Pelvic Fracture Treatment- An Overview

 

Introduction

• Pelvic fractures account for less than 5 percent of all skeletal injuries.

• They are clinically significant due to the high risk of severe hemorrhage.

• Approximately 10 percent of patients have associated visceral injuries, with an overall mortality rate of about 10 percent.

• In patients younger than 35 years, pelvic fractures are more commonly seen in females than males.

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Surgical Anatomy

• The pelvic ring consists of two innominate bones and the sacrum.

• Anterior articulation occurs at the symphysis pubis, while posterior articulation occurs at the sacroiliac joints.

• The pelvic ring transmits body weight from the trunk to the lower limbs.

• It also provides protection to pelvic viscera, major blood vessels, and neural structures.

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Pelvic Stability

• Anterior pelvic stability is primarily provided by the sacroiliac ligaments and the iliolumbar ligaments.

• Posterior pelvic stability is maintained by:

  • Posterior sacroiliac ligaments

  • Sacrococcygeal ligaments

  • Sacrotuberous ligaments

  • Sacrospinous ligaments

• Stability at the symphysis pubis is provided by the superior pubic ligament and the arcuate pubic ligament.

• Major branches of the common iliac arteries and veins course within the pelvis between the level of the sacroiliac joint and the greater sciatic notch.

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Clinical Assessment

• A pelvic fracture should be suspected in any patient with multiple traumatic injuries.

• Clinical signs may include swelling and bruising of:

  • Lower abdomen

  • Thighs

  • Perineum

  • Scrotum or vulva

• Abdominal guarding or tenderness suggests possible intraperitoneal bleeding.

• Repeated manipulation or assessment of an unstable pelvis can disrupt formed clots and worsen hemorrhage.

• Bladder rupture should be suspected in patients who do not void or in whom the bladder is not palpable after adequate fluid resuscitation.

• Bladder rupture may be intraperitoneal or extraperitoneal.

  • Intraperitoneal rupture may be associated with massive hemorrhage.

• A detailed neurological examination is required to assess potential injury to the lumbosacral plexus.

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Imaging Evaluation

• An anteroposterior radiograph of the pelvis should be systematically evaluated by dividing the pelvis into 5 zones:

  1. Sacroiliac joint region for diastasis or sacral fracture

  2. Ilium for fractures

  3. Teardrop region, representing the non-articular floor of the acetabulum, for acetabular fractures

  4. Obturator foramen for superior or inferior pubic ramus fractures

  5. Symphysis pubis for fracture or diastasis

• Inlet view

  • Provides an axial view of the sacrum and sacroiliac joints

• Outlet view

  • Provides a true anteroposterior view of the sacrum and pubic symphysis

• Judet views

  • Obtained at 30 degrees obliquity

  • Obturator oblique view demonstrates the anterior column of the acetabulum

  • Iliac oblique view demonstrates the posterior column and anterior wall of the acetabulum

• Six radiographic lines assist in diagnosing acetabular fractures:

  1. Anterior wall of the acetabulum

  2. Posterior wall of the acetabulum

  3. Roof or dome of the acetabulum

  4. Iliopectineal line, corresponding to the anterior column

  5. Ischiopectineal line

  6. Teardrop

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Mechanism of Injury

• Pelvic fractures are broadly classified based on energy transfer:

Low-Energy Injuries

• Sudden muscular contractions causing avulsion injuries in young athletes

• Low-energy falls

• Saddle-type injuries, such as those sustained during motorcycle riding or horse riding

High-Energy Injuries

• Motor vehicle collisions

• Pedestrian struck injuries

• Motorcycle accidents

• Falls from height

• Crush injuries

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Stress Fractures of the Pelvis

• Pubic ramus fractures are common in osteoporotic bone.

• Magnetic resonance imaging is useful for diagnosing posterior pelvic insufficiency fractures.

• Stress fractures may be seen in the superior and inferior pubic rami, particularly in slim individuals and long-distance runners.

• Patients typically present with groin pain lasting weeks to months.

• Initial radiographs may be normal, with fractures becoming more apparent during callus formation.

• Vitamin D levels should be evaluated to exclude deficiency.

• Most patients heal with rest and activity modification.

• Rarely, painful nonunion may persist and require surgical intervention.

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Classification of Pelvic Ring Injuries

• Pelvic fractures are commonly classified using:

  • Young and Burgess classification, based on mechanism of injury

  • Tile classification, based on pelvic stability

• The mechanism-based classification predicts injury severity and blood loss.

• Stability-based classification guides the need for operative fixation.

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Young and Burgess Classification

Anteroposterior Compression Injuries

• Caused by a front-on force transmitted through the pelvis.

• Initial injury occurs at the symphysis pubis, followed by posterior sacroiliac disruption with increasing force.

• Common in motorcyclists and horse riders.

• Associated with external rotation of both hemipelves.

• Anteroposterior Compression Type 1

  • Symphyseal widening less than 2.5 centimeters

• Anteroposterior Compression Type 2

  • Symphyseal widening greater than 2.5 centimeters with anterior sacroiliac joint widening

  • Posterior sacroiliac ligaments remain intact

• Anteroposterior Compression Type 3

  • Symphyseal widening greater than 2.5 centimeters with complete sacroiliac joint disruption

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Lateral Compression Injuries

• Most common mechanism of pelvic injury.

