1. Pelvis fracture

5. . iliac crest anterior superior iliac spine
anterior inferior iliac spine
acetabulum
obturator foramen
ischiopubic ramus
pubic tubercle
pectineal line of the pubis
pubic crest
pubic symphysis
pelvic brim (separates the true from the false pelvis)
iliac fossa
sacral promontory
sacrum
anterior sacral foramen
ala of sacrum
coccyx
ischial spine
pelvic brim extends from promontory of the sacrum, arcuate line of the ilium, pectineal line (pectin of pubis) and pubic crest
Greater (false ) pelvis is located above the pelvic brim and the lesser ( true ) pelvis below the brim.

6. Pelvic ring stability Provided by: Iliolumbar ligs.
Dorsal sacroiliac ligaments
Sacrotuberous ligs
Ventral sacroiliac ligs.
Sacrospinous ligs

7. Stability of the pelvic
Depends on both bony and ligamentous structures
Anterior portion of the pelvic ring neither participates in normal weight bearing nor it is essential for maintenance of pelvic stability .
Weight bearing portion : SI joints and ilia
Posteriorsuperior SI ligaments provide most of the ligamentous stability of the SI joints

8. .
HOW SOON SHOULD A PATIENT WITH A FRACTURED PELVIS BEAR WEIGHT? His weight is transmitted from his spine to his sacrum, then through his acetabulae to his femora. If this weight bearing column is fractured, he should be in bed for at least 3 weeks, and not bear weight until 6 weeks. But if the weight bearing parts of his pelvis are intact, he can start weight bearing in a few days, if his other injuries allow it

9. Stable pelvic fracture
# do not involve the pelvic ring and they are minimally displaced
Unstable pelvic # :
Involve the pelvic ring and are widely displaced

10. History
Due to high – velocity trauma following a RTA or due to fall from a height :
RTA %
Fall %
Compression # rest
Mechanism of injury :
Lateral compression ( between two cars ) ----cause stable or unstable #
Anteroposterior compression ( car above the body ) ----cause stable or unstable #
Vertical forces ( fall from height ) cause unstable #
Inferior forces ( fall on buttocks ) cause unstable #

11. Lateral Compression (LC): unilateral pubic rami fractures, with or without symphysis injury, and bilateral rami fractures, with or without pubic symphysis injury.         
Young and Burgess system
LC1   
unilateral ramii & ipsilat sacral compression.   
lateral force compressing sacrum   
usually stable 
Tx : -   protected weight bearing on the side of the posterior ring injury. Repeat x-rays 2- 5 days after injury 

12. LC2 unilateral ramii & ipsilat post. iliac #
lateral force compressing ilium   
usually stable
 Tx : --  anterior and posterior fixation

13. LC3 LC I/II & contralat. APC
 trapped between an unyielding object / rollover   
 unstable
 Tx  : -- anterior and posterior fixation  

14. AP Compression (APC) : - direct anterior force
symphysis <2cm & ant. SI lig. stretched   
low- to moderate-energy forces (sports)     
Stable  
Tx : --   symptomatic management only

15. AP2  
   symphysis >2cm & ant. SI lig. torn (+ the ligaments of the floor of the pelvis - sacrotuberous and sacrospinous)   
High energy - 'Open book'   
Unstable 
Tx : --   anterior reduction and stabilisation (ORIF)

16. AP3 Symphysis & ant & post SI lig. torn
High energy - pelvis rotates externally    
Very Unstable
  Tx : --   control haemorrhage by fracture reduction and stabilisation with external fixation.
Posterior percutaneous iliosacral screws, either acutely or on a delayed basis depending on the patient's physiologic status

17. Vertical Shear (VS) : - fall from height
    Ant & post vertical displacement.   
fall from a height with vertical forces   
Unstable 
Tx : --  depends on the posterior fracture location.
Reduction with traction, percutaneous iliosacral screw fixation, and anterior stabilization (ORIF or external fixation).

18. Combined Mechanical (CM)
    combination of other injuries.   
Mechanism of injury: - combination   
Unstable
Book’s fractures : -
Whole pelvis opens out like a book.

