AO Classification of

Pelvic Ring Fracture

Educational Package 2013 (version 2)

John Au
Liz Abbott
Dr Diana Perriman
Prof. Paul Smith
 Need to
know
= Need to
know

For your interest

= For your interest
 Why Classify?
Accurate identification and classification of
pelvic fracture guides treatment, is
potentially crucial to patient survival and is
necessary for data collection.
 Pelvic Fractures can be divided into:

1) Acetabular Fractures
– AO Classification
– Letournel & Judet Classification

2) Pelvic Ring Fractures

– AO Classification
– Young & Burgess Classification

3) Sacral Fractures
– Denis Classification
 Pelvic Fractures classification systems
include:
1) Acetabular Fractures
– AO Classification
– Letournel & Judet Classification

2) Pelvic Ring Fractures

– AO Classification
– Young & Burgess Classification

3) Sacral Fractures
– Denis Classification
– Isler Classification
 At Canberra Hospital and
Internationally:
1) Acetabular Fractures
– AO Classification
– Letournel & Judet Classification

Need to
know
2) Pelvic Ring Fractures
– AO Classification
– Letournel & Judet Classification
– Young & Burgess Classification

KnowFractures
3) Sacral how to classify acetabular # &
– pelvic
Denisring # using X-rays & CT scans
Classification
AO classification
AO Classification: 5 components
AO Classification: 5 components
Fracture Fracture Fracture
Bone Segment
Type Group Subgroup

A 1 1

B 2 2

C 3 3
# Localisation # Morphology

Fracture Fracture Fracture

Bone Segment
Type Group Subgroup

A 1 1

B 2 2

C 3 3
 Now focusing on
Pelvic Ring fractures
 Pelvic Ring Fracture

1. AO classification
2. Young & Burgess classification
 Need to
know

Pelvic Ring Fracture

1. AO classification
2. Young & Burgess classification
 Need to
know

With respect to pelvic ring #,

there are some definitions to
keep in mind.
Pelvic ring has two arches:
• (a) Posterior arch is behind
acetabular surface and includes
sacrum, sacroiliac joints and
their ligaments and posterior
ilium, and
• (b) Anterior arch is in front of
acetabular surface and includes
pubic rami bone and
symphyseal Joint.

Orthopaedic Trauma Association Classification, Database and Outcomes Committee (2007) Fracture and Dislocation Classification Compendium, JOT, 21(10), supplement
• Unilateral: only 1 hemipelvis involved posteriorly

• Bilateral: both hemipelvis involved posteriorly

• Contralateral: side opposite the major posterior lesion

• Ipsilateral: the side of the more severe lesion

Orthopaedic Trauma Association Classification, Database and Outcomes Committee (2007) Fracture and Dislocation Classification Compendium, JOT, 21(10), supplement
AO Classification: Pelvic Ring
Fracture Fracture Fracture
Bone Segment
Type Group Subgroup

61 = pelvic ring
A 1 1

B 2 2

C 3 3
AO Classification: Pelvic Ring
Fracture Fracture Fracture
Bone Segment
Type Group Subgroup

A 1 1

B 2 2

C 3 3
Need to
know

A B C
 Need to
know

AO Classification is based on
fracture stability
 = STABLE
Lesion sparing the posterior
arch; pelvic floor intact and
able to withstand normal
physiological stresses without
displacement

= PARTIALLY STABLE
Posterior osteoligamentous
integrity partially maintained
and pelvic floor intact

= UNSTABLE
Complete loss of posterior
osteoligamentous integrity;
A B C
pelvic floor disrupted
 pelvic #
are more frequently associated with
HAEMORRHAGE

UNSTABLE
Therefore, it is important NOT
to miss an unstable #
“Although the anterior structures, the
symphysis pubis and the pubic rami,
contribute approximately 40% to the
stiffness of the pelvis, clinical and
biomechanical studies have shown
that the posterior sacroiliac
complex is more important to
pelvic-ring stability.”