• Result from force applied from the side of the pelvis.

• Common in pedestrians struck by vehicles and side-impact collisions.

• Lateral Compression Type 1

  • Pubic ramus fracture with ipsilateral anterior sacral alar fracture

• Lateral Compression Type 2

  • Pubic ramus fracture with ipsilateral posterior iliac fracture dislocation

• Lateral Compression Type 3

  • Ipsilateral lateral compression injury with contralateral anteroposterior compression pattern, also known as a windswept pelvis

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Vertical Shear Injuries

• Usually occur after a fall from height landing on one leg.

• Characterized by vertical displacement of one hemipelvis.

• Involve complete disruption of:

  • Symphysis pubis

  • Sacrotuberous ligaments

  • Sacrospinous ligaments

  • Sacroiliac ligaments

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Tile Classification

• Assesses pelvic stability and guides treatment decisions.

• Type A

  • Stable pelvic fractures

• Type B

  • Rotationally unstable but vertically stable fractures

• Type C

  • Rotationally and vertically unstable fractures

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Pelvic Binders

• Pelvic binders should be applied at the level of the greater trochanters, not at the iliac crest.

• They reduce pelvic volume and provide temporary stabilization.

• Ideally, binders should not be left in place for more than 24 hours due to the risk of pressure sores.

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Angiography and Embolization

• Immediate transfer for angiography is indicated in ongoing hemorrhage.

• Selective embolization effectively controls arterial bleeding.

• Common bleeding sources include the internal iliac artery and superior gluteal artery.

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Preperitoneal Pelvic Packing

• An external fixator is applied initially.

• The pelvis is accessed using the Stoppa approach.

• The rectus abdominis muscle is divided in the midline.

• At least 6 large abdominal packs are inserted:

  • 3 on each side of the midline

  • Positioned posteriorly, mid-pelvis, and anteriorly

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Nonoperative Management

Indications

• Most lateral compression type 1 and anteroposterior compression type 1 injuries

Relative Indications for Surgery

• Symphyseal widening greater than 2.5 centimeters

• Leg-length discrepancy greater than 1.5 centimeters

• Rotational deformity

• Sacral displacement greater than 1 centimeter

• Intractable pain

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External Fixation

• Commonly used as a temporary stabilization method.

• Can serve as definitive fixation for anterior pelvic injuries.

• Typically involves insertion of 2 to 3 pins of 5 millimeters diameter along the anterior iliac crest.

• Supra-acetabular pin placement in the anteroposterior direction may be used, known as the Hanover frame.

• Contraindicated in acetabular fractures and iliac wing fractures.

• Vertically unstable fractures may require ipsilateral distal femoral skeletal traction.

• Temporary posterior stabilization devices, such as the Ganz clamp or Browner fixator, may be used during resuscitation.

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Internal Fixation

• Symphyseal diastasis is treated with plate fixation if there is no open injury or cystostomy tube.

• Sacral fractures may be treated with plate fixation or sacroiliac screw fixation.

• Iliac wing fractures are treated with open reduction and internal fixation using lag screws and neutralization plates.

• Unilateral sacroiliac dislocations are treated with cancellous screw fixation or anterior sacroiliac plating.

• Bilateral posterior instability requires fixation of the displaced hemipelvis to the sacral body using posterior screw fixation.

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Treatment Based on Tile Classification

• Type A

  • Protected weight bearing and symptomatic treatment

• Type B1 (Open book injuries)

  • Symphyseal diastasis up to 2 centimeters managed with external fixation or symphyseal plating

• Type B2 and B3 (Lateral compression injuries)

  • Ipsilateral injuries usually require no stabilization

  • Contralateral bucket-handle injuries with leg-length discrepancy greater than 1.5 centimeters require external fixation or open reduction and internal fixation

• Type C

  • Managed with external fixation with or without skeletal traction, or definitive open reduction and internal fixation

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Bowel Injury

• Rectal or anal perforations caused by bony fragments are considered open fractures and treated accordingly.

• Rarely, bowel entrapment at the fracture site may cause gastrointestinal obstruction.

• Presence of bowel injury mandates diverting colostomy.

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Postoperative Care

• Aggressive pulmonary care with incentive spirometry should be initiated early.

• Early mobilization is encouraged where stability permits.

• Thromboembolism prophylaxis includes:

  • Elastic stockings

  • Sequential compression devices

  • Pharmacological prophylaxis when hemodynamically appropriate

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Complications

• Infection rates range from 0 to 25 percent.

• Thromboembolic events

• Malunion, which is rare

• Nonunion, rare and more commonly seen in young patients

Mortality

• Hemodynamically stable patients: approximately 3 percent

• Hemodynamically unstable patients: approximately 38 percent

• Lateral compression injuries: head injury is the most common cause of death

• Anteroposterior compression injuries: pelvic and visceral injuries are the leading causes of death

• Vertical shear injuries: mortality rate approximately 25 percent