1. Hip Surgeon. Afshin Taheriazam, MD
Lower limb FRACTURES
Part 1
pelvic fractures
Hip Surgeon. Afshin Taheriazam, MD

2. Chapter one:
Pelvic fracture

3. Objectives: Epidemiology & relevance Anatomical review
Classification Systems
Examples
Management

4. Epidemiology ~3% of all fractures in ED (Emergency Department)
50-60% secondary to MVA
Motorcycle crashes ~15%
Car vs. pedestrian ~15%
Falls 10-30%
Crush injuries ~5%
( Mortality is about %) :
Mortality 6-10% ; Inc’s to ~50% in unstable pt (prothrombin time)
39% due to bleeding (early).
30% due to sepsis & multi-organ failure (late).
Complications:
Hemorrhage, neurological injury, deformity, GU injury, GI injury
Mortality quoted tends to be all causes of mortaltiy; less than 1% will die as a direct consequence of their pelvis fracture.

5. Anatomy of Pelvis Pelvis = sacrum + 2 inominate bones
Inominate bones = ilium, ischium, pubis
Strength from ligamentous + muscular supports

6. Anatomy of Pelvis Pelvis contains one pair of fused bone
Each half contains: ilium, pubis, and ischium
Joined together in posterior by sacrum
Joined in anterior by symphysis pubis
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

7. Anatomy of Pelvis Ilium Male Pelvis Female Pelvis Sacrum Pubis Ischium
Symphysis Pubis

8. Anatomy of Pelvis : ligaments
Anterior Support:
~40% of strength
Symphysis pubis
Fibrocartilaginous joint covered by ant & post symphyseal ligaments
Pubic rami
Posterior Support:
~60% of strength
Sacroiliac complex
Sacroiliac ligaments
Iliolumbar ligaments
Pelvic floor
Sacrospinous ligament
Sacrotuberous ligament
Pelvic diaphragm

9. Anatomy of Pelvis : ligaments
posterior ligaments are stronger than anterior ligaments:
Posterior SI
Anterior SI
Interosseous ligaments
Pubic symphysis
Sacrotuberous
Sacrospinous
Sacrospinous resists external rotation
Sacrotuberous resists rotational and vertical shearing forces

10. ASI
PSI ST SS ST

11. 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

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

13. Anatomy of Pelvis
Relationships

14. Acetabulum Divided into 3 columns:
Anterior superior column (= ilium)
Anterior inferior column (= pubis)
Posterior Column (= ischium)
Ant superior column is the primary weight bearing structure.
The ant inferior column is thin and easily fractured.
The post column is thick and strong but most commonly fractured.

15. Vascular Anatomy
Vessels lie closely adherent to posterior pelvic walls
Most common cause of bleeding is venous
Most commonly injured arteries are superior gluteal and internal pudendal aa.
Venous bleeding is most common because of relative deficiency in protective vasospasm, and lack of valves in pelvis with extensive collateral anastomoses.

16. 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.

17. Pelvic Stability
Stability : ability of pelvic ring to withstand physiologic forces without abnormal deformation.
Physiologic load may be sitting, side lying, or standing, as dictated by patient needs , else consider as unstable.
Strength of ring: 40% anterior and 60% posterior.
Vsphere = 4/3r³.

18. Pelvic Ring Stability
Posterior ring integrity is important in transferring load from torso to lower extremities

19. Common Fractures of Pelvis
Pelvic ring fractures
Pelvic ring is likely to separate in more than one location
Iliac crest fractures
Fractures to upper wing of ilium
Loss of posterior ring integrity leads to instability
Loss of anterior ring integrity may contribute to instability, and may be a marker to posterior ring injury.
Young and burgess classification will guide us for stability issues

20. Pelvic Fractures
Common mechanisms of pelvic injury result from high energy
ex. MVC, significant falls, skiing accident
Those at risk for pelvic fractures
Growing teens (especially those involved in sports)
Elderly patients (osteoporosis)

21. Classification systems
2 most common are Tile and Young systems
Tile Classification system:
Advantages
Comprehensive
Predicts need for operative intervention
Disadvantages
Does NOT predict morbidity or mortality
Young Classification System:
Based on mechanism of injury  predicts injury
Estimates mortality
Excludes more minor injuries

22. Tile :Classification System
Type A: Stable pelvis post structures intact
A1: avulsion injury
A2: iliac wing or ant arch
A3: Transverse sacrococcygeal

23. Tile :Classification System
Type B: Partially stable pelvis: incomplete posterior structure disruption
B1: open-book injury
B2: lateral compression injury
B3: contralateral / bucket handle injuries

24. Tile :Classification System
Type C: Unstable pelvis: complete disruption of posterior structures
C1: unilateral
C2: bilateral w/ one side Type B, one side Type C
C3: bilateral Type C

25. Young & Burgess Classification

26. Classification System: Young
Lateral Compression
(50%) – transverse of pubic rami, ipsilateral or contralateral to posterior injury
LC I – sacral compression on side of impact
LC II – iliac wing on side of impact
LC III – LC-I or LC-II on side of impact w/ contralateral APC injury

