PELVIC FRACTURES

PELVIC FRACTURES

 Fractures of the pelvis account for less than

5% of all skeletal injuries, but it is important
because it associated with:-
2. Soft tissue injuries and blood loss.
3. Shock.
4. Sepsis.
5. ARDS.
 Because of those mortality rate exceeds
10%.
PELVIC FRACTURES

 Fractures of the adult pelvis, exclusive of

the acetabulum, generally are either
stable fractures resulting from low-
energy trauma, such as falls in elderly
patients, or fractures caused by high-
energy trauma that result in significant
morbidity and mortality.
PELVIC FRACTURES

 As is true of fractures of other bones, low-

energy trauma to the pelvis generally
produces stable fractures that can be treated
symptomatically with crutch- or walker-
assisted ambulation and that can be expected
to heal uneventfully in most patients. High-
energy pelvic fractures often are managed
operatively, with the treatment method
determined by the degree of pelvic stability
remaining after the injury.
PELVIC FRACTURES

 Types of injury:
 Four groups
3. Isolated fractures with an intact ring.
4. Fractures with broken ring (stable or
unstable).
5. Fracture of the acetabulum; although it is ring
fracture but involvement of the joint raise a
special problem.
6. Sacrococcygeal fractures.
Isolated fractures

1. Avulsion fractures. A piece of bone is pulled

off by violent muscle contraction usually
seen in athletes.
a. The anterior superior iliac spine pulled off by
sartorius muscle.
b. The anterior inferior iliac spine by rectus femoris.
c. The pubis by adductor longus.
d. Part of ischium by the hamstrings
 All need only resting for few days and
reassurance.
Isolated fractures

2. Direct fractures. A direct blow to the

pelvis like fall from a height may lead to
fracture of the iliac blade or the
ischium.
 Rest until pain subsides is usually all
that is needed.
Isolated fractures

3. Stress fractures. Fractures of the pubic

rami and around the sacro-iliac joint in
severely osteoporotic and
osteomalacic patients; it is usually
painless and discovered accidentally.
Fractures of the pelvic ring

 Because of the rigidity of the pelvis, a break at

one point in the ring should be associated with
disruption at a second point except
a. Fractures due to direct blow.
b. Acetabular floor fractures.
c. Ring fractures in children.
 The second point break is usually not visible
either it is reduced immediately or the
sacroiliac joint is only partially disrupted.
Mechanisms of injury

 The basic mechanisms of pelvic ring

injury are:
3. Anteroposterior compression (APC).
4. Lateral compression (LC).
5. Vertical shear (VS).
6. Combinations of these.
Anteroposterior compression (APC)

 Usually caused by a frontal collision between

pedestrian and a car. This injury may lead to:
2. Fracture of the rami.
3. The innominate bones are sprung apart and
externally rotated with disruption of the
symphysis.
4. The anterior sacroiliac joint is partially torn.
5. Fracture of the posterior part of the ilium.
 This is called open book injury.
Lateral compression (LC)

 Side to side compression of the pelvis causes

the ring to buckle and break. This is due to a
side –on impact in a road accident or a fall
from a height.
 This injury may lead to
3. Anteriorly the pubic rami on one side or both
sides are fractured.
4. Posteriorly there is severe sacroiliac strain or
fracture of the sacrum or ilium, either on the
same side of the pubic fracture or on the
opposite side.
Vertical shear (VS)

 The innominate bone on one side is

displaced vertically, fracturing the pubic
rami and disrupting the sacroiliac region
on the same side. This is typically occurs
when falls from a height on one leg.
These are severe unstable injuries with
gross tearing of the soft tissues and
associated with retroperitoneal
hemorrhage.
Combination injuries

 In severe pelvic injuries there may be a

combination of the above.
Classification

 The Young-Burgess (1986; 1987) system is as

follows:
1. APC injury
 The hallmark of the AP compression injury is pubic
diastasis with or without disruption of the SI joints.
The location and degree of diastasis is correlated
with the magnitude of force imparted to the pelvis
and with the amount of resulting instability. The AP
compression causes the pelvis to open: one or both
hemipelves undergo external rotation. According to
the Young-Burgess classification system, 3 degrees
of AP compression injury are identified.
Classification

 APC- I injuries: Less than 2.5 cm of

the pubic diastasis is noted, either at
the symphysis or through vertically
oriented rami fractures. The SI joints
and posterior ligaments remain
intact, and stability is maintained.
Classification

 APC- II injuries: The amount of

anterior diastasis exceeds 2.5 cm.
In addition, diastasis occurs in 1 or
both of the SI joints. This incomplete
posterior arch disruption results in
rotational instability. The posterior
ligaments are not injured; therefore,
vertical stability is preserved.
Classification

 APC- III injuries: These injuries extend to

the posterior SI ligaments, which are
disrupted. Consequently, the pelvis is
vertically and rotationally unstable.
Classification

2. Lateral compression (LC) injury

 Lateral compression injury results in internal
rotation of the affected hemipelvis. This
internal rotation decreases rather than
increases the pelvic volume. Consequently,
pelvic vascular injuries and resulting
hemorrhage are less common with this
injury than with other injuries. Lateral
compression injuries are associated with
brain and intra-abdominal injuries.
Classification
 The hallmarks of a lateral compression
injury include sacral buckle fractures and
horizontal pubic rami fractures. The Young-
Burgess classification system describes 3
types of injuries.
Classification

