Pelvic Ring Fractures

Author: Brian Weatherford

Topic updated on 05/21/13 12:14pm

Introduction

Mechanism typically high energy blunt trauma
Mortality rate 15-25% for closed fractures, as much as 50% for open fractures
- hemorrhage is leading cause of death
- increased mortality associated with
  - systolic BP <90 on presentation
  - age >60 years
  - increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
  - need for transfusion > 4 units
Associated injuries
- chest injury in up to 63%
- long bone fractures in 50%
- head and abdominal injury in 40%
- spine fractures in 25%
- urogenital injuries in 12-20%
Prognosis
- high prevalence of poor functional outcome and chronic pain
- poor outcome associated with
  - SI joint incongruity of > 1 cm
  - high degree initial displacement
  - malunion or residual displacement
  - leg length discrepancy > 2 cm
  - nonunion
  - neurologic injury
  - urethral injury
Pediatric pelvic ring fractures
- children with open triradiate cartilage have different fracture patterns than do children whose triradiate cartilage has closed
  - if triradiate cartilage is open the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption
  - for this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment

Anatomy

Osteology
- ring structure made up of the sacrum and two innominate bones
- stability dependent on strong surrounding ligamentous structures
- displacement can only occur with disruption of the ring in two places
- neurovascular structures intimately associated with posterior pelvic ligaments
  - high index of suspicion for injury of internal iliac vessels or lumbosacral plexus
Ligaments
- anterior
  - symphyseal ligaments
    - resist external rotation
- pelvic floor
  - sacrospinous ligaments
    - resist external rotation
  - sacrotuberous ligaments
    - resist shear and flexion
- posterior sacroiliac complex (posterior tension band)
  - 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

Physical Exam

Symptoms
- pain & inability to bear weight
Physical exam
- inspection
  - test stability by placing gentle rotational force on each iliac crest
    - low sensitivity for detecting instability
    - perform only once
  - look for abnormal lower extremity positioning
    - external rotation of one or both extremities
    - limb-length discrepancy
- skin
  - scrotal, labial or perineal hematoma, swelling or ecchymosis
  - flank hematoma
  - lacerations of perineum
  - degloving injuries
- neurologic exam
  - rule out lumbosacral plexus injuries (L5 and S1 are most common)
  - rectal exam to evaluate sphincter tone and perirectal sensation
- urogenital exam
  - most common finding is gross hematuria
  - more common in males (21% in males, 8% in females)
- vaginal and rectal examinations
  - mandatory to rule out occult open fracture

Imaging

Radiographs
- AP Pelvis
  - part of initial ATLS evaluation
  - look for asymmetry, rotation or displacement of each hemipelvis
  - evidence of anterior ring injury needs further imaging
- inlet view
  - X-ray beam angled ~45 degrees caudad (may be as little as 25 degrees)
    - adequate image when S1 overlaps S2 body
  - ideal for visualizing:
    - anterior or posterior translation of the hemipelvis
    - internal or external rotation of the hemipelvis
    - widening of the SI joint
    - sacral ala impaction
- outlet view
  - X-ray beam angled ~45 degrees cephalad (may be as much as 60 degrees)
    - adequate image when pubic symphysis overlies S2 body
  - ideal for visualizing:
    - vertical translation of the hemipelvis
    - flexion/extension of the hemipelvis
    - disruption of sacral foramina and location of sacral fractures
- radiographic signs of instability
  - > 5 mm displacement of posterior sacroiliac complex
  - presence of posterior sacral fracture gap
  - avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of 5th lumbar vertebrae)
CT
- routine part of pelvic ring injury evaluation
- better characterization of posterior ring injuries
- helps define comminution and fragment rotation
- visualize position of fracture lines relative to sacral foramina

Classification & Treatment

Tile classification
- A: stable
  - A1: fracture not involving the ring (avulsion or iliac wing fracture)
  - A2: stable or minimally displaced fracture of the ring
  - A3: transverse sacral fracture (Denis zone III sacral fracture)
- B - rotationally unstable, vertically stable
  - B1: open book injury (external rotation)
  - B2: lateral compression injury (internal rotation)
    - B2-1: with anterior ring rotation/displacement through ipsilateral rami
    - B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)
  - B3: bilateral
- C - rotationally and vertically unstable
  - C1: unilateral
    - C1-1: iliac fracture
    - C1-2: sacroiliac fracture-dislocation
    - C1-3: sacral fracture
  - C2: bilateral with one side type B and one side type C
  - C3: bilateral with both sides type C
Young-Burgess Classification

