ORTHOPEDIC

Lec.11 Dr.Hasan
AbdulHadi.M

Injuries of the Pelvis

Pelvic fractures are common (5% of all fractures), particularly following road and industrial
accidents. The associated soft tissue injuries are usually more serious than the fractures
themselves because they frequently complicated by damage to the soft tissue e.g. urethra,
bladder, arteries & nerves & this can be fatal (figure 21-1). About 15% of fractures of the pelvis
associated with visceral injuries with mortality about 10%. The causes are:
• 60% from traffic accident.
• 30% from falls.
• 10% from crush injuries, athletic injuries.

Figure 21-1: Anatomy of the pelvis

Anatomy:
The unique anatomy of the pelvis presents a challenge in management when it is disrupted. The
pelvis is a ring structure of three bones: two innominate bones and, posteriorly, the sacrum. They
are joined by dense, strong ligamentous structures. Each innominate bone is formed from three
bones: ilium, ischium, and pubis, together circumscribing the acetabulum. The juncture between
the two innominate bones anteriorly is called the symphysis pubis (the anterior or pubic bridge),
and posteriorly there are two sacroiliac joints surrounded by dense sacroiliac ligaments (posterior
or sacroiliac bridge) to form a ring-like structure which transmits weight from the trunk to the LL &
provide protection for pelvic viscera, vessels & nerves.
The stability of the pelvic ring depends upon the rigidity of the bony parts & the integrity of the
strong ligaments that bind the 3 segments together the strongest & most important ligament are
the sacroiliac & iliolumbar ligaments & these are supplemented by the sacrotuberous and
sacrospinous ligaments & ligaments of symphysis pubis.
• Stable injury: if disruption occurs in one bridge (ant or post).
• Unstable injury: if disruption occurs in both bridges (ant & post).
1. Rotationally unstable & Vertically stable: if the long posterior sacroiliac &
sacrotuberous ligament intact.
2. Rotationally unstable & Vertically unstable: if these ligaments torn.

1
Classification
Classification systems based on the anatomic location of the injury, mechanism of injury, or
stability of the pelvic ring is used to classify pelvic injuries. These classification systems are
usually used together. The anatomic classification system helps to identify all of the injured bony
and ligamentous structures. The mechanism of injury system aids in fracture pattern recognition
and assists in the early resuscitation and treatment of the patient. Determining the stability of the
pelvic ring can help in the selection of the most appropriate definitive fixation for the injury.
So there are several classification systems for pelvic fractures. The most frequently used system
proposed by Tile (figure 21-2).
Tile Classification
Type A: Stable
• Type A1: Fractures of the pelvis not involving the ring; avulsion injuries
• Type A2: Stable, minimally displaced fractures of the ring
Type B: Rotationally unstable, vertically stable.
• Type B1: Open-book
• Type B2: Lateral compression; ipsilateral
• Type B3: Lateral compression; contralateral (bucket handle)
Type C: Rotationally and vertically unstable.
• Type C1: Unilateral.
• Type C2: Bilateral; one side rotationally unstable, with contralateral side vertically Unstable.
• Type C3: Associated acetabular fracture.

2
 Figure 21-2: Tile Classification

Types of pelvic Fractures:

1. Isolated fractures with intact pelvic ring.
2. Fractures of the pelvic ring.
3. Fractures of the acetabulum.
4. Sacrococcygeal fractures.

Isolated Fractures:
1. Avulsion fracture: a piece of bone is pulled off by
violent muscle contraction this usually seen in
athletes e.g. the Sartorius pulls off the anterior
superior iliac spine. Treatment by rest,
reassurance & analgesia (figure 21-3).
2. Direct fracture: direct blow to the pelvis (FFH)
may fracture the ischium or the iliac blade. Bed
rest until pain subsides all that is needed.
3. Stress fracture: Fractures of the pubic rami are
common in severely osteoporotic or osteomalacic
patient & often quite painless.

