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A 7-year old boy presents to the emergency room following a ATV accident with complaints of left pelvic pain. In the emergency room he is alert and oriented and is hemodynamically stable. On physical exam he is unable to bear weight on his left lower extremity. There is no tenderness to palpation at the posterior pelvis. A radiograph is performed and shown in Figure A and CT examination shows the posterior ring is stable and age-appropriate. What is the most appropriate treatment for this injury pattern?
Nonoperative management with weight bearing as tolerated
Percutaneous sacroiliac screw
Pelvic external fixation
Anterior pelvic ring plating
Anterior and posterior pelvic ring plating
Select Answer to see Preferred Response
The clinical presentation is consistent for a mildly displaced parasymphyseal fracture in a pediatric patient with an open triradiate cartilage. Weight bearing as tolerated is the most appropriate treatment.
In skeletally immature pelvic ring fractures, the majority of cases can be treated nonoperatively. Open reduction and internal fixation is required for acetabular fractures with >2 mm of fracture displacement and for any intra-articular or triradiate cartilage fracture displacement >2 mm. External fixation is necessary for pelvic ring displacement of >2 cm to prevent limb-length discrepancies.
Holden et al. emphasize that children with open triradiate cartilage have different fracture patterns than do children whose triradiate cartilage has closed. They report because of the immaturity of the pelvis, the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption has a chance to occur. For this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment.
Spiguel et al. reviewed 2850 pediatric trauma admissions at their institution and reviewed cases with a pelvic ring fracture. They found that although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries is significant. They report while the majority of pelvic fractures in children are treated nonoperatively, more than one-half of these patients have concomitant injuries requiring operative management.
Figure A shows an inferior rami fracture in a pediatric patient with an open triradiate cartilage.
Answers 1,3,4,5: These treatment options are not appropriate in a stable pelvic ring fracture in a child with open triradiate cartilage.
Holden CP, Holman J, Herman MJ.
J Am Acad Orthop Surg. 2007 Mar;15(3):172-7. PMID: 17341674 (Link to Abstract)
Holden, JAAOS 2007
Spiguel L, Glynn L, Liu D, Statter M.
Am Surg. 2006 Jun;72(6):481-4. PMID: 16808198 (Link to Abstract)
HPI - High speed Motorbike injury. No loss of consciousness or head injury. Closed injury pelvis with 4 rib fractures on the right side and transverse process fracture of L4-5 vertebrae bilaterally. No chest or abdominal injury.No urogenital injury.
How do you treat? Please state your views and reasoning behind it.
Please rate question.
Average 3.0 of 36 Ratings
Which of the following is an appropriate initial step in the management of a multiply injured patient with an unstable pelvic ring fracture and hemodynamic instability?
Application of an external fixator
Application of a pelvic binder
Percutaneous Iliosacral screws
Patients with multiple injuries including a pelvic ring fracture who present with hemodynamic instability should have a pelvic binder or circumferential pelvic sheet placed as part of their initial resuscitation.
A systematic approach to search for sources of bleeding and control ongoing hemorrhage is necessary for patients who present with hemodynamic changes in the setting of a pelvic ring fracture. Management of continued hypotension after pelvic binder placement is controversial and varies among trauma centers.
Krieg et al. prospectively evaluated 16 patients with unstable pelvic ring injuries initially managed with a novel circumferential compression device. The authors found substantial reduction in pelvic width with the use of this compressive device in patients with volume expanding pelvic ring fractures.
Croce et al. retrospectively compared patients with unstable pelvic ring injuries who were treated with either emergent pelvic fixation (EPF) or a pelvic orthotic device (POD). The authors found that those patients treated with POD had decreased transfusion requirements and shorter length of hospital stay.
Routt et al describe their technique for circumferential pelvic antishock sheeting (CPAS). The authors provide an illustrative case and discuss the potential advantages of sheet application versus other techniques of pelvic stabilization.
Illustration A is the initial AP radiograph of a patient with a pelvic fracture and hemodynamic instability. The pelvic binder was placed in the field prior to arrival. Illustration B demonstrates the same patient in the angiography suite after removal of the pelvic binder. Note the increased widening of bilateral SI joints, greater on the left than the right.
Answer 1: External fixation of pelvic ring fractures can be used to assist with resuscitation but pelvic binder application should be attempted first
Answer 2: The use of pelvic angiography is controversial and institution specific however some centers utilize pelvic angiography as part of the algorithm for management of ongoing hemorrhage.
Answer 3: Pelvic packing is utilized in some centers to control ongoing pelvic hemorrhage however it is not used as initial management of patients with hemodynamic instability
Answer 5: Percutaneous iliosacral screws can also be utilized as a form of resuscitation however they should not be used as as first line of management
Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M
J Trauma. 2005 Sep;59(3):659-64. PMID: 16361909 (Link to Abstract)
Krieg, JTACS 2005
Croce MA, Magnotti LJ, Savage SA, Wood GW 2nd, Fabian TC.
J Am Coll Surg. 2007 May;204(5):935-9; discussion 940-2. PMID: 17481514 (Link to Abstract)
Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA.