	Descriptions	Treatment	Xray	CT
Anterior Posterior Compression (APC)
APC I	Symphysis widening < 2.5 cm	Non-operative. Protected weight bearing
APC II	Symphysis widening > 2.5 cm. Anterior SI joint diastasis . Posterior SI ligaments intact.	Anterior symphyseal plate or external fixator
APC III	Disruption of anterior and posterior SI ligaments (SI dislocation). APCIII associated with vascular injury	Anterior symphyseal plate or external fixator and posterior stabilization with SI screws
Lateral Compression (LC)
LC Type I	Oblique ramus fracture and ipsilateral anterior sacral ala compression fracture.	Non-operative. Protected weight bearing
LC Type II	Ramii fracture and ipsilateral posterior ilium fracture dislocation (Crescent fracture).	Open reduction and internal fixation of ilium
LC Type III	Ipsilateral lateral compression and contralateral APC (windswept pelvis). Common mechanism is rollover vehicle accident or pedestrian vs auto.	Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.
Vertical Shear (VS)
Vertical shear	Posterior and superior directed force. Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%	Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.

Bleeding & Initial Treatment

Bleeding Source
- intraabdominal
- intrathoracic
- retroperitoneal
- extremity (thigh compartments)
- pelvic
  - common sources of hemorrhage
    - venous injury (80%)
      - shearing injury of posterior thin walled venous plexus
    - bleeding cancellous bone
  - uncommon sources of hemorrhage
    - arterial injury (10-20%)
      - superior gluteal most common (posterior ring injury, APC pattern)
      - internal pudendal (anterior ring injury, LC pattern)
      - obturator (LC pattern)
Treatment
- resuscitation
  - PRBC:FFP:Platelets ideally should be transfused 1:1:1
  - this ratio shown to improve mortality in patients requiring massive transfusion
- pelvic binder/sheet
  - indications
    - initial management of an unstable ring injury
  - contraindications
    - hypothetical risk of over-rotation of hemipelvis and hollow viscus injury (bladder) in pelvic fractures with internal rotation component (LC)
    - no clinical evidence exists of this complication occurring
  - technique
    - centered over greater trochanters to effect indirect reduction
    - do not place over iliac crest/abdomen
      - ineffective and precludes assessment of abdomen
    - may augment with internal rotation of lower extremities and taping at ankles
    - transition to alternative fixation as soon as possible
      - prolonged pressure from binder or sheet may cause skin necrosis
    - working portals may be cut in sheet to place percutaneous fixation
- external fixation
  - indications
    - pelvic ring injuries with an external rotation component (APC, VS, CM)
    - unstable ring injury with ongoing blood loss
  - contraindications
    - ilium fracture that precludes safe application
    - acetabular fracture
  - technique
    - theoretically works by decreasing pelvic volume
    - stability of bleeding bone surfaces and venous plexus in order to form clot
    - pins inserted into ilium
      - single pin in column of supracetabular bone from AIIS towards PSIS
        
        obturator outlet or "teepee" view to visualize this column of bone
        
        AIIS pins can place the lateral femoral cutaneous nerve at risk
      - multiple half pins in the superior iliac crest
        
        place in thickest portion of anterior ilium, gluteus medius tubercle or gluteal pillar
    - should be placed before emergent laparotomy
- angiography / embolization
  - indications
    - controversial and based on multiple variables including:
    - protocol of institution, stability of patient, proximity of angiography suite , availability and experience of IR staff
    - CT angiography useful for determining presence or absence of ongoing arterial hemorrhage (98-100% negative predictive value)
  - contraindications
    - not clearly defined
  - technique
    - selective embolization of identifiable bleeding sources
    - in patients with uncontrolled bleeding after selective embolization, bilateral temporary internal iliac embolization may be effective
    - complications include gluteal necrosis and impotence

Definitive Treatment

Nonoperative
- weight bearing as tolerated
  - indications
    - mechanically stable pelvic ring injuries including
      - LC1
        
        anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of posterior ring displacement
      - APC1
        
        widening of symphysis < 2.5 cm with intact posterior pelvic ring
      - isolated pubic ramus fractures
Operative
- ORIF
  - indications
    - symphysis diastasis > 2.5 cm
    - SI joint displacement > 1 cm
    - sacral fracture with displacement > 1 cm
    - displacement or rotation of hemipelvis
    - open fracture
  - technique
    - for open fractures aggressive debridement according to open fracture principles
- diverting colostomy
  - indications
    - consider in open pelvic fractures
      - especially with extensive perineal injury or rectal involvement