“Therefore, the AO classification of

pelvic fractures is based on the
stability of the posterior lesion.”
 Anatomy Review
Ligamentous structures are
major contributors to the
stability of the posterior arch
Iliolumbar
Ligament

Posterior Sacroiliac
Ligaments
Posterior

Anterior
Anterior Sacroiliac
Ligament

Sacrospinous
Ligament

Sacrotuberous
Ligament
AO Classification: Pelvic Ring
Fracture Fracture Fracture
Bone Segment
Type Group Subgroup

A 1 1

B 2 2

C 3 3
 Need to
know

A B C
A = no pelvic ring instability
Need to
know

A B C
B = Rotationally unstable but Vertically stable
Need to
know

A B C
C = Grossly Unstable
AO Classification: Pelvic Ring
Fracture Fracture Fracture
Bone Segment
Type Group Subgroup

A 1 1

B 2 2

C 3 3
 A B C
A = no pelvic ring instability
For your interest

A B C
For your interest

A B C
For your interest

A B C
A B C
B = Rotationally unstable but Vertically stable
For your interest

A B C
For your interest

A B C
For your interest

A B C
A B C
C = Grossly Unstable
For your interest

A B C
For your interest

A B C
For your interest

A B C
For your interest
In Summary
 Need to
TYPE GROUP HEMIPELVIS DISPLACEMENT STABILITY know

A1, Pelvic Ring fracture (avulsion)

Type A

Intact posterior arch

A2, Pelvic Ring fracture (direct blow) None
Stable
A3, Transverse Sacral fracture

B1, Open-book injury; Unilateral

External rotation
partial posterior arch disruption

Type B Rotationally
B2, Lateral Compression, Unilateral
Partial posterior arch partial posterior arch disruption
Internal rotation unstable,
disruption vertically stable
B3, Bilateral partial posterior arch
Bilateral
disruption

C1, Unilateral complete posterior arch

disruption
Vertical (cranial) Rotationally
Type C
C2, Ipsilateral complete, contralateral Ipsilateral vertical (cranial),
unstable,
Complete posterior arch incomplete posterior arch disruption contralateral internal or external vertically unstable
disruption rotation
C3, Bilateral complete posterior arch
disruption
Bilateral vertical (cranial) (Grossly Unstable)

Modified from: https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN39yBTAyMvLwOLUA93I4MQE_2CbEdFAF3RnT4!/?segment=Ring&bone=Pelvis&soloState=true&popupStyle=diagnosis&contentUrl=srg/popup/decision_support/61-Emergency/Tile_classification.jsp

Part 3: Sacral Fractures

For your interest

 For your interest

Part 3: Sacral Fractures

1. Denis classification
2. Isler classification
 For your interest

Part 3: Sacral Fractures

1. Denis classification
2. Isler classification
 For your interest

Denis, F., Davis, S. & Comfort, T. (1988) Sacral Fractures: An Important Problem. Retrospective Analysis of 236 Cases. CORR 227: 67-81
 For your interest

# Location Frequency of
neurologic injury
The region of the ala 5.9 percent, usually L5 root
Zone 1 (Lateral to the sacral foramina)
The region of the sacral foramina 28.4 percent, predominately
Zone 2 sciatica with rare bladder or
bowel involvement
The central sacral canal region ≥50 percent; most involve bowel,
Zone 3 (Medial to the sacral foramina)
bladder, or sexual dysfunction

Denis, F., Davis, S. & Comfort, T. (1988) Sacral Fractures: An Important Problem. Retrospective Analysis of 236 Cases. CORR 227: 67-81
X-rays & CTs
 Inlet view
(Pelvic Ring #)

Inlet Views is good for assessing:

• AP shear/Translation of hemipelvis
• Iliac Spines

Source: Up to date
Inlet view

Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 Outlet view
(Pelvic Ring #)

Outlet Views is good for assessing:

• Vertical shear & translation
• Obturator Foramina
• Sacral Foramina
Source: Up to date
Outlet view
 The arcuate lines represent the
inferior surfaces of the costal
elements that form the roofs of
the anterior sacal canals
Sacral Arcuate Lines (eyebrows) (foramina) and neural grooves

Jackson, H., Kam, J., Harris, J.H. & Harle, T.S. (1982) The sacral arcuate lines in upper sacral fractures. Radiology 145, 35-39
CT reconstruction

CT reconstruction is
a powerful tool for
imaging difficult #’s.
How should pelvic ring #
X-rays be approached?
 X-ray interpretation Need to
know