27. Classification System: Young
AP Compression (25%)
Symphyseal and / or Longitudinal Rami Fractures
APC I – slight widening of the pubic symphysis and/or anterior SI joint
APC II – disrupted anterior SI joint, sacrotuberous, and sacrospinous ligaments
APC III – complete SI joint disruption w/ lateral displacement and disruption of sacrotuberous and sacrospinous ligaments

28. Classification System: Young
Vertical Shear ( VS) (5%)
Symphyseal diastasis or vertical displacement anteriorly and posteriorly
Example : Fall from heights
Combined Mechanism (CM) combination of injury patterns

29. Young: Morbidity & Mortality
Fracture Type
Severe Bleeding
Bladder Rupture
Urethral Injury
Mortality
LC - I
0.5% 4% 2% 6%
LC – II
36% 7% 0%
LC – III
60%
20%
13%
APC – I 1% 8%
12%
APC – II
28%
11%
23%
APC – III
53%
14%
25% VS
75%
15% CM
58%
16%
21%
17%

30. Classify the fractures in the next slides

31. Tile B1 / Young APC II

33. Tile C1/ Young VS

35. Tile A1

37. Type A1 avulsion

39. Right iliac wing also called Duverney
Tile A2 / Young LC II

40. Risks of Pelvic Factures
Iliac Crest fracture
Typically pelvis still stable
Little blood loss
Pelvic Ring fracture
Internal organ damage
Significant blood loss (up to 4 liters) : Fracture and vascular injury can cause the formation of hematoma in the pelvis and retroperitoneum  Hypovolemic shock
90% bleeding  venous disruption or cancellous bone
10% bleeding  an arterial injury
Unstable pelvis
Risk of death (Mortality of 3.4%-42%)
Mortality rate found at:

41. Assessment ATLS Approach (Advanced Trauma Life Support)
Check Stability :
Mechanic
Haemodynamic
Pelvis specific assessment
Check for bruising, deformity, or abrasions
Listen/Feel for crepitus
Check limb length

42. Stability Assessment Check stability of pelvis (DON’T REPEAT)
Apply gentle medial pressure with palms by pressing inward on iliac crests
With patient supine, apply gentle posterior pressure by pressing downward on iliac crests
Apply gentle downward pressure on pubis to check pelvic ring stability
1) Medial pressure
2) Posterior iliac pressure
3) Posterior pubis pressure

43. Diagnosis
1. General: abrasion, contusion, hematoma, over bony prominence of pelvis, scrotal, vulvar hematoma.
2. PE ( Physical Exam )
3. X-ray
4. FAST
5. DPL
6. CT

44. IDENTIFY THE HIGH RISK PELVIC DISRUPTION
By Physical Exam
By Radiography

45. Radiographic Evaluation
X-Ray AP view:
Anterior lesions: pubic rami fractures
Symphysis displacement
Sacroiliac joint and sacral fractures
Iliac fractures
L5 transverse process fractures

46. Radiographic Signs of Instability
Broken ‘Ring’
Symphysis gap > 2.5 cm
Sacroiliac displacement of 5 mm in any plane.
Avulsion of the 5th lumbar transverse process, the lateral border of the sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous ligament).

47. Treatment Treat for life threatening injuries Treat for possible shock
Oxygen
Intravenous infusion
Splinting / Wrap
Pain control
RAPID TRANSPORT!!!

48. Patients with hemorrhagic shock and unstable pelvic fractures have four potential sources of blood loss :
(1) fractured bone surfaces
(2) pelvic venous plexus
(3) pelvic arterial injury
(4) extrapelvic sources.
The pelvis should be temporarily stabilized or "closed" using an available commercial compression device or sheet to decrease bleeding.

49. In the presence of unstable pelvic ring disruption and a positive abdominal study, stabilization of the pelvis should be undertaken before laparatomy.
If hemodynamic stability is not achieved after placement of the external fixator, arteriography should then be performed.

50. Non-Operative Management
( haemodinamically stable )
Lateral impaction type injuries with minimal
(< 1.5 cm) displacement
Pubic rami fractures with no posterior displacement
Minimal gapping of pubic symphysis

52. Operative Management Operative indications Pelvic unstable
symphysis diastasis > 2.5 cm 
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
Hemodynamically unstable

53. Operative Management Hemodynamically unstable
Reduce pelvic volume : promote blood clot as well as reducing blood volume from inside bleeding
Technique
First aid : pelvic wrap
(This is wrapped circumferentially around the pelvis)
Next : Ex fix/ C clamp

54. Haemodynamic Status Options for immediate hemorrhage control
Military antishock trousers (MAST): Typically applied in the field.
No impact on survival rate.
Severe complications reported (compartment syndrome, extremity loss)

55. Operative Management Posterior ring structure is important
Goal : restoration of anatomy and enough stability to maintain reduction during healing
Anterior ring fixation may provide structural protection of posterior fixation

56. Anterior Fixation of Pelvic

57. Posterior Fixation of Pelvic

58. Anterior external fixator:
In the acute phase many advocate external fixation as a temporary device to achieve stabilization of the fracture and a positive effect on haemorrhage.

