Pelvic Trauma

Stud.: Andris Džeriņš, MF V 5.gr.

Mentor: Dr. Med. Ruta Jakušonoka
Background

• “Pelvic fractures are one of the true (few) life-threatening

orthopaedic emergencies” (Dr. Archdeacon )
• Fractures of the bony pelvis account for 3% of all fractures;
• The overall mortality from pelvic ring injuries is 9% to 22%,
in open fractures- 30-50%.
• Patients with pelvic fractures and with shock on arrival to
the hospital have mortality rates of 33 to 57%.
 Anatomy I
• Ring Structure of three Bones—
Two innominate bones (ilium,
ischium, pubis) and the sacrum.
• Anteriorly -pubic and ischial rami
connected with the symphysis
pubis.
• Posteriorly- sacrum and the two
innominate bones are joined at
the sacroiliac joint by:
- interosseous sacroiliac
ligaments,
- anterior and posterior
sacroiliac ligaments,
- sacrotuberous ligaments,
- sacrospinous ligaments,
- iliolumbar ligaments.
Rosen's Emergency Medicine Eighth Edition
John A. Marx MD, Robert S. Hockberger MD and Ron M. Walls MD
 https://bluestarr.wordpress.com/2012/01/19/urinary-system/
Anatomy II
1. Visceral organs- urine bladder,
ureters, urethra, large intestine,
uterus, vagina, prostate gland
2. Blood vesels (superior gluteal
artery, internal pudendal artery,
pelvic veins)

http://doctorstock.photoshelter.com/image/I0000jIX1zJjr810
3. Nerves- Lumbosacral plexus,
sciatic nerve, Lumbosacral trunk,
L5 nerve root, cauda equina
 Etiology
• High-energy pelvic fractures result most commonly from:
- motor vehicle accidents, motorcycle accidents, automobile-
pedestrian encounters (60- 84%),
- Falls from height (5-12-30%),
- Industrial crush injuries, e.c.

http://blog.er24.co.za/wp-content/uploads/2011/12/Motorbike-accident-Potch-300x222.jpg http://venturegalleries.com/blog/finding-the-truth-in-news-reporting/

Rosen's Emergency Medicine Eighth Edition John A. Marx MD.

Emergency Medicine Second Edition James G. Adams MD.
Tile's Classification of Pelvic Fractures
• Type A —Stable
• Type B —Partially stable
• Type C —Unstable

A B

C
Pelvis - Orthopaedic Trauma Association
Tile’s- Type A
• Stable, posterior arch intact;
• A1 Avulsion injury
• A2 Iliac wing or anterior arch fracture caused by a direct
blow
• A3 Transverse sacrococcygeal fracture

A1 A2 A3
Pelvis - Orthopaedic Trauma Association
Tile’s- Type B
• Partially Stable (Incomplete Disruption of Posterior Arch)
• Rotationally unstable but vertically stable.
• B1 Open book injury (external rotation)
• B2 Lateral compression injury (internal rotation)
- B2-1 Ipsilateral anterior and posterior injuries B1
- B2-2 Contralateral (bucket-handle) injuries Pelvis - Orthopaedic Trauma Association

B 2-1 B 2-2
Clasification of Pelvic Fractures. Zahid Askar. B3
• B3 Bilateral – bilateral open book; B1/B2; B2/B2. Pelvis - Orthopaedic Trauma Association
Tile’s- Type C
• Unstable (Complete Disruption of Posterior Arch)
• C1 Unilateral • C2 Bilateral, with one • C3 Bilateral with
- C1-1 Iliac fracture side type B, one side both sides type C
- C1-2 Sacroiliac fracture- type C
dislocation
- C1-3 Sacral fracture

Pelvis - Orthopaedic Trauma Association

C1 C2 C3
Young-Burgess Classification of Pelvic Fractures
Based on the direction of forces causing fracture, associated
instability of pelivs, mechanism of injury
1. Lateral compression
2. Anterior–posterior compression
3. Vertical shear
4. Combined mechanism
Y-B: Lateral Compression
• I Sacral crush injury on ipsilateral side
• II Sacral crush injury with disruption of posterior SI ligaments; iliac
wing fracture may be present (rotationally unstable)
• III LC-I or LC-II injury on side of impact, contralateral side external
rotation (open-book injury) (rotationally unstable)

Browner BD: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed.
Y-B: Anteroposterior Compression
• I Slight widening of pubic symphisis (<2,5cm) and/or aneterior SI joint;
intact posterior SI ligaments
• II Symphysis diastasis >2.5 cm, sacrospinous, sacrotuberous and anterior
SI ligament disruption, intact posterior SI ligaments (rotational instability)
• III Symphysis diastasis >2.5 cm, with complete disruption of the anterior
and posterior SI ligament, (complete rotational and vertical instability)

Browner BD: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed.
• Y-B: Vertical Shear- symphyseal diastasis or vertical
displacement anteriorly and posteriorly, usually through the
SI joint, occasionally through the iliac wing and/or sacrum

• Y-B: Combined mechanism- combination of other injury

patterns. LC/VS most common.

