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Pelvic Ring Fractures
Christy Johnson
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Outline
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Background
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Anatomy and Function
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Assessment
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Radiology
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Classification
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Treatment
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Background
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Mechanism: high energy blunt
trauma
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Mortality rate:
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15-25% for closed fractures
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Up to 50% for open fractures
Hemorrhage is the leading cause
of death overall
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Venous (80%) > arterial
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Have a high index of suspicion for
injury of internal iliac vessels or
lumbosacral plexus
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Background
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Associated injuries:
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Chest injury (63%)
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Long bone fracture (50%)
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Head and abdominal injury (40%)
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Spine fractures (25%)
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Urogenital injuries in 12-20%
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Survivors: 1.89 additional injuries
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Non-survivors: 2.95 additional injuries
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Only 2 in 14 deaths (14%) are directly attributable to pelvic
injury
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Anatomy: Osteology
Ilium
Sacrum
Pubis
Femur
Ischium
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Osteology
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Ring structure made up of
the sacrum and two
innominate bones
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No inherent osseous stability
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Anatomy: Muscles
Iliacus
Piriformis
Pectineus
Sartorius
Rectus
femoris
Adductor longus
Adductor brevis
Adductor magnus
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Ligaments
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Anterior structures: provide 40% of stability
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Posterior structures: provide 60% of stability
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Pelvic Stabilizers
Sacrospinous
Ligament:
Resist ER
Iliolumbar:
Augment
posterior
stability
Sacrotuberous
Ligament:
Resist ER and
Vertical shear
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Posterior interosseous sacroiliac ligaments are the strongest
in the body
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Assessment
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Primary Survey
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Airway
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Breathing
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Circulation
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Disability
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Exposure
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Secondary Survey
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Pelvis assessed by
compression/distraction
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Skin evaluation
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Smith/Johnson/Cothren et al Journal
of Trauma 2007
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Resuscitation/ Hemorrhage
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2 large-bore IVs
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2L crystalloid on
arrival
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Hct/Hgb does
NOT correspond
to EBL
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Hypotension = 3040% EBL
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Patients presenting in shock (SBP<90) have mortality rates up
to 10 times that of normotensive patients
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Starr et al JOT 2002
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Sites of Hemorrhage
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External bleeding controlled by direct pressure
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Thoracic cavity evaluated by CXR for
hemothorax: chest tube if necessary
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Abdominal cavity evaluated by a FAST or CT
scan in stable patients or ex-lapin unstable
patients
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If other causes eliminated, then EBL likely from
pelvis
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Blood replacement as indicated by response to
fluid resuscitation
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Ratio of FFP: PRBC/ 1:1.5 associated with
decreased mortality and transfusion
requirements
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Injury 2010
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Physical Exam
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Test stability by placing gentle
rotational force on each iliac crest
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Perform ONCE
Look for external rotation of lower
extremity +/- limb-length
discrepancy
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Physical Exam (continued)
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Neurologic exam
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L5 and S1 injuries most common
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Rectal exam to evaluate sphincter tone and
perirectal sensation
Urogenital exam
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Concomitant urologic injury 12% of the time
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Catheter placement should be preceded by
rectal exam, evaluation of meatus, vaginal
exam
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57% of men with urethral injury show no
signs
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Vaginal injuries missed in up to 50% of cases
Vaginal and rectal exams
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Mandatory to rule out occult open fracture
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Radiographs
AP Pelvis
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Inlet
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Outlet
Oblique/Judet
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Obturator oblique
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Iliac oblique
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Mechanisms of Pelvic Injury
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Anterior Compression
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Lateral Compression
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Vertical Shear
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Combined mechanism
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Young and Burgess, Rad 1986
Young and Burgess J Trauma 1989
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AP Compression
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Anteroposterior Compression
Type
Definition
APC1
Symphysis widening < 2.5cm
APC2
Symphysis widening > 2.5 cm.
Sacrotuberous, sacrospinous and
anterior SI joint ligaments are
disrupted. Posterior SI ligaments
intact.
