Definition
Western Health Orthopaedic Registrar presentation – Fractures of the Pelvis and Acetabulum by Dr Peter Moore
Incidence
Aetiology
- Pelvic ring injuries are caused by high energy trauma. e.g. MVA, fall from height etc.
- This fact mandates a multidisciplinary approach, treating a polytrauma patient, with associated injuries:
- 50% long bone fracture.
- 25% spine injury
- 63% chest injury
- 40% head injury
- 18% intestinal injury
- 6-15% urethral/bladder injury
- Special attention had been given lately to elderly insufficiency fractures of the pelvic ring (see Rommens classification)
Anatomy
The pelvic ring is a strong bony-ligamentous construct, with several functions:
- Transferring loads from the spine and torso to the lower extremities
- Providing an origin for the pelvic girdle musculature
- Providing a rigid protection for the pelvic viscera
The bony elements comprise:
- Two innominate bones, which are the fusion of:
- Ilium
- Pubis
- Ischium
- The Sacrum
The ligamentous elements, providing rotational and vertical stability, comprise:
- The anterior, posterior and interosseous Sacro-Iliac ligaments, which is the strongest ligamentous construct in the body
- The Sacrospinous ligament
- The Sacrotuberous ligament
- The Pubic symphysis
Classification
Apley Classification
1. Avulsions
- Due to violent muscle action
- Sartorius from ASIS
- Rectus femoris from AIIS
- Adductor longus from pubis
- Hamstrings form ischial tuberosity
- Treatment
- rest and reassurance
2. Ring fractures
- Stable fractures
- symptomatic treatment
- Disruption of posterior structures
- 4 – 6 weeks RIB
- Unstable fractures
- Four poster
- Open book
- Malgaine type
- Direct fractures of the iliac wing
- bed rest
- Stress fractures of the pubis / pubic rami
- osteoporotic patients
3. Acetabular fractures
- Anterior pillar (not WB part of joint)
- Posterior pillar (often associated with dislocation of hip and involves WB part of joint)
- Transverse
- Comminuted both column type (difficult to reduce and degenerative changes common)
4. Sacral / coccygeal fractures
Young & Burgeuss Classification
- Mechanism-based
- Provides prognostic value
- predicts associated injuries
- Predicts blood product consumption
Tile Classification
| Type | Description |
|---|---|
| A | Stable |
| A1 | Fracture not involving the ring . avulsion fracture of ASIS,AIIS or ischium . fracture of iliac wing |
| A2 | Stable minimally displaced ring fractures |
| B | Rotationally unstable / Vertically stable |
| B1 | Open book (external rotation) . Stage . separation of the symphysis < 2.5 cm . implies no post lesion . separation of symphysis > 2.5 cm . unilateral . separation of symphysis > 2.5 cm . bilateral implies disruption of sacrospinous + anterior sacroiliac ligaments |
| B2 | Lateral compression (internal rotation) . B 2.1 Ipsilateral anterior and posterior injuries . B 2.2 Contralateral (bucket-handle) injuries |
| B3 | Lateral compression (contra-lateral posterior and anterior fractures= bucket handle) . the rotation of the bucket handle can cause gross pelvic deformity or significant LLD . External fixation ® definitive treatment, to aid or maintain reduction |
| C | Rotationally and vertically unstable |
| C1 | Unilateral . C 1.1 Iliac Fracture . C 1.2 Sacroiliac Fracture-dislocation . C 1.3 Sacral Fracture |
| C2 | Bilateral |
| C3 | Associated with acetabular fractures |
Pathology
History
Examination
Primary and Secondary ATLS | EMST survey
Look
- Destots sign
- blood above inguinal ligament or in scrotum
- Roux’s sign
- decrease distance from greater trochanter to pubic tubercle
- Associated injuries
- bladder, urethra, spine, femurs
Feel
- Hip compression | springing
- Earle’s sign
- tender swelling on PR
Investigations
Xrays
- Standard AP
- Inlet view
- tilt X-Ray beam 40° caudad
- shows posterior displacement
- Outlet view
- 40° cranial beam
- shows superior migration or rotation
CT scan and reconstructions
- plan surgical approach
Angiography
- embolisation of bleeding vessels
Treatment
Resuscitation
- fluid replacement
- antishock garment
- embolisation
- direct surgical intervention
- application of Ex Fix can reduce venous and bony bleeding
Provisional stabilisation
- for fractures that increase pelvic volume
- ie open book (B1) or vertical shear (C3)
- apply ex fix or pelvic clamp percutaneously in emergency room
- External fixation
- 2 pins placed percutaneously in Ileum
- 1 at ASIS,
- 1 at iliac tubercle,
- at ~ 45° to each other
- complete frame as anterior rectangle
- 2 pins placed percutaneously in Ileum
By Type
| Type | Treatment |
|---|---|
| A | symptomatic, mobilisation |
| B1 | Stage 1 . no stabilisation Stage 2+3 . stabilise with External fixateur or anterior plate |
| B2 | most need no stabilisation |
| B3 | displaced bucket handle if LLD less than 1.5 cm . accept . if LLD more than 1.5 cm or pelvic deformity excessive . reduction by ER of hemipelvis with pins in the iliac crest . maintained with anterior frame |
| C | Anterior frame and skeletal traction (supracondylar femoral pin) . ORIF |
Complications
- Non-union / malunion
- Infection
- increased incidence associated with open bowel injury
- 6% incidence
- increased with ilio-inguinal approach
- avoid operations in febrile patients
- use prophylactic antibiotics
- Nerve palsy
- usually peroneal component of sciatic nerve
- 11.2% (17.4% of posterior fractures)
- usually peroneal component of sciatic nerve
- Ectopic bone formation
- ~ 20%
- Thrombo-embolic problems
- urethral injury
- About 1/3 of unstable fractures (13% overall)
- Impotence
- ~ 40%
- Post traumatic osteoarthritis
- 4 – 15% dependant on quality of reduction
Prognosis
- Mortality
- Overall 5 – 20%
- Open fractures up to 42%
- Increasing age
- increased mortality
- Age more than 70 years
- 50% mortality
- Pedestrians
- 50% mortality
- Pregnancy
- 33% foetal loss
- 20 – 40% of females subsequently need caesarean section