Pelvis acetabulum - anatomy , imaging , classification

Pelvis acetabulum - anatomy , imaging , classification

1. Jatinder S. Luthra Anatomy, Radiographic evaluation & Classification of Pelvic Ring Fractures

2. Pelvic Fractures: Epidemiology Majority due to high impact blunt trauma (MVA, pedestrian vs. vehicle etc.) but also secondary to falls in frail elderly Mortality overall = 10% Mortality 50% if open #

3. Pelvic Anatomy Pelvis = sacrum, coccyx + 2 innominate bones Innominate bones = ilium , ischium , pubis Sacrum + innominate bones form a ring Strength from ligamentous supports (largely posterior aspect of ring)

4. Pelvic Anatomy 5 joints: Lumbosacral Sacroiliac (x2) Sacrococcygeal Symphysis

5. Anterior Support: Symphysis pubis Fibrocartilaginous joint covered by ant & post symphyseal ligaments Pubic rami Posterior Support: ~majority of stability Iliolumbar ligaments Sacroiliac ligaments Sacrospinous ligament Sacrotuberous ligament

6. Vascular Anatomy Vessels lie close to posterior pelvic walls Venous bleeding most common (sacral plexus) Most commonly injured arteries are superior gluteal and internal pudendal

7. Pelvic Anatomy Nerve supply through the pelvis derived from lumbar and sacral plexuses Other structures: lower GI/GU

8. Imaging – X- rays X Rays Pelvis AP – part of ATLS protocol

9. Imaging – X- rays AP VIEW: -Identifies most fractures -Look for disruption in iliopubic and ilioischial lines, sacral foramina, radiographic U, Shenton’s Lines Inlet and outlet views Judet Views

10. AP Pelvis Radiogram Acetabular fracture Posterior Pelvic lesion

11. S2

12. Imaging Look for any evidence of damage to the posterior pelvic structures Clues on X-rays: L5 transverse process avulsion (iliolumbar ligament) Ischial spine avulsion (sacrospinous ligament) Unable to clearly make out sacral foramina Assymmetry of sacral foramina Avulsion at lower lip of lateral sacrum (sacrotuberous ligament)

13. Inlet view X-ray beam at 40 o to plate directed towards feet Sacral Promontry should overlap anterior border of S1

14. Posterior displacement Rotational deformity Subtle SI joint injury Sacral Ala fracture

15. Outlet View Outlet view Beam aimed 30 o towards head Superior border of symphysis at level S2

16. Outlet View Vertical displacement Sacral foramina Flexion deformity

17. CT scan Detailed information of posterior lesion Sacral Foramina Subtle sacral impaction. Rotation of hemipelvis Associated Lesions Dysmorphysisum

18. Radiological criteria of instability

19. Displacement instead of impaction in posterior pelvis

20. Attention Stationary pelvic radiogram do not reflect true pathology Apparently stable patient should undergo Examination under anaesthesia Push Pull film under anaesthesia > 1cm is unstable Contraindicated – Zone 2/3 sacral fracture Haemodynamically unstable

21. Arteriogram Patients with pelvic fracture – persistent bleeding despite External stabilization ICE – intravenous contrast extravasation

22. Gross haematuria - Bloody urethral discharge Inability to void - swelling / echymosis in perineal region High riding prostate

23. Pelvic Fractures 5 General Categories: 1. Pelvic Ring 2. Acetabular 3. Sacral 4. Avulsion type 5. Single bone

24. Pelvic fracture classification Bucholz classification – JBJS 1981 Type1 - stable Type II- Open Book Type III – Rotaionally and vertically unstable

25. Pelvic fracture classification Letournal Classification

26. Pelvic Ring Fractures Young Classification System : Differentiates fracture patterns based on mechanism of injury/direction of causative force 3 major fracture patterns: 1. lateral compression (50%) 2. antero -posterior compression (25%) 3. vertical shear (5%)

27. Pelvic fracture classification Young & Burgess Classification Modification of tile – Based on mech of inj.

28. Young & Burgess Anteroposterior compression fracture External rotation force Neurovascular structures stretched. Symphyseal diastasis / Vertical fracture pubic ramus

29. Young & Burgess Anteroposterior compression fracture - I

30. Young & Burgess Anteroposterior compression fracture - II

31. Young APC II

32. Young & Burgess Anteroposterior compression fracture - III

33. Young & Burgess LATERAL COMPRESSION - I

34. Young & Burgess LATERAL COMPRESSION - II CRESCENT FRACTURE

35. Young & Burgess LATERAL COMPRESSION – III

36. Young & Burgess VERTICAL SHEAR

37. Tile C1/ Young VS

38. Young & Burgess COMBINED MECHANISM

39. Summary Classification system - - Assist surgeon in determining treatment and prognosis Young & Burgess – - Fluid resuscitation reqd - Solid organ injury Need for acute stabilization Pt. survival APC type 3 & VS injury – highest transfusion reqd.

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