PELVIC RING INJURY

Prepared by:
orthopaedic resident
Black Lion Hospital
Addis Ababa University
ETHIOPIA

1. Pelvic R ing I njury Moderator: Dr Samuel Hailu Presenter: Yasin Awil (OSR)

2. Outline Anatomy Biomechanics Mechanism of Injury Classification Approach to patient Imaging Management

3. Anatomy Osteology:

4. Ligaments

5. Neurovascular anatomy

6. Perineum and genitourinary anatomy Common site of urethral injury : Membranous Urethra ( males) Near bladder neck ( females)

7. Biomechanics “Reverse Keystone” on inlet “Keystone” on outlet

8. Posterior SI: works almost constantly; most powerful; ‘ Suspension Bridge’

9. Patho -anatomy Most important determinant is its ring structure A ring fails in two locations (at least) The degree of pelvic instability Correlates with the energy of the trauma Overall physiological status of the patient Guides definite management

10. MOI Pelvic ring may fail through the bone, ligaments, or both. First described by George F. Pennal, 1950s APC, LC, VS In clinical practice commonly is a combination of these forces.

11. Anterior-Posterior Compression

12. Lateral Compression

13. Complete unstable (vertical shear)

14. CLASSIFICATION Anatomic Young-Burgess (Mechanism of injury) Tile (Stability) AO/OTA Comprehensive Classification ( Modified Tile AO Müller classification)

15. The Letournel and Judet classification of pelvic fractures is anatomic.

16. YOUNG AND BURGESS CLASSIFICATION: B ased on the mechanism of injury. most likely potential associated injuries resuscitation requirements among the most favored classifications

17. Tile classification combines: mechanism of injury degree of pelvic stability site of injury

18. Subclassification of Crescent # dislocation Day Classification: Type I -a large crescent fragment, and less than one-third of the sacroiliac joint dislocation. Type II - an intermediate-sized crescent fragment and the dislocation comprises between one-third and two-thirds of the sacroiliac joint. Type III fractures are linked to a small crescent fragment where the dislocation comprises most of the joint.

19. Nakatani classification of superior ramus fractures Type I: medially to the medial border of the foramen. Type II: within the foramen. Type III: lateral to the lateral border of the foramen.

20. Clinical assessment Primary survey: ABCDE Multiply injured patients require: careful history regarding the mechanism of injury Proper physical exam: Lower limb deformity or shortening E valuation of peripheral perfusion ,

21. P/E: Evaluation of motor function and sensation, R ectal examination to evaluate for: Sacral root injury Presence of an open fracture, stability testing of the pelvic ring

22. Stability test

23. Stress examination

24. NEUROLOGIC INJURY

25. Associated Injuries Chest injuries (63%) Long bone fractures (50%) Head injury (40%), Solid organ injury (40%), Spinal fracture (25%). Intestinal injuries (14%)

26. APC are associated with higher blood loss Type III - 67% risk of shock LC associated with high incidence of head injury (50%) Type III- 20% risk of bowel injury, 40% extremity # VS high risk of hypovolemic shock (63%), mortality (25%), head injury (56.2%), lung injury (23%), and splenic injury (25%)

27. Genitourinary Tract injuries Bladder and Urethral injuries – 6% to15% Vaginal Injury 0 to 5% Urethral injury Male > Female Posterior >anterior

28. Dynamic Retrograde Urethrogram In posterior urethral injury: 10 to 20% risk of associated bladder rapture Bladder rupture: 60% EPBR, 30% IPBR, and 10% both 22%-34% mortality

29. Management IPBR: Exploratory laparotomy + bladder repair + Foley or suprapubic catheter Anterior fixation or ex-fix in same setting EPBR: Non-OP [Foley catheter + Antibiotics] - strong consideration for ex-fix as definitive management If ORIF anterior pelvis necessary – bladder repair can be done in same setting

30. Urethral Injury: Endoscopic realignment vs acute suprapubic drainage followed by delayed reconstruction Clear communication between the orthopedic trauma team and the urologic team

31. Morel- Lavallé lesion: Internal degloving which occur when the skin and subcutaneous tissue separate from the underlying fascia

32. Open Fractures 5% of all PRI Jones classification: Class 1 - Stable open PRF. Class 2 - Rotationally or vertically unstable, and there is no rectal or perineal wound. Class 3- Rotationally or vertically unstable, and a rectal or perineal wound with potential for fecal contamination is present Careful digital rectal and Vaginal examination

