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Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries Robert M. Harris MD Medical Director of Orthopaedic Trauma Mountain States.

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Presentation on theme: "Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries Robert M. Harris MD Medical Director of Orthopaedic Trauma Mountain States."— Presentation transcript:

1 Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries Robert M. Harris MD Medical Director of Orthopaedic Trauma Mountain States Health Alliance East Tenn State University Quillen School of Medicine Revised November 2010 Created March 2004 Revised April 2007 By Kyle Dickson MD

2 Marker for severe injury Overall mortality 6- 10% Life threatening Pelvic Ring Disruption

3 Magnitude of Forces ACL injury 500-1000N LC-I pelvic fracture 6000-9000N

4 Bone Anatomy Two innominate bones with sacrum. Coalesce at triradiate cartilage. Ilium, ishium and pubis have three separate ossification centers that fuse at sixteen years. Gap in symphysis < 5 mm SI joint 2-4 mm

5 Ligamentous Anatomy Ligaments - posterior ligaments are stronger than anterior ligaments: l Posterior SI l Anterior SI l Interosseous ligaments l Pubic symphysis l Sacrotuberous l Sacrospinous


7 Posterior Ligaments Ant. SI Joint – resist external rotation Post. SI and Interosseous – posterior stability by tension band (strongest in body) Iliolumbar ligaments augments posterior complex Sacrotuberous (sacrum behind sacro-spinous into ischial tuberosily vertically)Resists shear and flexion of SI joint Sacrospinous – (anterior sacral body to ischial spine horizontally) resists external rotation

8 Normal SI Joint Motion with Gait < 6 mm of translation < 6° rotation Intact cadaver resist 5,837 N (1,212 lbs)

9 ANATOMY Relationships

10 Vascular Anatomy Internal iliac artery courses medial to the vein, splits into anterior and posterior branches. Posterior branch is more likely injured (SGA is largest branch). Usual bleeding is from venous plexus.

11 Potentially Damaged Visceral Anatomy Blunt vs. impaled by bony spike –Bladder/urethra –Rectum –Vagina

12 Pelvic Stability Strength of ring: 40% anterior and 60% posterior. V sphere = 4/3 r³. Stability – ability of pelvic ring to withstand physiologic forces without abnormal deformation


14 Physical Exam Physical Exam-poor sensitivity (8%) for mechanically unstable pelvis fractures in blunt trauma patients Shlamovitz GZ, Mower WR, Morgan MT-Journal of Trauma Mar 09

15 Radiographs Anteroposterior (AP) Inlet (40° caudad) Outlet (40 ° cephalad) CT scan Judet (acetabular fractures)

16 AP VIEW If evidence of pelvic ring fracture...


18 Inlet (Caudad) View Horizontal Plane Rotation Posterior Displacement Sacral ala


20 Outlet (Cephalad) View Sacrum Cephalad Displacement Sacral Foramina

21 CT Scan Better defines posterior injury Amount of displacement versus impaction Rotation of fragments Amount of comminution Assess neural foramina


23 3D CT

24 Radiographic Signs of Instability Sacroiliac displacement of 5 mm in any plane Posterior fracture gap (rather than impaction) Avulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament)

25 Translational Deformities X axis – Diastasis or impaction Y axis – Caudad or cephalad displacement Z axis – Anterior or posterior displacement

26 Rotational Deformities X axis – Flexion or extension Y axis – Internal rotation or external rotation Z axis – Abduction or adduction

27 Classification Aids in predicting hemodynamic instability Aids in predicting visceral and g.u. injuries Aids in predicting pelvic instability Aids in understanding mechanism of injury, force vector of injury, and surgical tactic for reduction

28 Classification Systems Anatomical (Letournel) Stability & Deformity (Pennal, Bucholz, Tile) Vector force and associated injuries (Young & Burgess) OTA-research

29 Anatomical Classification (Letournel) Where The Pelvis Breaks

30 Anterior Posterior Rami fractures Symphyseal disruption Iliac wing fracture Iliac wing/sacroiliac (SI) joint (crescent fracture) SI joint Sacrum/SI joint Sacrum fracture

31 Pennal, 1961 Bucholz, 1981 Tile, 1988 Magnitude and direction of forces –Lateral posterior compression (LC) –Anterior posterior compression (APC) –Vertical shear (VS) Added stability to the classification

32 Tile Classification Type A: Stable fracture. Type B: Rotationally unstable, but vertically stable. Type C: Rotationally and vertically unstable.