Techniques

Anterior ring stabilization
- single superior plate
  - apply through rectus-splitting Pfannenstiel approach
  - may perform in conjunction with laparotomy or GU procedure
Posterior ring stabilization
- anterior SI plating
  - risk of L4 and L5 injury with placement of anterior sacral retractors
- iliosacral screws (percutaneous)
  - good for sacral fractures and SI dislocations
  - safe zone is in S1 vertebral body
    - outlet radiograph view best guides superior-inferior screw placement
    - inlet radiograph view best guides anterior-posterior screw placement
  - L5 nerve root injury complication with errors in screw placement
  - entry point best viewed on lateral sacral view and pelvic outlet views
  - risk of loss of reduction highest in vertical sacral fracture patterns
- posterior SI "tension" plating
  - can have prominent HW complications
Anterior and posterior ring stabilization
- necessary in vertically unstable injuries
Ipsilateral acetabular and pelvic ring fractures
- reduction and fixation of the pelvic ring should be performed first

Complications

Neurologic injury
- L5 nerve root runs over sacral ala joint
- may be injured if SI screw is placed to anterior
DVT and PE
- DVT in ~ 60%, PE in ~ 27%
- prophylaxis essential
  - mechanical compression
  - pharmacologic prevention (LMWH or Lovenox)
  - vena caval filters (closed head injury)

Urogenital Injuries

Present in 12-20% of patients with pelvic fractures
- higher incidence in males (21%)
Includes
- posterior urethral tear
  - most common urogenital injury with pelvic ring fracture
- bladder rupture
  - may see extravasation around the pubic symphysis
  - associated with mortality of 22-34%
Diagnosis
- made with retrograde urethrocystogram
- indications for retrograde urethrocystogram include
  - blood at meatus
  - high riding or excessively mobile prostate
  - hematuria
Treatment
- suprapubic catheter placement
  - suprapubic catheter is a relative contraindication to anterior ring plating
- surgical repair
  - rupture should be repaired at the same time or prior to definitive fixation in order to minimize infection risk
Complications
- long-term complications common (up to 35%)
  - urethral stricture - most common
  - impotence
  - anterior pelvic ring infection
  - incontinence

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Qbank (25 Questions)

TAG

(OBQ11.30) 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 required for proper placement of which of the following fixation methods? Topic

Review Topic

1. Anterior column percutaneous screw placement
2. Posterior column percutaneous screw placement
3. Pubic symphysis plating
4. Supra-acetabular pin placement
5. Percutaneous iliosacral screw placement

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997 Nov;11(8):584-9. PMID:9415865 (Link to Abstract)

2. Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000 Jun;(375):15-29. PMID:10853150 (Link to Abstract)

3. Barei DP, Bellabarba C, Mills WJ, Routt ML Jr. Percutaneous management of unstable pelvic ring disruptions. Injury. 2001 May;32 Suppl 1:SA33-44. PMID:11521704 (Link to Abstract)

Question Authors:

Terrill Julien MD, Ben Taylor MD, Michael Hughes MD,

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(OBQ11.31) 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? Topic

Review Topic

FIGURES: A

1. Weakness in knee extension
2. Decreased patellar reflex
3. Weakness in great toe extension
4. Weakness in ankle plantar flexion
5. Decreased Achilles reflex

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Incorrect answers:
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.

Illustrations: A

REFERENCES:

1. Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997 Nov;11(8):584-9. PMID:9415865 (Link to Abstract)

2. Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996;10(3):171-7. PMID:8667109 (Link to Abstract)

Question Authors:

Terrill Julien MD, Ben Taylor MD, Jan Szatkowski MD, Edward Perez M.D.,

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TAG

(OBQ11.165) 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? Topic

Review Topic

1. Inlet view helps best guide superior-inferior orientation
2. AP pelvis best guides anterior-posterior screw orientation
3. AP pelvis best guides superior-inferior screw orientation
4. Outlet view best guides anterior-posterior screw orientation
5. Outlet view best guides superior-inferior screw orientation

PREFERRED RESPONSE ▶

DISCUSSION: 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 shows the radiographic technique used to shoot an outlet pelvis view and illustration of the pelvic view. Illustration B 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.

