PELVIC RING INJURIES AND
ACETABULAR FRACTURES
NORDIC TRAUMA 2016, AARHUS
Ken F. Linnau, MD, MS
Emergency Radiology
Harborview Medical Center – University of Washington
Seattle, WA
Thanks to:
AJ Wilson, Spanaway, WA (formerly U of
Washington)
CC Blackmore, VMMC, Seattle, WA
RO Nathan, U of Washington, Seattle, WA
http://en.wikipedia.org/wiki/File:2008_Wrangler_JK_Unlimited_Sahara.jpg
Jeep Wrangler JK Unlimited Sahara
1948 kg, 55 km/h (15m/s)
http://en.wikipedia.org/wiki/File:2011_Ford_F-250_XLT_--_07-10-2010.jpg
Ford F250 Quad Cab
3715 kg, 65 km/h (18 m/s)
SOMETIMES THEY CRASH
CRASH!!
HOW BIG OF A BANG?
• E kin = ½ mv2
• E kin = ½ (3715 kg + 1948 kg)*
(18m/s +15 m/s)2
• E kin = 3 MJ
• ≈ two sticks of dynamite
SOMETIMES THEY CRASH
CRASH!!
EPIDEMIOLOGY: PELVIC RING
• Pelvic ring injury (19-37/100,000)
– About 2 % of all fractures
• Mortality rate: 9-19% (45% when open)
– Much higher than acetabular fx
• High-energy injury mechanism:
– MVC, MCC
– Car vs pedestrian
– Falls
• Associated injuries are very common
– Injury severity score (ISS) often > 15 (major trauma) Pohlemann-T et al. Injury 42 (2011): 997.
Gabbe-BJ et al. Injury 42 (2011): 985.
EPIDEMIOLOGY: ACETABULUM
• Acetabular fractures are uncommon (3/100,000)
• Mortality rate: about 3%
– Much lower than pelvic ring disruption
• Most common mechanism:
– MVC (up to 80%)
– Falls (increasing)
– Car vs pedestrian
• Elderly: Mean age trending up (falls?)
• Elderly: Injury severity (ISS) trending down
Laird-A, Keating- JF, JBJS, 2005; 87-B: 969
HOW DOES PELVIC RING INJURY KILL?
• Pelvic ring injuries bleed.
– Most bleeding is venous (> 80%)
– Arterial bleeding in less than 20%
– Arterial injury can be treated with embolization
• Level I recommendations for hemodynamically unstable patients
– Size of extraperitoneal hematoma predicts arterial injury and need for transfusion
– Pelvic angiography indicated in 3-10% of pelvic fractures
Blackmore-CC et al. Arch Surgery (2003); 138:504-9.
Cullinane-DC et al. J Trauma (2011) 71(6): 1850-68.
HOW TO SELECT FOR ANGIO?
• No CT available, xray only:
• Clinical prediction rule
• With CT available:
• Absence of blush dismisses need for pelvic hemorrhage control in majority of cases
• Arterial contrast extravasation: angio Blackmore-CC et al. J Trauma (2006); 61(2): 346-52.
Verbeek-DOF et al. J Trauma (2014); 76(2): 374-79.
Cullinane-DC et al. J Trauma (2011); 71(6): 1850-68.
PREDICTING MAJOR PELVIC
HEMORRHAGE
• Displaced obturator ring fracture (> 1cm)
• Diastatic symphysis (> 1cm)
• Hematocrit < 30%
• Pulse > 130 beats/min
None: less than 2% major pelvic hemorrhage
3 or 4: more than 60% major pelvic hemorrhage
Blackmore-CC et al. J Trauma (2006); 61(2): 346-52.
Pulse 130
First Hct 19%
IMAGING
–AP radiograph: overview
–Oblique pelvic views • Inlet and outlet views for pelvic ring injury
• Judet views for acetabulum (Obturator oblique/Iliac oblique)
–CT best for full assessment of injury • Consider 3D reformations
HOW TO CLASSIFY PELVIC RING INJURY
• Use Young-Burgess or modified Tile (AO/OTA).
