Pelvic fracture classification

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Classification of Pelvic FracturesZahid Askar FCPS(Ortho), FRCS (Ortho) Prof of Orthopaedics & TraumaKhyber Medical College, Peshawer

Value Of classificationMechanism of injuryTreatment optionsPrognosisRecords/communications It should also be :-Easily ReproducibleHave good Intra- & Interobservor reliabilityEasily remembered/applied Historical BackgroundFirst attempt by Malgaigne in 1859Described without radiographs of the so-called double vertical fractureMalgaigne I. F.: Traite des Fractures et desLuxations, Paris, J. B. Bailliere, 1855.

Historical classificationWatson-JonesConnolly & HedbergHuttinen & SlatisTrunkeyLooser & Crombie

Present classification systems started with the ground-breaking work by PennalClassified Injuries as APC/LC/VSPennal GF, Sutherland GO. Fractures of the Pelvis. Park Ridge, IL: American Academy ofOrthopedic Surgeons, 1961.Pennal, G. F., and Sutherland, G. 0.: Fractures of the Pelvis. Motion picture in AAOS film library, 1961. Classification SystemsLetournel Bucholz, TileYoung & BurgessOTA/AO -research Commonly used Classification systems:-Tile ClassificationYoung & Burgess ClassificationTile classificationModification of Pennal IdeaTile et al added the concept of stability The Tile classification system is mainly based on the integrity of the posterior sacroiliac complex

Which Tile ???Original Tile ClassificationPennal GF, Tile M, Waddell JP, et al. Pelvic disruption: assessment and classification. Clin Orthop Relat Res 1980;151:12-22.Type A: Pelvic Ring StableA1: fractures not involving the ring (i.e., avulsions, iliac wing, or crest fractures)A2: stable minimally displaced fractures of the pelvic ring

Type B: Pelvic Ring Rotationally Unstable, Vertically StableB1: open bookB2: lateral compression, ipsilateralB3: lateral compression, contralateral, or bucket-handle-type injury

Type C: Pelvic Ring Rotationally and Vertically Unstable:C1: unilateralC2: bilateralC3: associated with acetabular fractureC1: UnilateralC1-1: iliac fractureC1-2: sacroiliac fracture-dislocationC1-3: sacral fractureC2: Bilateral with one side type B and one side type CC3: Bilateral with both sides type CB - Rotationally unstable, vertically stable B1: Open book injury (external rotation) B2: Lateral compression injury (internal rotation) B2-1: Ipsilateral ant. and post. Injuries B2-2: Contralateral ant. and post. Injuries (bucket-handle injury) B3: BilateralA: stableA1: fracture not involving the ring (avulsion or iliac wing fracture)A2: stable or minimally displaced fracture of the ringA3: transverse sacral fracture (Denis zone III sacral fracture)Modified Tile ClassificationTile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg Br 1988;70:1-12.Comprehensive Classification

Type A: Stable (Posterior Arch Intact)A1Avulsion injuryA1.1Iliac spine A1.2Iliac crest A1.3Ischial tuberosityA2Iliac wing or anterior arch fracture caused by a direct blowA2.1Iliac wing fractures A2.2Unilateral fracture of anterior archA2.3Bifocal fracture of anterior archA3Transverse sacrococcygeal fractureA3.1Sacrococcygeal dislocationA3.2Sacrum undisplaced A3.3Sacrum displaced

Type B: Partially Stable (Incomplete Disruption of Posterior Arch)B1Open book injury (external rotation)B1.1Sacroiliac joint, anterior disruption B1.2Sacral fractureB2Lateral compression injury (internal rotation)B2-1Ipsilateral anterior and posterior injuriesB2-2Contralateral (bucket-handle) injuriesB3BilateralB3.1Bilateral open book B3.2Open book, lateral compressionB3.3Bilateral lateral compression

Type C: Unstable (Complete Disruption of Posterior Arch)C1UnilateralC1.1Iliac fracture C1.2Sacroiliac fracture-dislocation C1.3Sacral fractureC2Bilateral, with one side type B, one side type CC3BilateralModified Tile Classification

Tile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg Br 1988; 70:1-12.Tile Type A fracturesThe SI Joint is completely stable( Rotationally & vertically)Fractures are outside the pelvic ring !! A: stableA1: 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)

Tile Type B FracturesPartial Instability of the SI Joint ComplexRotationally Unstable while Vertically stableB - 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 ramiB2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)

B3: BilateralTile type B1- Open Book Injury(External Rotation Injury)

APC

B2- Lateral Compression InjuryB2: lateral compression injury (internal rotation)

B2-1: with anterior ring rotation/displacement through ipsilateral ramiB2-2: with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)

B2: lateral compression injury (internal rotation)

B2-1: Ipsilateral Ant/Post Injuries

B2-2-Contralateral Ant/Post Injuries (bucket-handle injury)B2.1B2.2

B2.2- Contralateral injuries

B3- BilateralThe B3 bilateral injuries can be bilateral open book type One side B1 and one side B2 or Bilateral B2 .