Illustrations: A

REFERENCES:

1. Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000 Jun;(375):15-29. PMID:10853150 (Link to Abstract)

2. Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997 Nov;11(8):584-9. PMID:9415865 (Link to Abstract)

Question Authors:

David Abbasi MD, Ben Taylor MD, John Badylak MD, Edward Perez M.D.,

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TAG

(OBQ11.181) Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess? Topic

Review Topic

1. Pubic symphysis diastasis, intact anterior sacroiliac ligaments, intact sacrotuberous ligament, intact posterior sacroiliac ligaments
2. Pubic symphysis diastasis, torn anterior sacroiliac ligaments, intact sacrotuberous ligament intact posterior sacroiliac ligaments
3. Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments
4. Pubic symphysis diastasis, torn anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments
5. Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, torn posterior sacroiliac ligaments

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56. PMID:2381002 (Link to Abstract)

2. Tile M. Acute pelvic fractures: I. Causation and Classification. J Am Acad Orthop Surg. 1996 May;4(3):143-151. PMID:10795049 (Link to Abstract)

Question Authors:

David Abbasi MD, Ben Taylor MD, John Badylak MD,

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TAG

(OBQ11.248) 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? Topic

Review Topic

1. Crescent fracture located on the side of impact
2. Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments
3. Complete SI disruption with lateral displacement
4. Sacral compression fracture on side of impact with transverse pubic rami fractures
5. Open-book injury with contralateral sacral compression fracture

PREFERRED RESPONSE ▶

DISCUSSION: 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 Illustration 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.

Incorrect Answers:
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")

Illustrations: A

REFERENCES:

2. Tile M. Acute Pelvic Fractures: I. Causation and Classification. J Am Acad Orthop Surg. 1996 May;4(3):143-151. PMID:10795049 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Dave Marcu MD, Ben Taylor MD, Edward Perez M.D.,

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(OBQ10.96) 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? Topic

Review Topic

FIGURES: A

1. Percutaneous SI screw placement
2. External fixation placement
3. Pubic symphysis plating
4. Posterior pelvic plating
5. Anterior sacroiliac plating

PREFERRED RESPONSE ▶

DISCUSSION: 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. 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.

REFERENCES:

1. Tile M. Acute Pelvic Fractures: II. Principles of Management. J Am Acad Orthop Surg. 1996 May;4(3):152-161. PMID:10795050 (Link to Abstract)

2. Stover MD, Mayo KA, Kellam JF. Pelvic ring disruptions. In: Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettek C, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction,, 4th ed. Philadelphia, PA: WB Saunders; 2009:1107-1170.

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Michael Hughes MD,

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TAG

(OBQ10.144) Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following? Topic

Review Topic

1. Head injury
2. Pulmonary injury
3. Traumatic amputation
4. Need for transfusion
5. Upper extremity fractures

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, Dunham CM, Gens D, Bathon H. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989 Jul;29(7):981-1000; discussion 1000-2. PMID:2746708 (Link to Abstract)

2. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Springer-Verlag, 1993, pp 29-61.

Question Authors:

Ben Taylor MD, Jan Szatkowski MD, John Badylak MD,

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(OBQ10.148) 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? Topic

Review Topic

FIGURES: A

1. Circumferential pelvic sheeting
2. Retrograde urethrogram to evaluate for associated urologic injury
3. Emergent transport to OR for pelvic anterior external fixator placement
4. CT scan to assess for occult femoral neck fracture
5. Bedside posterior pelvic C-clamp application

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am. 2002;84-A Suppl 2:43-7. PMID:12479338 (Link to Abstract)

2. Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005 Sep;59(3):659-64. PMID:16361909 (Link to Abstract)

3. Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB. Noninvasive reduction of open-book pelvic fractures by circumferential compression. J Orthop Trauma. 2002 Jul;16(6):367-73. PMID:12142823 (Link to Abstract)

4. Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma. 2002 Jan;16(1):45-8. PMID:11782633 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD,

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(OBQ10.205) 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? Topic

Review Topic

FIGURES: A

1. PRBC should be transfused until Hgb>8
2. PRBC, platelets, and FFP should be transfused in equal ratios
3. Platelets and fresh frozen plasma should be given when INR >1.4, platelet count <100,000
4. FFP is not needed unless INR>1.5
5. Platelets should not be transfused unless platelet count <10,000

PREFERRED RESPONSE ▶

DISCUSSION: 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 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 decreases in 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