– Most widely used by orthopedic surgeons
– Both aim to aid in treatment decision making
• Modified Tile (AO/OTA):
– Emphasizes stability and mechanism of injury
• Young-Burgess:
– Based primarily on mechanism of injury
– Higher reliability over all (optimal) Koo-H et al. J Orthop Trauma (2008) 22 (6):379-84.
Young Burgess:
Combined Mechanism (CM)
ACETABULUM: SURGEONS WANT TO
KNOW…
– Type of fracture
– Alignment and displacement
– Stability
– Type of surgical exposure
– Letournel acetabular classification
• Helps to select appropriate exposure
• May predict outcome
ML Routt, Jr.: “Surgical treatment of acetabular fractures” in Skeletal
Trauma, 4th Ed, Saunders 2009
38 YOM, 6 FT FALL
Logroll
patient 45°
in each
direction
LETOURNEL AND JUDET COLUMN
CONCEPT
ANTERIOR COLUMN OF THE
ACETABULUM
– Anterior border of the iliac wing
– Pelvic brim: the bony ridge in the cavity of the pelvis that marks the boundary between the false pelvis and the true pelvis
– Superior pubic ramus
– Anterior wall of acetabulum
POSTERIOR COLUMN OF THE
ACETABULUM
• Posterior column – Greater and lesser
sciatic notch
– Ischial tuberosity
– Posterior wall of acetabulum
LETOURNEL AND JUDET FRACTURE
CLASSIFICATION
Simple
fractures
Posterior wall Posterior
column
Anterior wall Anterior
column
Transverse
Complex
fractures
Posterior
column and
Posterior wall
Transverse
and posterior
wall
T- type
transverse
Anterior column
and posterior
hemitransverse
Both column
30%
70%
LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse Ant column Anterior wall
Transv/ post wall Post column Post wall
T-type AC/ post hemitransv Transverse / post wall
PC/ post wall Post col/ post wall
Both column
LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse Ant column Anterior wall
Transv/ post wall Post column Post wall
T-type AC/ post hemitransv Transverse / post wall
PC/ post wall Post col/ post wall
Both column
Transverse Column Wall
Sagittal Coronal Peripheral
MORE EPIDEMIOLOGY
Ferguson TA, et al. JBJS-Br 2010: 92-B, 2: 250
LETOURNEL AND JUDET CLASSIFICATION –
RESHUFFLED BY PREVALENCE
Transverse Column Wall
Transverse/ post wall
Both column Post wall
T-type AC/ post hemitransverse Anterior wall
Transverse
Ant column
PC/ post wall
Post column
LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse/ post wall Both column Post wall
T-type
Transverse
80-90% of all acetabular fxs
22 YOM MVC
22 YOM MVC
Posterior wall fracure
47 YOM BICYCLE CRASH
LETOURNEL AND JUDET
CLASSIFICATION -- RESHUFFLED
Transverse Column Wall
Transverse/ post wall Both column Post wall
T-type
Transverse
85 YOF FALL
Sagittal
85 YOF FALL
Transverse
29 YOF MVC
29 YOF MVC
Sagittal
29 YOF MVC
Superior
Inferior
Transverse T-
type
22 YOM MVC
22 YOM MVC
22YOM MVC
Both
column
Anterior
Posterior
22YOM MVC
Johnson TS. Radiology 2005; 235(3): 1023
43 YOM MCC
43 YOM MCC
Sagittal Peripheral
Transverse with associated posterior wall fracture
43 YOM MCC
SUMMARY
• Pelvic ring injuries may require angio-embolization
– Consider using clinical prediction rule
– Retroperitoneal hematoma size
– Blush on CT
• Posterior wall, both column and transverse variants account for 80-90% of acetabular fractures
• Column == Coronal at the tectum
• Transverse == Sagittal at tectum, no iliac wing extension
SURGICAL APPRAOCH
Surgical approach Fracture type
Kocher - Langenbeck Posterior wall
Posterior column
Transverse
Transverse –Posterior wall
Some T-type
Ilioinguinal Anterior column
Anterior wall
Anterior column posterior
hemitranverse
Transverse
Both column
Some T-type
Extended Iliofemoral, Stoppa,
trochanteric flip
Variable
Copyright © 2006 by the American Roentgen Ray Society
Durkee, N. J. et al. Am. J. Roentgenol. 2006;187:915-925
--Normal pelvic bone anatomy