Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries Robert M. Harris MD Medical Director of Orthopaedic Trauma Mountain States Health Alliance East Tenn State University Quillen School of Medicine Revised November 2010 Created March 2004 Revised April 2007 By Kyle Dickson MD
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Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries Robert M. Harris MD Medical Director of Orthopaedic Trauma Mountain States.
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Anatomy, Radiographic Evaluation, and Classification
of Pelvic Ring Injuries
Robert M. Harris MDMedical Director of Orthopaedic Trauma
Mountain States Health AllianceEast Tenn State University Quillen School of Medicine
If evidence of pelvic ring fracture...If evidence of pelvic ring fracture...
INLET VIEWINLET VIEW
Inlet (Caudad) View
• Horizontal Plane Rotation
• Posterior Displacement
• Sacral ala
OUTLET VIEWOUTLET VIEW
Outlet (Cephalad) View
• Sacrum• Cephalad
Displacement• Sacral Foramina
CT Scan
• Better defines posterior injury• Amount of displacement versus impaction• Rotation of fragments• Amount of comminution• Assess neural foramina
CT SCANCT SCAN
3D CT
Radiographic Signs of Instability
• Sacroiliac displacement of 5 mm in any plane
• Posterior fracture gap (rather than impaction)
• Avulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament)
Translational Deformities
• X axis – Diastasis or impaction• Y axis – Caudad or cephalad displacement• Z axis – Anterior or posterior displacement
Rotational Deformities• X axis – Flexion or extension• Y axis – Internal rotation or external
rotation• Z axis – Abduction or adduction
Classification
• Aids in predicting hemodynamic instability• Aids in predicting visceral and g.u. injuries• Aids in predicting pelvic instability• Aids in understanding mechanism of injury,
force vector of injury, and surgical tactic for reduction
– Young/Burgess –Kappa .72-better for the training surgeon
– CT-improved assessment of stability
• Furey AJ, O”Toole RV, Turen C, Ortho June 2009– Interobserver – moderate degree of agreement– Intraobserver- moderate for Tile
• Substantial for Burgess
LATERAL COMPRESSION
LC I:LC I: Sacral compression Sacral compression
Lateral Compression• Most common pattern.• LC1 – stable, load to posterior ring.• LC2 – load to anterior ring, posterior ligaments
injured, ST and SS intact.• LC3 – LC2 + external rotation injury of the
other side.
LC-I
LATERAL COMPRESSION
Common anterior patternCommon anterior pattern
LATERAL COMPRESSION
LC I: LC I: Sacral compressionSacral compression
What Constitutes a LCI
• Lefaivre KA, Padalecki JR, Starr AJ- J Ortho Trauma Jan 2009
• LC I-Spectrum of injuries
• Complete sacral disruptions– Denis classification– Predicted by severity of anterior pelvic ring disruption– Abdominal AIS– Rami fracture location– ISS
• . Classification of pelvic fractures: analysis of inter- and intraobserver variability using the Young-Burgess and Tile classification systems.Furey AJ, O'Toole RV, Nascone JW, Sciadini MF, Copeland CE, Turen C. Orthopedics. 2009 Jun;32(6):401
• Interobserver reliability of the young-burgess and tile classification systems for fractures of the pelvic ring.Koo H, Leveridge M, Thompson C, Zdero R, Bhandari M, Kreder HJ, Stephen D, McKee MD, Schemitsch EH.Division of Orthopaedic Surgery; and daggerMartin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto, Ontario, Canada. J Orthop Trauma. 2008 Jul;22(6):379-84
• Fracture of the pelvis: current concepts of classification.Young JW, Resnik CS.Department of Radiology, University of Maryland Medical System/Hospital, Baltimore 21201. AJR Am J Roentgenol. 1990 Dec;155(6):1169-75.
• Do initial radiographs agree with crash site mechanism of injury in pelvic ring disruptions? A pilot study.Linnau KF, Blackmore CC, Kaufman R, Nguyen TN, Routt ML Jr, Stambaugh LE 3rd, Jurkovich GJ, Mock CN.Department of Radiology, Harborview Medical Center, Seattle, Washington 98104-2499, USA. J Orthop Trauma. 2007 Jul;21(6):375-80.
References• How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in
blunt trauma patients? Shlamovitz GZ, Mower WR, Bergman J, Chuang KR, Crisp J, Hardy D, Sargent M, Shroff SD, Snyder E, Morgan MT. Department of Emergency Medicine and Traumatology, Hartford Hospital, UCONN School of Medicine, University of Connecticut, Hartford, Connecticut, USA. J Trauma. 2009 Mar;66(3):815-20
• What constitutes a Young and Burgess lateral compression-I (OTA 61-B2) pelvic ring disruption? A description of computed tomography-based fracture anatomy and associated injuries. Lefaivre KA, Padalecki JR, Starr AJ. Department of Orthopaedics Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA. J Orthop Trauma. 2009 Jan;23(1):16-21.
• Predicting blood loss in isolated pelvic and acetabular high-energy trauma. Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Nashville, Tennessee 37232-8774, USA. Orthop Trauma. 2007 Oct;21(9):603-7
• Pelvic disruption: assessment and classification. Pennal GF, Tile M, Waddell JP, Garside H. Clin Orthop Relat Res. 1980 Sep;(151):12-21
• Pelvic fractures: value of plain radiography in early assessment and management. Young JW, Burgess AR, Brumback RJ, Poka A. Radiology. 1986 Aug;160(2):445-51
• Pelvic ring disruptions: effective classification system and treatment protocols.Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ.Shock Trauma Center, Maryland Institute for Emergency Medical Services Systems, Baltimore J Trauma. 1990 Jul;30(7):848-56
See Emergent Management of Pelvic Injuries for Application of
Classification to Treatment
Acknowledgment
Return to Pelvis Index
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Questions/Comments
If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected]
Andy Burgess and Kyle Dickson for the use of their slides