Pelvic injuries dr.satish

Pelvic injuries dr.satish - SER2016

1. Dr. SATISH KUMAR .C


PROFESSOR,ORTHOPAEDI
CS
VIMS & RC BANGALORE

2. The incidence of this injury that jeopardize not
only the function, but the very life of the patient
has increased for past two decades due to high
speed motor vehicle accidents.

3. An understanding of the complex inter-relationship
of the anatomic structures that comprise the
pelvis, is the foundation on which the diagnosis
and management of pelvic injury is based

5. The largest contributor to the hemipelvis, is the
primary structural element in the transference of
body weight from the spine to the lower
extremities in erect position

8. Ischium Serves as terminal point of weight
transmission in sitting position
Pubis has three parts
◦Superior rami
◦Inferior rami
◦Symphysis

11. Thin large triangular bone inserted like a key
stone or wedge between two innominate bones

14. Small auricular shaped, relatively small,
essentially immobile synovial articulations, which
contains small joint cavity and minimal synovial
fluid. The SI joint is cartilaginous convoluted
surfaces and surrounding ligamentous structures
continue to minimize mobility

15. Anterior SI ligament:
Posterior SI ligament:
Interosseous ligament: tuberosities of
sacrum and ilium.
Sacrotuberous ligament:connects sacrum
and coccyx to the ischial tuberosity. It forms
posterior boundary of greater and lesser sciatic
foramen.
Sacrospinous ligament: sacrum and
coccyx to the ischial spine.
The superior pubic and the arcuate
(inferior) pubic ligaments: The ligaments
of pubic symphysis

17. Primary artery is internal iliac, has branches which
are divided into 3 sections
◦Somatic segmental branches
◦Visceral
◦Branches to limb and perineum

19. The neural elements anatomically surrounded by
pelvic ring include elements of both lumbar and
sacral plexus together taken as lumbosacral
plexus. Primarily the nerves that arise from these
plexus are the nerves to lower extremities

21. Pelvis allows transfer of weight from 5th lumbar
vertebra to the upper three segments of sacrum,
SI joint, to the thick strut of ilium that forms roof of
greater sciatic notch and then to roof of
acetabulum in standing position and ischial
tuberosity in sitting position

23. Pelvis fracture in general can be divided into
two major types based on amount of energy
involved.
Low energy fractures: This class includes
domestic falls avulsion injuries of the muscle
apophyses in skeletally immature patients, low
velocity vehicle accidents and sports injury
High energy fractures:
Results in more severe injury to pelvic ring,
associated soft tissue and viscera

24. Severe pelvic ring instability causes life
threatening hemorrhage and must be treated
rapidly and efficiently.
The forces disrupting the pelvis
◦Anteroposterior compression (APC)
◦Lateral compression (LC)
◦Vertical shearing (VS)
◦Crush injuries

25. History:
◦Mechanism of injury forms the key component in the
diagnosis, classification and management of pelvic
injuries
Physical examination …

26. The diagnostic evaluation of trauma patient
should begin with ABC i.e. Airway, Breathing
and Circulation, to identify the initiate treatment
of injuries that an immediately life threatening.
The skin including perineum should be
inspected for open wounds abrasions,
echymosis, hematoma and cutaneous
sensations.
Look for external urinary meatus for presence of
blood

27. Destot’s Sign: A large superficial hematoma
formation beneath the inguinal ligament or in
the scrotum.
Roux’s Sign: A decrease in distance of
greater trochanter to pubic spine on affected
side in lateral compression injury.
Earle’s Sign: A bony prominence or large
hematoma, as well as tenderness on rectal
examination

28. Palpation: ASIS are pushed towards each other to note
any internal rotation and tenderness and then pushed
apart to know external rotation. Vertical stability is
assessed by pushing the extended lower extremity. This
part of examination should be gentle and done only once
to avoid risk of hemorrhage.
All pelvic fracture patients should have rectal
examination for continuity and vaginal examination in
female.
A detailed neurological examination should follow this

30. Plain radiographs
◦AP
◦Inlet view: demonstrates subtle injuries of sacrum,
anteroposterior displacement of posterior ring, degree
and direction of rotational displacement
◦Outlet view: allows vertical displacement of hemipelvis,
slightly widening of SI joint, discontinuity of sacral
foraminal borders or non displaced sacral fractures

32. CT Scans
◦It allows detailed information about posterior ilium, SI
joint, sacrum and indirect information about
ligamentous injuries. Allows accurate assessment of
reduction and exact placement of implants
MRI
◦It has limited use due to constraints related to the
presence of strong magnetic fields such as ventilators
and external fixators

33. Retrograde urethrogram
Retrograde cystogram
Peritoneal lavage
Angiography

34. The ideal classification
Should facilitate injury identification, aid in
prediction of morbidity and mortality in terms of
associated injuries, form the basis for treatment
and descriptions and allow the inter study
compression of treatment and outcome

35. Type A:
Stable:
A1:Fracture of pelvis not involving the ring
A2: Stable, minimally displaced fractures of the ring
Type B:
Rotationally unstable, vertically stable
B1:Open book
B2:Lateral compression, ipsilateral
B3:Lateral compression, contralateral (Bucket’s handle)
Type C:
Rotationally and vertically unstable
C1:Unilateral
C2:Bilateral
C3:Associated with an acetabular fracture

36. Young and co-workers further refined pelvic ring
classification, they related type of injury to the
direction of injuries force applied to the pelvic ring

37. Category Features
Lateral compression Transverse fracture of pubic rami ipsilateral
or contralateral to posterior injury
I.Sacral compression on side of impact
II.Crescent (iliac wing) fracture on side of
impact
III.LC-I or LC-II on side of impact’s
contralateral open book (APC) injury
Anteroposterior compression Symphyseal diastasis or longitudinal rami
fractures
I.Slight widening of pubic symphysis or
anterior SI joint; stetched but intact anterior
SI, sacrotuberous and sacrospinous
ligaments; interat posterior SI ligament
II.Widening of SI joint , disrupted anterior SI,
sacrotuberous sacrospinous and intact
posterior SI ligaments.
III.Complete SI joint disruption with lateral
displacement..
Vertical shearing Symphyseal diastasis or vertical
displacement anteriorly and posteriorly,
usually through the SI joint, occasionally
through the sacral or iliac wing
Combined mechanism Combination of other injury patients, LC/VS
being the most common

38. Result of impaction or collapse of pelvis from a
laterally applied force
Shortens the anterior SI, sacrotuberous and
sacrospinous ligaments
Defined by both their anterior and posterior
pathology
But further classified according to posterior
pathology into……

39. LC- I
◦Compression or impaction injury to the sacrum is the
posterior injury of LC-I fracture.
LC- II
◦May involve portions of SI joint extending cephalad
through the iliac wing and leaving a portion of ilium
firmly attached to the sacrum
LC- III
◦Results in lateral compression injury to the site of
primary impact and then an external rotation injury to
the contralateral SI joint, this occurs when the victim
is trapped between an unyielding object, such as
permanent, and an injurious force rolling over the
victim. The side of secondary impact is more
unstable.

41. Results from anteriorly directed forces applied
either directly to the pelvis or indirectly via the
lower extremities or ischial tuberosities.
Results in an external rotation or “open book”
type of injury
CLASSIFIED AS….

42. APC – I: Results from low to moderate energy
forces. The radiographic picture in one of slight
(< 2 cm) widening of pubic symphysis.
APC – II: Acts as “true open book pelvis”
and are define by tearing of both SI and pelvic
floor (sacrotuberous and sacrospinus)
ligaments. Leaving behind the “Binding of
the book” (the post SI ligament) intact.
Marker for injuries to the soft tissue contained
within the pelvis

45. APC – III: By definition shows destruction of all
the ligamentous contrains connecting the
involved side of hemipelvis to the axial skeleton
and the opposite hemipelvis. Resemble a
typical vertical shearing pattern of hemipelvis
dislocation, but without cephloposterior
dislocation and they have highest rate of
associated neurovascular injury and
blood loss.

47.  The classic mechanism of injury is a fall from a
height, landing on extended lower extremity, when
a standing victim is struck from above by a falling
tree or motor vehicle accident when victim reflexly
extends his or her leg against the floor board just
before impact. This causes posterocephalad
displacement of the hemipelvis seen on inlet view.

49. Entrapment factor, as a victim in trapped by
moving object. The initially impact is usually an
lateral compression injury and the ensuring
crush mechanism opens the pelvis and cause
anteroposterior compression injury on the side
contralateral to the initial impact.
Penetrating injuries infrequently results in
substantial damage to the mechanical integrity
of the pelvic ring. The major morbidity is
secondary to associated visceral and
neurovascular injuries

51. Malgaigne fracture: fracture of both pubic
rami with dislocation of S1 joint
Straddle fracture: Bilateral fracture of both
pubic rami
Unusual fracture of childhood: Total
dislocation of ilium

52. This unusual fracture is represented by
dislocation of central portion of upper sacrum
from the remainder of pelvic ring. There is
bilateral vertical sacral fracture in association
with transverse fracture (H-shaped) a
characteristic of this injury. This is commonly
seen in “suicide jumpers”. Neurological
injury to the sacral nerve root is common in
this type

53. Type I:Fracture occurs lateral to neural
foramina through sacral ala
Type II:Fractures are transforminal
Type III:Fracture medial to neural foramina
and transverse fracture of sacrum

55. objectives
Restoration of bony anatomy
Preventing deformity
Minimizing discomfort
Facilitating return of function

56. General guidelines Treatment
Minimally displaced LC-I
and APC-I
Protected weight bearing and
symptomatic treatment
Displaced disruption of
anterior ring without
complete posterior ring
disruption. E.g. APC II, LC
I, with marked displacement
Reduction and anterior ring
stabilization
Complete disruption of
posterior ring LC II, LC III,
APC III, VS
Stabilization of both anterior
and posterior pelvic ring

57. The most frequently used method for managing
pelvic ring injury, remains non-surgical, Stable,
minimally displaced fracture may be managed
with gentle mobilization and protected weight
bearing

59. Primarily useful as a temporizing measure for the
treatment of posterior ring instability when
satisfactory reduction and/or stabilization of
cephalad and posterior displacement cannot be
achieved

60.  The efficacy of PASG’s in treatment of
posterior traumatic hypotension is controversial.
PASGs may be of value in transport and initial
stabilization of patient with pelvic injuries, for
whom it may act as a large air splint.

63. Use of a PASG restricts access to the patient,
may restrict patient mobility, can adversely affect
pulmonary toilet and is associated with an
increased risk of compartment syndrome.

64. External Fixation:
Using pins placed in the iliac crest attached to
external frame used as a method of hemorrhage
management temporary fracture reduction and
stabilization or as definitive means of fracture
stabilization. It allows stabilization of anterior
ring disruption but not posterior or vertical
displacement.

65. A tamponade effect on the retroperitoneal
hematoma
Less motion of fracture surfaces, which allows more
effective clot formation.
Greater patient mobility during transport

66. ◦For rotationally unstable injuries
◦Three half pins are passed to anterior part of iliac crest
on each side. On these pins frame is set using universal
ball joint.
◦An attempt is made to reduce pelvis by grasping the
posterior iliac wings or using the leg on the unstable
hemipelvis by traction and extremes of rotation. Best
preliminary reduction is accepted.
◦Vertically unstable fractures can not be maintained and
normally require additional posterior fixation.
◦If it is used for definitive treatment, frame is left in place
for 8-12 weeks.

69. ◦Used for hemodynamically unstable patient with type C
injuries until definitive fixation is possible.
◦With patient in supine an imaginary line is drawn between
ASIS and PSIS. The nail is inserted 3-4 finger breadth from
PSIS on this line.
◦With generous stab incision over each entry point
Steinmann pin is inserted and advanced until bone and
hammered into the bone for approximately 1cm.
◦Medially the arm is slided on each side till threaded bolt
come into contact with bone and bolts are driven inwards
using a wrench.
◦This closes the diastasis and stabilizes the posterior pelvic
ring.