33. Faringer et al Classification: Zone I consists of the perineum, anterior pubis, median buttocks, and posterior sacrum. Zone II consists of the thigh or groin crease. Zone III consists of the iliac crest and more lateral buttocks

34. Packing and I&D

35. Pelvic ring disruption in women: genitourinary and obstetrical implications Urinary complaints Sexual function Dyspareunia Infertility Mode of delivery

36. IMAGING Plain Radiographs: AP Overview of complete pelvis Rami Symphysis

37. Outlet: SI joint Sacral foramina Sympysis

38. INLET View: Pelvic brim Pubic rami SI joint Sacral ala Iliac wing

39. Radiographic Signs of Instability SI displacement of 5 mm in any plane. post/vertical Posterior fracture gap (rather than impaction). Avulsion of the 5th lumbar transverse process, the lateral border of the sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous ligament)

40. CT: Integral in the management of PRI. Aids in the classification of injuries CT scan with contrast and CTA evaluate: life threatening hemorrhage in high energy PRI

41. MRI and Scintigraphy: Occult fractures Persistent posterior pelvic pain after trauma despite the absence of an obvious fracture on CT scan

42. Acute Management The ladder of resuscitation for hemodynamic instability: Fluid resuscitation Blood transfusion Emergent stabilization of the unstable pelvis Pelvic binder External fixator ( a shock that doesn’t respond for binder may not respond for the ex-fix ) Pelvic packing Angiographic embolization

43. Orthopaedic Damage Control

44. Specific Treatments of Pelvic Ring Disruption Closed reduction No posterior and Vertical Displacement: Both legs are slightly flexed at the hips and knees and internally rotated and tapped. Pelvic sheet or binder is applied Posterior and Vertical displacement: Skeletal traction Pelvic sheet or binder

45. Pelvic binder: Applied at the level of the greater trochanters Should be flat against the skin to maximize surface area 24-48 hours

46. Anterior external fixation Indication: Temporary stabilization of unstable fracture Definitive stabilization of pelvic ring # U ndergoing laparotomy – pelvic packing or Urologic and abdominal procedures. Should be done before laparotomy An open pelvic ring injury or associated injury of genitourinary organs

47. Techniques of Pelvic Ex- fix Application A)Iliac crest

48. B)supra- acetabular

49. Pelvic C- Clamp Posterior ring stabilization through pins placed in posterior ilium lateral to SI joint Mechanically superior to any anterior frame, especially in the case of completely unstable (type C) injuries C/I – presence of iliac wing fracture Complications - vascular and nerve injuries or displacement of the unstable hemipelvis into the true pelvis ( rare)

50. Pelvic Packing Midline infraumbilical incision from 1 to 2 cm inferior to the umbilicus to the pubic symphysis. Gently remove the blood clots. Retract the bladder to one side Place a laparotomy sponge below pelvic brim Place a second and third sponge anterior to the first. Repeat the same on the contralateral side

51. Angiography Diagnostic vs Therapeutic Indication Hemodynamic instability despite adequate resuscitation and application of external pelvic compression device There should be no evidence of intraabdominal bleeding.

52. DEFINITIVE MANAGEMENT Recommendations for therapy are based primarily on two factors: Fracture pattern (including pelvic stability) Patient factors (e.g., associated injuries, soft tissue conditions within and around the zone of injury, and comorbidities).

53. Cont… ORIF of pubic symphysis: Ex fix Plating Cerclage wiring Strength Two plates >> one plate Box plates – Allow Biplanar screw insertion Plates >> Ex fix Ramus fracture location further from mid line Plating becomes less significant

54. SI dislocation: SI screw Long thread (32 mm) First sacral body Ant Platting Trans-iliac bars Trans-iliac plating

55. References TILE.M (2015). Fractures of the Pelvis and Acetabulum: Principles and Methods of Management, 4th ed., Switzerland: AO Foundation. BROWNER B.D.( 2020). Skeletal Trauma. Basic Science, Management and Reconstruction, 6th edition., Philadelphia, USA COURT-BROWN C.M. (2015). Rockwood’s and Green’s Fractures in Adults, 8th ed., Philadelphia: Lippincott Williams & Wilkins MOORE K.L. (2014). Moore clinically oriented anatomy, 7th ed., Philadelphia: Lippincott Williams & Wilkins journal homepage: www.elsevier.com/locate/injuryJames A.C. Fagga,b ,, Mehool R. Acharyaa , Tim J.S. Chessera , Anthony J. Warda