33 OTA/AO – Pelvic Injury Classification 61A – Lesion sparing (or with no displacement of ) posterior arch B – Incomplete disruption at posterior arch; partially stable C – Complete disruption of posterior arch; unstable

34 A Fractures – Ring Intact A-1 – Fracture of innominate bone; avulsion A-2 – Fracture of innominate bone; direct blow A-3 – Transverse fracture of sacrum and coccyx

35 B-Ring Injury – Partially stable B-1 – Unilateral partial disruption of posterior arch, external rotation (open book injury) B-2 – Unilateral, partial disruption of posterior arch, internal rotation (lateral compression injury) B-3 – Bilateral, partial lesion of posterior arch

36 C – Complete Disruption Posterior Arch, Unstable Pelvis C-1 – Unilateral, complete disruption of posterior arch C-2 – Bilateral, ipsilateral complete, contralateral incomplete C –3 – Bilateral, complete disruption

37 Young-Burgess Radiology 1986 Based on mechanism of injury Predictive of associated local & distant injury Useful for planning acute treatment

38 MECHANISM OF INJURY (MOI) Do initial radiographs agree with MOI in pelvic ring disruptions- Linnau KF, Blackmore CC, Routt ML, Mock CN-J Ortho Trauma Jul 2007 more reliable for LC than AP mechanisms

39 MECHANISM OF INJURY Lateral compression Lateral compression (implosion) AP compression AP compression (external rotation) Vertical shear Vertical shear Combined injury Combined injury

40 LATERAL COMPRESSION fracture of anterior ring plus: LATERAL COMPRESSION fracture of anterior ring plus: LC -I Compression fracture of anterior sacrum LC -I Compression fracture of anterior sacrum LC -II Iliac wing fracture posteriorly (unstable) LC -II Iliac wing fracture posteriorly (unstable) LC -III Windswept pelvis (contralateral SI injury) LC -III Windswept pelvis (contralateral SI injury) ANTERIOR-POSTERIOR COMPRESSION ANTERIOR-POSTERIOR COMPRESSION APC - I Partial disruption APC - I Partial disruption APC - II Posterior sacroiliac ligaments intact APC - II Posterior sacroiliac ligaments intact APC - III Posterior sacroiliac ligaments disrupted APC - III Posterior sacroiliac ligaments disrupted VERTICAL SHEAR cephlad and posterior displacement VERTICAL SHEAR cephlad and posterior displacement COMBINED MECHANISM (LC & VS most common) COMBINED MECHANISM (LC & VS most common) Young-Burgess Classification

41 CLASSIFICATION Mechanism and direction of injury

42 DISRUPTED PELVIC RING Posterior/SI injury is a marker for associated vascular injuries Tamponade efforts and fluid resuscitation may be rendered useless

43 Resuscitation Young and Burgess classification: –LC III –APC II –APC III –VS –CM

44 units blood 1st 24 hours RESUSCITATION REQUIREMENTS

45 Deaths : Mortality

46 Interobserver Reliability of the Young/Burgess and Tile classifications Koo H, Leveridge M, McKee,MD, Schemitsch EH, J Ortho Trauma Jul 2008 –Young/Burgess –Kappa.72-better for the training surgeon –CT-improved assessment of stability Furey AJ, OToole RV, Turen C, Ortho June 2009 –Interobserver – moderate degree of agreement –Intraobserver- moderate for Tile Substantial for Burgess

47 LATERAL COMPRESSION LC I: Sacral compression

48 Lateral Compression Most common pattern. LC1 – stable, load to posterior ring. LC2 – load to anterior ring, posterior ligaments injured, ST and SS intact. LC3 – LC2 + external rotation injury of the other side.

49 LC-I

50 LATERAL COMPRESSION Common anterior pattern

51 LATERAL COMPRESSION LC I: Sacral compression

52 What Constitutes a LCI Lefaivre KA, Padalecki JR, Starr AJ- J Ortho Trauma Jan 2009 LC I-Spectrum of injuries Complete sacral disruptions –Denis classification –Predicted by severity of anterior pelvic ring disruption –Abdominal AIS –Rami fracture location –ISS

53 LATERAL COMPRESSION LC II: Iliac wing fracture

54 LC-II


56 LC III: Windswept pelvis




60 Anteroposterior Compression APC1- stable injury, anterior ligament injury. APC2 – SS and anterior SI injury, possibly ST. APC3 – anterior and posterior injury, completely unstable.


62 AP I Note that the ligaments are stretched, and not torn


64 AP II APC-2 – Sacrotuberous, sacrospinous, and anterior SI joint ligaments disrupted (post SI ligaments intact) are Note: pelvic floor ligaments are violated, as well as anterior SI ligaments

65 AP-II

66 AP II Ligamentous pathology

67 AP II These anterior SI ligaments are disrupted... But these posterior SI ligaments remain intact

68 ANTEROPOSTERIOR COMPRESSION APC III: Complete iliosacral dissociation APC-3 – Complete SI joint disruption (usually not vertically displaced)




72 ASSOCIATED INJURIES Lateral Compression: l Abdominal visceral injury l Head injury l Few pelvic vascular injuries AP Compression: l Urologic injury l Hemorrhage/pelvic vascular injury: APCII-10%, APCIII-22%

