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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:

  1. Iliolumbar ligs.

  2. Dorsal sacroiliac ligaments

  3. sacrotuberous ligs

  4. Ventral sacroiliac ligs.

  5. sacrospinous ligs

  6. 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:

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


Radiographs

AP Pelvis x-ray as part of ATLS series

Inlet view:

Outlet View:

CT Scans:


Management

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

Haemorrhage:

External Fixation:

  

Internal Fixation:

Indications:

1. Rotational instability:

2. Vertically unstable:

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


Neurological Injuries

  1. avulsion of lumbar nerve roots

  2. superior gluteal nerve

  3. obturator nerve

  4. sciatic nerve

  5. pudendal nerve


Further Reading: