PELVIC FRACTURE

Supervisor: Mr Jeff
• The pelvis consists of the sacrum,
the coccyx, the ischium, the ilium,
and the pubis
• The two hip bones are joined
anteriorly at the pubic symphysis and
posteriorly to the sacrum at the
sacroiliac joint. The hip bones
incorporate the acetabulum, which
articulates with the proximal femur at
the hip joint
• In addition to carrying upper body
weight, this multi-surfaced pelvic ring
can transfer upper body weight to the
lower limbs and act as attachment
points for lower limb and trunk
muscles.
Ligaments
Blood vessels
• Major vessels to
- Pelvic content
- Lower extremities

• Disruption leads to
- Major bleeding
- Loss of blood flow to limbs
Nerves
• Emerges from lower lumbar
spine and sacrum
• 2 largest nerves are sciatic nerve
and femoral nerves
Pathophysiology
• The bony pelvis, comprised of the ilium (iliac wings), ischium, and pubis, forms an anatomic ring
with the sacrum.
• Due to the amount of force that is required to fracture this ring, a fracture in one part of the pelvis
is frequently accompanied by a fracture or damage to ligaments or structures within or outside of
the pelvis.
• The Young-Burgess classification distinguishes various pelvic ring injuries mechanistically, with
common fracture patterns correlating with the direction of applied impact at the time of injury
( the most commonly used for the evaluation of pelvic ring injuries in orthopedic trauma surgery )
• There are 3 mechanisms for Young-Burgess classification :
o anterior to posterior compression injuries (APC),
o lateral compression injuries (LC),
o vertical shear injuries (VS)
Anterior to Posterior Compression injuries
(AC)
• Ligamentous structures fail from an anterior to posterior direction.
• damage to the symphyseal ligaments at the pubic symphysis.
• followed by disruption of the ligaments of the pelvic floor, that is the
sacrospinous and sacrotuberous ligaments. And finally, there is
disruption of the posterior sacroiliac compex.
• The progression of this injury pattern divides APC type pelvic ring
injuries into 3 types:
• APC type 1
• APC type 2
• APC type 3
Anterior to Posterior Compression injuries
(AC)
• APC Type I: disruption of the symphyseal ligaments only and are
typically caused by isolated disruption of the symphyseal ligaments.
• APC Type II: disruption of the symphyseal ligaments and the
ligaments of the pelvic floor (sacrospinous and sacrotuberous
ligaments). On radiographs, this manifests as a widening of the
symphyseal ligaments by more than 2.5 cm.
• APC Type III: disruption of both the anterior and posterior sacroiliac
ligaments, including the posterior sacroiliac complex, the strongest
ligaments in the body. APC III injuries have the highest rate of
mortality, blood loss, and need for transfusion of all pelvic ring
injuries[
Lateral Compression injuries (LC)
• LC Type I: Presents as rami fractures with ipsilateral sacral ala
fractures, resulting from a lateral impact over the posterior aspect of
the pelvis.
• LC Type II: Results of a lateral compression injury with a more
anteriorly directed force compared to LC I injuries. Typically presents
as rami fractures with ipsilateral crescent fracture of the ilium.
• LC Type III: Colloquially described as "windswept pelvis." Results
from the highest energy mechanism of all lateral compression type
fractures. Presents as an ipsilateral disruption lateral compression type
I or II injury with a contralateral external rotation type injury
resembling an APC type injury.
Vertical Shear (VS)
• result of an axial load to one hemipelvis.
• These injuries are more commonly seen with falls from height or
motorcycle collisions where one leg is more likely to be forcefully
loaded compared to the other.
• The iliac wing is driven up relative to the sacrum, with disruption of
the symphyseal ligaments, pelvic floor, and the strong posterior
sacroiliac complex
• Classification of pelvic fractures by Tile is based on the integrity
of the posterior sacroiliac complex
• Type A: rotationally and vertically stable, the sacroiliac complex is
intact. Type A fractures are mostly managed non-operatively.
o A1: avulsion fractures
o A2: stable iliac wing fractures or minimally displaced pelvic ring
fractures
o A3: transverse sacral or coccyx fractures
• Type B: rotationally unstable and vertically stable, caused by
external or internal rotational forces, results in partial disruption of
the posterior sacroiliac complex.
o B1: open-book injuries
o B2: lateral compression injuries
o B3: bilateral rotational instability
• Type C: rotationally unstable and vertically unstable, complete
disruption of the posterior sacroiliac complex. These unstable
fractures are mostly caused by high-energy trauma like falls from
height, motor vehicle accidents or crushing injuries.
o C1: unilateral injury
o C2: bilateral injuries in which one side is rotationally unstable
and the contralateral side is vertically unstable
o C3: bilateral injury in which both sides are vertically unstable
Imagings
• Anteroposterior (AP) pelvic radiograph
• Computed tomography (CT) abdomen/pelvis
o visualization of pelvic anatomy and allow for evaluation of
any pelvic, retroperitoneal, or intraperitoneal bleeding.
o Confirmation of hip dislocation
o determine whether or not there is an associated acetabular fracture
Imagings
• Focus Assessment with Sonography for Trauma (FAST) examination
• Retrograde urethrography - suspected of having a urethral tear
• Cystography- Individuals presenting with hematuria in the setting of
an intact urethra
• Pelvic Angiography
Management
• primary goal in the acute setting
o provide early stable fixation
• Excessive movement of the pelvis should be avoided
Mechanical stabilization
• pelvic binder or sheet centered over the greater trochanter
o stabilize the pelvic ring
o staunch internal bleeding from the venous plexus in APC type pelvic ring
injuries
o should be avoided in lateral compression (LC) type pelvic ring injuries with an
internal rotation component.
• skeletal traction - for a vertical shear pelvic ring injury.
Treatment: pelvic ring
• Conservative management
• Lateral compression: are managed with early ambulation
• If both back and front ring are unstable, surgical intervention is
required

Treatment: acetabular fracture

• Surgical intervention is required if there is displacement
Nonsurgical treatments
• APC Type I and LC Type I fractures can remain weight-bearing as
tolerated,
• Minimally displaced pelvic fractures can often be treated non-
operatively
Prognosis

• Significantly lower quality of life both mentally and physically two

years after treatment for pelvic injuries
• Pelvic fractures are highly associated with concomitant injuries
• Patients with concomitant orthopedic injuries in particular suffered
worse disability and significantly worse psychological, social, and
occupational outcomes
Complications

• 56% of women report dyspareunia, with symphyseal displacement of 5 mm or

more being associated with increased pain during intercourse.
• women with a history of pelvic ring injury are more likely to require a cesarean
section than others.
• Men up to 61% of patients reporting some level of sexual dysfunction and 19%
with erectile dysfunction, with rates going up when considering only APC type
injuries up to 90%.
• Thromboembolism