Browner BD: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed.
 Judet and Letournel Acetabular Fracture
Classification
• Type A
- Fractures of one column of the acetabulum (anterior or posterior
column).
• Type B
- Transverse (T-type) fractures through both anterior and posterior
columns; portion of acetabulum remains attached to proximal ilium.
• Type C
- Transverse (T-type) fractures through both anterior and posterior
columns; no portion of acetabulum remains attached to axial skeleton.

Browner BD: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed.
Presenting Signs and Symptoms
• Pelvic pain
• Inability to bear weight
• Swelling of the pelvic area
• Hematoma in the area of the pelvic bone
• Pelvic deformity
• Uneven leg length or asymmetry of the iliac wings
• Numbness or tingling in the perineum or at the top of the
thigh
• Perineal ecchymoses, scrotal or labial hematomas
• Blood at the urethral meatus
Physical Examination
1. Assess for other life-threatening injuries using Primary Survey
(cABCDE).
2. Careful palpation of the posterior pelvis in awake patients can
identify posterior pelvic injuries.
3. Rectal examination—high-riding prostate may indicate urethral
tear. Palpation of the sacrum for irregularity.
4. Vaginal examination —bleeding or lacerations indicating open
fractures.
5. Perineal skin —lacerations may indicate open fracture, scrotal,
labial hematoma, swelling or ecchymosis, flank hematoma
Imaging
• Radiographs
1. Anteroposterior pelvis - part of the initial trauma series along
with a chest and lateral cervical spine X-ray. Can identify up to
90% of pelvic injuries.
2. Pelvic inlet view - 40° to 45° caudal tilt. Shows anterior–
posterior displacement (rotational deformity), internal or
external rotation of the hemipelvis; widening of SI joint; sacral
ala impaction.
3. Pelvic outlet view - 40° to 45° cephalad tilt. Shows superior–
inferior displacement (vertical displacement) and visualizes the
sacral foramen.
A Forty-degree caudal inlet view of pelvis.
B Forty-degree cephalad outlet view of pelvis.

Fractures of Acetabulum and Pelvis- Campbell's Operative

Orthopaedics. Guyton, James L.; Perez, Edward A.. Published January
2, 2013. Pages 2777-2828.e5. © 2013.
• CT
• CT is the diagnostic test of choice for detecting pelvic and
intraabdominal injuries.
• Better characterization of posterior ring injuries.
• Reveals bleeding in both the peritoneal and retroperitoneal spaces.
• CT with intravenous contrast often can distinguish a stable
hematoma from ongoing bleeding from pelvic arteries.
• FAST
• Identify free intraperitoneal fluid in the trauma patient.
• FAST is not helpful for evaluating the retroperitoneal space where
pelvic hemorrhage occurs.
 Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics. Guyton, James L.; Perez, Edward
A.. Published January 2, 2013. Pages 2777-2828.e5. © 2013.
A Tile type B1 pelvic injury with diastasis of symphysis and anterior widening of sacroiliac
joint.
B CT scan shows that posterior sacroiliac joint ligaments are intact.
Initial Treatment
HD unstable patients: Hemorrhage
• Occurs in up to 75% of pelvic fractures.
• Leading cause of death in patients with pelvic
fractures.
• Three sources of bleeding—osseous, vascular,
and visceral.
• Posterior pelvic venous plexus accounts for more
than 80% of hemorrhages.
• Intra-abdominal source of bleeding is present in
up to 40% of cases.
• Arterial source of bleeding is present in only 10-
15% of cases.
• Retroperitoneal space can hold up to 4 L of blood.
http://benthamopen.com/contents/figures/TOORTHJ/TO
ORTHJ-9-283_F6.jpg
 HD unstable patients
• Damage Control Orthopedics
1. Temporary stabilisation of the pelvis
2. Resuscitation of Patients in Hypovolemic Shock (i/v fluids)
3. External Fixation- AEF, Pelvic C-Clamp
• Open reduction and internal fixation when the patient's state
of health has stabilized:
- ≥5 days
- Acetabular fractures 5-10 days
Stabilization
• Pelvic Binder
˗ Commercial device that can be
used for prehospital and emergent
stabilization of pelvic fractures.
˗ In APC (“open-book”) fractures,
use of a pelvic binder will close the
ring and tamponade venous
bleeding.
˗ An improvised binder can be made
using a sheet to provide
circumferential compression
around the pelvis.
• Skeletal Traction —May be used Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics. Guyton,
James L.; Perez, Edward A.. Published January 2, 2013. Pages 2777-2828.e5. ©

to correct vertical displacement 2013.

of the hemipelvis.
Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics.
Guyton, James L.; Perez, Edward A.. Published January 2, 2013. Pages 2777-
2828.e5. © 2013.

