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Pelvic Trauma: Atlas of Pelvic Fractures

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Page 1: Pelvic Trauma: Atlas of Pelvic Fractures

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TraumaPelvic

Atlas of Pelvic Fractures

Dorothy Tamayo, Harvard Medical School Year IIIGillian Lieberman, MD

Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Page 2: Pelvic Trauma: Atlas of Pelvic Fractures

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

1. Case presentation of a patient2. Menu of diagnostic tests for pelvic trauma3. Imaging and findings from patient4. Normal pelvic anatomy5. Abnormal pelvic anatomy of our patient6. Statistics of pelvic fractures7. Common pelvic fractures classificaton8. Examples of common pelvic fractures on radiograph9. Classification of our patients fracture

Table of Contents

Page 3: Pelvic Trauma: Atlas of Pelvic Fractures

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Dorothy Tamayo, MS3Gillian Lieberman, MD

Patient is a 21-year-old woman who was struck by a motor vehicle at high speed,while crossing the street. By report she was thrown approximately 100 feet.

She arrived intubated and sedated.Stable after receiving 4 L of crystalloid, packed red blood cells and FFP

Patient Presentation

9.19.2011

Image from Bidmc PACS

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Menu of Diagnostic Tests for Pelvic TraumaUltrasound: Check for hemoperotoneumPlain radiograph: Inlet, outlet and Judet (oblique) viewsCT scan: Gold standardRetrograde cystourethrogram: If suspected GU traumaDiagnostic peritoneal aspirate: If hemodynamically unstable

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Portable chest CT head w/o contrast CT C-spine w/o contrastCT chest w/contrast CT abd and pelvis w/contrast Foot xray

Patient requires full-body CT scan

Imaging Obtained for Our Patient

Image from Bidmc PACS

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Pelvic fractures Spinous process fracture C6-T4 R PneumothoraxLacerated liverComminuted fracture of humerusSternoclavicular dislocationMultiple rib fractures

Imaging Findings from Our Patients

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Normal Pelvic Anatomy

Posted by Dr.Sunil http://basicxray.blogspot.com/

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Normal Pelvic Anatomy: Contours

Iliopectineal Line

Ilioischial Line

Anterior Acetabular Wall

Posterior Acetabular Wall

Obturator Foramen

http://www.ajronline.org/cgi/content-nw/full/187/4/915/FIG3

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Normal Pelvic Anatomy: Ligaments

Sacrotuberous Ligament

Sacrospinous ligament

Sacroiliac ligament

Pubic symphysis

http://en.wikipedia.org/wiki/File:Gray319.png

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Pelvic fracture present in: Bilateral superior and inferior pubic ramiSacroiliac jointsSacrum

Abnormal Pelvic Anatomy of Our Patient

Images from Bidmc PACS

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Most common mechanism of pelvic fracture:MVA 58%Pedestrian struck by vehicle 22%Falls 30%

Associated injuries with pelvic trauma: Venous hemorrhage 38%Visceral injury 17%Bladder/urethra injury 6%Nerve deficits 15%Thoracic aorta rupture 1%

Statistics on Pelvic Trauma

www.uptodate.com+adult-pelvic-trauma; James Fiecht

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Most Common Fractures of the PelvisLateral Compression

AnteroPosteriorCompression

Vertical Shear Injury

www.uptodate.com+adult-pelvic-trauma; James Fiecht

The blue arrows illustrate the force direction.A) Lateral compression injuries with subsequent bilateral involvement as forces increase; B) Anteroposterior injuries with progression of injury; C) Vertical shear injury.

Burgess, AR, Eastridge, BJ, Young, JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma, 1990, 30:848.

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Lateral Compression Fracture: Type IMost common

A) Type I lateral compression fracture with bilateral superior and inferior rami fractures and left sacral fracture. B) Inlet view showing greater detail of the pelvic ring disruption. C) Outlet view illustrating greater detail of the sacral fracture in addition to the bilateral rami fractures.Images from Jim Fiechtl, MD.

www.uptodate.com+adult-pelvic-trauma; James Fiecht

Sacral fracture on side of impact

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Lateral Compression Fracture: Type IICrescent “Iliac wing”

Crescent fracture on side of impact

A) Type II lateral compression fracture with left sided rami and sacral fractures. B) CT scan illustrating the classic crescent fracture pattern.Images from Jim Fiechtl, MD.

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Lateral Compression Fracture: Type III“Wind swept pelvis”“crescent and open book”

Type I or II crescent injury with contralateral open book injury

(B) Anteroposterior plain radiograph; (C) CT scan.Images from Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta,

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

AP Compression Fracture: Type I

Usually less than 2cm spread with intact posteriorPelvic ring ligaments

(B) Plain radiograph with outlet view.Images from: Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

AP Compression Fracture: Type II

Opening of sacoiliac joint, sacrotuberous, and sacrospinousligaments

AP radiograph; Sagi, Claude. Lower extremity: Pelvic ring fractures.In: Rockwood and Green's Fractures in Adults, vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, P (Eds), Lippincott Williams & Wilkins, Philadelphia 2010.

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

AP Compression Fracture: Type III

Complete disruption of sacroiliac joint

(B) AP radiograph; from: Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults,vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, P (Eds)

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Vertical Shear Stress Fracture

Wide pubic symphysis, broken SI ligament with unilateral or bilateral rami fracture

(B) AP radiograph; (C) 3-dimensional reconstruction from a CT scan.from: Sagi, Claude. Lower extremity: Pelvic ring fractures. In: Rockwood and Green's Fractures in Adults,vol 2, 7th ed, Bucholz, RW, Court-Brown, CM, Heckman, JD, Tornetta, P (Eds), Lippincott Williams & Wilkins

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Patient’s Injury Classified

Vertical Shear: broken SI ligament with bilateral rami fractureImages from Bidmc PACS

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Surgery to Stabilize Our Patient’s Pelvis

Image from Bidmc PACS

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Follow up Removal of Hardware and Stabilization of SI Joints

Image from Bidmc PACS

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

SummaryLateral Compression

AnteroPosteriorCompression

Vertical Shear Injury

www.uptodate.com+adult-pelvic-trauma; James Fiecht

Burgess, AR, Eastridge, BJ, Young, JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma, 1990, 30:848.

With our patient showing evidence for vertical shear

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

Thanks!

Dr. Gillian Lieberman, Course DirectorEmily Hanson, Educational CoordinatorDaniel Barkhuff, MS3 involved in case

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Dorothy Tamayo, MS3Gillian Lieberman, MD

9.19.2011

ReferencesBramos A Velmahos GC, Butt UM, Fikry K, Smith RM Chang Y. Predictors of bleeding from stable pelvic fractures. SourceDivision of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School.

Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005.

Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005

Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta- analysis. J Bone Joint Surg Br 2005

Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008

Sathy AK, Starr AJ, Smith WR, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am 2009

Balogh Z, King KL, Mackay P, et al. The epidemiology of pelvic ring fractures: a population-based study. J Trauma 2007

Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br 2005

http://www.ajronline.org/cgi/content-nw/full/187/4/915/FIG3