59. External fixation 1. Advantages
It helps tamponade bleeding from bone edges .
Stabilizing the clots and the bone.
Could be done in 20 min.
2. Disadvantages
Can’t stop arterial bleeding. Delay the embolization for ongoing arterial hemorrhage.
Degrade the quality of CT and Angio.

60. Complications
Infection
Thromboembolism
Non-Union
Malunion

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

62. Imaging Plain films CT scans AP Inlet view / Outlet view
Judet view (oblique)
AP alone ~90% sensitive; combined w/ inlet / outlet views ~94% sensitive
Limited in ability to clearly delineate posterior injuries
Pelvic films are NOT necessary in pts with normal physical exam + GCS >13
At least one study shows clinical exam reliable in EtOH
Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5
CT scans
Evaluates extent of posterior injury better
Superior imaging of sacrum and acetabulum
More detailed info about associated injuries

63. EtOh levels up to 104 mmol/l, most were > 21.7
Prospective study of 2176 consecutive blunt trauma pts of which 4.5% had pelvic #’s
AP plevis alone missed more injuries than clinical exam even in intoxicated pts
On the other hand, plain films can help to predict bleeding complications and should be done if pelvis is suspected to be busted as the first step in the work up

64. Inlet & Outlet Views Inlet view
X-ray beam at 60o to plate directed towards feet
Used to look for vertical & horizontal fracture displacement, and SI widening
Outlet view
Beam aimed 30o towards head
Used to look at sacral fractures & SI disruption

65. Imaging
What you really want to know is if there has been damage to the posterior 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
Significant displacement of anterior arch fracture
Sacral avulsion (sacrotuberous ligament)
Ist 2 always denote mechanical instability

67. 6 lines of the pelvis:
1. Iliopubic (arcuate) line – disruption indicates ant column injury
2. Ilioischial line which defines the posterior column
3. Teardrop or Roentgenographic U formed by roof of acetabaulum and ilioischial spine defines quadrangular plate – disruption means intraplevic penetration
4. Roof of acetabulum
5. Post rim of acetabulum
6. Ant rim of acetabulum
7. Shenton’s line = medial femoral shaft  obturator foramen: disruption in hip dislocation or femoral neck #’s

69. Pelvic Fracture Complications
Early complications
Delayed complications

70. Hemorrhage The most dangerous & life threatening condition
( hypovolemic shock )
Sources :
Retroperitoneal
(Bone-Small & Large vessels )
Multiple trauma
(Chest-Abdomen- Long bone fractures)

71. • Evaluating Pelvic Hemorrhage (EPH) Study – 724 consecutive pelvic fractures at Harborview • 62 % male • Average age = 34 • Mechanism – Motor vehicle crash 57% – Car versus pedestrian 21% – Fall (>3.3 meters) 11% – Crush 5%

72. • Hemodynamic shock in Emergency Dept.
– Blood pressure< %
– Pulse> %
– Transfuse in ED %
• Blood requirement
– Any %
– 6 or more units %
– Range (0 to 171 units)
• Death %

73. Sign & Symptom Back pain Abdominal pain Swelling & Echymosis
(Flank – Buttock – Inguinal – Perineum )
Hypotension & Shock

74. X-ray :
Soft tissue shadow displacement
(Int.obturator, Iliopsoas, Gluteal Fat pad
Bladder , Uterus)
CT scan :
Hematoma
Angigraphy :

75. Fracture Type
APC (anterior posterior compression) & VS (vertical shear) ( high risk)
Artery & Vein Inj.
Iliac – Iliolumbar – Sup.Gluteal –
Internal Pudental.
LC (rare)
Fx site – Visceral Inj.
Stable Fx (very rare)

76. Treatment Transfusion Pelvic belt Antishock garment
Reduction & Fixation
Angiographic embolization

77. Thromboembolism Pelvic bone trauma & Immobilization
Ipsilateral or contralateral
Calf – Thigh – Pelvic veins
Proximal thrombosis has Greatest risk of embolism

78. Increased risk of DVT
Older age Spinal cord Inj. Lower extremity Inj. History of DVT

79. Rate MR Venography 35% Thrombosis Contrast Venography 29%
Dopler Sonography %
Pulmonary Embolism – 12%
Fatal Pulmonary Embo – 10%

80. Prophylaxy Routin prophylaxis is mandatory Method is controversial
Drug : Aspirin – Warfarin
Low dose Heparin
Low M.W.Heparin
Mechanical devices :
Compresion stocking
Foot pump
Compresion device thigh & leg
Vena cava filter

81. Fat Embolism Gasterointestinal Inj. Open fracture
Deep pelvic infection
Retroperitoneal absces
Peritonitis
High mortality rate

82. Gasterointestinal Inj.
Wound in perineum
Blood in rectum
More proximal Injury (Contrast CTscan)
Direct Inj. (Bone fragment)
Indirect Inj. (Ext.Rot. Streching)

83. Summary Pelvic fracture  High morbidity and mortality
Multiple trauma  Team work (ATLS Approach)
Check stability (Mechanic and Haemodynamic)
Early immobilization  Pelvic Wrap
Diagnostic tools
Definitive treatment