Type C Injuries- Unstable

C1: UnilateralC1-1: iliac fractureC1-2: sacroiliac fracture-dislocationC1-3: sacral fracture

C2: Bilateral with one side type B and one side type C

C3: Bilateral with both sides type CC1- Unilateral InjuriesC1: UnilateralC1-1: iliac fractureC1-2: sacroiliac fracture-dislocationC1-3: sacral fracture

Tile- Type C2 Injuries

Bilateral with one side type B and one side type C

C3 InjuriesBilateral with both sides type C

Young and Burgess ClassificationBased on the direction of forces causing fracture, associated instability of pelvisOriginal Work of Pennal Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: Value of plain radiography in early assessment and management. Radiology 1986;160:445-51.Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols.J Trauma. Jul 1990;30(7):848-56.Young and Burgess classificationFour Injury PatternsLateral compression (LC) Anteroposterior compression (APC) (external rotation)Vertical shear (VS)Combined Mechanism (CM)

LC-1

LC-2

Crescent FractureLC-3

Windswept Injury

APC

APC-1Symphysis widening < 2.5 cm

APC-2Symphysis widening > 2.5 cm. Anterior SI joint diastasis . Posterior SI ligaments intact. Disruption of sacrospinous and sacrotuberous lig

APC-3Disruption of anterior and posterior SI ligaments (SI dislocation).Disruption of sacrospinous and sacrotuberous ligaments.

C-Vertical Shear Injuries

CM- Combined MechanismCombined VS & LC LC &APC

Pelvic ring disruptions: effective classification system and treatment protocols.Burgess AR, et al J Trauma.1990Jul;30(7):848-56.

Which one is better ???Easily reproducibleInter observor AgreementRelationship to prognosis/treatmentKappa values ( Agreement grades)Poor ======= =0 to 0.20 ,Fair =========0.21 to 0.40 , Moderate ====0.41 to 0.60 Substantial ===0.61 to 0.80 Perfect ======>0.80 Intraobserver agreement SUBSTANTIAL---- for the full Young-Burgess system , Average kappa value = 0.61 (95% CI 0.53, 0.69). SUBSTANTIAL ---- without the subclasses of the Young-Burgess system , Average kappa value = 0.72 (95% CI 0.66, 0.78)MODERATE ------- for the Tile system is Average kappa value = 0.47 (95% CI 0.31, 0.64)Andrew et al: Classification of Pelvic Fractures: Analysis of Inter- and Intraobserver Variability Using the Young-Burgess and Tile Classification Systems :Orthopedics June 2009 - Volume 32 Issue 6 Interobserver AgreementMODERATE for full Young-Burgess system Average kappa value = 0.46 (95% CI 0.39, 0.52MODERATE for only the 4 main fracture typesAverage kappa value= 0.58 (95% CI 0.45, 0.72),. MODERATE for Tile system, Average kappa value = 0.47 (95% CI 0.42, 0.52). Koo et al : Interobserver reliability of the Young-Burgess and Tile classification systems for fractures of the pelvic ring. J Orthop Trauma. 2008 Jul;22(6):379-84. CONCLUSIONS:The CT scan can improve the reliability of assessment of pelvic stability (Pre-CT and post-CT = 0.59 and 0.93)Investigation (Xrays/CT scan)ClassificationType of SurgeonAverage kappa scoreXraysYoung-BurgessAll0.72( Substantial)Xrays/CT scanAll0.63(Substantial)XraysTileAll0.30( Fair)Xrays/CT scanAll0.33(Fair)The Young-Burgess system may be optimal for the learning surgeon. The Tile classification system is more beneficial for specialistsOsterhoff et al : Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess. Injury 2014 Apr;45(4):742-7ConclusionsIn this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.Predictive Value ???Guthrie HC, Owens RW,Bircher MD. Fractures of the pelvis: J Bone Joint Surg Br. 2010 Nov;92(11):1481-8We recommend using the Young and Burgess classification which is derived from the initial anteroposterior (AP) radiograph and is based predominantly on the mechanism of injury and severity of pelvic fracture.Classification of Pelvic Injuries in ChildrenTorode and Zieg modification of Watts classificationType I avulsion fracturesType II - Iliac wing frac