PELVIC FRACTURE

Prepared by:
Alzubaidah
 INTRODUCTION

• Fracture pelvis accounts for 5% of all skeletal injuries.

• They are particularly important because of high incidence of
associated:
- soft tissue injuries
- severe blood loss
- shock
• Mortality rate 1-15% for closed fractures, as much as 50% for
open fractures
ANATOMY OF PELVIS
BLOOD SUPPLIES
 TYPES OF CLASSIFICATION

• Apleys classification
• Tiles classification
• Young burges classification
 APLEYS CLASSIFICATION
1. Isolated fracture with intact pelvic ring
-avulsion fracture: Sartorius from ASIS, Rectus femoris from AIIS,
Adductor longus from
pubis, Hamstrings form ischial tuberosity
-direct fracture
-stress fracture
2. Fractures with broken pelvic ring
-stable
-unstable
3. Fractures of acetabulum
4. Sacrococcygeal fractures
 TILES CLASSIFICATION

Tiles A: stable
• A1: fracture not involving the ring
(avulsion or iliac wing fracture)
• A2: stable or minimally displaced
fracture of the ring
• A3: transverse sacral fracture (Denis
zone III sacral fracture)
Tiles B: rotationally unstable,
vertically stable
• B1: open book injury (external
rotation)
• B2: lateral compression injury
(internal rotation)
• B2-1: with anterior ring
rotation/displacement through
ipsilateral rami
• B2-2-with anterior ring
rotation/displacement through
contralateral rami (bucket-handle injury)

• B3: bilateral
Tiles C: rotationally and vertically
unstable
• C1: unilateral
• C1-1: iliac fracture
• C1-2: sacroiliac fracture-dislocation
• C1-3: sacral fracture

• C2: bilateral with one side type B

and one side type C
• C3: bilateral with both sides type C
 YOUNG BURGES CLASSIFICATION
Anterior Posterior Compression (APC)
APC I Symphesis widening <2.5 cm

APC II Symphesis widening > 2.5 cm.

Anterior Si joint diastasis, posterior Si ligaments intact.
Disruption of sacrospinous and sacrotuberous ligaments.

APC III Disruption of anterior and posterior Si ligaments (SI dislocation).

Disruption of sacrospinous and sacrotuberous ligaments.
Associated with vascular injury.
Lateral Compression (LC)
LC I Oblique or transverse ramus fracture and ipsilateral anterior sacral ala
compression fracture.
LC II Rami fracture and ipsilateral posterior ilium fracture dislocation
(crescent fracture)
LC III Ipsilateral lateral compression and contralateral APC (windswept
pelvis).
Common mechanism is rollover vehicle accident or pedestrian vs auto.
Vertical Shear (VS)
Vertical shear Posterior and superior directed force.
Associated with the highest risk of hypovolemic shock (63%); mortality
APC I APC II

APC III
LC I LC II

LC III Vertical shear

 CLINICAL FEATURES

Symptoms:
• Pain at pelvic region/lower abdomen
• Swelling at pelvic region
• Urinary retention
• Hematuria
 PHYSICAL EXAMINATION

• Swelling /bruises at lower abdomen, thigh, perineum,

scrotum/vulva
• Guarding on palpation of abdomen
• Positive pelvic spring
• Blood at the meatus/ hematuria
• Rectal examination: high riding prostate, feel coccyx/sacrum
• Neurological examination of lower limb
• Roux’s sign
- decrease distance from greater
trochanter to pubic tubercle
• Earle’s sign
- presence of bony prominence,
palpablehematoma or tender # line
on DRE
• Destot sign
- hematoma above inguinal ligament
or in scrotum
• Moral lavale lesion
- closed degloving soft tissue injury,
as a result of abrupt separation of
skin and subcutaneous tissue from
the underlying fascia
 INVESTIGATIONS
• Radiographs recommended views
• AP
• part of initial ATLS evaluation
• look for asymmetry, rotation or displacement of each hemipelvis
• inlet

• xray beam angled 40° caudad (may be as little as 25 degrees)

• adequate image when S1 overlaps S2 body (i.e. perpendicular to S1 endplate)

• ideal for visualizing

• anterior or posterior translation of the hemipelvis
• internal or external rotation of the hemipelvis
• widening of the SI joint
• sacral ala impaction

• outlet
• xray beam angled ~40° cephalad (may be as much as 60 degrees)
• adequate image when pubic symphysis overlies S2 body