REFERENCES:

1. Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009 Jul;17(7):447-57. PMID:19571300 (Link to Abstract)

2. Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, Cocanour CS, Balldin BC, McKinley BA. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007 Jan;62(1):112-9. PMID:17215741 (Link to Abstract)

Question Authors:

Jan Szatkowski MD,

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(OBQ09.40) What risk factor leads to the highest rate of postoperative loss of reduction in unstable posterior pelvic ring injuries? Topic

Review Topic

1. Lack of anterior fixation
2. Male sex
3. Usage of a transiliac bar
4. Vertical sacral fracture
5. Sacroiliac joint fracture-dislocation

PREFERRED RESPONSE ▶

DISCUSSION: 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."

REFERENCES:

1. Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 389-397

2. Griffin DR, Starr AJ, Reinert CM: Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: Does posterior injury pattern predict fixation failure? J Orthop Trauma 2006;20:S30-S36 PMID:16385205 (Link to Abstract)

Question Authors:

Ben Taylor MD, Derek Moore, Patrick McCulloch MD, Edward Perez M.D.,

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(OBQ08.41) What nerve is most at risk when applying the external fixator shown in Figure A using a minimally invasive fluoroscopic technique of pin insertion? Topic

Review Topic

FIGURES: A

1. Ilioinguinal nerve
2. Obturator nerve
3. First branch of the femoral nerve
4. Lateral femoral cutaneous nerve
5. Superior gluteal nerve

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA. Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop Relat Res. 2005 Aug;(437):164-8. PMID:16056045 (Link to Abstract)

2. Riina J, Tornetta P 3rd, Ritter C, Geller J. Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails. J Orthop Trauma. 1998 Aug;12(6):379-81. PMID:9715443 (Link to Abstract)

3. Gardner MJ, Nork SE. Stabilization of unstable pelvic fractures with supraacetabular compression external fixation. J Orthop Trauma. 2007 Apr;21(4):269-73. PMID:17414555 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Derek Moore, Jan Szatkowski MD,

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(OBQ08.80) Risk of postoperative fixation failure for the injury seen in figure A has been associated with what variable? Topic

Review Topic

FIGURES: A

1. Anterior pelvic ring fixation method
2. Vertical nature of sacral fracture
3. Iliosacral screw length
4. Number of iliosacral screws
5. Age > 50

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008.

2. Griffin DR, Starr AJ, Reinert CM, Jones AL, Whitlock S. Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure? J Orthop Trauma. 2006 Jan;20(1 Suppl):S30-6; discussion S36. PMID:16385205 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD,

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(OBQ08.152) 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? Topic

Review Topic

FIGURES: A

1. Posterior bridge plating and anterior ring external fixation
2. Percutaneous iliosacral screw and anterior ring external fixation
3. Percutaneous iliosacral screw and anterior ring internal fixation
4. Transiliac screw
5. Two percutaneous iliosacral screws

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Baumgaertner MR, Tornetta P III, (eds): Orthopaedic Knowledge Update: Trauma 3, 2005 pp 233-241

2. Sagi HC, Ordway NR, DiPasquale T. Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating. J Orthop Trauma. 2004 Mar;18(3):138-43. PMID:15091266 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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(OBQ08.188) 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? Topic

Review Topic

1. Length of hospital stay
2. Association with neurological deficit(s)
3. Length of intensive care stay
4. Cardiac collapse
5. Mortality

PREFERRED RESPONSE ▶

DISCUSSION: 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 are not as predictive of mortality as choice 5.

REFERENCES:

1. Kellam JK, Mayo KA: Pelvic ring disruptions, in Browner BD, Jupiter JB, Levine AM, et al (eds) Skeletal trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, WB Saunders, 2003, pp1052-1108

2. Smith W, Williams A, Agudelo J, Shannon M, Morgan S, Stahel P, Moore E. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007 Jan;21(1):31-7. PMID:17211266 (Link to Abstract)

Question Authors:

Ben Taylor MD, Michael Hughes MD, Jan Szatkowski MD,

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(OBQ08.205) 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? Topic

Review Topic

1. L4 nerve root
2. L5 nerve root
3. S1 nerve root
4. Sacroiliac joint cartilage
5. External iliac artery

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996;10(3):171-7. PMID:8667109 (Link to Abstract)

2. Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000 Jun;(375):15-29. PMID:10853150 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Michael Hughes MD,

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(OBQ08.207) 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? Topic