J Orthop Trauma. 2002 Jan;16(1):45-8. PMID: 11782633 (Link to Abstract)
Routt, JOT 2002
Average 3.0 of 9 Ratings
A 37-year-old male is struck by a car while walking at night. He is hemodynamically unstable at initial evaluation in the trauma bay. Advanced Trauma Life Support protocols are started, and an initial survey is completed. A chest radiograph and a pelvis AP radiograph (Figure A) are obtained. What is the most appropriate next step?
The patient should be taken directly to the OR for percutaneous placement of a pelvic external fixator
Dedicated inlet and outlet views of the pelvis to better classify the fracture
Continued resuscitation and immediate CT of the chest, abdomen and plevis
Emergent trip to interventional radiology for pelvic embolization
Immediate application of pelvic binder, continued resuscitation and re-evaluation of hemodynamic status
The patient has an Anterior-Posterior Compression type 3 pelvic ring injury (APC3), and this injury places the patient at risk of life- threatening hemorrhage. The most appropriate next step in the trauma bay is to place the patient in a pelvic binder in order to minimize pelvic volume and impart stability to the injured hemipelvis to allow for clot formation.
Pelvic fractures are high energy injuries with a high association of concomitant musculoskeletal trauma and damage to multiple organ systems. It is important that any patient with a high-energy pelvic ring injury undergo a complete work-up including a CT of the chest abdomen and pelvis to look for alternative sources of bleeding. Application of a pelvic binder should occur once a pelvic ring injury is identified as part of the ongoing resuscitation of the patient.
Karadimas et al. retrospectively reviewed 34 patients at a single center who underwent pelvic arterial embolization as part of their resuscitation. APC injuries had the highest mean transfusion rate during the initial 24 hours, and the overall mortality for pelvic fractures requiring embolization was 23.5% in this series.
Manson et al. conducted a retrospective case-controlled study, evaluating mortality factors on LC-1 fractures. They found that in LC-1 fractures, the sacral fracture pattern does not predict mortality; however, mortality rate was increased in patients with a brain injury, chest injury, or abdominal injury.
Figure A demonstrates an APC3 pelvic ring injury with widening of both the symphysis and the right SI joint. Illustration A demonstrates the same injury as seen in Figure A after application of a pelvic binder with improved alignment of the pelvic ring. Illustration B shows appropriate application of a pelvic binder in a multiply injured patient.
Answer 1: While this patient may need to go emergently to the OR for multiple reasons, the work-up needs to be completed. However, the patient’s pelvis should be stabilized with a pelvic binder in the interim.
Answer 2: These images should be obtained, but the pelvis should be closed with a pelvic binder first.
Answer 3: While the pelvis may not be the only location of bleeding, the patient has a known source for bleeding, and it can be quickly stabilized with a pelvic binder. After the pelvic binder is placed, continued resuscitation and investigation of other possible locations of bleeding should occur.
Answer 4: While this patient may benefit from embolization, the first step is to close down the pelvis. Closing down the pelvis may prevent the need for embolization.
Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV.
Int Orthop. 2011 Sep;35(9):1381-90. Epub 2011 May 17. PMID: 21584644 (Link to Abstract)
Karadimas, INTORT 2011
Manson TT, Nascone JW, Sciadini MF, O'Toole RV
J Trauma. 2010 Oct;69(4):876-9. PMID: 20938275 (Link to Abstract)
Manson, JOT 2010
Average 4.0 of 21 Ratings
Alternating single-leg-stance radiographs are most helpful for evaluation of which of the following diagnoses?
Leg length discrepancy
Pelvic ring instability
Hip abductor weakness
Alternating single-leg-stance radiographs are used for the diagnosis of chronic or subtle pelvic instability.
Pelvic instability is a rare etiology of lumbar and low-back discomfort; patients report subjective instability and mechanical symptoms. Static radiographs (AP pelvis, inlet pelvis, outlet pelvis) are often not adequate for diagnosis of this condition.
Garras et al. performed a study of healthy volunteers and reported on the normal range of physiologic motion with single leg stance radiographs. They found that multiparous women exhibited the most symphyseal motion with alternating single leg stance weightbearing AP pelvic radiographs, and up to 5mm of symphyseal translation was seen in healthy, asymptomatic patients.
Siegel et al. reviewed 38 patients with pelvic instability and pain. They found that single leg stance radiographs were more indicative of instability than standard AP pelvis and inlet/outlet radiographs. They found that up to 5 cm of sympyhseal translation can be present with these injuries.
Illustration A shows a single leg stance (left leg) AP pelvis radiograph with cephalad displacement of the left hemipelvis. Illustration B shows a single leg stance (right leg) AP pelvis radiograph, with cephalad displacement of the right hemipelvis.
Answer 1,3,4,5: Standing alternating single-leg-stance radiographs are not used for diagnosis or evaluation of these disorders.
Garras DN, Carothers JT, Olson SA.
