Presentation on theme: "Robert M. Harris MD Medical Director of Orthopaedic Trauma"— Presentation transcript:
1 Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries Robert M. Harris MDMedical Director of Orthopaedic TraumaMountain States Health AllianceEast Tenn State University Quillen School of MedicineRevised November 2010Created March 2004 Revised April 2007By Kyle Dickson MD
2 Pelvic Ring Disruption Marker for severe injuryOverall mortality 6-10%Life threatening
3 Magnitude of Forces ACL injury 500-1000N LC-I pelvic fracture N
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 mmSI joint 2-4 mm
5 Ligamentous AnatomyLigaments - posterior ligaments are stronger than anterior ligaments:Posterior SIAnterior SIInterosseous ligamentsPubic symphysisSacrotuberousSacrospinous
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 complexSacrotuberous (sacrum behind sacro-spinous into ischial tuberosily vertically)Resists shear and flexion of SI jointSacrospinous – (anterior sacral body to ischial spine horizontally) resists external rotation
8 Normal SI Joint Motion with Gait < 6 mm of translation< 6° rotationIntact cadaver resist 5,837 N (1,212 lbs)
10 Vascular AnatomyInternal 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 spikeBladder/urethraRectumVagina
12 Pelvic Stability Strength of ring: 40% anterior and 60% posterior. Vsphere = 4/3r³.Stability – ability of pelvic ring to withstand physiologic forces without abnormal deformation
13 IDENTIFY THE HIGH RISK PELVIC DISRUPTION By RadiographyBy Physical Exam
14 Physical ExamPhysical Exam-poor sensitivity (8%) for mechanically unstable pelvis fractures in blunt trauma patientsShlamovitz GZ, Mower WR, Morgan MT-Journal of Trauma Mar 09
24 Radiographic Signs of Instability Sacroiliac displacement of 5 mm in any planePosterior 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 impactionY axis – Caudad or cephalad displacementZ axis – Anterior or posterior displacement
26 Rotational Deformities X axis – Flexion or extensionY axis – Internal rotation or external rotationZ axis – Abduction or adduction
27 Classification Aids in predicting hemodynamic instability Aids in predicting visceral and g.u. injuriesAids in predicting pelvic instabilityAids 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
31 Magnitude and direction of forces Pennal, Bucholz, 1981 Tile, 1988Magnitude and direction of forcesLateral 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 archB – Incomplete disruption at posterior arch; partially stableC – Complete disruption of posterior arch; unstable
34 A Fractures – Ring Intact A-1 – Fracture of innominate bone; avulsionA-2 – Fracture of innominate bone; direct blowA-3 – Transverse fracture of sacrum and coccyx
46 Interobserver Reliability of the Young/Burgess and Tile classifications Koo H, Leveridge M, McKee,MD, Schemitsch EH, J Ortho Trauma Jul 2008Young/Burgess –Kappa .72-better for the training surgeonCT-improved assessment of stabilityFurey AJ, O”Toole RV, Turen C, Ortho June 2009Interobserver – moderate degree of agreementIntraobserver- moderate for TileSubstantial for Burgess
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.
52 What Constitutes a LCI LC I-Spectrum of injuries Lefaivre KA, Padalecki JR, Starr AJ- J Ortho Trauma Jan 2009LC I-Spectrum of injuriesComplete sacral disruptionsDenis classificationPredicted by severity of anterior pelvic ring disruptionAbdominal AISRami fracture locationISS
79 Surgeon variability in the treatment of pelvic ring injuries Furey AJ, O”Toole RV, Nascone JW, Sciadini MF- Ortho Oct 2010Young and Burgess, and Tile ClassificationsKappa Value-Intraobserver moderate agreementInterobserver moderate agreementConsistent treatment for certain patterns
80 ReferencesSurgeon variability in the treatment of pelvic ring injuries.Furey AJ, O'Toole RV, Nascone JW, Copeland CE, Turen C, Sciadini MF. Orthopedics Oct 11;33(10). Classification of pelvic fractures: analysis of inter- and intraobserver variability using the Young-Burgess and Tile classification systems.Furey AJ, O'Toole RV, Nascone JW, Sciadini MF, Copeland CE, Turen C. Orthopedics Jun;32(6):401Interobserver reliability of the young-burgess and tile classification systems for fractures of the pelvic ring.Koo H, Leveridge M, Thompson C, Zdero R, Bhandari M, Kreder HJ, Stephen D, McKee MD, Schemitsch EH.Division of Orthopaedic Surgery; and daggerMartin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto, Ontario, Canada. J Orthop Trauma Jul;22(6):379-84Fracture of the pelvis: current concepts of classification.Young JW, Resnik CS.Department of Radiology, University of Maryland Medical System/Hospital, Baltimore AJR Am J Roentgenol Dec;155(6):Do initial radiographs agree with crash site mechanism of injury in pelvic ring disruptions? A pilot study.Linnau 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 , USA. J Orthop Trauma Jul;21(6):
81 ReferencesHow (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 Mar;66(3):815-20What 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 Jan;23(1):16-21.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 , USA. Orthop Trauma Oct;21(9):603-7Pelvic disruption: assessment and classification. Pennal GF, Tile M, Waddell JP, Garside H. Clin Orthop Relat Res Sep;(151):12-21Pelvic fractures: value of plain radiography in early assessment and management. Young JW, Burgess AR, Brumback RJ, Poka A. Radiology Aug;160(2):445-51Pelvic ring disruptions: effective classification system and treatment protocols.Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ.Shock Trauma Center, Maryland Institute for Emergency Medical Services Systems, Baltimore J Trauma Jul;30(7):848-56
82 See Emergent Management of Pelvic Injuries for Application of Classification to Treatment
83 Andy Burgess and Kyle Dickson for the use of their slides AcknowledgmentAndy Burgess and Kyle Dickson for the use of their slidesIf 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 toOTAaboutQuestions/CommentsReturn toPelvisIndex
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