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Ilium Fractures

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Topic updated on 04/25/14 11:28pm
Introduction
  • Most are unstable fractures
  • Typically progress from iliac crest to greater sciatic notch
  • Iliac wing fractures have high incidence of associated injuries
    • open injuries 
    • bowel entrapment
    • soft tissue degloving
Anatomy
  • Osteology
    • pelvic girdle is comprised of 
      • sacrum
      • 2 innominate (coxal) bones 
        • each formed from the union of 3 bones: ilium, ischium, and pubis
    • ilium
      • 2 important anterior prominences
        • anterior-superior iliac spine (ASIS)
          • origin of sartorius and transverse and internal abdominal muscles
        • anterior-inferior iliac spine (AIIS)
          • origin of direct head of rectus femoris and iliofemoral ligament (Y ligament of Bigelow)
      • posterior prominences
        • posterior-superior iliac spine (PSIS)
          • located 4-5 cm lateral to the S2 spinous process
        • posterior-inferior iliac spine (PIIS)
Imaging
  • Plain radiographs
    • standard set of AP pelvis, inlet/outlet, and judet views 
      • helpful for evaluating the iliac wing in addition to pelvic stability and possible acetabular involvement
  • CT scan
    • carefully assess CT scan for signs of bowel entrapment
    • evaluate for presence of gas or air in the soft tissues which can be associated with open injury or bowel disruption
Classification
  • No specific classification for iliac wing fractures
  • Generally described as specific subtypes of more common classification systems
    • Tile Classification 
      • stable (intact posterior arch)
        • A1-1: iliac spine avulsion injury
        • A1-2: iliac crest avulsion
        • A2-1: iliac wing fractures often from a direct blow
      • partially stable (incomplete disruption of posterior arch)
        • B2-3: incomplete posterior iliac fracture
      • unstable (complete disruption of posterior arch)
        • C1-1: unilateral iliac fracture
Treatment
  • Nonoperative
    • mobilization with an assist device
      • indications
        • nondisplaced fractures
        • isolated iliac wing fractures
  • Operative
    • open reduction and internal fixation
      • indications
        • displaced fractures of ilium
Operative Techniques
  • Wound Mangement
    • evaluate all wounds for 
      • soft tissue disruption or internal degloving injury
      • possible soft tissue or bowel entrapment in the fracture site
    • prophylactic antibiotics as appropriate 
    • serial debridements as necessary
  • Open Reduction Internal Fixation
    • approach
      • posterior approach 
      • ilioinguinal approach  
      • Stoppa approach (lateral window) 
    • recommend early reconstruction
      • single pelvic reconstruction plate or lag screw along the iliac crest
      • supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim or sciatic buttress
    • coordination with trauma team
      • injury to bowel may require diversion procedures
      • plan surgical intervention with trauma team to minimize recurrent trips to the operating room
Complications
  • Malunion with deformity of the iliac wing
  • Internal iliac artery injury
  • Bowel perforation
  • Lumbosacral plexus injury

 

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