71. Anterior approach to ilium and sacroiliac joints:
◦It allows direct visualization of SI joint, ilium superior lateral sacral
ala and can be utilized for reduction and stabilization of SI joint
injuries and some iliac wing fractures but not sacral
fractures.
◦Medial dissection is limited by the L5 nerve root medial to S1 joint
at sacral ala and crosses it anteriorly to form the sciatic nerve
◦The skin incision beginning 1cm medial to ASIS and parallel to
subcutaneous iliac crest is continued subperiostially along iliac
wing and iliac fossa to S1 joint and pelvic brim after elevating
abdominal wall musculature (external and oblique) from the iliac
crest.

72. Pfannenstiel incision , 1.5cm above pubis
The superior and posterior surface of pubis and superior
rami are exposed subperiosteally , the rectus fascia
longitudinally in the mid line along intramuscular raphe
and disrupting rectus attachment to the pubis on one
side of symphysis in association with pubis symphysis
disruption.
protect the bladder, which lies directly posterior to
symphysis.
This approach should be avoided in case of suprapubic
cystotomy catheter.

74. ◦Two hole plate is used in this procedure
◦Diastesis is reduced by ilium to ilium compression
◦Plate is fixed on superior surface with 6.5 mm
cancellous screws in the body of each pubic bone
◦Webb et al believed the smaller plate allowed more
physiological motion of symphysis.

76. ◦Allows direct exposure to the posterior ilium, SI joint
and sacrum
◦The major disadvantage is wound break down and
infection.
◦With patient in prone position, the incision is made
parallel to and either slightly medial (sacral fracture) or
lateral (ilium fracture) to the posterior iliac crest.
◦The SI joint and posterior sacrum if required are
exposed by elevating the gleuteas maximus and
abductor muscles from outer surface of iliac crest and
ilium. Damage to the superior gleuteal artery and
nerve must be avoided.

79. ◦They recommend ORIF for the displaced and unstable
fracture of posterior ring with displaced more than
1cm, including sacral fractures, ilium fractures and
dislocation of S1 joint.
◦With posterior approach fracture site is exposed and
reduced under image control, screws are inserted from
lateral surface of ilium to the S1 vertical body.

81.  With upper ½ Smith Peterson incision S1 joint
is exposed, manipulated and reduced taking care
of L5 nerve root. Sacral ala is fixed to joint using
two, two hole DCP and 4.5mm screws.

83. Intraoperative fluoroscopic imaging even during
initial resuscitation of patient there by
diminishing pelvic bleeding.
Most successful when performed within 5 days
after injury
Anterior pelvic fixation the most common form
of percutaneous fixation, while diminishing
operative blood loss and operative time.

84. Indications:
Significant soft tissue injury
Severe open fractures fecal or environmental
contamination, extensive degloving injuries and
abrasion or laceration.
Contraindications:
To percutaneous pelvic fixation include sacral
dimorphism and other unusal anatomical
variations

85. Retrograde and antigrade pubic ramus fixation:
Retrograde from the pubic tubercle and directed laterally,
Antigrade from the supra acetabular area and directed medially. A
soft tissue sleeve protects the local structures such as spermatic
card from iatrogenic injury.
Iliac wing fixation:
The percutaneous screw is inserted from AIIS, above the greater
sciatic notch, and terminating in posterior iliac crest.
SI joint disruption:
A full threaded 6.5mm cancellous screw is passed from ilium
perpendicular to and across S1 joint (or sacral fracture) through
sacral ala terminating within the body of S1 vertebra.

87. Sacral fractures:
length of screw is inserted perpendicular to fracture
line. A lag screw can be used for compression and a
second full threaded screw for support to post pelvic
fixation.
Crescent iliac fractures:
If the Iliac fragment is small percutaneous screw
fixation can be done. If the Iliac fragment is large
ORIF with plate and screw to the Iliac fracture and SI
dislocation is ideal.
Trans iliac rod fixation of sacral Fractures:
Two rods are passed from outer aspect of one
ilium through the opposite ilium and nuts tightened
over threaded ends to apply compression.