Figure 21-3: Pelvic avulsion fractures

Fractures of the Pelvic Ring:

Because of the rigidity of adult pelvis, a break of one point in the ring must be accompanied by
disruption at a second point; exceptions are comminuted fracture due to direct blows, & ring
fracture in children.
Mechanisms of injury:young bugress classification..
1. Antero-posterior compression: caused by a frontal collision between a car & a
pedestrian. The pubic rami are fracture or the innominate bones are sprung a part and
externally rotated with disruption of the symphysis the so called open-book fracture. A small
separation at the symphysis (< 2cm) suggests a stable injury; larger separation will indicate
instability & the need for urgent fixation.

3
 2. Lateral compression: side-to-side compression of the pelvis causes thke ring to buckle &
break. This due to a side on impact in a road accident or a fall from a height (FFH).
Anteriorly the pubic rami on one or both sides are fracture & posteriorly there is a severe
sacroiliac strain or a fracture of the ilium or sacrum. If the sacroiliac injury is much
displaced, the pelvis is unstable.

3. Vertical Shear: the innominate bone on one side is displaced vertically fracturing the pubic
rami & disrupting the sacroiliac region on the same side. This occurs typically when some
one falls from a height on to one leg. These unstable injuries associated with gross tearing
of the tissues & retroperitoneal hemorrhage.

4. Combination injuries: combination of above lead to severe pelvic injuries.

Clinical Features:
With isolated fracture & stable injuries the patient is not severely shocked but has pain on
attempting to walk. There is localized tenderness but seldom any damage to pelvic viscera. With
unstable injuries the patient is severely shocked, in great pain & unable to pass urine. There may
be blood at the external meatus. Tenderness is widespread & attempting to move the ilium is very
painful by pressure from side to side on the iliac crests, then outward on the anterior superior iliac
spines & then directly on the symphysis. One leg may be partly anesthetic because of sciatic
nerve injury. These are extremely serious injuries, carrying a high risk of associated visceral
damage.
X-Ray: include AP, inlet view, outlet view & 2 oblique views (figure 21-4).

4
 Figure 21-4: X-ray views for fractured pelvis
Early Management:
Treatment should not a wait full & detailed diagnosis, with any severely injured patient the first
step is to make sure that the airway is clear & ventilation is unimpaired. Resuscitation must be
started immediately and active bleeding controlled. The patient is rapidly examined for multiple
injuries & painful fracture is splinted. A single AP x-ray of the pelvis is obtained.
A more careful examination is then carried out paying attention to the pelvis, abdomen, perineum
& the rectum. The urethral meatus is inspected for bleeding. The lower limbs are examined for
signs of nerve injuries. If there is an unstable fracture of the pelvis, hemorrhage will be reduced by
rapidly applying a compression belt or external fixator.
Urological injuries occur in 10% & patient who cannot pass urine must not be catheterized, gentle
retrograde urethrography may show the tear & urinary drainage should be provided by suprapubic
cystostomy.
Treatment of the fracture:
1. Undisplaced fracture------- bed rest with LL skin traction for 4wk.
2. Anterior disruptions without sacroiliac displacement------- open-book fracture with gap <2cm
need Hammock traction for 6wk (to close the book). If >2cm -----external fixator 8 – 12wk
(patient can walk).
3. Displaced fracture with sacroiliac (SIJ) disruption ---- 2 options:
• Anterior external fixator + posterior screws across the SIJ.
• Anterior plating of symphysis + posterior screws across SIJ.

Figure 21-5: Treatment of fractured pelvis

Complication:
1. Urogenital damage.
2. Nerve injury (sciatic N).
3. Persistent sacroiliac pain due to unstable fracture ------- Arthrodesis.

Fractures of the Acetabulum:

5
Mechanism of injuries:
The pathological anatomy of the fracture depends on the position of the femoral head at the
moment of impact (Fig. 21-6). The femoral head acts as a hammer against the acetabulum,
producing the injury. There are two basic mechanisms of injury: first, those caused by a direct
blow on the acetabulum and, second, the so-called dashboard injury, in which the flexed knee
joint strikes the dashboard of a motor vehicle, driving the femur posteriorly on the acetabulum. A
blow directly upon the greater trochanter usually causes a transverse-type acetabular fracture,
depending on the degree of abduction and rotation of the femoral head, whereas the dashboard
injury causes a posterior wall or posterior column fracture or fracture-dislocation of the hip joint.
In general, the externally rotated hip causes injuries to the anterior column, the internally rotated
hip to the posterior column; the abducted hip causes a low transverse fracture, the adducted hip a
high transverse fracture.

