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Updated: May 25 2021

Ilium Fractures

Images - AP pelvis - Displaced Ilium fx_moved.jpg pelvis 1f.jpg
  • Summary
    • Ilium fractures are high energy pelvic fractures that are often unstable and typically progress from the iliac crest to the greater sciatic notch.
    • Diagnosis can made with pelvis radiographs but frequently require pelvic CT scan for full characterization.
    • Treatment may be nonoperative or operative depending on fracture displacement, associated pelvic ring instability and patient activity demands.
  • Epidemiology
    • Associated injuries
      • 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
        • 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
  • Techniques
    • Wound Management
      • 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
        • percutaneous screws and reduction techniques possible as well 
        • 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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