90. Infection: Contusion or shear injuries of the posterior
skin , posterior approach
Thromboembolism: Disruption of pelvic ring
vasculature, combined with immobilization. Investigations
using contrast venography and magnetic resonance
venography pulmonary
embolism occurred in a range from 2-12%.
Malunion: limb length inequality, abnormal gait, sitting
difficulties and persistent low back pain.
Non union: It is rare and results in disability treatment is
by stable fixation with bone grafting.

91. potential risk of infection, associated visceral injuries and
haemorrhage. Associated rectal injury leads to fecal
contamination causing increased morbidity and mortality.
Principles of Treatment:
Control of haemorrhage: Is the first priority with
wound packing with sterile guaze
Debridement of wound
Fecal Diversion: In injuries associated with rectal
injuries by diverting colostomy.
Stabilization of pelvic fracture

94. Haemorrhage: In pelvic fracture is due to
Bleeding from fracture surface
Small arterial and venous tears – from pelvic
plexus, nutrient arteries and foramen
Tearing of major vessels-internal iliac artery and
tributaries
Hamorrhage is most in APC III and VS injuries
disrupting SI joint, tearing the closely related
internal iliac artery and its tributaries

95. Control obvious external bleeding
Replace estimated blood loss
Response stable C,D,E,F Response unstable
Invasive
Mini laprotomy
Negative Positive
Laprotomy
Surgical control
Response stable (intraperitoneal
bleeding)
Response unstable
(extraperitoneal bleed)
Proximal control of
bleeding (? Aorta)
Stabilize pelvic with anterior frame
Response
stable
Response
unstable
Angiography
Identify bleeding vessels
Large bore femoral
external iliac common
iliac internal iliac
Small bore
superior gluteal iliolumbar
internalpudendal
Response stable Response unstable
Pack bleeding, open
PASG,pelvic packing ?
hemipelvectomy
C
D
E
F

96. Bladder Injury:
when bladder is distended. gross
haematuria , microscopic haematuria, 85%
ruptures are extraperitonal on anterolateral wall.
They are difficult to differentiate from
membranous urethral rupture. Intraperitoneal
rupture occur mostly at the dome of bladder.
Diagnosis:Is by retrograde cystography.
Treatment: repair the rupture and
catheterization either suprapubic or urethral

97. Male , unstable pubic ramus fractures
female ,vaginal lacerations
Clinically
◦Blood at distal meatus
◦A high riding prostate
◦A perineal hematoma
◦Inability to void
Diagnosis:A retrograde urethrogram
Treatment:Surgical repair by railroad technique

98. Ureteral Injury: penetrating injuries and
associated with acetabular fracture.
Genital and Gonadal Injury: Can affect the
functional, cosmetic and psychologic sequelae of
pelvic fracture and genital injures in women may
be an open injury.

99. Gastro Intestinal Injury: Usually rectum and
anus. May rupture caecum and duodenum.
Rupture of Diaphragm: severe antero
posterior compression of the trunk. An AP view is
mandatory in all cases of severely displaced
pelvic fracture

100. subcutaneous tissue is separated traumatically from
the underlying fascia hematoma and necrotic fat
results, may compromise skin vascularity,
scar formation. Locations- flank,
proximal lateral thigh, and lumbodorsal region
open debridement
with closure over suction drains, open packing after
debridement, or observation.

101. High energy pelvic ring disruption are
associated with neurological injuries,
Particularly the lumbosacral plexus.
Sacral fractures often undiagnosed and
untreated, frequently result in
neurological symptoms and deficits to
lower extremities and urinary rectal and
sexual dysfunction.

102. Zone I – alar – occasionally associated with partial
damage to L5 root.
Zone II – Involving the nerve root path way –
frequently associated with sciatica but rarely with
bladder dysfunction.
Zone III – involving central portion of sacrum –
frequently associated with saddle anaesthesia and
loss of sphincter function

103. The nerve root decompression is performed at the
same procedure ORIF of fractures.
Foraminal debridements are recommended for
patients in whom the anticipated reductions
maneuver would cause nerve root injury because
of bone debris with in the sacral neural tunnel.