APC3
Disruption of anterior and posterior
SI ligaments. Disruption of
sacrospinous and sacrotuberous
ligaments
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Lateral Compression
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Lateral Compression
Type
Definition
LC1
Oblique or transverse ramus
fracture and ipsilateral anterior
sacral ala compression fracture
LC2
Rami fracture and ipsilateral
posterior ilium fracture dislocation
(crescent fracture)
LC3
Ipsilateral lateral compression and
contralateral APC (windswept
pelvis). Common mechanism:
rollover vehicle or peds struck
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Vertical Shear
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Vertical Shear
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Associated with the highest risk of
hypovolemic shock, mortality
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Usually result from falls from height
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Posterior and superior directed force
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APCIII + vertical displacement
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Mortality from Pelvic Injuries
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Hemodynamic instability + pelvic fracture
= 40% mortality
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Major cause of death: Hemorrhage (15%)
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Major cause of death LC injuries: closed
head injuries
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Major cause of death APC: combined pelvic
and visceral injuries
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Hemorrhage in pelvic injuries
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Venous bleeding more common than arterial
bleeding
Superior gluteal artery (most common arterial
injury in APC)
Internal pudendal artery (most common in
LC)
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Metz et al Orthop Clin N Am 2004
Smith et al J Trauma 2007
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Circumferential Pelvic Antishock
Sheeting
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Rapid, inexpensive,
temporary means of
decreasing pelvic volume
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Indications: initial
management of an
unstable ring injury
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Risk of bladder injury in
pelvic fractures with
internal rotation
component (i.e. LC
injuries)
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Technique: center over greater trochanters (NOT iliac crest/abdomen)
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External Fixation
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Advantages:
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Indications:
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Pelvic ring injuries with an
external rotation component
(APC, VS)
Unstable ring injury w/ ongoing
blood loss
Contraindications
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Decreases pelvic volume
Stabilization of pelvis
Ilium fracture that precludes safe
application
Acetabular fracture
Technique: Iliac wing or supraacetabular pins
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Egbers Orthopade 1992
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Angiography/ Embolism
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Small percentage of pelvic
fractures have significant arterial
injuries amendable to angio
(10%)
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Must have stabilized pelvis
(pattern or ex-fix) because most
bleeding is venous which will
tamponade
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Eliminate other sources of
bleeding
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Successful in 70-90% of cases but
takes 3-4hrs
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Treatment Overview
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Nonoperative
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Indicated for mechanically stable pelvic ring
injuries
 LC1: anterior impaction fracture of sacrum and
oblique ramus fx with <1cm of posterior ring
displacement
 APC1: widening of symphysis <2.5 cm with
intact posterior pelvic ring
 Isolated pubic ramus fx
Operative
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Anterior ring stabilization: Symphyseal fixation
Posterior ring stabilization
 Anterior or posterior SI joint fixation
 Sacral bar
 Iliac wing fixation
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Treatment Comparison
Technique
Pro
Con
Pubic
Symphysis
Plating
Can be done
simultaneously w/
laparotomy
Only stabilizes anterior
ring
Posterior
approachORIF
Visualization of
reduction and sacral
screw placement;
limits risk of
neurologic injury
Prominent hardware
complications
Anterior
approach –
ORIF
Allows for placement
of multiple plates
across the SI joint
Risk of L4 and L5 injury
Percutaneous Good for sacral fx and Neurologic injury;
Iliosacral
SI dislocations; low soft technically demanding
screw
tissue complications
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Tenets of Fixation
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Complete instability of posterior ring:
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Complete instability of posterior ring
with vertical (cephalad) displacement
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Anterior fixation alone is inadequate for
maintaining reduction
Posterior fixation should be supplemented
with anterior stabilization
Posterior injury is regarded as the more
critical and in need of accurate reduction
with stable fixation
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Reduction generally proceeds from back to
front
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Summary
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Pelvic ring injuries are highly associated with other injuries
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Evaluation of pelvic stability is critical and requires an
understanding of mechanism of injury, a careful examination,
and scrutiny of radiographic imaging
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Management requires an interdisciplinary approach and may
be life saving
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Questions?
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Thanks to:
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Dr. Helfet
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Matt Griffith
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Chris Mattem
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Milton Little