PELVIC

FRACTURES
PRINCE K SAM
 INTRODUCTION
 Pelvic fractures account for less than 5 % of all skeletal injuries.

 These are associated with soft tissue injuries, shock, sepsis.

 The close proximity of osteoligamentous structures to pelvic organs,

neurovascular, hollow viscera and urogenital structure can lead to severe
complications and sequele.

 Disabilities due to anatomic disruption of pelvic ring.

 PELVIS

 Pelvic ring composed of sacrum & 2 innominate

bones
 Innominate bones composed of fused
ilium,ishium& pubic bones.
 Joined anteriorly at pubic symphysis and
posteriorly at sacroiliac joints.
 TRUE VS FALSE
PELVIS

The pelvis is divided into true & false pelvis with line of demarcation
at pelvic brim.
True pelvis - bladder ,urethra and rectum and the uterus & vagina in
females & the prostate gland in men.
False pelvis forms lower part of abdominal cavity
 MECHANISM OF INJURY

 High energy injuries

- Motorvehicle accident, Fall from height,Pedestrian accidents
Low energy – domestic falls, avulsion injury, postmenopausal.
BY DIRECTION OF FORCE :
 Anteroposterior force (AP) force. There is external rotation of both hemipelvis. Pubic
symphysis diastasis is present.
Pelvis opens up like a book – open book injury
 Lateral compression force (LC) force : Side impact is the most common mode of
violence.
 Vertical shear: Mainly from longitudinal forces applied to an extended extremity
 EVALUATION
 History:

1. Age – Fracture occurs in elderly with less violent force, and associated with
less soft tissue disruptions than young patients.
2. Gender:
 In males, more associated injuries to urethra compared to females
 In females- vaginal tear.
PHYSICAL EXAMINATION
 ABCDE
- Airway, breathing, circulation, disability, exposure

 Vitals
-BP, heart rate, RR, temp, SpO2

 Look for all life threatening injuries

- Head, chest, abdomen, spine
INSPECTION

 1) WOUNDS- open wounds ,abrasions, ecchymosis, hematoma

 2) CONTUSIONS
 3) BLEEDING GENITALIA-
 In men ,blood from urethra suggests a urethral rupture
 In women ,blood from urethra /vagina suggests an occult open
fracture of the pelvis.
 4) DISPLACEMENT OF PELVIS / LOWER EXTREMITIES
 In displaced fracture , shortening of one of the lower limbs

 The limb lies in external rotation.

 Hematoma in the region of pubic symphysis or at sacro iliac joint.

Bleeding in pelvic fractures is mainly from the fractured surfaces.
The usual cause of retroperitoneal hemorrhage secondary to pelvic fracture is a
disruption of the venous plexus in the posterior pelvis.
The superior gluteal artery can be injured and can be managed with rapid fluid
resuscitation, appropriate stabilization of the pelvic ring, and embolization.
 Palpation – localised tenderness or crepitus

 Gap at pubic symphysis is felt

 Clinical examination

• Look in all cases of RTAs with multiple injuries, hypovolemic shock and with major
lower limb fractures.
• Pelvic compression test
• The patient lies in supine position on couch. The examiner compresses both iliac
crests of the patient’s pelvis towards each other
• Any pain during this manoeuvre or a ‘springy’ feeling- indicates pelvis fracture.
• Pelvic compression tests should be performed only once, because once the clot that
is formed is disrupted uncontrollable retroperitoneal haemorrhage may occur.
 PALPATION

 Palpate for crepitus / abnormal motion in the hemipelvis

 Palpation of posterior aspect may reveal large hematoma
 Maneuvers
1. Test for anterior defects-
 Direct palpation of symphysis pubis may reveal a gap / ecchymosis ,
indicating a symphysis disruption.
 Test for rotational instability -
 Grasping the iliac crests & pushing the unstable hemipelvis inward & outward
 Test for vertical instability-
Can be appreciated when movement of hemipelvis detected as manual
compression & traction are applied through an extended uninjured lower
extremity.

Rectal & vaginal examination :

• To assess the stability of pelvic ring. May reveal bone fragments if an
associated sacral fracture is present.

Neurological examination :
Injury to lumbosacral plexus ,especially L5 and S1 root is common
RADIOLOGICAL EXAMINATION

 Ap pelvic view mandatory

 Oblique views (inlet and outlet films) are included for
Inlet view of the pelvis:• Beam is directed 45- 60 caudally perpendicular to the pelvic brim with the
patient in supine position.
Helps to identify anterior and posterior displacements of the sacroiliac joint, sacrum.
3. Outlet view of the Pelvis:• Beam is directed 45° cephalad. This is useful for determination of vertical
displacement of the hemipelvis,a slightly widened sacroiliac joint, discontinuity of the sacral borders,
nondisplaced sacral fractures, or disruption of the sacral foramina.
 RADIOGRAPHIC SIGNS OF INSTABILITY

• >5MM DISPLACEMENT OF POSTERIOR SACROILIAC COMPLEX.

• PRESENCE OF POSTERIOR SACRAL FRACTURE

• AVULSION FRACTURES OF ISCHIAL SPINE, ISCHIAL TUBEROSITY, SACRUM,

TRANSVERSE PROCESS OF 5TH LUMBAR VERTEBRAE
Other investigations:

 C T scan
-better characterization of posterior ring injuries
- helps define comminuted fragment and fragment rotation
- visualize position of fracture lines relative to sacral foramina

 MRI
 Angiography & embolization
only arterial bleeding can be controlled
Ischio- pubic rami fracture
 Commonest of pelvic fractures

 One or more rami fractured on one or both sides (straddle fracture)

 Minimal displacement
 Pain, tenderness over fracture site
 Treatment :
for pain relief, bed rest for 1-3 weeks.
ILIAC WING FRACTURE
 Results from direct injury to the wing of ileum ( in rta)
 develops hypovolemic shock
 Unite in 4-6 weeks with rest and analgesics.
Avulsion fractures
 Commonly around anterior inferior iliac spine and ischial tuberosity
 Bone pulled off by violent muscle contraction.
 Seen in sportsmen and athletes.
 Treatment : rest, muscle rehabilitation
 TYPE A –isolated fractures
 Pelvic ring stable
ISCHIO – PUBIC RAMI fracture (straddle fracture)
ILIAC WING fracture
AVULSION fracture AIIS
 Due to violent contraction of rectus femoris muscle during a jump.