Be systematic
• Front to back, then as a whole
i. Anterior structures
ii. Posterior sturctures
iii. Pelvic Ring
iv. Hemipelvis
 X-ray interpretation Need to
know

Anterior Normal
a) Pubic Symphysis Pelvic X-ray

b) Rami
c) Femur
d) Iliac Crests & Wings
e) ASIS & AIIS
 X-ray interpretation Need to
know

Anterior
a) Pubic Symphysis
– widening? overlap?
– Vertical alignment: is it in line with tip of coccyx in the midline?
– Normal symphysis: 4 to 5mm in width & does not exceed 1cm
b) Rami
– Obturator Ring: disruption?
c) Femur
– Head, Neck, GT, LT & shaft
– #? hip dislocation?
d) Iliac Crests & Wings
– #?
e) ASIS & AIIS Widened pubic
– Avulsion #? symphysis

Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 X-ray interpretation Need to
know

Anterior
a) Pubic Symphysis
– widening? overlap?
– Vertical alignment: is it in line with tip of coccyx in the midline?
– Normal symphysis: 4 to 5mm in width & does not exceed 1cm
b) Rami Sclerotic line representing iliac wing #

– Obturator Ring: disruption?

c) Femur
– Head, Neck, GT, LT & shaft
– #? hip dislocation? Superior pubic ramus #

d) Iliac Crests & Wings

– #?
e) ASIS & AIIS
– Avulsion #? Inferior pubic ramus #

Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 X-ray interpretation Need to
know

Anterior
a) Pubic Symphysis
– widening? overlap?
– Vertical alignment: is it in line with tip of coccyx in the midline?
– Normal symphysis: 4 to 5mm in width & does not exceed 1cm
b) Rami
– Obturator Ring: disruption?
c) Femur
– Head, Neck, GT, LT & shaft
Avulsion ASIS
– #? hip dislocation?
d) Iliacfragment
Crests & Wings Avulsion ASIS
fragment
– #?
e) ASIS & AIIS
– Avulsion #?
Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 X-ray interpretation Need to
know

Posterior Normal
Pelvic X-ray
a) Sacroiliac joint
b) Sacrum
c) L5 TP
 X-ray interpretation Need to
know

Posterior
a) Sacroiliac joint (SIJ)
– Widening? Hinging? Vertical Shear? Overlap?
– joints should be symmetrical
– joint space less than 2 to 4mm in width
b) Sacrum
– #?
– Sacral arcuate lines (eyebrows) – disruptions?
– Which zone? 1, 2 or 3? (implications for neurological involvement)
c) L5 TP (attachment of the iliolumbar ligament)
– #?
– “A fracture of the transverse process of L5 in the presence of a
pelvic fracture is associated with an increased risk of instability
of the pelvic fracture” (Starks et al. 2011, JBJS Br)
Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 X-ray interpretation Need to
know

Posterior
a) Sacroiliac joint (SIJ)

Normal
Widened SIJ
SIJ

Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
X-ray interpretation Need to
know

SIJ
diastasis

Widened Pubic
Symphysis

Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 X-ray interpretation Need to
know

Pelvic Ring
Follow ring formed by the inferior portion of the sacrum and the medial
ilium and ischium, sweeping down the pubic bone to the pubic
symphysis and back up the opposite side. This should follow a
continuous ring.

Normal
Pelvic Ring

Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 X-ray interpretation Need to
know

Hemipelvis
Cranial displacement is consistent with a vertical shear #
Vertical Shear #
Vertically unstable,
Rotationally unstable

UNSTABLE

Cranial displacement of
the right hemipelvis

Pubic Rami #
Slater, S.J. & Barron, D.A. (2010) Pelvic Fractures – a guide to classification and management, 74, 16-23.
How should pelvic ring #
CTs be approached?
 CT interpretation Need to
know

Be systematic
• For axial CTs, top to bottom, 3 locations:
i. L5 vertebrae
ii. Iliac Wing
iii. Inferior Pelvis
 CT interpretation Need to
know

L5 vertebrae (axial view)

