Summary Pelvic ring fractures are high energy fractures of the pelvic ring which typically occur due to blunt trauma. Diagnosis is made radiographically with pelvic radiographs and further characterized with CT scan. Treatment is typically operative fixation depending on degree of pelvis instability, fracture displacement and patient activity demands. Etiology Associated injuries orthopaedics login to view 3 more bullets non-orthopaedic login to view 3 more bullets Pediatric pelvic ring fractures children with open triradiate cartilage have different fracture patterns than do children whose triradiate cartilage has closed login to view 2 more bullets 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 login to view 1 more bullet Ligaments anterior login to view 2 more bullets pelvic floor login to view 4 more bullets posterior sacroiliac complex (posterior tension band) login to view 10 more bullets Vascular common iliac system begins near L4 at bifurcation of abdominal aorta login to view 2 more bullets corona mortis is a connection between the obturator and and external iliac systems login to view 1 more bullet venous plexus in posterior pelvis accounts for 90% of the hemorrhage associated with pelvic ring injuries Neurologic Lumbosacral trunk crosses anterior sacral ala and SI joint L5 nerve root exits below L5 TP a courses over sacral ala 2cm medial to SI joint Classification Tile classification 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 Anterior Posterior Compression (APC) APC I Symphysis widening < 2.5 cm APC II Symphysis widening > 2.5 cm. Anterior SI joint diastasis. Posterior SI ligaments are intact. Disruption of sacrospinous and sacrotuberous ligaments. APC III Disruption of anterior and posterior SI ligaments (SI dislocation). Disruption of sacrospinous and sacrotuberous ligaments. APCIII associated with vascular injury Lateral Compression (LC) LC I Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture. LC II Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture). LC III Ipsilateral lateral compression and contralateral APC (windswept pelvis). Common mechanism is rollover vehicle accident or pedestrian vs auto. Vertical Shear (VS) Vertical shear Posterior and superior directed force. Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25% Physical Exam Symptoms pain & inability to bear weight Physical exam inspection login to view 6 more bullets skin login to view 4 more bullets neurologic exam login to view 3 more bullets urogenital exam login to view 2 more bullets vaginal and rectal examinations login to view 1 more bullet Imaging Radiographs recommended views login to view 24 more bullets findings login to view 4 more bullets 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 radiographic signs of sacral dysmorphism: login to view 4 more bullets Studies Serum labs hgb serum lactate base excess Initial Management & Resusitation Bleeding Source intraabdominal (present in up to 40% of cases) intrathoracic retroperitoneal extremity (thigh compartments) pelvic login to view 10 more bullets Treatment resuscitation login to view 2 more bullets pelvic binder/sheet login to view 9 more bullets external fixation login to view 7 more bullets angiography / embolization login to view 12 more bullets Definitive Treatment Overview by Classification Definitive treatment of Anterior Posterior Compression (APC) injuries APC I Non-operative. Protected weight bearing APC II Anterior symphyseal plate or external fixator +/- posterior fixation APC III Anterior symphyseal multi-hole plate or external fixator and posterior stabilization with SI screws or plate/screws Definitive treatment of Lateral Compression (LC) injuries LC I Majority non-operative.-Protected weight bearing (complete, comminuted sacral component.-Weight bearing as tolerated (simple, incomplete sacral fracture) -Posterior stabilization in unstable fractures results in decreased short-term pain LC II Open reduction and internal fixation of ilium LC III Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference. Definitive treatment of Vertical Shear (VS) injuries Vertical Shear Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference. Nonoperative weight bearing as tolerated login to view 9 more bullets Operative ORIF login to view 9 more bullets anterior subcutaneous pelvic fixator (INFIX) login to view 4 more bullets diverting colostomy login to view 3 more bullets Techniques Pelvic Binding technique login to view 7 more bullets early pelvic binding and CT have been associated with underestimation of pelvic ring instability login to view 1 more bullet External fixation theoretically works by decreasing pelvic volume stability of bleeding bone surfaces and venous plexus in order to form clot pins inserted into ilium login to view 14 more bullets ORIF anterior ring stabilization login to view 3 more bullets posterior ring stabilization login to view 13 more bullets anterior and posterior ring stabilization login to view 1 more bullet ipsilateral acetabular and pelvic ring fractures login to view 1 more bullet Rehabilitation stable fractures treated nonsurgically login to view 1 more bullet unstable fractures treated surgically login to view 4 more bullets Complications Urogenital Injuries present in 12-20% of patients with pelvic fractures login to view 1 more bullet includes login to view 5 more bullets diagnosis login to view 5 more bullets treatment login to view 4 more bullets complications login to view 6 more bullets Neurologic injury L5 nerve root runs over sacral ala joint may be injured if SI screw is placed to anterior anterior subcutaneous pelvic fixator may give rise to LFCN injury (most common) or femoral nerve injury DVT and PE DVT in ~ 60%, PE in ~ 27%, fatal PE in 2% prophylaxis essential login to view 3 more bullets Chronic instability rare complication; can be seen in nonoperative cases presents with subjective instability and mechanical symptoms diagnosed with alternating single-leg-stance pelvic radiographs (flamingo views) Infection risk factors include: login to view 8 more bullets Prognosis High prevalence of poor functional outcome due to chronic pain and/or sexual dysfunction 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 Mortality rate 1-15% for closed fractures, as much as 50% for open fractures hemorrhage is leading cause of death overall login to view 1 more bullet increased mortality associated with login to view 5 more bullets