J Bone Joint Surg Am. 2008 Oct;90(10):2114-8. PMID: 18829908 (Link to Abstract)
Garras, JBJS 2008
Siegel J, Templeman DC, Tornetta P
J Bone Joint Surg Am. 2008 Oct;90(10):2119-25. PMID: 18829909 (Link to Abstract)
Siegel, JBJS 2008
Average 2.0 of 30 Ratings
A 23-year-old male is an unrestrained driver in a motor vehicle accident and sustains an unstable pelvic ring fracture. During fluoroscopic-aided fixation, a lateral sacral view is used for proper placement of which of the following fixation methods?
Anterior column percutaneous screw placement
Posterior column percutaneous screw placement
Posterior iliosacral plating
Supra-acetabular pin placement
Percutaneous iliosacral screw placement
The lateral sacral view is used to place percutaneous iliosacral screws. Sacral alar morphology has been shown to be variable from patient to patient. Therefore, intraoperative fluoroscopy is recommended. During placement of the screws, the L5 nerve root is at risk.
Routt et al (1997) examined the sacral slope and sacral alar anatomy in cadavers and a series of patients. They determined that the pelvic outlet and lateral sacral plain films provide the best plain radiographic view of the sacral ala. They recommended routine usage of these views intraoperatively to guide screw placement.
Routt et al (2000) reported on the early complications of percutaneous placement of iliosacral screws for treatment of posterior pelvic ring disruptions. While technically challenging, this technique leads to less blood loss and lower rates of infection compared to traditional open techniques.
Barei et al described methods of anterior and posterior pelvic ring disruptions. They determined that successful placement depends on accurate closed reduction, excellent intraoperative fluoroscopic imaging, and detailed preoperative planning. Early treatment decreased hemorrhage, provides patient comfort, and allows early mobilization.
Routt ML Jr, Simonian PT, Mills WJ.
J Orthop Trauma. 1997 Nov;11(8):584-9. PMID: 9415865 (Link to Abstract)
Routt, JOT 1997
Routt ML, Nork SE, Mills WJ
Clin. Orthop. Relat. Res.. 2000 Jun;(375):15-29. PMID: 10853150 (Link to Abstract)
Routt, CORR 2000
Barei DP, Bellabarba C, Mills WJ, Routt ML Jr.
Injury. 2001 May;32 Suppl 1:SA33-44. PMID: 11521704 (Link to Abstract)
Barei, INJURY 2001
Average 3.0 of 22 Ratings
A 23-year-old female is an unrestrained driver in a motor vehicle collision, sustaining the injury shown in Figure A. She subsequently undergoes reduction and percutaneous bilateral iliosacral screw placement. Which of the following is the most likely neurologic complication associated with percutaneous iliosacral screw insertion?
Weakness in knee extension
Decreased patellar reflex
Weakness in great toe extension
Weakness in ankle plantar flexion
Decreased Achilles reflex
Figure A shows an unstable bilateral pelvic ring injury. Percutaneous posterior iliosacral screw fixation places the L5 nerve root at risk as it courses across the sacral ala. Injury to the L5 nerve root would typically result in weakness in great toe extension and sensory changes on the dorsum of the foot. It is important to notice that L5 often partially innervates tibialis anterior along with L4, so weakness to ankle dorsiflexion may be present as well. Illustration A shows the post-operative films with bilateral iliosacral screws.
Routt et al examined the sacral slope and sacral alar anatomy in cadavers and a series of consecutive patients. They determined that the pelvic outlet and lateral sacral plain films provide the best plain radiographic views of the sacral ala. They recommended routine usage of these views intraoperatively to guide screw placement.
In another study, Routt et al reported on the early complications of percutaneous placement of iliosacral screws for treatment of posterior pelvic ring disruptions. While technically challenging, this technique leads to less blood loss and lower rates of infection compared to traditional open techniques.
Illustration B displays the root diagrams for sensation, reflex, and motor of the L4-S1 nerves.
1: Weakness to knee extension would be caused primarily by an injury to the L4 nerve root.
2: Decreased patellar reflex would be caused primarily by an injury to the L4 nerve root.
4: Weakness in ankle plantar flexion would be caused primarily by an injury to the S1 nerve root.
5: Decreased Achilles reflex would be caused primarily by an injury to the S1 nerve root.
Routt ML Jr, Simonian PT, Agnew SG, Mann FA.
J Orthop Trauma. 1996;10(3):171-7. PMID: 8667109 (Link to Abstract)
Routt, JOT 1996
Average 4.0 of 32 Ratings
A 32-year-old male sustains an APC-III pelvic ring disruption after a motor vehicle collision. Which of the following imaging techniques best describes the correct utilization of intraoperative flouroscopy for percutaneous iliosacral screw placement across S1?
Inlet view helps best guide superior-inferior orientation
AP pelvis best guides anterior-posterior screw orientation
AP pelvis best guides superior-inferior screw orientation
Outlet view best guides anterior-posterior screw orientation
Outlet view best guides superior-inferior screw orientation
The outlet view best guides superior-inferior screw orientation during percutaneous S1 screw placement. This is due to the relative forward flexion of the sacrum and pelvis due to pelvic incidence. A lateral sacral view and an inlet pelvis view would best guide anterior-posterior screw orientation.