• L5 Transverse Process (attachment of the iliolumbar ligament)
– L5 TP #?
– Iliolumbar ligament is the last ligament to fail in disruptions to
the posterior sacroiliac complex in pelvic ring #

“A fracture of the transverse process

of L5 in the presence of a pelvic
fracture is associated with an
increased risk of instability of the
pelvic fracture” (Starks et al. 2011, JBJS Br)

UNSTABLE
Mulligan, M. & Talmi, D. (2009). Are pelvic radiographs needed in assault victims? Emerg Radiol 16(4): 299-301
 CT interpretation Need to
know

Iliac wing (axial view)

a) SIJ
b) Ilium
c) Sacrum
 CT interpretation Need to
know

Iliac wing (axial view)

a) SIJ
– Disruptions?
e.g. Widening? Hinging?

b) Ilium
– #?
– Avulsion #?

c) Sacrum Widened Normal

– #? right SIJ left SIJ
– Vertical shear?
– Which zone is it in?
 CT interpretation Need to
know

Iliac wing (axial view)

a) SIJ
– Disruptions?
e.g. Widening? Hinging? UNSTABLE
b) Ilium
– #?
– Avulsion #?

c) Sacrum
– #?
Unilateral
Widenedcomplete
– Vertical shear? disruption
rightofSIJ
posterior
– Which zone is it in? arch
 CT interpretation Need to
know

Iliac wing (axial view)

a) SIJ
– Disruptions?
e.g. Widening? Hinging?

b) Ilium
– #?
– Avulsion #?

c) Sacrum Normal
Iliac wing #
– #? Iliac wing
– Vertical shear?
– Which zone is it in?
 CT interpretation Need to
know

Iliac wing (axial view)

a) SIJ
– Disruptions? UNSTABLE
e.g. Widening? Hinging?

b) Ilium
– #?
– Avulsion #?

c) Sacrum
Unilateral complete
Sacral #
– #?
disruption of posterior
– Vertical shear? arch
– Which zone is it in?
 CT interpretation Need to
know

Inferior pelvis (axial view)

a) Ischial Tuberosities
b) Pubic Symphysis
c) Pubic Rami
d) Coccyx
 CT interpretation Need to
know

Inferior pelvis (axial view)

a) Ischial Tuberosities
– #? Symmetry?

b) Pubic Symphysis
– widening? overlap?

c) Pubic Rami
– #? Symmetry?

d) Coccyx
Widened pubic
Symphysis
 CT interpretation Need to
know

Inferior pelvis (axial view)

a) Ischial Tuberosities
– #? Symmetry?

b) Pubic Symphysis
– widening? overlap?

c) Pubic Rami
– #? Symmetry?
Minimally displaced right
d) Coccyx superior pubic ramus #
 CT interpretation Need to
know

Inferior pelvis (axial view)

a) Ischial Tuberosities
Normal inferior
– #? Symmetry?
pubic ramus
b) Pubic Symphysis
– widening? overlap?

c) Pubic Rami
– #? Symmetry?

d) Coccyx Inferior pubic

ramus #

Pubic rami #
• Spike # could pierce bladder (suggestive of internal rotation: B2)
• Transverse # (suggestive of external rotation, B1 ‘open book’)
 NOTE:
Even though we have divided the educational
package into pelvic ring & acetabular #s, the
two types of #s can occur together. Therefore,
in clinical practice, you need to assess the
landmarks for both acetabular* & pelvic ring #s

* See acetabular # educational package

For Example
Complete
Complete disruption SIJ
disruption SIJ

UNSTABLE

Acetabular #

Femoral Head
Fracture

Inferior pubic ramus #

Inferior pubic ramus #

When there are more than 1 #s in the
pelvis, you would classify the #s in that
patient based on the individual #s (e.g.
Right 61B1 & Left 61A1). However, the
main # is the more severe one.
 Now, Classifying Pelvic-ring
fractures using X-rays & CTs
Is this X-ray
normal?

