Evaluation and Management of Pelvic Fracture Emergencies

Avulsion fractures

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  Caused by violent contraction of muscles

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  Types of fractures and specific muscles involved

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    Anterior superior iliac spine: Sartorius muscle

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    Anterior inferior iliac spine: Rectus femoris

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    Pubis: Adductor longus

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    Part of the ischium: hamstrings (Biceps femoris, semimembranosus, semitendinosous)

Direct fractures

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  Caused by local injury

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  Types

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    Fracture of the iliac blade

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    Fracture of the ischium

Fractures of the pubic rami in osteoporosis

Anteroposterior compression (APC) fractures (open book fracture of the pelvis)

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  APC I

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    Pubic symphysis diastasis <2.5 cm

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    No sacro-iliac (SI) joint diastasis due to intact anterior and posterior SI joints ligaments.

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    Stable fracture

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  APC II

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    Pubic symphysis diastasis >2 cm

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    Diastasis of one or both anterior SI joint due to disruption of anterior SI joint ligaments causing SI joints rotational instability

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    Intact posterior SI ligaments. Disruption of sacrospinous and sacrotuberous ligaments. No vertical instability.

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    High incidence of vascular injury with hemodynamic instability

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    Unstable fracture

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  APC III

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    Complete disruption of both anterior and posterior SI ligaments causing SI joint dislocation. Disruption of sacrospinous and sacrotuberous ligaments

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    High incidence of vascular injury with hemodynamic instability

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    Vertically and rotationally unstable pelvic fracture

Lateral compression (LC) fractures

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  LC I

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    Ipsilateral horizontal pubic rami fractures

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    Ipsilateral sacral ala fracture

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    Less common: disruption of pubic symphysis with overlap of pubic bones

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    Intact posterior ligaments

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    Stable fracture

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  LC II

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    Internal rotation of the hemipelvis

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    Pubic rami fracture associated with ipsilateral iliac wing fracture or disruption of the ipsilateral posterior SI joint

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    Severely unstable injury associated with soft tissue injuries, intraabdominal injuries, and retroperitoneal hemorrhage

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    Rotationally unstable, vertically stable pelvis

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  LC III

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    Type I or II injury with internal rotation of pelvis and external rotation of contralateral pelvis on the side of the injury

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    May have contralateral vertical pubic rami fractures or disruption of the ligaments

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    Rotationally unstable pelvis, vertically stable pelvis

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    Associated with soft tissue injuries, intraabdominal injuries, and retroperitoneal hemorrhage

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    Unstable injury

Vertical shear (VS) fractures

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  Anterior vertically oriented fractures of the pubic rami

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  Vertical displacement of the innominate bone (hemipelvis) on one side with fracture of the pubic rami

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  Disruption of the SI joint ligaments on the side of the displaced hemipelvis

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  Occasional disruption of contralateral SI joint ligaments

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  Associated with soft-tissue injuries, intraabdominal injuries, and retroperitoneal hemorrhage

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  Unstable fracture

Combination mechanism (CM) fractures

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  Combination of any injury patterns

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  Results in severe injury

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  Associated with soft tissue, intraabdominal, and vascular injuries

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  Associated with hemodynamic instability

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  Unstable fracture

Type A: Stable fractures

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  A1: Fractures of the pelvis not involving the ring

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  A2: Minimally displaced fractures of the ring

–Type B: Rotationally unstable, vertically stable

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  B1: Open book

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  B2: Lateral compression; ipsilateral

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  B3: Lateral compression; contralateral (bucket handle)

Type C: Rotationally and vertically unstable

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  C1: Rotationally and vertically unstable

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  C2: Bilateral injury

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  C3: Associated with an acetabular fracture

Both columns (anterior and posterior) fracture

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  Most common acetabular fracture

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  Fracture pattern

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    Disruption of obturator ring

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    Extension of fracture line into the iliac wing

T-shaped fracture

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  Fracture pattern

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    Disruption of obturator ring

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    No extension of fracture line into the iliac wing

Transverse fracture with posterior wall involvement

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  Fracture pattern

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    No disruption of obturator ring

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    Disruption of ilioischial and ischiopectineal line

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    Fracture of the posterior wall

Transverse fracture

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  Fracture pattern

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    No disruption of obturator ring

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    Disruption of ilioischial and ischiopectineal line

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    No fracture of the posterior wall

Isolated posterior wall fracture

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  No disruption of obturator ring

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  No disruption of ilioischial and ischiopectineal line

AO classification of sacral injuries

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  Type A: Lower sacrococcygeal injuries

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  Type B: Posterior pelvic injuries

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  Type C: Spinopelvic injuries

Denis classification

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  Commonly used

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  Types

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    Zone 1: Fracture of involves the sacral ala lateral to the neural foramina

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    Zone 2: Fracture of the sacrum involving the neural foramina (but not the spinal canal)

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    Zone 3: Fracture of the sacrum medial to the neural foramen involving the spinal canal

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      Fracture lines may be transverse or longitudinal.

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      Subclassified into four types

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        Type 1: Only kyphotic angulation at the fracture site, no displacement of the fracture fragments

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        Type 2: Kyphotic angulation with anterior displacement of the distal sacrum

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        Type 3: Kyphotic angulation with complete displacement of the fracture fragments

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        Type 4: Comminuted S1 segment, usually caused by axial compression

Isler classification

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  Used for fractures involving the lumbosacral articulation

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  Isler 1: Fracture lateral to the L5-S1 facet

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  Isler 2: Fracture involving the L5-S1 facet

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  Isler 3: Fracture medial to the L5-S1 facet

Abdominal aorta bifurcates into the two common iliac arteries at the L4-L5 vertebra level.

Ureters cross anterior to the bifurcation of the common iliac artery.

Common iliac artery divides into the external and internal (hypogastric) iliac arteries.

Internal iliac artery divides into the anterior and posterior branches at the level of the greater sciatic foramen.

Superior gluteal artery

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  Branch from the posterior division of the internal iliac artery

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  Most common source of arterial bleeding in pelvic fractures

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  Gives off the iliolumbar and lateral sacral arteries

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  Exits the pelvis through the greater sciatic notch

Branches of the anterior division of the internal iliac artery

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  Superior vesical artery

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  Obturator artery: Courses along the lateral pelvic wall and exits the pelvis through the obturator canal

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  Inferior vesical artery

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  Middle rectal artery

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  Internal pudendal artery

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    Source of bleeding in anterior ring fracture

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    Passes through the greater sciatic foramen, courses around the sciatic spine, and enters the perineum through the lesser sciatic foramen

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  Inferior gluteal artery

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  Median sacral artery (middle sacral artery): A branch from the posterior aspect of the abdominal aorta superior to its bifurcation

External iliac artery

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  Becomes the femoral artery posterior to the inguinal ligament

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  Branches

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    Inferior epigastric artery

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    Deep circumflex artery