Routt et al did a review of percutaneous techniques of pelvic surgery. Although anterior pelvic external fixation remains the most common form of percutaneous pelvic fixation, iliosacral screws have the advantage of stabilizing pelvic disruptions directly while diminishing operative blood loss and operative time. They stress importance of a thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations for surgical success.
Routt et al also looked at the complications that can result from percutaneous iliosacral screw placement. Complications ranged from inability for adequate imaging due to patient obesity, L5 nerve root injuries, fixation failure, and sacral nonunions. They support quality triplanar fluoroscopic imaging during iliosacral screw insertions to help accurately reduce injured posterior pelvic rings.
Illustration A is an example of an outlet view image status post anterior pelvic ring plating and percutaneous iliosacral screw. This outlet view allows superior S1 neural foramen visualization to help guide screw placement and avoid nerve injury.
Average 4.0 of 17 Ratings
Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess?
Pubic symphysis diastasis, intact anterior sacroiliac ligaments, intact sacrotuberous ligament, intact posterior sacroiliac ligaments
Pubic symphysis diastasis, torn anterior sacroiliac ligaments, intact sacrotuberous ligament intact posterior sacroiliac ligaments
Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments
Pubic symphysis diastasis, torn anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments
Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, torn posterior sacroiliac ligaments
APC II injuries are unstable injuries and occur as a result of high-energy trauma. Anatomic structures which are injured or torn include the pubic symphysis, anterior iliosacral ligaments, and the sacrotuberous ligaments. The posterior sacroiliac ligaments are spared in APC-II injuries, and differentiate an APC-II injury from an APC-III injury, in which the posterior ligaments are also torn.
Burgess et al review the classifications of pelvic ring disruptions and their association with mortality. They concluded that APC injuries required more blood replacement and were related to death more often than lateral compression, vertical shear, or combined mechanism pelvic injuries.
Tile studied the anatomy of anterior to posterior pelvic ring injuries. Although the anterior structures, the symphysis pubis and the pubic rami, contribute to 40% to the stiffness of the pelvis, clinical and biomechanical studies have shown that the posterior sacroiliac complex is more important to pelvic-ring stability. The posterior sacroiliac ligamentous complex is more important to pelvic-ring stability than the anterior structures and therefore, the classification of pelvic fractures is based on the stability of the posterior lesion.
Illustration A shows the APC classification.
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS, Poka A, Bathon GH, Brumback RJ
J Trauma. 1990 Jul;30(7):848-56. PMID: 2381002 (Link to Abstract)
Burgess, ICL 1990
J Am Acad Orthop Surg. 1996 May;4(3):143-151. PMID: 10795049 (Link to Abstract)
Tile, JAAOS 1996
Average 4.0 of 27 Ratings
A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system?
Crescent fracture located on the side of impact
Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments
Complete SI disruption with lateral displacement
Sacral compression fracture on side of impact with transverse pubic rami fractures
Open-book injury with contralateral sacral compression fracture
Lateral compression type II fractures (as described by the Young-Burgess Classification System) are associated with a crescent fracture of the iliac wing located on the side of impact. A representative CT scan image and illustration of this injury are shown in Illustrations A and B respectively. A table describing each pelvic injury and their associated complications is shown in Illustration C. Illustration D shows each Young-Burgess pelvic injury type.
Burgess et al discuss the effectiveness of a treatment protocol as determined by their pelvic injury classification and hemodynamic status. The injury classification system was based on lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury types. They found that their classification-based treatment protocols reduce the morbidity and mortality related to pelvic ring disruption.
Tile discusses acute pelvic trauma and his classification system for pelvic injuries (ie. Types A, B, and C). He states that any classification system must be seen only as a general guide to treatment, and that the management of each patient requires careful, individualized decision making.
Answer 2: This describes an APC-II injury
Answer 3: This describes an APC-III injury
Answer 4: This describes and LC-I injury
Answer 5: This describes an LC-III injury (ie. "wind-swept pelvis")
Average 4.0 of 24 Ratings
A 35-year-old male involved in a high-speed motor vehicle collision presents to the trauma bay hypotensive and with a clinically unstable pelvis. A pelvis radiograph is shown in Figure A. He is placed in a pelvic binder, and his blood pressure normalizes temporarily. An abdominal CT demonstrates free fluid and air in the intraperitoneal cavity, and a laparotomy is indicated. What is the most appropriate next step in orthopaedic management?
Percutaneous SI screw placement
External fixation placement
Pubic symphysis plating
Posterior pelvic plating
Anterior sacroiliac plating
In the management of patients with multiple injuries, controversy often arises as to the appropriate method of initial pelvic stabilization. It is generally agreed upon that applying an external frame is appropriate in the setting of an unstable patient with intraperitoneal fluid and labile blood pressure. Ex-fix placement can support hemodynamic stabilization and assist the general surgeons with their laparotomy procedure. Plate or screw fixation of the pelvis should be delayed because the laparotomy takes precedence in a patient who is hemodynamically unstable, and internal fixation in the presence of bowel contamination can result in increased rates of infection.
Furthermore, Tile noted increased septic complications with intrapelvic hardware fixation in the setting of intraperitoneal soft tissue damage and bleeding. Angiography and embolization may help with the pelvic bleeding, but will not stabilize the pelvis during the laparotomy. The review article by Tile et al discusses the assessment of the patient with a pelvic injury, and summarizes the various methods of temporary and definitive pelvic fixation.
