0. Pelvic Ring Injuries: Stability and Reduction Techniques
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Pelvic Ring Injuries: Stability and Reduction Techniques V4

1. Pelvic Ring Injuries Classification of Pelvic Ring Injuries
Young-Burgess
Based upon mechanism of injury
Tile
Based upon stability of pattern

2. Pelvic Ring Injuries Young-Burgess Lateral Compression (LC 1-3)
Anterior-Posterior Compression (APC 1-3)
Vertical Shear (VS)
Combined Mechanism of Injury (CMI)

3. Pelvic Ring Injuries Tile Type A: Stable
A1: Not involving ring
A2: Minimally displaced ring fracture
A3: Transverse fractures of sacrum/coccyx
Type B: Partially stable (rotationally unstable, vertically and posteriorly stable)
B1: External rotation instability, open book
B2: Internal rotation instability, lateral compression
B3: Bilateral rotational instability
Type C: Unstable (rotationally, vertically and posteriorly unstable)
C1: Unilateral injury
C2: Bilateral injury, one side rotationally unstable one side vertically unstable
C3: Bilateral injury, both sides completely unstable

4. Pelvic Ring Injuries Young-Burgess Widely utilized
Characteristic fracture patterns can be visualized based on classification
Inter-observer variability
Wide variations in stability and need for surgery within single level of classification (LC-1, LC-2, APC-2)

5. Pelvic Ring Injuries Tile
May be more helpful determining need for surgery (front, back, front & back) based upon classification
Difficult to visualize fracture pattern based upon classification

6. Pelvic Ring Injuries Treatment in many cases controversial
Important to understand that there are fractures that could be classified as ANY of the Young-Burgess or Tile types for which surgical treatment may be indicated
Since Tile classification is based upon stability, may be less susceptible to confusion
Controversy still exists regarding indications for surgery in certain fracture patterns

7. Pelvic Ring Injuries
LC-1

8. Pelvic Ring Injuries
LC-1

9. Pelvic Ring Injuries
LC-2

10. Pelvic Ring Injuries
LC-2
Crescent fracture

11. Pelvic Ring Injuries
LC-3

12. Pelvic Ring Injuries
LC-3

13. Pelvic Ring Injuries
APC-1
Floor ligaments stretched, not torn

14. Pelvic Ring Injuries APC-2
Floor ligaments and anterior SI ligaments disrupted

15. Pelvic Ring Injuries SI involvement may be subtle, even on CT APC-2
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Pelvic Ring Injuries
SI involvement may be subtle, even on CT
APC-2 V4

16. Pelvic Ring Injuries
APC-2
Neutral
IR stress
ER stress

17. Pelvic Ring Injuries
APC-3: Complete iliosacral dissociation

18. Pelvic Ring Injuries
APC-3

19. Pelvic Ring Injuries
Vertical shear

20. Pelvic Ring Injuries
Vertical shear

21. Pelvic Ring Injuries

22. Pelvic Ring Injuries: Surgical Indications
Posteriorly unstable fractures
Vertically unstable fractures
Rotationally unstable fractures
Which are these?
LC-3, APC-3, VS
Some LC-1
Some LC-2
Some CMI
? APC-2
Assessment of stability independent of Young-Burgess classification

23. Pelvic Ring Injuries: Surgical Indications
Example: “Bad” LC-1
Complete sacral fracture
Internal rotation deformity
Potential for vertical instability

24. Pelvic Ring Injuries: Surgical Indications
“Bad” LC-1

25. Pelvic Ring Injuries: Surgical Indications
“Bad” LC-1

26. Pelvic Ring Injuries: Surgical Indications
Intermediate LC-1: Complete sacral fracture, minimal rotational deformity, ? Risk of vertical migration

27. Pelvic Ring Injuries: Surgical Indications

28. Pelvic Ring Injuries: Surgical Indications
“Bad” LC-2: Rotationally and vertically unstable, almost but not quite involving the acetabulum

29. Pelvic Ring Injuries: Surgical Indications
“Bad” LC-2

30. Pelvic Ring Injuries: Surgical Indications
APC-2
Treatment may be controversial
Identical injury may be treated with symphyseal plating only, symphyseal plating plus iliosacral screw, or nothing
More dependent upon surgeon than injury
No good data to direct treatment

31. Pelvic Ring Injuries: Reduction
Stable Injuries
Generally non- or minimally-displaced
Reduction not usually an issue
Intermediate and “bad” LC-1 fractures?
Correction of internal rotation deformity
May not be necessary depending upon degre
Closed reduction, external fixation adequate

32. Pelvic Ring Injuries: Reduction
Unstable Injuries
Displaced
Rotationally
Vertically
Both
Anteriorly
Posteriorly

33. Pelvic Ring Injuries: Reduction
Open
Closed
Combination
Determined by degree of displacement/instablilty

34. Pelvic Ring Injuries: Reduction
Early traction and/or binder!
Very important, if indicated
Can reduce need for open reduction at time of definitive fixation
Patients with pelvic ring injuries often sick
Definitive fixation delayed
If left significantly displaced for even a few days, open reduction may become necessary

35. Pelvic Ring Injuries: Reduction
Anterior injuries
Sympyseal disruption
Pfannenstiel incision
May be approached via standard midline as well
Placement of tenaculum on pubic tubercles
Use of pelvic reduction clamp attached to screws may be necessary
Allows for correction of rotational deformity as well as diastasis

36. Pelvic Ring Injuries: Reduction
Anterior injuries
Anterior reduction aids posterior reduction
Usually address symphysis first with reduction, +/- instrumentation
Address SI joint second, if necessary
Rami fractures
Often amenable to closed reduction and control with anterior external fixator
Intramedullary rami screws may also be effective
Difficult trajectory
? fixation

37. Pelvic Ring Injuries: Reduction
Anterior injuries
Rami fractures
Often amenable to closed reduction and control with anterior external fixator
Intramedullary rami screws may also be effective
Difficult trajectory
? fixation

38. Pelvic Ring Injuries: Reduction
Posterior Injuries
SI disruption
Closed reduction easiest if performed early
Massive displacement requires open reduction
May be approached anteriorly via lateral window or posteriorly via direct approach to SI joint
Posterior ilac fractures (crescent fractures)
Closed reduction if not widely displaced
Open reduction
Anterior via lateral window if fracture/dislocation of SI joint
Direct posterior approach via outer table

39. 45 yo Female, T-Bone MVA, Front Seat Passenger
Case Discussion
45 yo Female, T-Bone MVA, Front Seat Passenger
Currently Hemodynamically Stable
Pelvic Deformity
Grossly Unstable Pelvic Ring Injury
Left Foot Insensate And 0/5 Motor Function

43. Post Injury Day # 4
Post-Injury Day 4