Fracture of Pelvis

Basaria Manurung, drg

Pembimbing :
Dr. Dicky Mulyadi, dr., Sp.OT(K)
Fractures of the pelvis : 5 per cent of all skeletal
injuries
high incidence of associated softtissueinjuries and
the risks of severe blood loss, shock, sepsis and adult
respiratory distress syndrome (ARDS)
two-thirds of all pelvic fractures occur in road
accidents involving pedestrians
 ANATOMI PELVIS
Pelvis tdd:
1 sacrum
2 tulang innominata  ilium, ischium dan pubis

 Tulang-tulang innominata menyatu dengan sacrum di bagian posterior pada dua persendian sacroiliaca
di bagian anterior, tulang-tulang ini bersatu pada simfisis pubis
 Simfisis bertindak sebagai penopang sepanjang memikul beban berat badan untuk mempertahankan
struktur cincin pelvis
 The major branches of the common
iliac arteries arise within the pelvis
between the level of the sacroiliac joint
and the greater sciatic notch
 With their accompanying veins they
are particularly vulnerable in fractures
through the posterior part of the pelvic
ring
 The nerves of the lumbar and sacral
plexuses, likewise, are at risk with
posterior pelvic injuries
MEKANISME TRAUMA
Antero-Posterior Compression

 caused by a frontal collision between a

pedestrian and a car.
 The pubic rami are fractured or the innominate
bones are sprung apart and externally rotated
 with disruption of the symphysis – the so-called
‘open book’ injury
 The anterior sacroiliac ligaments are strained and
may be torn, or there may be a fractureof the
posterior part of the ilium
 Lateral compression

 Side-to-side compression of the pelvis causes the

ring to buckle and break
 due to a side-on impact in a road accident or a fall
from a height
 Anteriorly the pubic rami on one or both sides are
fractured, and posteriorly there is a severe sacroiliac
strain or a fracture of the sacrum or ilium, either on
the same side as the fractured pubic rami or on the
opposite side of the pelvis.
 If the sacroiliac injury is much displaced, the pelvis
is unstable.
 Vertical shear

 The innominate bone on one side is displaced vertically,

fracturing the pubic rami and disrupting the sacroiliac
region on the same side.
 This occurs typically when someone falls from a height
onto one leg.
 These are usually severe, unstable injuries with gross
tearing of the soft tissues and retroperitoneal
haemorrhage.

 Combination injuries  In severe pelvic injuries there may be a combination of

the above.
 Types of injury
Avulsion
fractures

Isolated fractures with Direct

an intact pelvic ring fractures

Stress
fractures

Type of Injury Stable

fractures with a
broken ring
Unstable
fractures of the
acetabulum

sacrococcygeal
fractures
 Clinical Feature

Stable ring injuries

 The patient is not severely shocked but has pain on attempting to
walk
 Localized tenderness but seldom any damage to pelvic viscera
 Plain x-rays reveal the fractures

Unstable ring injuries

 The patient is severely shocked, in great pain and unable to stand
 He or she may also be unable to pass urine and there may be
blood at the external meatus
 Tenderness is widespread, and attempting to move one or both
blades of the ilium is very painful
Haemodynamic instability
 High-energy fractures of the pelvis are extremely serious
injuries, carrying a great risk of associated visceral
damage, intra-abdominal and retroperitoneal
haemorrhage, shock, sepsis and ARDS
 the mortality rate is considerable, The patient should be
repeatedly assessed and re-assessed for signs of blood
loss and hypovolaemia
 Management
EARLY MANAGEMENT
Six questions must be asked and the answers acted
 Is there a clear airway?
 Are the lungs adequately ventilated?
 Is the patient losing blood?
 Is there an intra-abdominal injury?
 Is there a bladder or urethral injury?
 Is the pelvic fracture stable or unstable?
If the patient’s general condition is stable, further x-rays can then be obtained. If a urethral
tear is suspected, an urethrogram is gently performed