J Am Acad Orthop Surg. 1996 May;4(3):152-161. PMID: 10795050 (Link to Abstract)
Average 3.0 of 27 Ratings
Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following?
Need for transfusion
Upper extremity fractures
Of the pelvic ring injuries, APC type III have the highest rate of mortality, blood loss, and need for transfusion. They also have a high rate of urogenital injury and abdominal organ injury. Lateral compression injuries (especially type III) have the highest rate of head injury. Vertical shear and combined injuries also have significant rates of concomitant injuries. The referenced article by Dalal et al is a review of Shock Trauma's pelvic ring injuries; they found significant increases in associated injuries as the grade of pelvic ring injury increased, regardless of mechanism/pattern. The aforementioned information was also found to be true with their patient review.
Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, Dunham CM, Gens D, Bathon H.
J Trauma. 1989 Jul;29(7):981-1000; discussion 1000-2. PMID: 2746708 (Link to Abstract)
Dalal, JTACS 1989
Average 3.0 of 35 Ratings
A 34-year-old female presents to the trauma bay with hemodynamic instability following a motor vehicle collision. A chest radiograph shows a left-sided hemothorax and her pelvis radiograph is shown in Figure A. Which of the following is the next most appropriate step in managment?
Circumferential pelvic sheeting
Retrograde urethrogram to evaluate for associated urologic injury
Emergent transport to OR for pelvic anterior external fixator placement
CT scan to assess for occult femoral neck fracture
Bedside posterior pelvic C-clamp application
Unstable anteroposterior compression (APC) pelvic fractures are most appropriately managed with a pelvic binder or circumferential pelvic sheeting as described by Routt et al in the emergency room prior to definitive treatment. Illustration A demonstrates the utility of circumferential wrapping for the case shown in Figure A. Rapid, temporary fixation of unstable pelvic fracture patients with hemodynamic instability can be performed in the trauma bay. Pelvic binders can remain in place during further diagnostic tests such as pelvic vessel angiography.
Bottlang et al performed a cadaveric study in JBJS of Young-Burgess type-II and III anteroposterior compression fractures and found that a pelvic binder reduced rotation instability by 61%.
The study by Krieg et al followed 16 patients treated with pelvic binders and found that the binder reduced the pelvic fracture displacement by 9% which closely approximated the reduction achieved with definitive fixation.
The Bottlang article published in JOT is a cadaveric study which determined that 180 +/- 50 Newtons of circumferential compression is needed to stabilize an unstable pubis symphysis diastasis. Tile Type A pelvic fractures are stable and include avulsion, iliac-wing, anterior-arch fracture due to a direct blow, or transverse sacrococcygeal fractures.
Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM.
J Bone Joint Surg Am. 2002;84-A Suppl 2:43-7. PMID: 12479338 (Link to Abstract)
Bottlang, JBJS 2002
Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB.
J Orthop Trauma. 2002 Jul;16(6):367-73. PMID: 12142823 (Link to Abstract)
Bottlang, JOT 2002
Average 4.0 of 18 Ratings
A 25-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. He is intubated in the field and receives 2 liters of LR and continues to be tachycardic and hypotensive. A massive transfusion protocol is initiated. Which of the following is true regarding the transfusion of packed red blood cells, platelets, and fresh frozen plasma?
PRBC should be transfused until Hgb>8
PRBC, platelets, and FFP should be transfused in equal ratios
Platelets and fresh frozen plasma should be given when INR >1.4, platelet count <100,000
FFP is not needed unless INR>1.5
Platelets should not be transfused unless platelet count <10,000
High energy pelvic injuries such as the one seen in Figure A continues to be a source of high mortality in orthopaedics. Active involvment of the orthpaedic surgeon in managing these life threatening injuries remains critical. A sheet or pelvic binder needs to be emergently applied in this clinical scenario. An aggressive resuscitation protocol must also be initiated. The review article by Hak et al discussed the advances in prehospital, interventional, surgical, and critical care that have led to increase survival rates for pelvic injuries. Gonzalez et al found that initial coagulopathy in trauma patients was associated with decreased survival. They noted that hypothermia and acidosis was well managed but pre-ICU coagulopathy was the most difficult to treat. They recommended early FFP in a FFP:PRBC ratio of 1:1
Hak DJ, Smith WR, Suzuki T.
J Am Acad Orthop Surg. 2009 Jul;17(7):447-57. PMID: 19571300 (Link to Abstract)
Hak, JAAOS 2009
Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, Cocanour CS, Balldin BC, McKinley BA.
J Trauma. 2007 Jan;62(1):112-9. PMID: 17215741 (Link to Abstract)
Gonzalez, JTACS 2007
Average 3.0 of 20 Ratings
What risk factor leads to the highest rate of postoperative loss of reduction in unstable posterior pelvic ring injuries?