A Initial anteroposterior radiograph of open-book pelvic

fracture. B After application of pelvic binder (C) .
Pelvic Fractures- Emergency Medicine Second Edition. James G. Adams MD. Copyright © 2013, 2008 by Saunders, an imprint of Elsevier Inc .
Resuscitation of Patients in Hypovolemic Shock
• Two large bore intravenous lines (16G or larger) in the upper
extremities.
• Administer crystalloid, coloid solution and determine response.
• If only a transient improvement or no response then begin EM
administration.
• Platelets and fresh frozen plasma will be required with massive
transfusions to correct dilutional coagulopathy.
• Avoid or correct hypothermia. Warm fluids, increase ambient
temperature, and avoid heat loss. Hypothermia can lead to coagulation
problems, ventricular fibrillation and acid– base disturbances.
External Fixation: Anterior external fixator
• Anterior superior iliac spine (ASIS) pin and the anterior inferior
iliac spine (AIIS) pin.
• Two 5-mm pins are placed in between the iliac cortical
tables and placement is confirmed on fluoroscopy.

Poka A, Libby EP: Indications and techniques for external fixation of the pelvis, Clin
• Emergently placed in hemodynamically unstable patient
who does not respond to initial fluid resuscitation.
• Anterior external fixation alone does not provide adequate
posterior stabilization if the posterior ring is disrupted.
• Indications

Orthop Relat Res 329:54, 1996.

- pelvic ring injuries with an external rotation component (APC, VS)
- unstable ring injury with ongoing blood loss
• Contraindications
- ilium fracture that does not allow safe application
External Fixation: Pelvic Clamps

Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics.

Guyton, James L.; Perez, Edward A.. Published January 2, 2013. Pages 2777-
2828.e5. © 2013.

• Pelvic clamps have been developed to help control the posterior

pelvis in the resuscitation phase: the Ganz C-clamp.
• These devices use large, percutaneously placed pins over the
region of the sacroiliac joint posteriorly.
• Pelvic C-Clamps—in original design, points of clamp applied to
posterior ilium in line with the sacrum.
• Requires fluoroscopy and technical expertise.
• Higher risk of iatrogenic injury than standard anterior external
fixator.
Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics. Guyton, James L.; Perez,
Edward A.. Published January 2, 2013. Pages 2777-2828.e5. © 2013.
Pelvic Packing
• Patients who hemorrhage from both the pelvis and the
abdomen have mortality rates above 40%.
• Packing may aid in tamponading bleeding from the posterior
venous plexus.
• Pelvis should be stabilized before
packing to provide solid structural
support against which packing may
be performed.
• Packs can be placed in the pre-
peritoneal and retro-peritoneal spaces.

http://www.hwbf.org/ota/s2k/images/pohlcs.jpg
 Angiography / embolization
• Contrast material injected through
the femoral artery on the less-injured
side or via the upper extremity.
• Transcatheter embolization with
thrombogenic coils, foam, or
spherules
• Indicated for patients who remain
HD unstable following resuscitation,
application of external fixator, and
after other sources of bleeding
(abdomen, chest) are ruled out.
• Arterial source of bleeding is present
in only 10% to 15% of patients.
http:// www.wheelessonline.com/images/
HD stable patient
• Stable pelvic fracture- nonoperative treatment

• Unstable pelvic fracture

- External fixation- anterior external fixator/ Pelvic-clamps
- Open Reduction and Internal Fixation
Nonoperative Treatment
• Stable nondisplaced or minimally displaced fractures may be treated
nonoperatively (isolated pubic ramus fractures, B1-1).
• Bed rest 2-3 weeks
• Lateral compresion fractures- weight bearing only on the unaffected
side.
• Vertically unstable fractures in which there is a contraindication to
operative treatment may be treated with skeletal traction.
 Internal Fixation
• Indications:
- symphysis diastasis > 2.5 cm
- SI joint displacement > 1 cm
- sacral fracture with displacement >1 cm
- pubic rami fractures >2 cm displacement Fractures of Acetabulum and Pelvis- Campbell's
Operative Orthopaedics. Guyton, James L.; Perez,

- displacement or rotation of hemipelvis Edward A.. Published January 2, 2013. Pages 2777-
2828.e5. © 2013.