Review Topic

FIGURES: A

1. Testicular torsion
2. Posterior urethral tear
3. Bladder denervation
4. Testicular rupture
5. Renal hematoma

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 243-257

2. Watnik NF, Coburn M, Goldberger M: Urologic injuries in pelvic ring disruptions. Clin Orthop Relat Res 1996;329:37-45 PMID:8769434 (Link to Abstract)

3. Routt ML, Simonian PT, Defalco AJ, Miller J, Clarke T. Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: a team approach. J Trauma. 1996 May;40(5):784-90. PMID:8614081 (Link to Abstract)

Question Authors:

Ben Taylor MD, Michael Hughes MD,

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(OBQ07.133) 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? Topic

Review Topic

1. lateral radiograph to clear the cervical spine
2. external fixator application to the left ankle in the operating room
3. external fixator application to the pelvis in the operating room
4. pelvic binder application
5. reduction and splinting of the right forearm

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005 Sep;59(3):659-64. PMID:16361909 (Link to Abstract)

2. Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am. 2002;84-A Suppl 2:43-7. PMID:12479338 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore,

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(OBQ05.98) 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? Topic

Review Topic

1. pubic symphysis
2. anterior sacroiliac ligaments
3. posterior sacroiliac ligaments
4. sacrospinous ligament
5. sacrotuberous ligament

PREFERRED RESPONSE ▶

DISCUSSION: An APC type 1 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%.

Incorrect answers:
1,2,4,5: An APC - 2 pelvic ring injury involves injury to all of these structures.

REFERENCES:

1. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology. 1986 Aug;160(2):445-51. PMID:3726125 (Link to Abstract)

2. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56. PMID:2381002 (Link to Abstract)

Question Authors:

Ben Taylor MD, Guillem Lomas MD, Ben Taylor MD,

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(OBQ05.213) 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? Topic

Review Topic

FIGURES: A

1. Pelvic external fixator
2. Open reduction and reconstruction plating of the symphysis
3. Protected weightbearing and binder as needed and observation
4. Open reduction and wiring of the symphysis
5. Symphysiotomy

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW. Parturition induced pelvic dislocation: A report of four cases. J Orthop Trauma 1997:11:277-281 PMID:9258826 (Link to Abstract)

Question Authors:

Greg Galano MD, Ben Taylor MD, Michael Hughes MD,

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(OBQ05.229) 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? Topic

Review Topic

1. External iliac artery
2. Obturator nerve
3. Corona mortis
4. L5 nerve root
5. Ilioinguinal nerve

PREFERRED RESPONSE ▶

DISCUSSION: 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. 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.

REFERENCES:

1. Atlihan D, Tekdemir I, Ates Y, Elhan A. Anatomy of the anterior sacroiliac joint with reference to lumbosacral nerves. Clin Orthop Relat Res. 2000 Jul;(376):236-41. PMID:10906881 (Link to Abstract)

2. Ebraheim NA, Padanilam TG, Waldrop JT, Yeasting RA. Anatomic consideration in the anterior approach to the sacro-iliac joint. Spine (Phila Pa 1976). 1994 Mar 15;19(6):721-5. PMID:8009340 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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(OBQ05.272) An anterior approach to the sacroiliac joint is indicated with which of the following concomitant injuries? Topic

Review Topic

1. Ipsilateral symphysis dislocation
2. Ipsilateral posterior wall acetabular fracture
3. Contralateral sacral ala fracture
4. Contralateral sacroiliac dislocation
5. L5-S1 retrolisthesis

PREFERRED RESPONSE ▶

DISCUSSION: An anterior approach to the sacroiliac joint is indicated with the presence of a symphysis dislocation, which can be reduced through the same approach. The other choices are all relative contraindications to this approach. A sacroiliac dislocation or malalignment can lead to gait abnormalities, pelvic obliquity, back or buttock pain, as well as neurological changes. The first referenced article by Simpson et al noted that an anterior approach was safe and that excellent results correlated significantly with anatomic reductions of the SI joint. The second reference discusses pelvic ring injuries in depth and covers typical treatment protocols.