Type of anterior fixation
Usage of a transiliac bar
Vertical sacral fracture
Sacroiliac joint fracture-dislocation
According to the referenced article by Griffin et al, the risk of postoperative loss of reduction is greatest with a vertical sacral fracture pattern (13%, all within 3 weeks). There was no significant association between failure and anterior fixation method, iliosacral screw arrangement or length, or any demographic or injury variable.
Their conclusion: "Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction."
Griffin DR, Starr AJ, Reinert CM, Jones AL, Whitlock S.
J Orthop Trauma. 2006 Jan;20(1 Suppl):S30-6; discussion S36. PMID: 16385205 (Link to Abstract)
Griffin, JOT 2006
Average 3.0 of 29 Ratings
What nerve is most at risk when applying the external fixator shown in Figure A using a minimally invasive fluoroscopic technique of pin insertion?
First branch of the femoral nerve
Lateral femoral cutaneous nerve
Superior gluteal nerve
Pelvic external fixation with supraacetabular pins through the AIIS can be utilized to stabilize a pelvic fracture. While using this technique, care must be taken not to injure the lateral femoral cutaneous nerve (LFCN). Gardner et al describe the technique for placement of supraacetabular external fixation pins and state that pins in this location are more stable biomechanically compared to other locations in the iliac crest. Grothaus et al performed a cadaveric study to determine the anatomic detail and variation of the LFCN and the distances it traveled from various landmarks.The found the nerve to potentially be at risk as far as 7.3 cm medial to the anterior superior iliac spine along the inguinal ligament and as much as 11.3 cm distal on the sartorius muscle from the anterior superior iliac spine. Riina et al performed a cadaveric study to define the neurovascular structures at risk with the placement of anterior-posterior locking screws in the proximal femur. They found that risks to the neurovascular structures during anterior-posterior locking in the proximal femur are diminished if locking is performed above the level of the lesser trochanter.
Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA.
Clin Orthop Relat Res. 2005 Aug;(437):164-8. PMID: 16056045 (Link to Abstract)
Grothaus, CORR 2005
Riina J, Tornetta P 3rd, Ritter C, Geller J.
J Orthop Trauma. 1998 Aug;12(6):379-81. PMID: 9715443 (Link to Abstract)
Riina, JOT 1998
Gardner MJ, Nork SE.
J Orthop Trauma. 2007 Apr;21(4):269-73. PMID: 17414555 (Link to Abstract)
Gardner, JOT 2007
Average 3.0 of 17 Ratings
Risk of postoperative fixation failure for the injury seen in figure A has been associated with what variable?
Anterior pelvic ring fixation method
Vertical nature of sacral fracture
Iliosacral screw length
Number of iliosacral screws
Age > 50
Figure A, a coronal CT image, shows a vertical sacral fracture, which creates a vertically unstable pelvic ring. Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.
According to the referenced study by Griffin et al, fixation failure of iliosacral screws was significantly associated with vertical sacral fractures and not with any of the other answers listed above. All cases of hardware failure occured within the first 3 weeks; a lesser relationship between hardware failure and sacroiliac joint injury was noted.
Average 3.0 of 25 Ratings
A 24-year-old male sustains the injury seen in Figure A after being thrown from a motorcycle at a high speed. Which of the following fixation methods has been shown to be the most stable fixation construct for this injury?
Posterior bridge plating and anterior ring external fixation
Percutaneous iliosacral screw and anterior ring external fixation
Percutaneous iliosacral screw and anterior ring internal fixation
Two percutaneous iliosacral screws
Figure A shows an APC III injury, which is a rotationally and vertically unstable injury, with damage to the anterior ring, pelvic floor, and posterior ligamentous stabilizing structures.
The referenced study by Sagi et al found that biomechanically, a percutaneous iliosacral screw and anterior ring internal fixation was the most stable construct. In addition, he found no biomechanical support for addition of a second iliosacral screw.
Sagi HC, Ordway NR, DiPasquale T.
J Orthop Trauma. 2004 Mar;18(3):138-43. PMID: 15091266 (Link to Abstract)
Sagi, JOT 2004
For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable?
Length of hospital stay
Association with neurological deficit(s)
Length of intensive care stay
Unstable pelvic fractures can be devastating injuries often resulting in significant morbidity and even death.
According to the referenced study by Smith et al, fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased ISS or RTS scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours).
Incorrect Answers: Choices 1-4 do not correlate with increased blood transfusions to the extent of Option 5.
Smith W, Williams A, Agudelo J, Shannon M, Morgan S, Stahel P, Moore E.
J Orthop Trauma. 2007 Jan;21(1):31-7. PMID: 17211266 (Link to Abstract)
Smith, JOT 2007
During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure?
L4 nerve root
L5 nerve root
S1 nerve root
Sacroiliac joint cartilage
External iliac artery
Unstable anterior and posterior pelvic ring injuries are amenable to percutaneous treatment if reduction is able to be obtained in a closed manner and appropriate radiographic visualization is able to be achieved. In the 1996 reference by Routt et al, proper SI screw placement is described. Pelvic inlet, outlet, and lateral sacral images must be obtained to safely place a percutaneous iliosacral screw. The iliac cortical density seen adjacent to the SI joint is the anterior edge of the insertion safe zone, and is only able to be seen on the lateral image. Failure to place the screw behind this radiographic line would lead to an "in-out-in" screw (in the ilium, and then exiting anterior to the sacral ala, only to re-enter in the sacral body), which would cause direct injury to the L5 nerve root.