MANAGEMENT OF SEVERE BLEEDING

 Severe bleeding is the main cause of death following high-energy pelvic fractures
 If there is an unstable fracture of the pelvis, haemorrhage will be reduced by rapidly
applying an external fixator
 TREATMENT OF THE FRACTURE

Isolated fractures and minimally displaced fractures

 These injuries need only bed rest
 possibly combined with lower limb traction
 Within 4–6 weeks the patient is usually comfortable and may then be
allowed up using crutches

Open-book injuries
 Provided the anterior gap is less than 2 cm and it is certain that there are
no displaced posterior disruptions,
 these injuries can usually be treated satisfactorily by bed rest; a posterior
sling or a pelvic binder helps to ‘close the book’
 The most efficient way of maintaining reduction is by external fixation
with pins in both iliac blades connected by an anterior bar; ‘closing the
book’ may also reduce the amount of bleeding
Internal fixation by attaching a plate across the symphysis should be performed:

(1) during the first few days after injury only if the patient needs a laparotomy;
(2) later on if the gap cannot be closed by less radical method
APC-III and VS injuries
These are the most dangerous injuries and the most difficult to treat
 It may be possible to reduce some or all of the vertical displacement by skeletal traction
combined with an external fixator
 the patient needs to remain in bed for at least 10 weeks, this prolonged recumbency is not
without risk
 As these injuries represent loss of both anteriorand posterior support, both areas will need to be
stabilized

Two techniques are used:

 (a) anterior
external fixation and posterior stabilization using screws across the sacroiliac joint, or
 (b) plating anteriorly and iliosacral screw fixation posteriorly
Posterior operations are hazardous (the dangers include massive haemorrhage, neurological
damage and infection

Open pelvic fractures

 Open fractures are best managed by external fixation
 A diversion colostomy may be necessary.
 Complications
Thromboembolism
 A careful watch should be kept for signs of deep vein thrombosis or pulmonary
embolism
Sciatic nerve injury
 It is essential to test for sciatic nerve function both before and after treating the
pelvic fracture.
 If the nerve is injured it is usually a neuropraxia and one can afford to wait
several weeks for signs of recovery.
Urogenital problems
 Urethral injuries sometimes result in stricture, incontinence or impotence and
may require further treatment
Persistent sacroiliac pain
 Unstable pelvic fractures are often associated with partial or complete
sacroiliac joint disruption, and this can lead to persistent pain at the back of the
pelvis
 Occasionally arthrodesis of the sacroiliac joint is needed
 FRACTURES OF THE ACETABULUM
Fractures of the acetabulum occur when the head of the femur is driven into the pelvis
Caused :
 a blow on the side (as in a fall from a height) or
 by a blow on the front of the knee, usually in a dashboard injury when the femur also
may be fractured

Acetabular fractures

(a) Fractures occur through the (b) Of particular importance is the roof (superior dome –
wall (rim) or supporting Columns which
 Patterns of fracture
1. The anterior column fracture
from the pubic symphysis, along the superior pubic ramus, across
the acetabulum to the anterior part of the ilium

2. The posterior column fracture

from the ischium, across the posterior aspect of the acetabular
socket to the sciatic notch and the posterior part of the
innominate bone
3. TRANSVERSE FRACTURE
 runs transversely through the acetabulum, involving both the anterior and
posterior columns, and separating the iliac portion above from the pubic
and ischial portions below.
 a vertical split into the obturator foramen may coexist, resulting in a T-
fracture

(c) a transverse fracture (d) a T-type fracture involving two columns

4. COMPLEX FRACTURES
 damage either the anterior or the posterior columns (or
both) as well as the roof or the walls of the acetabulum
 a variant of the T-fracture in that the two columns are
involved but the transverse part of the ‘T’ lies just above the
acetabulum
 no portion of the acetabulum remains connected to the
rest of the pelvis

Complex fracture patterns share the following features:

(1) the injury is severe
(2) the joint surface is disrupted
(3) they usually need operative reduction and internal fixation (e) the bothcolumn
Fracture resulting a
(4) the end result is likely to be less than perfect, unless surgical ‘floating’ acetabulum
restoration has been exact. with no part of the socket
attached to the ilium
 Clinical features
 There has usually been a severe injury; either a traffic accident or a fall from a height
 Associated fractures are not uncommon and, because they may be more obvious, are
liable to divert attention from the more urgent pelvic injuries
 The patient may be severely shocked, and the complications associated with all pelvic
fractures should be excluded
 Rectal examination is essential
 There may be bruising around the hip and the limb may lie in internal rotation (if the hip is
dislocated), No attempt should be made to move the hip.
 Careful neurological examination is important, testing the function of the sciatic, femoral,
obturator and pudendal nerves.
 Imaging
At least four x-ray views should be obtained in every case:
 a standard anteroposterior view,
 the pelvic inlet view
 two 45 degrees oblique views
Each view shows a different profile of the acetabulum; with practice the various landmarks
(iliopectineal line, ilioischial line and the boundaries of the anterior and posterior walls) can be
identified,
thus providing a fairly good mental picture of the fracture type, the degree of comminution and
the amount of displacement
 Treatment
1. EMERGENCY TREATMENT
 The first priority is to counteract shock and reduce a dislocation
 Skeletal traction is then applied to the distal femur (10 kg will suffice) and during the
next 3–4 days the patient’s general condition is brought under control
 Occasionally, additional lateral traction through the greater trochanter is needed for
central hip dislocations
 Definitive treatment of the fracture is delayed until the patient is fit and operation
facilities are optimal.
 NON-OPERATIVE TREATMENT

 conservative treatment is still preferable in certain well-defined situations:

(1) acetabular fractures with minimal displacement (in the weightbearing zone,
less than 3 mm)
(2) displaced fractures that do not involve the superomedial weightbearing
segment (roof) of the acetabulum – usually distal anterior column and distal
transverse fractures
(3) a both-column fracture that retains the ball and socket congruence of the
hip by virtue of the fracture line lying in the coronal plane and displacement
being limited by an intact labrum
(4) fractures in elderly patients, where closed reduction seems feasible
(5) patients with ‘medical’ contraindications to operative treatment (including
local sepsis)
 In all patients treated conservatively, longitudinal traction, if necessary supplemented
by lateral traction, is maintained for 6–8 weeks; this will unload the articular cartilage
and will help to prevent further displacement of the fracture
 OPERATIVE TREATMENT

 Operative treatment is indicated for all unstable hips and fractures resulting
in significant distortion of the ball and socket congruence
 The hip may be dislocated centrally, anteriorly or posteriorly
 Patients with isolated posterior wall fractures and dislocation may require
immediate open reduction and stabilization
 In other cases operation is usually deferred for 4 or 5 days
 Complications

 Iliofemoral venous thrombosis

This is potentially serious and in some clinics prophylactic anticoagulation is used
 Sciatic nerve injury
Nerve injury may occur either at the time of fracture or during the subsequent operation
 Hereterotopic bone formation Periarticular ossification
common after severe soft-tissue injury and extended surgical dissections
In cases where this is anticipated, prophylactic indomethacin is useful
 Avascular necrosis
Osteonecrosis of the femoral head may occur even if the hip is not fully dislocated
 Loss of joint movement and secondary osteoarthritis
Displaced fractures involving the weightbearing portion of the joint may result in loss of movement
and early onset osteoarthritis.
 Injuries To The Sacrum And Coccyx

 A blow from behind, or a fall onto the ‘tail’ may fracture the sacrum or coccyx, or sprain
the joint between them
 Women seem to be affected more commonly than men
 Bruising is considerable and tenderness is elicited when the sacrum or coccyx is palpated
from behind or per rectum.
 Sensation may be lost over the distribution of sacral nerves

Treatment
If the fracture is displaced, reduction is worth attempting
X-rays :
(1) a transverse fracture of the sacrum, in rare cases with the lower fragment pushed
forwards;
(2) a fractured coccyx, sometimes with the lower fragment angulated forwards; or
(3) a normal appearance if the injury was merely a sprained sacrococcygeal joint.

(a) Fractured sacrum; (b) fractured

coccyx.
Haturnuhun