Jatinder S. Luthra
Anatomy, Radiographic evaluation &
Classification of Pelvic Ring Fractures
Pelvic Fractures: Epidemiology
Majority due to high impact blunt trauma (MVA, pedestrian vs. vehicle etc.) but also secondary to falls in frail elderly
Mortality overall = 10% Mortality 50% if open #
Pelvic Anatomy Pelvis = sacrum,
coccyx + 2 innominate bones
Innominate bones = ilium, ischium, pubis
Sacrum + innominate bones form a ring
Strength from ligamentous supports (largely posterior aspect of ring)
Pelvic Anatomy 5 joints: Lumbosacral Sacroiliac (x2) Sacrococcygeal Symphysis
Anterior Support:– Symphysis pubis
Fibrocartilaginous joint covered by ant & post symphyseal ligaments
– Pubic rami Posterior Support:
– ~majority of stability Iliolumbar
ligaments Sacroiliac
ligaments Sacrospinous
ligament Sacrotuberous
ligament
Vascular Anatomy Vessels lie
close to posterior pelvic walls
Venous bleeding most common (sacral plexus)
Most commonly injured arteries are superior gluteal and internal pudendal
Pelvic Anatomy Nerve supply through the pelvis
derived from lumbar and sacral plexuses
Other structures: lower GI/GU
Imaging – X- rays
X Rays Pelvis AP – part of ATLS protocol
Imaging – X- rays AP VIEW:-Identifies most fractures-Look for disruption in iliopubic and ilioischial
lines, sacral foramina, radiographic U, Shenton’s Lines
Inlet and outlet views
Judet Views
AP Pelvis Radiogram
Acetabular fracture
Posterior Pelvic lesion
S2
Imaging Look for any evidence of damage to
the posterior pelvic structures– Clues on X-rays:
L5 transverse process avulsion (iliolumbar ligament)
Ischial spine avulsion (sacrospinous ligament)
Unable to clearly make out sacral foramina Assymmetry of sacral foramina Avulsion at lower lip of lateral sacrum
(sacrotuberous ligament)
Inlet view– X-ray beam at
40o to plate directed towards feet
Sacral Promontry should overlap anterior border of S1
Posterior displacement
Rotational deformity
Subtle SI joint injury
Sacral Ala fracture
Outlet View Outlet view
– Beam aimed 30o towards head
– Superior border of symphysis at level S2
Outlet View Vertical
displacement
Sacral foramina
Flexion deformity
CT scan Detailed
information of posterior lesion
Sacral Foramina Subtle sacral
impaction. Rotation of
hemipelvis Associated Lesions Dysmorphysisum
Radiological criteria of instability
Displacement instead of impaction in posterior pelvis
Attention Stationary pelvic radiogram do not reflect true
pathology
Apparently stable patient should undergo Examination under anaesthesia
Push Pull film under anaesthesia > 1cm is unstable Contraindicated – Zone 2/3 sacral fracture Haemodynamically unstable
ArteriogramPatients with pelvic fracture – persistent bleeding despite External stabilization
ICE – intravenous contrast extravasation
-Gross haematuria-- Bloody urethral discharge-Inability to void-- swelling / echymosis in perineal region-High riding prostate
Pelvic Fractures 5 General Categories: 1. Pelvic Ring 2. Acetabular 3. Sacral 4. Avulsion type 5. Single bone
Pelvic fracture classification
Bucholz classification – JBJS 1981
Type1 - stable Type II- Open
Book
Type III – Rotaionally and vertically unstable
Pelvic fracture classification
Letournal Classification
Pelvic Ring FracturesYoung Classification System:
Differentiates fracture patterns based on mechanism of injury/direction of causative force
3 major fracture patterns: 1. lateral compression (50%) 2. antero-posterior compression
(25%) 3. vertical shear (5%)
Pelvic fracture classification Young & Burgess
Classification
Modification of tile – Based on mech of inj.
Young & Burgess Anteroposterior compression fracture
External rotation force
Neurovascular structures stretched.
Symphyseal diastasis / Vertical fracture pubic ramus
Young & Burgess Anteroposterior compression fracture - I
Young & Burgess Anteroposterior compression fracture - II
Young APC II
Young & Burgess Anteroposterior compression fracture - III
Young & Burgess LATERAL COMPRESSION - I
Young & Burgess LATERAL COMPRESSION - II
CRESCENT FRACTURE
Young & Burgess LATERAL COMPRESSION – III
Young & Burgess VERTICAL SHEAR
Tile C1/ Young VS
Young & Burgess COMBINED MECHANISM
Summary Classification system - - Assist
surgeon in determining treatment and prognosis
Young & Burgess – - Fluid resuscitation reqd - Solid organ injury Need for acute stabilization Pt. survival
APC type 3 & VS injury – highest transfusion reqd.
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