Pelvic Fractures

• Pelvic fractures in adult are either stable fractures resulting from low-energy trauma, such as falls in elderly patients, or fractures caused by high-energy trauma that result in significant morbidity and mortality.
• Mortality rate is 15% for closed fractures, and 50% for open pelvic fractures.
• Early mortality most commonly results from hemorrhage or closed-head injury.
• Late mortality occurs from sepsis or multiple system organ failure.

Risk factors for increased mortality

• Risk factors for increased mortality in pelvic fractures include:
  1. Patient’s age
  2. injury severity score
  3. Associated head or visceral injury
  4. Blood loss
  5. Hypotension
  6. Coagulopathy
  7. Unstable or open pelvic fractures.

Potential complications of high-energy pelvic fractures:

1. Injuries to the major vessels and nerves of the pelvis.
2. Injuries to the major viscera, such as the intestines, the bladder, and the urethra.
3. Avulsion injuries to the surrounding soft tissues.

Anatomy of the pelvis

1. Bones:
   • The pelvis is composed anteriorly of the ring of the pubic and ischial rami connected with the symphysis pubis. A fibrocartilaginous disc separates the two pubic bodies.
   • Posteriorly, the sacrum and the ilium bones are joined at the sacroiliac joint on each side.
2. Ligaments:
   • Symphyseal ligaments:
     • Resist external rotation.
   • Pelvic floor: consists of the:
     1. Sacrospinous ligaments:
        • Resist external rotation.
     2. Sacro-tuberous ligaments:
        • Resist shear and flexion.
   • Posterior sacroiliac complex (posterior tension band):
     • The Strongest ligaments in the body:
       • More important than anterior structures for pelvic ring stability.
     • Anterior sacroiliac ligaments:
       • Resist external rotation after failure of pelvic floor and anterior structures.
     • Interosseous sacroiliac:
       • Resist anterior-posterior translation of pelvis.
     • Posterior sacroiliac:
       • Resist cephalad-caudad displacement of pelvis.
     • Iliolumbar:
       • Resist rotation and augment posterior SI ligaments.

Classification

Tile Classification of Pelvic fractures:

Young-Burgess Classification:

1. Anterior Posterior Compression (APC):
   • APC-I:
     • Symphysis widening < 2.5 cm.
   • APC-II:
     • Symphysis widening > 2.5 cm.
     • Anterior SI joint diastasis.
     • Posterior SI ligaments intact.
     • Disruption of sacrospinous and sacro-tuberous ligaments.
   • APC-III:
     • Disruption of anterior and posterior SI ligaments (SI dislocation).
     • Disruption of sacrospinous and sacro-tuberous ligaments.
     • APCIII associated with vascular injury.
2. Lateral Compression (LC):
   • LC-I:
     • Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture.
   • LC-II:
     • Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture).
   • LC-III:
     • Ipsilateral lateral compression and contralateral APC (windswept pelvis).
     • Common mechanism is rollover vehicle accident or pedestrian vs auto.
3. Vertical Shear:
   • Posterior and superior directed force.
   • Associated with the highest risk of hypovolemic shock (63%).
   • Mortality rate up to 25%.

Clinical Evaluation:

1. Hemodynamic status:
   • Hemorrhage is a leading cause of death.
   • There are three main sources for hemorrhage resulting from pelvic fractures: vascular, osseous, and visceral.
2. Neurologic examination:
   • The lumbosacral trunk and sciatic nerve are at risk with fractures and dislocations of the sacrum and sacroiliac joint.
   • The femoral nerve is less commonly injured.
   • Pelvic fractures can also injure the pudendal nerve.
3. Gastrointestinal injury:
   • Required abdominal and rectal examination.
4. Genitourinary injury:
   • If blood is present at the urethral meatus, a retrograde urethrogram should be performed.
   • Bladder injuries are common with pelvic fractures and should be looked for on CT scan or cytogram.

Radiographic evaluation:

• Anteroposterior pelvis.
• Inlet view: evaluate anteroposterior displacement of sacroiliac joint and internal/external rotational deformity.
• Outlet view: evaluate vertical displacement of sacroiliac joint and flexion of hemipelvis.
• CT: particularly useful to evaluate posterior pelvic injury patterns.

Treatment

Initial Treatment:

• Control hemorrhage and provisionally stabilize pelvic ring.
  • 85% of bleeding due to venous injury, only 15% arterial source.
• Volume resuscitation and early blood transfusion.
• Pelvic binder, wrapped sheet or external fixation.
• Angiographic embolization.

Nonoperative Treatment:

• Indicated for stable pelvic fractures:
  • Weight bearing as tolerated for isolated anterior injuries.
  • Protected weight bearing for ipsilateral anterior and posterior ring injuries.

Operative treatment:

• Indications:
  1. Symphysis diastasis greater than 2.5 cm.
  2. Anterior and posterior sacroiliac ligament disruption.
  3. Vertical instability of posterior hemipelvis.
  4. Sacral fracture with displacement greater than 1 cm.
  5. Open fractures.

• Anterior injuries:
  1. ORIF with plate fixation.
  2. External fixation.
• Posterior injuries:
  1. Percutaneous iliosacral screw fixation.
  2. Anterior plate fixation across the sacroiliac joint.
  3. Posterior transiliac sacral bars or sacral plating.
  4. Spinal-pelvic fixation considered for bilateral sacral fractures.

• Vertically unstable patterns with anterior and posterior dislocations:
  1. Anterior ring internal fixation and percutaneous sacroiliac screw has been shown to be most stable fixation construct.
  2. Spinal-pelvic fixation may also be considered.

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Donald Shelby

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