Pelvic Fractures

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Pelvic Fractures

Pelvic fractures are the main cause of death in multiple trauma patients.

Anatomy

Pelvic ring stability is provided by:

Iliolumbar ligs.
Dorsal sacroiliac ligaments
sacrotuberous ligs
Ventral sacroiliac ligs.
sacrospinous ligs
Posterosuperior interosseous ligs.

Classifications

1. Tile’s Classification (Tile, M.: Pelvic Ring Fractures: Should They Be Fixed? J. Bone Joint Surg., 70B:1-12, 1988)

TYPE A - Stable
A1—Fractures of the pelvis not involving the ring
A2—Stable, minimally displaced fractures of the ring
TYPE B - Rotationally unstable, vertically stable
B1—Open book
B2—Lateral compression: ipsilateral
B3—Lateral compression: contralateral (bucket-handle)
TYPE C - Rotationally and vertically unstable
C1—Rotationally and vertically unstable
C2—Bilateral
C3—Associated with an acetabular fracture

Young & Burgess Classification (J Trauma. 30:848-56. 1990)

stability can be judged by fracture pattern, direction of the force of injury, and by knowledge of pelvic ligamentous anatomy.

Death rates:

LC - 7%
AP- 20%
VS- 0% (cause of death is usually MOF & ARDS)

Type	Description	Mechanism	Un/Stable	Picture
Lateral Compression(LC):	unilateral pubic rami fractures, with or without symphysis injury, and bilateral rami fractures, with or without pubic symphysis injury.
LC1	unilateral ramii (transverse) & ipsilat sacral compression.	lateral force compressing sacrum	usually stable
LC2	unilateral ramii & ipsilat post. iliac #	lateral force compressing ilium	usually stable
LC3	LC I/II & contralat. APC	trapped between an unyielding object / rollover	unstable
AP Compression(APC)	direct anterior force
AP1	symphysis <2cm or ramii (vertical) & ant. SI lig. stretched	low- to moderate-energy forces (sports)	Stable
AP2	symphysis >2cm or ramii & ant. SI lig. torn (+ the ligaments of the floor of the pelvis - sacrotuberous and sacrospinous)	High energy - 'Open book'	Unstable
AP3	symphysis or ramii & ant & post SI lig. torn	High energy - pelvis rotates externally until the posterior iliac wing contacts the posterior sacrum; highest incidence of major Hge	Very Unstable
Vertical Shear(VS)	ant & post vertical displacement.	fall from a height with vertical forces	Unstable
Combined Mechanical(CM)	combination of other injuries.	combination	Unstable

Clinical

ATLS
Abrasions & contusions
Destot sign - superficial haematoma above the inguinal lig or or scrotum or thigh
Limb length discrepency & deformity
Assess pelvic stability by bimanual compression & distraction of the iliac wings, plus abduction & adduction of the hips
Rectal & Vaginal examinations

Radiographs

AP Pelvis x-ray as part of ATLS series

Inlet view:

Outlet View:

CT Scans:

Provides more detail of fractures, SIJ & acetabulum

Management

See Emergency Management of Pelvic Fractures (Mark Emerton, 1997)

Haemorrhage:

Mortality from pelvic Hge= 10-20%.
AP bleed much more than LC.
Major Haemorrhage associated with AP & VS (not usually LC)
The major blood loss is from:
1. Bony surfaces
2. venous plexus from ant. branches of the internal iliac artery
3. the superior gluteal artery (as it passes through the sciatic notch) - rarely
Retroperitoneal space can hold 4 litres of blood.
Exclude intraabdominal bleeding - 40% of patients with pelvic fractures have an intraabdominal source of bleeding.
Since the fracture site is the major cause of bleeding in 85% external pelvic stabilisation should be used.
Steps to control pelvic bleeding:
- External Fixation
- Pelvic packing (if no other source of bleeding found) plus optimize fixation
- Angiogram & embolisation

External Fixation:

Used worldwide, but there have been no studies to confirm reduction of blood loss after placement of an external fixator.
Indications (J. Kellam):
1. resuscitation to decrease pelvic volume
2. comfort - to help mobilise the patient for tests prior to definitive fixation
3. definitive management for some fractures (AP compression)
Technique:
- Hoffmann 2 inverted 'A' frame (dedicated set)
  - ideal site extends posteriorly along the iliac crest from the anterior spine for 8-10 cm. Below this area is a thick triangle of bone with its apex inferiorly.
  - Transverse Incisions
  - To determine the plane of the iliac crest small guide wires pass along the interior or exterior surfaces of the crest & insert the self drilling 5 mm screw along this plane. Test each one manually for security & add a third if there is any doubt.
  - Reduce pelvis manually & tighten frame. Frame must be well clear of abdomen to allow for ileus & laparotomy.
  - Convert 'A' to quadrilateral frame when due to mobilise.
- Ganz Pelvic-C Clamp:
  - Stab incision- Intersection of a line joining ant & post superior iliac spines & the elongation of the dorsal border of the femur. i.e. into iliac wing.
  - (Ganz, M.D., R. "The Antishock Pelvic Clamp," Clinical Orthopaedics and Related Research No. 267, June 1991. pp. 71-78; PF Heini, J Witt, R Ganz, Injury, 1996, Vol 27, Suppl 1)
  - Problems = neurovascular injury, iliac wing penetration, failure of good purchase.
Need to add skeletal traction to shortened limb for a vertical shear injury

Internal Fixation:

Indications:

1. Rotational instability:

Anterior stabilisation only
1. Anterior external fixator
2. anterior DCP via Pfannenstiel incision

2. Vertically unstable:

Anterior & posterior stabilisation
Posterior stabilisation:
1. SIJ instability:
  1. iliosacral screws - percutaneous
  2. anterior plates - via ilioinguinal approach
2. Transacral instability:
  1. Transacral plate
  2. Sacral bars

By Fracture Type:

LC1	protected weight bearing on the side of the posterior ring injury. Repeat x-rays 2- 5 days after injury
LC2	anterior and posterior fixation
LC3	anterior and posterior fixation
AP1	symptomatic management only
AP2	anterior reduction and stabilisation (ORIF)
AP3	control haemorrhage by fracture reduction and stabilisation with external fixation. posterior percutaneous iliosacral screws, either acutely or on a delayed basis depending on the patient's physiologic status.
VS	depends on the posterior fracture location. Reduction with traction, percutaneous iliosacral screw fixation, and anterior stabilization (ORIF or external fixation).

Open Pelvic Fractures

= 50% Mortality
always look for perineal lacerations
rectal examination - spicules from sacral fractures
Treat aggressively
Faecal divertion essential - will require high placed end colostomy

Neurological Injuries

10% incidence
often missed

avulsion of lumbar nerve roots
superior gluteal nerve
obturator nerve
sciatic nerve
pudendal nerve

Further Reading:

Emergency Management of Pelvic Fractures (Mark Emerton, 1997)