73 Vertical Shear Always unstable Ant. symphsis or vertical rami fractures- post. Injury variable Vertical displacement

74 VERTICAL SHEAR Vertically unstable – often due to a unilateral injury. Similar to APC3.


76 COMBINED MECHANICAL INJURY Combined vectors occasionally 2 separate injuries (ejection/landing) Often LC/VS, or AP/VS


78 CLASSIFY INJURY (Young-Burgess) LC-I, AP-I AP-II AP-III, VS ConservativeTreatmentAnteriorStabilization Anterior and Posterior Stabilization

79 Surgeon variability in the treatment of pelvic ring injuries Furey AJ, OToole RV, Nascone JW, Sciadini MF- Ortho Oct 2010 Young and Burgess, and Tile Classifications Kappa Value- –Intraobserver- 0.56 moderate agreement –Interobserver- 0.47 moderate agreement Consistent treatment for certain patterns

80 References Surgeon variability in the treatment of pelvic ring injuries. Furey AJFurey AJ, O'Toole RV, Nascone JW, Copeland CE, Turen C, Sciadini MF. Orthopedics. 2010 Oct 11;33(10)O'Toole RVNascone JWCopeland CETuren CSciadini MF. Classification of pelvic fractures: analysis of inter- and intraobserver variability using the Young-Burgess and Tile classification systems. Furey AJFurey AJ, O'Toole RV, Nascone JW, Sciadini MF, Copeland CE, Turen C. Orthopedics. 2009 Jun;32(6):401O'Toole RVNascone JWSciadini MFCopeland CETuren C Interobserver reliability of the young-burgess and tile classification systems for fractures of the pelvic ring. Koo HKoo H, Leveridge M, Thompson C, Zdero R, Bhandari M, Kreder HJ, Stephen D, McKee MD, Schemitsch EH.Leveridge MThompson CZdero RBhandari MKreder HJStephen DMcKee MDSchemitsch EH Division of Orthopaedic Surgery; and daggerMartin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto, Ontario, Canada. J Orthop Trauma. 2008 Jul;22(6):379-84 Fracture of the pelvis: current concepts of classification.Young JW, Resnik CS.Department of Radiology, University of Maryland Medical System/Hospital, Baltimore 21201. AJR Am J Roentgenol. 1990 Dec;155(6):1169- 75.Young JWResnik CS Do initial radiographs agree with crash site mechanism of injury in pelvic ring disruptions? A pilot study. Linnau KFLinnau KF, Blackmore CC, Kaufman R, Nguyen TN, Routt ML Jr, Stambaugh LE 3rd, Jurkovich GJ, Mock CN.Department of Radiology, Harborview Medical Center, Seattle, Washington 98104-2499, USA. J Orthop Trauma. 2007 Jul;21(6):375-80.Blackmore CCKaufman RNguyen TNRoutt ML JrStambaugh LE 3rdJurkovich GJMock CN

81 References How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? Shlamovitz GZ, Mower WR, Bergman J, Chuang KR, Crisp J, Hardy D, Sargent M, Shroff SD, Snyder E, Morgan MT. Department of Emergency Medicine and Traumatology, Hartford Hospital, UCONN School of Medicine, University of Connecticut, Hartford, Connecticut, USA. J Trauma. 2009 Mar;66(3):815-20Shlamovitz GZMower WRBergman JChuang KRCrisp JHardy DSargent MShroff SDSnyder EMorgan MT What constitutes a Young and Burgess lateral compression-I (OTA 61-B2) pelvic ring disruption? A description of computed tomography-based fracture anatomy and associated injuries. Lefaivre KA, Padalecki JR, Starr AJ. Department of Orthopaedics Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA. J Orthop Trauma. 2009 Jan;23(1):16-21.Lefaivre KAPadalecki JRStarr AJ Predicting blood loss in isolated pelvic and acetabular high-energy trauma. Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Nashville, Tennessee 37232-8774, USA. Orthop Trauma. 2007 Oct;21(9):603-7Magnussen RATressler MA Obremskey WTKregor PJ Pelvic disruption: assessment and classification. Pennal GF, Tile M, Waddell JP, Garside H. Clin Orthop Relat Res. 1980 Sep;(151):12-21Pennal GFTile MWaddell JPGarside H Pelvic fractures: value of plain radiography in early assessment and management. Young JW, Burgess AR, Brumback RJ, Poka A. Radiology. 1986 Aug;160(2):445-51Young JWBurgess AR Brumback RJPoka A Pelvic ring disruptions: effective classification system and treatment protocols. Burgess ARBurgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ.Eastridge BJYoung JWEllison TSEllison PS JrPoka ABathon GHBrumback RJ Shock Trauma Center, Maryland Institute for Emergency Medical Services Systems, Baltimore J Trauma. 1990 Jul;30(7):848-56

82 See Emergent Management of Pelvic Injuries for Application of Classification to Treatment

83 Acknowledgment Return to Pelvis Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to Andy Burgess and Kyle Dickson for the use of their slides

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