Jatinder S. Luthra

Anatomy, Radiographic evaluation &

Classification of Pelvic Ring Fractures

Pelvic Fractures: Epidemiology

Majority due to high impact blunt trauma (MVA, pedestrian vs. vehicle etc.) but also secondary to falls in frail elderly

Mortality overall = 10% Mortality 50% if open #

Pelvic Anatomy Pelvis = sacrum,

coccyx + 2 innominate bones

Innominate bones = ilium, ischium, pubis

Sacrum + innominate bones form a ring

Strength from ligamentous supports (largely posterior aspect of ring)

Pelvic Anatomy 5 joints: Lumbosacral Sacroiliac (x2) Sacrococcygeal Symphysis

Anterior Support:– Symphysis pubis

Fibrocartilaginous joint covered by ant & post symphyseal ligaments

– Pubic rami Posterior Support:

– ~majority of stability Iliolumbar

ligaments Sacroiliac

ligaments Sacrospinous

ligament Sacrotuberous

ligament

Vascular Anatomy Vessels lie

close to posterior pelvic walls

Venous bleeding most common (sacral plexus)

Most commonly injured arteries are superior gluteal and internal pudendal

Pelvic Anatomy Nerve supply through the pelvis

derived from lumbar and sacral plexuses

Other structures: lower GI/GU

Imaging – X- rays

X Rays Pelvis AP – part of ATLS protocol

Imaging – X- rays AP VIEW:-Identifies most fractures-Look for disruption in iliopubic and ilioischial

lines, sacral foramina, radiographic U, Shenton’s Lines

Inlet and outlet views

Judet Views

AP Pelvis Radiogram

Acetabular fracture

Posterior Pelvic lesion

S2

Imaging Look for any evidence of damage to

the posterior pelvic structures– Clues on X-rays:

L5 transverse process avulsion (iliolumbar ligament)

Ischial spine avulsion (sacrospinous ligament)

Unable to clearly make out sacral foramina Assymmetry of sacral foramina Avulsion at lower lip of lateral sacrum

(sacrotuberous ligament)

Inlet view– X-ray beam at

40o to plate directed towards feet

Sacral Promontry should overlap anterior border of S1

Posterior displacement

Rotational deformity

Subtle SI joint injury

Sacral Ala fracture

Outlet View Outlet view

– Beam aimed 30o towards head

– Superior border of symphysis at level S2

Outlet View Vertical

displacement

Sacral foramina

Flexion deformity

CT scan Detailed

information of posterior lesion

Sacral Foramina Subtle sacral

impaction. Rotation of

hemipelvis Associated Lesions Dysmorphysisum

Radiological criteria of instability

Displacement instead of impaction in posterior pelvis

Attention Stationary pelvic radiogram do not reflect true

pathology

Apparently stable patient should undergo Examination under anaesthesia

Push Pull film under anaesthesia > 1cm is unstable Contraindicated – Zone 2/3 sacral fracture Haemodynamically unstable

ArteriogramPatients with pelvic fracture – persistent bleeding despite External stabilization

ICE – intravenous contrast extravasation

-Gross haematuria-- Bloody urethral discharge-Inability to void-- swelling / echymosis in perineal region-High riding prostate

Pelvic Fractures 5 General Categories: 1. Pelvic Ring 2. Acetabular 3. Sacral 4. Avulsion type 5. Single bone

Pelvic fracture classification

Bucholz classification – JBJS 1981

Type1 - stable Type II- Open

Book

Type III – Rotaionally and vertically unstable

Pelvic fracture classification

Letournal Classification

Pelvic Ring FracturesYoung Classification System:

Differentiates fracture patterns based on mechanism of injury/direction of causative force

3 major fracture patterns: 1. lateral compression (50%) 2. antero-posterior compression

(25%) 3. vertical shear (5%)

Pelvic fracture classification Young & Burgess

Classification

Modification of tile – Based on mech of inj.

Young & Burgess Anteroposterior compression fracture

External rotation force

Neurovascular structures stretched.

Symphyseal diastasis / Vertical fracture pubic ramus

Young & Burgess Anteroposterior compression fracture - I

Young & Burgess Anteroposterior compression fracture - II

Young APC II

Young & Burgess Anteroposterior compression fracture - III

Young & Burgess LATERAL COMPRESSION - I

Young & Burgess LATERAL COMPRESSION - II

CRESCENT FRACTURE

Young & Burgess LATERAL COMPRESSION – III

Young & Burgess VERTICAL SHEAR

Tile C1/ Young VS

Young & Burgess COMBINED MECHANISM

Summary Classification system - - Assist

surgeon in determining treatment and prognosis

Young & Burgess – - Fluid resuscitation reqd - Solid organ injury Need for acute stabilization Pt. survival

APC type 3 & VS injury – highest transfusion reqd.

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