 LC- I injuries: These involve a force directed

posteriorly to the lateral aspect of the
hemipelvis, which results in an ipsilateral
sacral buckle fractures; ipsilateral horizontal
pubic rami fractures; or, less commonly,
disruption of the pubic symphysis with overlap
of the pubic bones. The posterior ligaments
remain intact; therefore, the pelvis is stable.
Classification
 LC- II injuries: These involve more internal
rotation of the hemipelvis. As in type I injuries,
ipsilateral sacral buckle fractures and horizontal
pubic rami fractures are associated with fracture
of the ipsilateral iliac wing or disruption of the
ipsilateral posterior SI joint. The pelvis is
rotationally unstable, but its vertical stability is
maintained.
Classification
 LC- III injuries: The force continues from the
ipsilateral side across the midline to affect the
contralateral hemipelvis. The ipsilateral
hemipelvis sustains either a type I or type II
injury with associated internal rotation. The
contralateral pelvis undergoes external rotation.
Contralateral vertical pubic rami fractures or
disruption of the ligaments may occur. As in type
II injuries, the pelvis is rotationally unstable but
vertically stable.
Classification

3. Vertical shear injury

 A vertically oriented force applied to a
hemipelvis, usually by the femur, results in a
vertical shear injury. At the anterior aspect,
vertically oriented fractures of the pubic rami
occur. Posteriorly, the ipsilateral SI joint (or
occasionally the contralateral SI joint) and
its associated ligaments are disrupted.
Classification
 The affected hemipelvis is displaced in a
cranial direction. Complete disruption of the
posterior ligaments yields a rotationally and
vertically unstable pelvis.
 Associated injuries seen in the vertical
shear pattern are similar to those
encountered in type III AP compression
injuries.
Clinical features and
clinical assessment

2. Fracture of the pelvis should be suspected in

every patient with serious abdominal injury or
lower limb injury.
3. H\O road traffic accident, fall from a height or
crush injury.
4. Severe pain, swelling and bruises in the lower
abdomen, perineum, thighs, scrotum or valva.
5. Extravasations of urine.
6. Symptoms and signs of bleeding and
hemorrhagic shock.
Clinical features and clinical
assessment
1. Tenderness all over the pelvic bone
especially when attempt to compress
or distract the pelvis.
2. Tender abdomen due to bleeding or
intrapelvic structure injuries.
3. Rectal examination should be done in
every case.
Clinical features and clinical
assessment
1. Bleeding in external meatus indicates
urethral injury. If no bleeding ask the patient
to void and give direct look to the urine, if the
patient able to void this indicates either no
urethral injury or there is only minimal
damage to the urethra.
Note no attempt should be made to pass a
catheter, as this could convert the partial
injury to complete injury.
3. Neurological examination should be done to
exclude sacral and lumber plexus injury.
Radiography

1. plain radiography: 5 views are necessary

1. Anteroposterior view.
2. Pelvic inlet view in which the tube is cephalad to
the pelvis and tilted 30° downwards.
3. Pelvic outlet view in which the tube is caudad to
the pelvis and tilted 40° upwards.
4. Right oblique view.
5. Left oblique view.
Radiography

2. CT scan which gives accurate details

and much information about the injury.
3. Urethrography for diagnosis of urethral
injury
Management

1. Early management
 Treatment should not await full and
detailed diagnosis. Doctor should move
according to the priority of life saving
measures with the already available
information.Six questions must be asked
and the answers acting upon as they
emerge:
Management

1. Is there a clear airway?

2. Are the lungs adequately ventilated?
3. Is the patient losing blood?
4. Is there an intra abdominal injury?
5. Is there a bladder or urethral injury?
6. Is the pelvic fracture stable or not?
Management

 After exclusion of the above, the doctor

now has a good idea about the patient
general condition and the associated
injuries so further investigation can be
done.
Management

2. Management of severe bleeding

 Treatment of shock.
 Laprotomy.
 External fixation to close the book.
3. Management of urethral and bladder
injury.
Management

4. Treatment of the fracture

2. Isolated fractures and minimally
displaced fractures: need only bed rest
with lower limb traction.
Management

1. Open book injuries if the diastasis less

than 2.5 cm only bed rest and posterior
sling to close the book. If the diastasis
more than 2.5 cm the book should be
closed surgically either by closed
reduction and external fixation or if the
patient need laparotomy so open
reduction and internal fixation by
special plates and screws or by K. wire.
Management

1. LC-II with limb length discrepancy more

than 1.5 cm needs reduction and
external fixation.
Management

1. AP-III and VC are the most dangerous

and the most difficult to treat. These
are unstable fractures and needs
reduction and fixation by either external
fixation or plate and screws.
Management

1. Open fractures are treated by external

fixation.
Secondary complications

1. Sciatic nerve injury.

2. Urogenital problem like stricture,
incontinence and impotence.
3. Persistent sacroiliac pain due to
unstable pelvis.