 TYPE B
 Pelvis unstable.
 Rotational displacement occurs but no vertical displacement.

 TYPE C
 most unstable
STRESS FRACTURES
 Common in osteoporotic bone
 Difficult to diagnose near SI joint in elderly. ( sacro iliac pain)
 Also seen in superior and inferior pubic rami in slim individuals and long distance
runners.
 Check vit D to exclude deficiency
APC

 Anterior structure opens up- as energy increases posterior structures are injured.
 Seen in horse riders
 APC I - <2.5 cm widening at PS
 APC II - >2.5 cm widening of PS & anterior widening of SI joint
 APC III - >2.5 cm widening of PS with dislocation of SI joint
 LC (LATERAL COMPRESSION)

 Force applied to and transmitted from the side of pelvis.

 By pedestrians hit by an automobile
 Mild – hemipelvis affected , as energy increases opp side affected.
 LC I – rami fracture and ipsilateral anterior sacral alar fracture
 LC II – rami fracture and ipsilateral postr ileum fracture dislocation
 LC III – ipsilateral lateral compression and contralateral APC pattern injury
VERTICAL SHEAR

 Through a vertically oriented force

 Seen after fall from height, landing on one leg with one hemi pelvis
driven up
 Complete disruption of all posterior structures
 ASSOCIATED INJURIES

NEUROLOGIC IMPAIRMENT
 Lumbosacral plexus
 Presacral plexes
 Sciatic nerve
 Femoral nerve
 Other motor nerves (gluteal,obturator,pudendal)
 Lateral femoral cutaneous nerve of thigh
 Genitofemoral,ilioinguinal
 Lumbosacral nerve roots
VISCERAL INJURIES

INTRAPELVIC
 Intestinal-large & small bowel
 Urinary-bladder & urethra
 Genital
INTRABDOMINAL – abdominal compartment syndrome,
retroperitoneal hematoma.
 MANAGEMENT
• Early management- ABCDE

STABILISATION
 Reduction and stabilization of pelvis by mechanical means:

 Bind the pelvis by a rolled sheet with inner rotation and slight flexion of knees.
 External fixator
 Pelvic c- clamps
PELVIC C CLAMPS

 Compression of the pelvis through

percutaneously inserted pins to the
outer surface of ilium
 PELVIC BINDER

 Centered over greater trochanters to effect

indirect reduction
 Do not place over iliac crest or abdomen
 Prolonged pressure – skin necrosis
 DEFENITIVE PELVIC FRACTURE
MANAGEMENT

Objectives:
 Anatomic restoration

 Relief of pelvic pain

 Patient mobilization

 Minimal predilection for late complications

1.AN INJURY WITH MINIMAL OR NO
DISPLACEMENT
 Absolute bed rest for 3-4 weeks
 When pain subsides, gradual mobilization and weight
bearing

2.AN INJURY WITH ANTERIOR OPENING

OF PELVIS
 External fixator :
2 or 3 pins threaded at the tip (schanz pin) inserted into
anterior part of wing of iliac bone.
 Internal fixation:
Pubic symphysis disruption reduced and Internally fixed with a plate

 Hammock – sling traction

Bilateral upper tibial skeletal traction.
Heavy weight (20kg) to acquire reduction.
After 3 weeks , weight is reduced to 10kg to maintain position
Traction removed after 6-8 weeks and the patient mobilised
NON OPERATIVE TREATMENT

Indication
 Pubic rami fracture with no post. displacement
 Gapping of pubic symphysis <2.5cm
 Lateral impaction type with minimal displacement
OPTIONS:
 Tractions
 Protected weight bearing
 Pelvic binders
 Early mobilization with use of walking aid
Operative treatment

INDICATIONS
 Open pelvic fractures associated with visceral injuries
 Open book and vertically unstable fractures
 Symphyseal diastasis > 2.5cm
 SI joint displacement > 1cm
 Leg length discrepnancy > 1.5cm
 Rotational deformity
 Sacral fracture displacement > 1cm
 SURGICAL TECHNIQUES

 External fixation
 ORIF of pubic symphysis with plates
 Posterior ring fixation with plates or screws
 Posterior SI tension plating
 Percutaneous iliosacral screw fixation for sacroiliac disruptions
 Reduction of hemipelvis involves traction and rotation to correct deformity.
MANAGEMENT OF OPEN PELVIC FRACTURES

 Isolated iliac wing fractures are managed with aggressive debridement &
stabilisation of fractured component
 Perineal lacerations & wounds that communicate with the rectum / colon require
early diverting colostomy
 Early detection & repair of vaginal lacerations to minimize subsequent pelvic
abscesses.
 suprapubic urine catheter drainage ,insertion of a transurethral catheter & suture
of the bladder after urological injuries.
 COMPLICATIONS

EARLY LATE
 haemorrhage * fixation failure
 GI tract injury *malunion
 Neurologic injury * chronic persistent pain
 Vascular injury * non union
 Infection * sexual dysfunction
 Thromboembolism
 Bladder injury
 Urethral injury
THANK YOU