Fig. 21-6: The type of acetabular fracture will depend upon the position of the femoral head at the moment of impact. If externally rotated (striped
arrow), the anterior column will be involved; if internally rotated (red solid arrow), the posterior column will be involved.

Types of Acetabular Fractures:

1. Acetabular wall fracture: fracture of the anterior or posterior part of the acetabular rim
affects the depth of the socket & may lead to hip instability unless they are properly
reduced & fixed.
2. Anterior column fracture: the fracture runs through the anterior part of the acetabulum
separating a segment between the anterior inferior iliac spine & the obturator foramen. It is
uncommon, does not involve the weight bearing area & has a good prognosis.
3. Posterior column fracture: the fracture runs upward from the obturator foramen in to the
sciatic notch, separating the posterior ischiopubic column of bone & breaking the weight
bearing part of the acetabulum. It is usually associated posterior dislocation of the hip &
may injured the sciatic N. treatment is more urgent & involve internal fixation to obtain a
stable J.
4. Transverse fracture: it is un-comminuted fracture running transversely through the
acetabulum & separating the iliac portion above from the pubic & ischial portion below,
sometime there is a vertical split in to the obturator foramen (a T- fracture).
5. Complex fracture: include damage to various portion of the acetabulum including the roof &
the floor. The articular surface is badly disrupted & the fracture needs operative treatment
but this likely to be less than perfect (Figure 21-7).

6
 Figure 21-7: Types of Acetabular Fractures
Clinical Features:
The patient may be severely shocked & the complication associated with all pelvic fracture should
seek. Rectal examination is essential there may be bruising around the hip & the limb may lie in
internal rotation (if the hip is dislocated). No attempt should be made to move the hip. Careful
vascular & nerve examination is needed.
X-Ray: several view and best by CT scan (Figure 21-8).

Figure 21-8: X-ray of fractured acetabulum

CT scan: provides additional information, e.g. on bony fragments within the joint space, cartilage
fragments which can be inferred from joint space widening, & 3D reconstruction which can allow
removal of the femoral head from the picture to simplify things.

7
Treatment:
1. Initial management: consist of counteracting shock & reduce the dislocation. Traction is
then applied to the limb (10kg) & during the next 3 – 4day the patient general condition
brought under control.
2. Conservative treatment: used for undisplaced fracture &fracture which do not involve the
weight bearing surface (roof) ----- traction 6 – 8wk. if fracture displaced ---- combination of
longitudinal & lateral skeletal traction. If these fail do SURGERY.
3. Operative treatment: indicated for:
• All unstable hips & fracture resulting in significant distortion of the ball & socket
congruence.
• Associated fracture of the femoral head.
• Retained bone fragment in the joint.

8
 Figure 21-9: treatment of fractured acetabulum
Complication:
1. Nerve injury e.g. sciatic N.
2. Avascular necrosis of the femoral head needs Arthroplasty.
3. Heterotrophic ossification: due to severe soft tissue injuries & extended surgical dissection
need prophylactic Indomethacin.
4. Osteoarthritis: secondary OA is common late complication & especially if involve the weight
bearing surface.
5. Iliofemoral venous thrombosis.

Injuries of the Sacrum & coccyx:

A blow from behind or fall on to the buttock may fracture the sacrum or coccyx or sprain the joint
between them. If the fracture is markedly displaced reduction is worth attempting the lower
fragment may be pushed by a finger in the rectum. The reduction is stable; the patient is allowed
to resume normal activity but is advised to use a rubber ring cushion when sitting.
Persistent pain especially on sitting is common after coccygeal injuries. If the pain is not reduced
by the use of a cushion or by injection of local anaesthetic & steroid in the tender area, excision of
the coccyx may be considered.

Figure 21-10: Injuries of the Sacrum & coccyx

9
10