Pelvic Fractures

Definition

Western Health Orthopaedic Registrar presenation -
Fractures of the Pelvis and Acetabulum by Dr Peter Moore


Incidence

Aetiology

Anatomy

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

Tile Classification

Tile Classification of Pelvic Fractures
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

By Type

Treatment of Pelvic Fractures according to Tile Classification
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)
  • 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
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