- open fracture
- rotationally unstable pelvic injuries with significant limb-length
discrepancy >1.5 cm or unacceptable pelvic rotational deformity
• Tile type C pelvic injuries require anterior and posterior fixation to
regain rotational and vertical stability.
• Anterior ring stabilization
- single superior plate
• Posterior ring stabilization
- anterior SI plating
- iliosacral screws
- posterior SI "tension" plating
A and B Anterior plating of sacroiliac joint.

Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics. Guyton, James L.; Perez,
Edward A.. Published January 2, 2013. Pages 2777-2828.e5. © 2013.
Associated Injuries
1. Hemorrhage 75%
2. Chest injury 63%
3. Long bone fractures 50%
4. Head and abdominal injury 40%
5. Spine fractures 25%
6. Urogenital injuries (posterior urethral tear, bladder rupture) 12-20%
7. Lumbosacral plexus injuries 8%

http://www.orthobullets.com/trauma/1030/pelvic-ring-fractures
Case report
• A 37 year old man was brought into the Hospital of Traumatology and orthopedics
Emergency Department after falling of a motorcycle.
• The patient had severe pain in the pelvic area, left upper leg, right shoulder and
inability to move his left leg about the hip joint.
• BP- 115/73mmHg
• P- 87’
• BF-16’
• Radiographs of the pelvis, right shoulder and lungs were made.
Radiographs of the pelvis and right
shoulder

Images from TOS archive

• Abdominal USG- small amount of fluid int the pelvis.
• Lab.: Er- 3,68x1012/L (4,5-5,9) ↓; Hb-110g/L (132-175g/L)↓; Ht- 32% (40-51%)↓
• NISS-24
• ISS-16
• Dg:
- Patient after polytrauma including pelvic fractures: Partially stable pelvic injury
injury including disruption of the pubic symphysis, left-sided fracture of the
the acetabulum, fracture of both pubic rami, fracture of inferior pubic rami in
in the right side, partial disruption of the left posterior arch (B2), left-sided hip
sided hip posterior dislocation. Wedge fracture of the right clavicle.
Hypovolemic shock.
• Treatment:
- Closed reduction of the left hip dislocation- unsuccesful!
- Open reduction of the left hip dislocation
- Left leg skeletal traction
• The next day patient was transported to RAKUS for further
investigation and treatment. An external fixator was put to
stabilase the pelvis. No other traumas were diagnosted.
• The next day patient was transported back to Hospital of
Traumatology and Orthopedics for further treatment:
- After 3 days- Reconstruction of the left acetabulum, OS of
the symphisis and pubic rami with REKO plate.
- After 7 days- OS of the right clavicle with REKO plate.
Postoperative Radiographs

Images from TOS archive

Conclusion
• “Pelvic fractures are one of the true (few) life-threatening orthopaedic
emergencies” (Dr. Archdeacon )
• The overall mortality from pelvic ring injuries is still high
• Bleeding is the leading cause of death in patients with pelvic
fractures.
• High-energy pelvic fractures result most commonly from motor
vehicle accidents.
• First priority is to assess for other life-threatening injuries using
Primary Survey (cABCDE).
• The initial treatment for HD stable/unstable patients varies.
• Damage Control Orthopedics.
Literature
• Pelvic Ring Injuries- Skeletal Trauma: Basic Science, Management, and Reconstruction.
Bellabarba, Carlo; Winkelmann, Marcel. Published January 1, 2015. Pages 1021-1105.e7.
© 2015. Pelvic Fractures- Emergency Medicine. Patterson, Leigh A.. Published January 2,
2013. Pages 710-715.e1. © 2013.
• Pelvic Trauma- Rosen's Emergency Medicine. Choi, Stephen B.; Cwinn, A. Adam. Published
January 1, 2014. Pages 656-671.e2. © 2014.
• Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics. Guyton, James L.; Perez,
Edward A.. Published January 2, 2013. Pages 2777-2828.e5. © 2013.
• Pelvic Fractures- Emergency Medicine Second Edition. James G. Adams MD. Copyright ©
2013, 2008 by Saunders, an imprint of Elsevier Inc.
• The Pelvis and Acetabulum- Review of Orthoppaedic Trauma. Mark R. Brinker, MD. Copyright ©
2013 by Lippincott Williams and Wilkins
• Pelvis - Orthopaedic Trauma Association http://ota.org/media/23066/97042.7pelvis-s59-s67.pdf
• Pelvic Ring Fractures, Acetabulum Fractures- Orthobullets
http://www.orthobullets.com/trauma/1030/pelvic-ring-fractures
• Clasification of Pelvic Fractures. Zahid Askar. Prof of Orthopaedics & Trauma, Khyber Medical
College, Peshawer http://www.slideshare.net/zahidaskar/pelvic-fracture-classification