In the 2000 reference by Routt et al, they state "a thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations are mandatory for percutaneous pelvic fixation to be effective."
Illustration A shows a representative lateral sacral radiograph, with the major anatomic landmarks labeled. Safe SI screw insertion in the S1 body should be underneath the sacral ala line to minimize risk of a "in-out-in" screw that would come out in the area of the ala and injure the L5 nerve root that sits directly on top of this structure. Dysmorphic pelvic rings will often have a more vertical sacral line, or one that starts more inferiorly.
A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What is the most common urological injury associated with this injury pattern?
Posterior urethral tear
The figure shows an anteroposterior pelvic ring injury. The most common urological injury with pelvic ring injuries remains the posterior urethral tear, followed by bladder rupture.
Watnik et al notes lower urinary tract (bladder to end of urethra) injuries in up to 25% of patients with this injury. He reports that when contaminated urine communicates with the anterior arch, the possibility of infection exists, and early repair of bladder disruptions with simultaneous anterior arch plating minimizes this risk.
Routt et al notes that even with simultaneous treatment of these injuries, complications are common (late stricture in 44%, impotence in 16%, delayed incontinence in 20% of females, anterior deep pelvic infection in 4%). Despite this, they report that early urological repairs are easily performed at the time of anterior pelvic open reduction and internal fixation.
Watnik NF, Coburn M, Goldberger M.
Clin Orthop Relat Res. 1996 Aug;(329):37-45. PMID: 8769434 (Link to Abstract)
Watnik, CORR 1996
Routt ML, Simonian PT, Defalco AJ, Miller J, Clarke T.
J Trauma. 1996 May;40(5):784-90. PMID: 8614081 (Link to Abstract)
Routt, JTACS 1996
Average 4.0 of 12 Ratings
A 41-year-old woman is brought to the emergency department after she was the unrestrained driver in a rollover motor vehicle accident. She was placed in a cervical collar and intubated at the scene. Her blood pressure is 80/40 and pulse is 140. She has obvious open fractures of the right forearm and left ankle. On exam, the lower extremities are externally rotated and the pubic symphysis is widened and unstable. Intravenous access is obtained and radiographs are pending. What is the most urgent next step in management?
Lateral radiograph to clear the cervical spine
External fixator application to the left ankle in the operating room
External fixator application to the pelvis in the operating room
Pelvic binder application
Reduction and splinting of the right forearm
Pelvic ring injuries are associated with a high incidence of mortality mainly due to retroperitoneal hemorrhage. Early stabilization is an integral part of hemorrhage control. Temporary stabilization can be provided by a pelvic sheet, sling, or an inflatable garment. However, these devices lack control of the applied circumferential compression.
Krieg et al showed a pelvic circumferential compression device (PCCD) significantly reduced the pelvic width by 9.9 +/- 6.0% of external rotation (APC) pelvic injuries, and did not overcompress internal rotation (LC) injuries.
Bottlang et al determined that a widened pelvis can be effectively reduced in the emergency department with a pelvic strap (binder). While the other choices are urgent as well, hypotension caused by pelvic widening demands the most immediate attention.
Average 4.0 of 20 Ratings
Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following?
anterior sacroiliac ligaments
posterior sacroiliac ligaments
The posterior sacroiliac ligaments are not disrupted in an APC type II pelvic fracture.
Young and Burgess classification of pelvic ring injuries is largely based on the mechanism and energy of injury. An APC type I involves slight widening of pubic symphysis and/or anterior sacroiliac (SI) joint. An APC II is a continuation of this force, and additionally involves a disrupted anterior SI joint, as well as sacrotuberous and sacrospinous ligaments. An APC III also involves disrupted posterior SI ligaments, causing complete SI joint disruption with potential translational and rotational displacement.
The reference by Young et al is a classic article that describes the Young and Burgess classification of pelvic ring injuries. They retrospectively analyzed pelvic ring radiographs and discussed four patterns of injury: anteroposterior compression, lateral compression, vertical shear, and a complex/combined pattern.
The reference by Burgess et al is a validation of the aforementioned classification and study, as they reviewed 210 consecutive patients who sustained a pelvic ring injury. They validated the classification scheme and found that overall blood replacement averaged: lateral compression, 3.6 units; anteroposterior compression, 14.8 units; vertical shear, 9.2 units; combined mechanical, 8.5 units. Overall mortality was: lateral compression, 7.0%; anteroposterior, 20.0%, vertical shear, 0%; combined mechanical, 18.0%.
Illustration A shows an APC-II injury pattern - (a) is an outlet radiograph, (b) is an axial CT cut, (c) is a 3-D CT cut, and (d) is a representative fixation construct.
1,2,4,5: An APC - 2 pelvic ring injury involves injury to all of these structures.
Young JW, Burgess AR, Brumback RJ, Poka A.