• ideal for visualizing

• vertical translation of the hemipelvis
• flexion/extension of the hemipelvis
• disruption of sacral foramina and location of sacral fractures
 CT PELVIS
• CT routine part of pelvic ring injury evaluation
• better characterization of posterior ring injuries
• helps define comminution and fragment rotation
• visualize position of fracture lines relative to
sacral foramina
• radiographic signs of sacral dysmorphism:
• anterior up-sloping upper sacral ala
• irregular, non-curcular, sacral nerve root tunnels
• residual S1 disk
• tongue-and-groove SI joint
 MANAGEMENT
• Bleeding Source
• intraabdominal (present in up to 40% of cases)
• intrathoracic
• retroperitoneal
• extremity (thigh compartments)
• pelvic
• common sources of hemorrhage

• venous injury (80%)

• shearing injury of posterior thin walled venous plexus
• leads to retroperitoneal hematoma (can hold up to 4L of blood)
• bleeding cancellous bone
• uncommon sources of hemorrhage
• arterial injury (10-20%)
• superior gluteal most common (posterior ring injury, APC pattern)
• internal pudendal (anterior ring injury, LC pattern)
• obturator (LC pattern)
 Treatment
• resuscitation
• PRBC:FFP:Platelets ideally should be transfused 1:1:1

• this ratio shown to improve mortality in patients requiring massive transfusion

• pelvic binder/sheet
• indications
• initial management of an unstable ring injury
• contraindications
• hypothetical risk of over-rotation of hemipelvis and hollow viscus injury (bladder) in pelvic
fractures with internal rotation component (LC)
• no clinical evidence exists of this complication occurring
• pitfalls
• binder can mask pelvic ring injuries, creating false negative radiographs and CT images
• stress examination under anesthesia may be indicated in patients who present to the trauma
slot in a pelvic binder, hemodynamic instability, and negative pelvis radiographs/CT scan
• external fixation
• indications
• pelvic ring injuries with an external rotation component (APC, VS, CM)
• unstable ring injury with ongoing blood loss
• should be placed before emergent laparotomy
• contraindications
• ilium fracture that precludes safe application
• acetabular fracture

• angiography / embolization
• indications
• controversial and based on multiple variables including:
• protocol of institution, stability of patient, proximity of angiography suite , availability and experience of IR staff

• CT angiography useful for determining presence or absence of ongoing arterial hemorrhage

• contraindications
• not clearly defined
• technique
• selective embolization of identifiable bleeding sources
• in patients with uncontrolled bleeding after selective embolization, bilateral temporary internal iliac embolization
may be effective
• complications include gluteal necrosis and impotence
Classification Treatment

Anterior Posterior Compression (APC)

APC I Non-operative. Protected weight bearing
APC II Anterior symphyseal plate or external fixator +/- posterior fixation
APC III Anterior symphyseal multi-hole plate or external fixator and posterior stabilization with SI screws or plate/screws

Lateral Compression (LC)

LC I Non-operative. Protected weight bearing (complete, comminuted sacral component. Weight bearing as tolerated
(simple, incomplete sacral fracture).

LC II Open reduction and internal fixation of ilium

LC III Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and
surgeon preference.

Vertical Shear (VS)

Vertical shear Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and
surgeon preference.
 Nonoperative
• weight bearing as tolerated
• indications
• mechanically stable pelvic ring injuries including
• LC1
• anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of
posterior ring displacement
• APC1
• traumatic widening of symphysis < 2.5 cm with intact posterior pelvic ring
• isolated pubic ramus fractures
• parturition-induced pelvic diastasis

• bedrest and pelvic binder in acute setting with diastasis less than 4cm
• ORIF
• indications
• symphysis diastasis > 2.5 cm
• SI joint displacement > 1 cm
• sacral fracture with displacement > 1 cm
• displacement or rotation of hemipelvis
• open fracture
• chronic pain and diastasis in parturition-induced diastasis or acute setting >4-6cm
• technique
• for open fractures aggressive debridement according to open fracture principles
• anterior subcutaneous pelvic fixator (INFIX)
• indications
• same indications as anterior external fixation and symphyseal plating
• complications
• heterotopic ossification, femoral nerve injury, infection
• diverting colostomy
• indications
• consider in open pelvic fractures
• especially with extensive perineal injury or rectal involvement