Source: up to date
Courtesy of Jim Fiechtl, MD
AP Pelvic X-ray
Avulsion # of Left ASIS
Common in immature skeleton

Think about origin of muscles

ASIS avulsion #
• Sartorius (small avulsion)
• TFL (bigger avulsion)
• or both

AIIS avulsion #
• Rectus Femoris

61 A1
Source: up to date
Courtesy of Jim Fiechtl, MD
 ?

Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 X-ray
Avulsion # of
Right AIIS
Avulsion
fragment of AIIS

61 A1
Broder, J. (2011) Diagnostic Imaging for the Emergency Physician – Chapter 13 Imaging of the pelvis and hip, 706-747
 This is an isolated transverse fracture
of the sacrum, approximately at the
X-ray
level of the inferior margin of the left
SIJ.
Transverse sacral #
This runs through the neural foramen
of the sacrum, so that the arcuate
lines of the foramen do not form a
complete circle.

Transverse Because the fracture only separates

Sacral # the caudad portion of the sacrum
from the cephalad portion, the
sacrum continues to form a complete
bridge between the iliac wings, and
the pelvis remains stable.

Transverse
Sacral #

61 A3
 X-ray
Widening of pubic symphysis
Therefore, open book #
Therefore, at least type B

However, difficult to classify

because of incomplete information
(e.g. completeness of posterior
arch disruption? involvement of
one or both sides?)

At least a Type B
NB: diastasis at the pubic symphysis can cause
significant haemorrhage. Emergent treatment
consists of closing the # and stabilising the pelvis by
applying a pelvic binder or tying a sheet tightly
around the lower pelvis

Source: up to date
 Schematic X-ray
Schematic representation of
Widening of pubic symphysis
• Pubic Symphysis disruption
(Therefore not a type A, at least a type B)
• Ligamentous disruption

61 B1
CT
Partial disruption of
posterior arch
(Therefore type B)
Unilateral
(Therefore B1)

Source: up to date
 X-ray (A)
Bilateral sup. & inf. rami #
Left Sacral #

Lateral compression injury

with internal rotation of the
hemiplevis

No vertical shear
(Therefore not type C)
No pubic symphysis diastasis
(Therefore not B1)

X-ray (B)
Inlet view showing greater
detail of the pelvic ring
disruption

X-ray (C)
61 B2 Outlet view showing greater
detail of the sacral # & the
bilateral rami # Source: up to date
Courtesy of Jim Fiechtl, MD
X-ray
Widening of pubic symphysis
(Therefore not a type A, at least a type B)
Rami #
Widening of right SIJ

CT
Bilateral partial posterior arch disruption
• Opening of right SIJ anteriorly
• Posterior right SIJ hinging
• Opening of left SIJ anteriorly

Rotationally unstable
but Vertically stable

61B3
Source: up to date
Courtesy of Jim Fiechtl, MD
 Tricky one!
X-ray
Pubic symphysis intact
No vertical shear
(Probably a type B)

CT
Complete posterior disruption
Currently vertically stable (Type B) but
has the potential to become vertically
unstable (Type C) because of the
complete posterior arch disruption

Type B,
arguably Type C
 Schematic X-ray
Schematic representation of
Huge pubic symphysis disruption
• Pubic Symphysis disruption
(Therefore not a type A, at least a type B)
• Posterior arch disruption

CT
61C1
Complete disruption
of posterior arch
(Therefore, type C)
Unilateral
(Therefore, C1)

UNSTABLE
Source: up to date
 Schematic
Schematic representation of X-ray
• Pubic Symphysis disruption
Pelvic Vertical Shear
• Posterior arch disruption

CT
reconstruction
61 C1
Unilateral complete
disruption of posterior
arch

UNSTABLE Source: up to date

X-ray
Widening of pubic symphysis
(Therefore not a type A, at least a type B)

UNSTABLE

61 C2
CT
Complete posterior arch disruption
(Therefore, type C)
Ipsilateral complete
Contralateral incomplete (arrow)
(Therefore, C2)

Source: up to date
 X-ray
Vertical Shear injury
Right Rami #
Left Sacral #
Left Transverse Acetabular #

Vertical Shear

Pelvic Type C

Transverse Acetabular #

Acetabular Type B1
Need to
know UNSTABLE
Main Fracture is the Type C Pelvic Ring # NB: need CT scans to
provide more
because of it implications. It is associated information about the #s
with a left transverse acetabular #
Source: up to date
Courtesy of Jim Fiechtl, MD
The end
Thank you for your attention,
good luck with the test.