Radiology. 1986 Aug;160(2):445-51. PMID: 3726125 (Link to Abstract)
A 27-year-old woman gives birth by normal spontaneous vaginal delivery. Two weeks after delivery she reports anterior pelvic pain and a radiograph is obtained (Figure A). What is the next step in management?
Pelvic external fixator
Open reduction and reconstruction plating of the symphysis
Protected weightbearing and binder as needed and observation
Open reduction and wiring of the symphysis
The clinical presentation and radiograph is consistent with an open-book type parturition-induced pelvic dislocation.
The case series by Kharrazi et al reports four patients treated with open-book type parturition-induced pelvic dislocations. The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a symphyseal diastasis less than 4.0 cm. All four patients had significant symptoms and radiographic widening (anterior splaying) of the sacroiliac joints. The three patients who had presented acutely were treated with closed reduction and application of a pelvic binder, while two had closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. At latest follow-up the diastasis at the pubic symphysis reduced to an average of 1.7 cm (range: 1.5-2.0) The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a symphyseal diastasis of 4.0 cm of less and operative treatment for diastasis greater than 4cm.
Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW.
J Orthop Trauma. 1997 May;11(4):277-81; discussion 281-2. PMID: 9258826 (Link to Abstract)
Kharrazi, JOT 1997
What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?
Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk.
Illustration A shows a diagram of the lumbosacral plexus, indicating the proximity of the L4 and L5 nerve roots to the anterior sacrum and SI joint.
The first referenced article by Atlihan et al reported on the anatomy of the anterior sacroiliac joint and reported that the L4 nerve root is within 1 cm of the joint at its inferior margin.
The second article by Ebraheim et al found that the L4 and L5 nerve roots are 10 mm medial to the sacroiliac joint at the pelvic brim.
Atlihan D, Tekdemir I, Ateŝ Y, Elhan A.
Clin Orthop Relat Res. 2000 Jul;(376):236-41. PMID: 10906881 (Link to Abstract)
Atlihan, CORR 2000
Ebraheim NA, Padanilam TG, Waldrop JT, Yeasting RA.
Spine (Phila Pa 1976). 1994 Mar 15;19(6):721-5. PMID: 8009340 (Link to Abstract)
Ebraheim, SPINE 1994
Average 3.0 of 15 Ratings
A 40-year-old male laborer sustained a fall from height and has isolated pelvic pain. He is otherwise hemodynamically stable. A radiograph is shown in Figure A. A stress examination under anesthesia does not show any further anterior diastasis or posterior pelvic ring displacement. Computed tomography reveals no asymmetry of the sacroiliac joints. What is the most appropriate management of this injury?
protected weight-bearing and pain control
open reduction and internal fixation
skeletal traction followed by open reduction and internal fixation
pelvic external fixation
pelvic external fixation followed by sacroiliac screws
This patient sustained an open-book pelvic fracture with a pubic symphysis diastasis of less than 2.5cm. From the Young and Burgess classification, he has anteroposterior compression (AP) type 1 injury. Treatment of this is protected weight-bearing and symptomatic treatment. Stress examination can be utilized in order to ensure that the injury is, in fact, a APC-1 injury, and not a more severe posterior injury that would require operative intervention.
Average 3.0 of 21 Ratings
A 31-year-old male sustains an ipsilateral displaced transverse acetabular fracture, pubic rami fractures, and a sacroiliac joint dislocation. What structure should be reduced and stabilized first?
In an ipsilateral unstable pelvic ring and acetabular fractures, the pelvic ring injury must be initially stabilized in order to reduce the acetabular fracture to a stable base.
The referenced article by Matta reviewed 259 patients with acetabular fractures treated within 21 days of injury and found that the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.
J Bone Joint Surg Am. 1996 Nov;78(11):1632-45. PMID: 8934477 (Link to Abstract)
Matta, JBJS 1996
Average 4.0 of 35 Ratings
HPI - 17 year old male had RTA 2 days back.hemodynamically stable has passed urine several time since injury without any blood traces.
What are the treatment options for the pelvic fracture?
HPI - H/O RTA on 10/10/2015
How would you treat this fracture?
HPI - History of fall from height while working with building blocks.
What Young-Burgess Classification would you assign this fracture
HPI - History of road traffic accident 5 Months back. Treated conservatively with bed rest and analgesics.Started ambulation with bilateral crutches 3 months post injury. Currently complain of incapacitating low back pain.
Possible management options for this patient?
HPI - Polytrauma patient after severe head-on collision in a motorcycle accident. He suffered: 1)a right sacral ala fracture involving the foramina with right leg neurologic deficit 2)both pubic and ischial bones comminuted fractures with pubic symphysis displacement 3)severe perineal wound 4) open (grade I) left radius and ulna diaphysis fracture 5)comminuted intraarticular distal right radius fracture with DRUJ diastasis 6) open (grade IIIB)comminuted right tibia and fibula fracture
How would you deal with the anterior pelvic ring disruption 6 months post injury
HPI - Pain with mobilization following delivery
How would you treat this patient?
HPI - 23yr old female presented to the ER 8 hrs following MVA sustaining injury to her pelvis and a perineal wound.
How would you manage further ?
How To Apply Pelvic C Clamp
Axial CT scan of pelvic ring injury
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Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bath...