displacement, or

• other rotationally unstable pelvic other rotationally unstable pelvic injuries with significant limb-length injuries with significant limb-length discrepancy of more than 1.5 cm or discrepancy of more than 1.5 cm or

• unacceptable pelvic rotational unacceptable pelvic rotational deformity. deformity.

• Operative treatment of rotationally Operative treatment of rotationally unstable pelvic fractures can be unstable pelvic fractures can be accomplished by accomplished by

• an anterior external fixator used for an anterior external fixator used for definitive treatment or definitive treatment or

• open reduction and internal fixation with open reduction and internal fixation with anterior plating. anterior plating.

• Retrograde pubic ramus screws placed Retrograde pubic ramus screws placed percutaneously or with an open technique percutaneously or with an open technique also have been described also have been described

• External fixator ay be especially useful in External fixator ay be especially useful in patients with associated genitourinary or patients with associated genitourinary or gastrointestinal injuries with significant gastrointestinal injuries with significant contamination or other soft tissue contamination or other soft tissue problems that might preclude anterior problems that might preclude anterior open reduction and internal fixation. open reduction and internal fixation.

• Some authorsadvocate the use of a single Some authorsadvocate the use of a single four- or six-hole 3.5-mm reconstruction four- or six-hole 3.5-mm reconstruction plate. plate.

Anterior Internal Fixation of Anterior Internal Fixation of Tile Types B and C Pelvic Tile Types B and C Pelvic Fractures Fractures • Approach the symphysis through a Approach the symphysis through a

Pfannenstiel incision Pfannenstiel incision

• for reduction of the symphysis, place a for reduction of the symphysis, place a Weber clamp anterior to the rectus Weber clamp anterior to the rectus muscles onto the body of the pubis muscles onto the body of the pubis bilaterally. bilaterally.

• a curved, 3.5-mm reconstruction plate on a curved, 3.5-mm reconstruction plate on the superior surface of the symphysis is the superior surface of the symphysis is used for fixation used for fixation

• Double plating is used only in type C Double plating is used only in type C injuries when it is not certain that posterior injuries when it is not certain that posterior fixation is possible during the initial fixation is possible during the initial procedure, as in a patient undergoing procedure, as in a patient undergoing emergency laparotomyemergency laparotomy

• If internal fixation of a pubic ramus If internal fixation of a pubic ramus fracture is indicated in a type B or C pelvic fracture is indicated in a type B or C pelvic fracture, it is performed through an fracture, it is performed through an ilioinguinal incision . ilioinguinal incision .

• Tile type C pelvic injuries require posterior Tile type C pelvic injuries require posterior fixation to regain vertical stability.fixation to regain vertical stability.

• External fixation alone is not External fixation alone is not recommended as definitive treatment for recommended as definitive treatment for vertically unstable pelvic fractures, vertically unstable pelvic fractures,

• because the posterior instability cannot because the posterior instability cannot be controlled by this treatment method. be controlled by this treatment method.

• For Tile type C fractures the anterior ring can be For Tile type C fractures the anterior ring can be fixed with either an external fixator or an anterior fixed with either an external fixator or an anterior plate as described above.plate as described above.

• Posterior treatment generally is determined by the Posterior treatment generally is determined by the portion of the posterior ring disrupted.portion of the posterior ring disrupted.

• For sacral fractures and sacroiliac joint disruptions For sacral fractures and sacroiliac joint disruptions some authors have described image intensifier–some authors have described image intensifier–directed screw fixation from the ilium posteriorly into directed screw fixation from the ilium posteriorly into the sacral body . the sacral body .

• This technique risks damage to the L5 nerve root This technique risks damage to the L5 nerve root and iliac vessels anterior to the body of the sacrum and iliac vessels anterior to the body of the sacrum and to the sacral nerve roots within its bony confinesand to the sacral nerve roots within its bony confines

• Because neurological injury occurs with 30% of Because neurological injury occurs with 30% of transforaminal sacral fractures (Denis zone II transforaminal sacral fractures (Denis zone II fractures), fractures),

• some authors advocate open reduction and some authors advocate open reduction and internal fixation of such fractures with internal fixation of such fractures with decompression of the involved neural foramina. decompression of the involved neural foramina.

