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Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries

Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries. Robert M. Harris MD Medical Director of Orthopaedic Trauma Mountain States Health Alliance East Tenn State University Quillen School of Medicine Revised November 2010 Created March 2004 Revised April 2007

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Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries

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  1. Anatomy, Radiographic Evaluation, and Classification of Pelvic Ring Injuries Robert M. Harris MD Medical Director of Orthopaedic Trauma Mountain States Health Alliance East Tenn State University Quillen School of Medicine Revised November 2010 Created March 2004Revised April 2007 By Kyle Dickson MD

  2. Pelvic Ring Disruption • Marker for severe injury • Overall mortality 6-10% • Life threatening

  3. Magnitude of Forces • ACL injury 500-1000N • LC-I pelvic fracture 6000-9000N

  4. Bone Anatomy • Two innominate bones with sacrum. • Coalesce at triradiate cartilage. • Ilium, ishium and pubis have three separate ossification centers that fuse at sixteen years. • Gap in symphysis < 5 mm • SI joint 2-4 mm

  5. Ligamentous Anatomy • Ligaments - posterior ligaments are stronger than anterior ligaments: • Posterior SI • Anterior SI • Interosseous ligaments • Pubic symphysis • Sacrotuberous • Sacrospinous

  6. ANATOMY Ligamentous ASI PSI ST SS ST

  7. Posterior Ligaments • Ant. SI Joint – resist external rotation • Post. SI and Interosseous – posterior stability by tension band (strongest in body) • Iliolumbar ligaments augments posterior complex • Sacrotuberous (sacrum behind sacro-spinous into ischial tuberosily vertically)Resists shear and flexion of SI joint • Sacrospinous – (anterior sacral body to ischial spine horizontally) resists external rotation

  8. Normal SI Joint Motion with Gait • < 6 mm of translation • < 6° rotation • Intact cadaver resist 5,837 N (1,212 lbs)

  9. ANATOMY Relationships

  10. Vascular Anatomy • Internal iliac artery courses medial to the vein, splits into anterior and posterior branches. • Posterior branch is more likely injured (SGA is largest branch). • Usual bleeding is from venous plexus.

  11. Potentially Damaged Visceral Anatomy • Blunt vs. impaled by bony spike • Bladder/urethra • Rectum • Vagina

  12. Pelvic Stability • Strength of ring: 40% anterior and 60% posterior. • Vsphere = 4/3r³. • Stability – ability of pelvic ring to withstand physiologic forces without abnormal deformation

  13. IDENTIFY THE HIGH RISK PELVIC DISRUPTION By Radiography By Physical Exam

  14. Physical Exam • Physical Exam-poor sensitivity (8%) for mechanically unstable pelvis fractures in blunt trauma patients • Shlamovitz GZ, Mower WR, Morgan MT-Journal of Trauma Mar 09

  15. Radiographs • Anteroposterior (AP) • Inlet (40° caudad) • Outlet (40 ° cephalad) • CT scan • Judet (acetabular fractures)

  16. AP VIEW If evidence of pelvic ring fracture...

  17. INLET VIEW

  18. Inlet (Caudad) View • Horizontal Plane Rotation • Posterior Displacement • Sacral ala

  19. OUTLET VIEW

  20. Outlet (Cephalad) View • Sacrum • Cephalad Displacement • Sacral Foramina

  21. CT Scan • Better defines posterior injury • Amount of displacement versus impaction • Rotation of fragments • Amount of comminution • Assess neural foramina

  22. CT SCAN

  23. 3D CT

  24. Radiographic Signs of Instability • Sacroiliac displacement of 5 mm in any plane • Posterior fracture gap (rather than impaction) • Avulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament)

  25. Translational Deformities • X axis – Diastasis or impaction • Y axis – Caudad or cephalad displacement • Z axis – Anterior or posterior displacement

  26. Rotational Deformities • X axis – Flexion or extension • Y axis – Internal rotation or external rotation • Z axis – Abduction or adduction

  27. Classification • Aids in predicting hemodynamic instability • Aids in predicting visceral and g.u. injuries • Aids in predicting pelvic instability • Aids in understanding mechanism of injury, force vector of injury, and surgical tactic for reduction