19. Key and conwell`s classification
# of individual bones without a break in the pelvic ring :
Avulsion # of the :
Anterosuperior iliac spine
Anteroinferior iliac spine
Ischial tuberosity
# of pubis
# wing of ilium
# sacrum
# or dislocation of coccyx

20. Cont … Single break in the pelvic ring :
# of both ipsilateral rami
# near or subluxation of symphysis pubis
# near or subluxation of sacroiliac joints
Double breaks in the pelvic ring :
Double vertical # or dislocation of pubis ( straddle # )
Double vertical # or dislocation of pelvis ( malgaigne`s # )
Acetabulum # :
Undisplaced
displaced

21. Avulsion Fractures of the Pelvis - occurs when a tendon that attaches a muscle to a bone pulls part of the bone away.

22. Tile’s Classification
TYPE A - Stable A1—Fractures of the pelvis not involving the ring A2—Stable, minimally displaced fractures of the ring
TYPE B - Rotationally unstable, vertically stable B1—Open book B2—Lateral compression: ipsilateral B3—Lateral compression: contralateral (bucket-handle)
TYPE C - Rotationally and vertically unstable C1—Rotationally and vertically unstable C2—Bilateral C3—Associated with an acetabular fracture

23. Investigation AP view of the chest, Lateral view of the cervical spine
Oblique view c oblique projection
Internal and external rotation view
Inlet and outlet view
AP view of the pelvis : -
Anterior lesions
pubic rami fractures and symphysis displacement
Sacroiliac joint and sacral fractures
Iliac fractures
L5 transverse process fractures
Computed tomography:
for assessing the posterior pelvis, including the sacrum and sacroiliac joints.
Magnetic resonance imaging:
critically injured patient,
provide superior imaging of genitourinary and pelvic vascular structures.

24. Cont…
Outlet View
Inlet View of the Pelvis

25. AP view - Inlet and Outlet

26. Pelvic X-ray Interpretation1

27. Clinical features Symptoms : - History of high velocity trauma
Hypovolaemic shock :
Pale look , cold nose , sweating , tachycardia , hypotension , cold and clammy , unconsciousness
Features of intra – abdominal injuries and
Features of genitourinary injuries

28. Milch signs
Destot`s sign large haematoma above inguinal ligament or scrotum
Roux`s sign distance from greater trochanter to pubic spine is increased on the affected side
Earle`s sign on per rectal examination , the bony prominence or a large haematoma can be palpated

29. Clinical tests Compression test :
When a compression force is applied through the two iliac bones patient complains of pain in pelvic #

30. Cont .. Distraction test :
When a disraction force is applied to the two iliac bones at the anterosuperior iliac spine patient complains of pain in pelvic #
Direct pressure test :
Direct pressure over the symphysis pubis elicits pain

31. Pelvis assessment Pelvis assessment posterior pressure
Pelvis assessment medial pressure

32. Pelvis assessment Pelvis assessment pubis symphysis
Pelvic stabilization sheet wrap

33. Management Stable # --------- nonoperative teatment
Unstable Reduction and stabilisation by external fixators or internal fixation
Resuscitation and correction of hypovolaemic shock ( multiple # and multiple system injuries )
Proposed by Mc Murthy ( poly trauma case ) : -
A : airway management
B : blood and fluid replacement
C : CNS management
D : digestive system management
E : excretory system management
F : fracture management

34. Treatment methods Resuscitation ( stabilize the patient )
Blood transfusion and other medical and surgical emergency measures
Avulsion fractures :
Conservative treatment like , bed rest , traction , physiotherapy ( rarely need surgery )
Undisplaced fractures :
NSAIDs , bed rest , traction , pelvic sling
pelvic sling

35. Displaced fractures Reduction : Retention : by lateral compression
Spica cast
Sling
External fixation

36. Role of external and internal fixators
# associated with multiple system injuries need to be stabilised either by external fixators or by open reduction and internal fixation ( ORIF )
Advantages :
Gives firm stability
Helps early mobilisation
Reduces period of bed rest
Helps early control of osseous bleeding

37. Complications Urological complications — common
• Intraperitoneal rupture of the bladder
• Extraperitoneal rupture of the bladder
• Rupture of the membranous urethra
• Rupture of the penile urethra.
Neurological complications :
10% incidence
often missed
avulsion of lumbar nerve roots
superior gluteal nerve
obturator nerve
sciatic nerve
pudendal nerve

38. Vascular complications
• Major vessel damage
• Massive haemorrhage from retropelvic vessels
Intestinal complications
• Paralytic ileus — common
• Small intestinal damage — uncommon
• Large intestine and rectal damage — uncommon.
Other complications
• Damage to liver, spleen and pancreas
• Damage to the heart, lungs and great vessels
• Damage to the spinal cord, brain and limbs.