• Transiliac rod fixation has been reported for Transiliac rod fixation has been reported for sacral disruptions, although there is a risk of sacral disruptions, although there is a risk of neurological injury with compression of the neurological injury with compression of the sacrum sacrum

• . Tension band plating also can be used between . Tension band plating also can be used between the two posterior iliac crests the two posterior iliac crests

• Simpson et al. reported excellent results Simpson et al. reported excellent results with the use of the anterior retroperitoneal with the use of the anterior retroperitoneal approach for anterior plating of the approach for anterior plating of the sacroiliac joint because it allowed direct sacroiliac joint because it allowed direct observation of the joint .observation of the joint .

• If this approach to the sacroiliac joint is If this approach to the sacroiliac joint is used, the superior gluteal artery, L4 nerve used, the superior gluteal artery, L4 nerve root, and lumbosacral trunk must be root, and lumbosacral trunk must be carefully protected, especially in the inferior carefully protected, especially in the inferior third of the joint. third of the joint.

• For iliac wing fractures, open reduction For iliac wing fractures, open reduction and pelvic reconstruction plate fixation and pelvic reconstruction plate fixation techniques are used. techniques are used.

• For fracture-dislocations of the sacroiliac For fracture-dislocations of the sacroiliac joint (the so-called joint (the so-called crescent fracturecrescent fracture), ), the fracture can be reduced and fixed the fracture can be reduced and fixed anteriorly or posteriorly, with or without anteriorly or posteriorly, with or without hardware transfixing the sacroiliac joint.hardware transfixing the sacroiliac joint.

• Internal Fixation: Posterior Screw Fixation of Internal Fixation: Posterior Screw Fixation of Sacral Fractures and Sacroiliac Dislocations Sacral Fractures and Sacroiliac Dislocations (Prone)(Prone)

• Use a standard posterior vertical incision, 2 Use a standard posterior vertical incision, 2 cm lateral to the posterior superior spine, cm lateral to the posterior superior spine, for sacroiliac dislocations, fracture-for sacroiliac dislocations, fracture-dislocations, or sacral fractures.dislocations, or sacral fractures.

• Reflect the posterior portion of the gluteal Reflect the posterior portion of the gluteal muscles from the posterior iliac wing and muscles from the posterior iliac wing and the gluteus maximus origin from the the gluteus maximus origin from the sacrum. Expose the greater sciatic notch to sacrum. Expose the greater sciatic notch to evaluate reduction. evaluate reduction.

• Under image intensifier control, Under image intensifier control, insert screws perpendicular to the insert screws perpendicular to the iliac wing across the sacroiliac joint iliac wing across the sacroiliac joint into the sacral ala, directing the into the sacral ala, directing the screws toward the S1 vertebral body. screws toward the S1 vertebral body.

• Percutaneous Iliosacral Screw Fixation of Percutaneous Iliosacral Screw Fixation of Sacroiliac Disruptionsand Sacral Fractures Sacroiliac Disruptionsand Sacral Fractures (Supine)(Supine)

• the normal sacral ala has an inclined the normal sacral ala has an inclined anterosuperior surface, the sacral alar anterosuperior surface, the sacral alar slope, that extends from proximal-slope, that extends from proximal-posterior to distal-anterior .posterior to distal-anterior .

• Anterior to the sacral ala in this region run Anterior to the sacral ala in this region run the L5 nerve route and the iliac vessels. the L5 nerve route and the iliac vessels.

• The cortex of the alar slope forms the anterior The cortex of the alar slope forms the anterior boundary of the "safe zone" for passage of boundary of the "safe zone" for passage of iliosacral screws into the body of S1. The iliosacral screws into the body of S1. The posterior boundary of the safe zone is formed posterior boundary of the safe zone is formed by the foramen of the S1 nerve root. by the foramen of the S1 nerve root.

• Screws used to fix sacroiliac joint disruptions Screws used to fix sacroiliac joint disruptions are placed perpendicular to the joint, whereas are placed perpendicular to the joint, whereas

• screws used to fix sacral fractures are placed screws used to fix sacral fractures are placed more transversely to allow passage of the more transversely to allow passage of the screw into the contralateral ala. screw into the contralateral ala.

• Anterior Approach and Stabilization of Anterior Approach and Stabilization of Sacroiliac JointSacroiliac Joint

• Upper half of a Smith-Petersen incision Upper half of a Smith-Petersen incision along the anterior iliac crest is usedalong the anterior iliac crest is used

• initially used staples but now uses initially used staples but now uses dynamic compression plates, dynamic compression plates, reconstruction plates, or four-hole reconstruction plates, or four-hole plates. plates.