  28. Classification Systems • Anatomical (Letournel) • Stability & Deformity (Pennal, Bucholz, Tile) • Vector force and associated injuries (Young & Burgess) • OTA-research

  29. Anatomical Classification(Letournel) Where The Pelvis Breaks

  30. Rami fractures Symphyseal disruption Iliac wing fracture Iliac wing/sacroiliac (SI) joint (crescent fracture) SI joint Sacrum/SI joint Sacrum fracture Anterior Posterior

  31. Magnitude and direction of forces Lateral posterior compression (LC) Anterior posterior compression (APC) Vertical shear (VS) Added stability to the classification Pennal, 1961 Bucholz, 1981 Tile, 1988

  32. Tile Classification • Type A: Stable fracture. • Type B: Rotationally unstable, but vertically stable. • Type C: Rotationally and vertically unstable.

  33. OTA/AO – Pelvic Injury Classification • 61A – Lesion sparing (or with no displacement of ) posterior arch • B – Incomplete disruption at posterior arch; partially stable • C – Complete disruption of posterior arch; unstable

  34. A Fractures – Ring Intact • A-1 – Fracture of innominate bone; avulsion • A-2 – Fracture of innominate bone; direct blow • A-3 – Transverse fracture of sacrum and coccyx

  35. B-Ring Injury – Partially stable • B-1 – Unilateral partial disruption of posterior arch, external rotation (“open book” injury) • B-2 – Unilateral, partial disruption of posterior arch, internal rotation (lateral compression injury) • B-3 – Bilateral, partial lesion of posterior arch

  36. C – Complete Disruption Posterior Arch, Unstable Pelvis • C-1 – Unilateral, complete disruption of posterior arch • C-2 – Bilateral, ipsilateral complete, contralateral incomplete • C –3 – Bilateral, complete disruption

  37. Young-Burgess Radiology 1986 • Based on mechanism of injury • Predictive of associated local & distant injury • Useful for planning acute treatment

  38. MECHANISM OF INJURY (MOI) • Do initial radiographs agree with MOI in pelvic ring disruptions- Linnau KF, Blackmore CC, Routt ML, Mock CN-J Ortho Trauma Jul 2007 • more reliable for LC than AP mechanisms

  39. MECHANISM OF INJURY • Lateral compression(implosion) • AP compression(external rotation) • Vertical shear • Combined injury

  40. Young-Burgess Classification • LATERAL COMPRESSION fracture of anterior ring plus: • LC -I Compression fracture of anterior sacrum • LC -II Iliac wing fracture posteriorly (unstable) • LC -III Windswept pelvis (contralateral SI injury) • ANTERIOR-POSTERIOR COMPRESSION • APC - I Partial disruption • APC - II Posterior sacroiliac ligaments intact • APC - III Posterior sacroiliac ligaments disrupted • VERTICAL SHEAR cephlad and posterior displacement • COMBINED MECHANISM (LC & VS most common)

  41. CLASSIFICATION Mechanism and direction of injury

  42. DISRUPTED PELVIC RING • Posterior/SI injury is a marker for associated vascular injuries • Tamponade efforts and fluid resuscitation may be rendered useless

  43. Resuscitation • Young and Burgess classification: • LC III • APC II • APC III • VS • CM

  44. RESUSCITATION REQUIREMENTS units blood 1st 24 hours

  45. Mortality Deaths:

  46. Interobserver Reliability of the Young/Burgess and Tile classifications • Koo H, Leveridge M, McKee,MD, Schemitsch EH, J Ortho Trauma Jul 2008 • Young/Burgess –Kappa .72-better for the training surgeon • CT-improved assessment of stability • Furey AJ, O”Toole RV, Turen C, Ortho June 2009 • Interobserver – moderate degree of agreement • Intraobserver- moderate for Tile • Substantial for Burgess

  47. LATERAL COMPRESSION LC I: Sacral compression

  48. Lateral Compression • Most common pattern. • LC1 – stable, load to posterior ring. • LC2 – load to anterior ring, posterior ligaments injured, ST and SS intact. • LC3 – LC2 + external rotation injury of the other side.

  49. LC-I

  50. LATERAL COMPRESSION Common anterior pattern

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