REFERENCES:

1. Simpson LA, Waddell JP, Leighton RK, Kellam JF, Tile M. Anterior approach and stabilization of the disrupted sacroiliac joint. J Trauma. 1987 Dec;27(12):1332-9. PMID:3694724 (Link to Abstract)

2. Kellam JF, Fischer TJ, Tornetta P III: Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 177-190

Question Authors:

Ben Taylor MD,

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(OBQ04.60) 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? Topic

Review Topic

FIGURES: A

1. protected weight-bearing and pain control
2. open reduction and internal fixation
3. skeletal traction followed by open reduction and internal fixation
4. pelvic external fixation
5. pelvic external fixation followed by sacroiliac screws

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Kellam JF (ed): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 255-275

Question Authors:

Paul D. Kim MD, Derek Moore, Ben Taylor MD,

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(OBQ04.158) 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? Topic

Review Topic

1. Pubic rami
2. Posterior column
3. Anterior column
4. Sacroiliac joint
5. Quadrilateral plate

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Letournel, Judet: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993, pp 323-328

2. Matta JM. Fractures of the Acetabulum: Accuracy of Reduction and Clinical Results in Patients Managed Operatively within Three Weeks after the Injury. J. Bone Joint Surg. Am., Nov 1996; 78: 1632 - 45. PMID:8934477 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Michael Hughes MD,

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Cases

$http://upload.orthobullets.com/cases/1517/pelvic fracture.jpg$	Closed pelvic fracture with unilateral hip fracture dislocation (C1517) Trauma - Treatment Consult - Pelvic Ring Fractures HPI - High speed Motorbike injury. No loss of consciousness or head injury. Closed inj... How do you treat? Please state your views and reasoning behind it.	1 day ago 69 responses 4
	Open Pelvic Fracture with Moralle Lavalle injury over low back (C1506) Trauma - Treatment Consult - Pelvic Ring Fractures HPI - 23yr old female presented to the ER 8 hrs following MVA sustaining injury to her... How would you manage further ?	1 week ago 63 responses 3

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Atlihan D, Tekdemir I, Ates Y, Elhan A. Anatomy of the anterior sacroiliac joint with reference to lumbosacral nerves. Clin Orthop Relat Res. 2000 Jul;(376):236-41. PMID:10906881 (Link to Abstract)
Ebraheim NA, Padanilam TG, Waldrop JT, Yeasting RA. Anatomic consideration in the anterior approach to the sacro-iliac joint. Spine (Phila Pa 1976). 1994 Mar 15;19(6):721-5. PMID:8009340 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Matta JM. Fractures of the Acetabulum: Accuracy of Reduction and Clinical Results in Patients Managed Operatively within Three Weeks after the Injury. J. Bone Joint Surg. Am., Nov 1996; 78: 1632 - 45. PMID:8934477 (Link to Abstract)

Level of Evidence 4 (Case Series)

Spiguel L, Glynn L, Liu D, Statter M. Pediatric pelvic fractures: a marker for injury severity. Am Surg. 2006 Jun;72(6):481-4. PubMed PMID: 16808198. PMID:16808198 (Link to Abstract)
Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997 Nov;11(8):584-9. PMID:9415865 (Link to Abstract)
Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996;10(3):171-7. PMID:8667109 (Link to Abstract)
Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997 Nov;11(8):584-9. PMID:9415865 (Link to Abstract)
Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, Dunham CM, Gens D, Bathon H. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989 Jul;29(7):981-1000; discussion 1000-2. PMID:2746708 (Link to Abstract)
Smith W, Williams A, Agudelo J, Shannon M, Morgan S, Stahel P, Moore E. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007 Jan;21(1):31-7. PMID:17211266 (Link to Abstract)
Watnik NF, Coburn M, Goldberger M: Urologic injuries in pelvic ring disruptions. Clin Orthop Relat Res 1996;329:37-45 PMID:8769434 (Link to Abstract)
Routt ML, Simonian PT, Defalco AJ, Miller J, Clarke T. Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: a team approach. J Trauma. 1996 May;40(5):784-90. PMID:8614081 (Link to Abstract)
Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology. 1986 Aug;160(2):445-51. PMID:3726125 (Link to Abstract)
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56. PMID:2381002 (Link to Abstract)
Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW. Parturition induced pelvic dislocation: A report of four cases. J Orthop Trauma 1997:11:277-281 PMID:9258826 (Link to Abstract)
Simpson LA, Waddell JP, Leighton RK, Kellam JF, Tile M. Anterior approach and stabilization of the disrupted sacroiliac joint. J Trauma. 1987 Dec;27(12):1332-9. PMID:3694724 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Holden CP, Holman J, Herman MJ. Pediatric pelvic fractures. J Am Acad Orthop Surg. 2007 Mar;15(3):172-7. Review. PubMed PMID: 17341674. PMID:17341674 (Link to Abstract)
Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000 Jun;(375):15-29. PMID:10853150 (Link to Abstract)
Tile M. Acute Pelvic Fractures: II. Principles of Management. J Am Acad Orthop Surg. 1996 May;4(3):152-161. PMID:10795050 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Stover MD, Mayo KA, Kellam JF. Pelvic ring disruptions. In: Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettek C, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction,, 4th ed. Philadelphia, PA: WB Saunders; 2009:1107-1170.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Springer-Verlag, 1993, pp 29-61.
Kellam JK, Mayo KA: Pelvic ring disruptions, in Browner BD, Jupiter JB, Levine AM, et al (eds) Skeletal trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, WB Saunders, 2003, pp1052-1108
Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 243-257
Kellam JF, Fischer TJ, Tornetta P III: Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 177-190
Letournel, Judet: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993, pp 323-328

Undefined

Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997 Nov;11(8):584-9. PMID:9415865 (Link to Abstract)
Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000 Jun;(375):15-29. PMID:10853150 (Link to Abstract)
Barei DP, Bellabarba C, Mills WJ, Routt ML Jr. Percutaneous management of unstable pelvic ring disruptions. Injury. 2001 May;32 Suppl 1:SA33-44. PMID:11521704 (Link to Abstract)
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56. PMID:2381002 (Link to Abstract)
Tile M. Acute pelvic fractures: I. Causation and Classification. J Am Acad Orthop Surg. 1996 May;4(3):143-151. PMID:10795049 (Link to Abstract)
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56. PMID:2381002 (Link to Abstract)
Tile M. Acute Pelvic Fractures: I. Causation and Classification. J Am Acad Orthop Surg. 1996 May;4(3):143-151. PMID:10795049 (Link to Abstract)
Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am. 2002;84-A Suppl 2:43-7. PMID:12479338 (Link to Abstract)
Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005 Sep;59(3):659-64. PMID:16361909 (Link to Abstract)
Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB. Noninvasive reduction of open-book pelvic fractures by circumferential compression. J Orthop Trauma. 2002 Jul;16(6):367-73. PMID:12142823 (Link to Abstract)
Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma. 2002 Jan;16(1):45-8. PMID:11782633 (Link to Abstract)
Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009 Jul;17(7):447-57. PMID:19571300 (Link to Abstract)
Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, Cocanour CS, Balldin BC, McKinley BA. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007 Jan;62(1):112-9. PMID:17215741 (Link to Abstract)
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 389-397
Griffin DR, Starr AJ, Reinert CM: Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: Does posterior injury pattern predict fixation failure? J Orthop Trauma 2006;20:S30-S36 PMID:16385205 (Link to Abstract)
Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA. Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop Relat Res. 2005 Aug;(437):164-8. PMID:16056045 (Link to Abstract)
Riina J, Tornetta P 3rd, Ritter C, Geller J. Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails. J Orthop Trauma. 1998 Aug;12(6):379-81. PMID:9715443 (Link to Abstract)
Gardner MJ, Nork SE. Stabilization of unstable pelvic fractures with supraacetabular compression external fixation. J Orthop Trauma. 2007 Apr;21(4):269-73. PMID:17414555 (Link to Abstract)
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008.
Griffin DR, Starr AJ, Reinert CM, Jones AL, Whitlock S. Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure? J Orthop Trauma. 2006 Jan;20(1 Suppl):S30-6; discussion S36. PMID:16385205 (Link to Abstract)
Baumgaertner MR, Tornetta P III, (eds): Orthopaedic Knowledge Update: Trauma 3, 2005 pp 233-241
Sagi HC, Ordway NR, DiPasquale T. Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating. J Orthop Trauma. 2004 Mar;18(3):138-43. PMID:15091266 (Link to Abstract)
Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996;10(3):171-7. PMID:8667109 (Link to Abstract)
Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res. 2000 Jun;(375):15-29. PMID:10853150 (Link to Abstract)
Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005 Sep;59(3):659-64. PMID:16361909 (Link to Abstract)
Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am. 2002;84-A Suppl 2:43-7. PMID:12479338 (Link to Abstract)
Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB. Noninvasive reduction of open-book pelvic fractures by circumferential compression. J Orthop Trauma. 2002 Jul;16(6):367-73. PMID:12142823 (Link to Abstract)
Kellam JF (ed): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 255-275

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Pelvic Ring Fractures

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