Radiographic evaluation anatomy and classification of pelvic ring injuries
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Radiographic Evaluation, Anatomy, and Classification of Pelvic Ring Injuries. Kyle F. Dickson, MD Chief of Orthopaedics, Charity Hospital Director of Orthopaedic Trauma Tulane University Created March 2004 Reviewed April 2007. Palpable Bony Landmarks. Symphysis Pubis

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Radiographic evaluation anatomy and classification of pelvic ring injuries

Radiographic Evaluation, Anatomy, and Classification of Pelvic Ring Injuries

Kyle F. Dickson, MD

Chief of Orthopaedics, Charity Hospital

Director of Orthopaedic Trauma

Tulane UniversityCreated March 2004Reviewed April 2007


Palpable bony landmarks
Palpable Bony Landmarks Pelvic Ring Injuries

  • Symphysis Pubis

  • Anterior Superior Iliac Spine (ASIS)

  • Iliac Wing

  • Posterior Superior Iliac Spine (PSIS)


Pelvic ring
Pelvic Ring Pelvic Ring Injuries

  • 2 innominate bones

  • 1 Sacrum

  • Gap in symphysis < 5 mm

  • SI joint 2-4 mm


Important stabilizing ligaments
Important Stabilizing Ligaments Pelvic Ring Injuries

  • Posterior Iliosacral

  • Anterior Iliosacral

  • Sacrospinous

  • Sacrotuberous

  • Symphyseal


Important muscles
Important Muscles Pelvic Ring Injuries

  • Gluteus Maximus

  • Iliopsoas

  • Rectus Abdominus


Possible arterial bleeders in pelvic injuries
Possible Arterial Bleeders in Pelvic Injuries Pelvic Ring Injuries

  • Iliolumbar artery

  • Superior gluteal artery

  • Lateral sacral artery

  • Internal iliac artery

  • Internal pudendal (active bleeding most commonly found)


Neurologic damage
Neurologic Damage Pelvic Ring Injuries

  • L5 & S1, most common

  • L2 to S4 possible

  • Dependent on location of fracture and amount of displacement


Denis corr 1988
Denis, CORR 1988 Pelvic Ring Injuries

  • Sacral Fractures – Neurologic Injury

    • Lateral to foramen – 6% injury

    • Through foramen – 28% injury

    • Medial to foramen – 57% injury


Pohlemann corr 1994
Pohlemann, CORR 1994 Pelvic Ring Injuries

  • Amount of displacement move important then location


Potentially damaged visceral anatomy
Potentially Damaged Visceral Anatomy Pelvic Ring Injuries

  • Blunt vs. impaled by bony spike

    • Bladder/urethra

    • Rectum

    • Vagina


Pelvic ring1
Pelvic Ring Pelvic Ring Injuries

  • No inherent stability

  • Ligaments give the pelvis stability


Symphyseal ligaments
Symphyseal Ligaments Pelvic Ring Injuries

  • Resist external rotation in double-leg stance

  • Rami act as struts to resist compressive and internal rotation in single leg stance

  • Sectioning causes little pelvic instability


Ghanayem j trauma 1995
Ghanayem, J Trauma 1995 Pelvic Ring Injuries

  • Abdominal wall contributes to pelvic stability (laparotomy increased pelvic displacement in cadaveric model)



Sacrum
Sacrum Pelvic Ring Injuries

  • Inlet View Reverse keystone where compression forces displace sacrum anteriorly

  • Outlet View True keystone compression locks sacrum into pelvic ring

  • Small rotating movements during gait


Posterior ligaments
Posterior Ligaments Pelvic Ring Injuries

  • Ant. SI Joint – resist external rotation

  • Post. SI and Interosseous – posterior stability by tension band (strongest in body)

  • Iliolumbar ligaments augments posterior complex


Sacrotuberous Pelvic Ring Injuries (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


Normal si joint motion with gait
Normal SI Joint Motion with Gait Pelvic Ring Injuries

  • < 6 mm of translation

  • < 6° rotation

  • Intact cadaver resist 5,837 N (1,212 lbs)


Nachemson acta orthop scand 1966
Nachemson, Acta Orthop Scand 1966 Pelvic Ring Injuries

  • Sitting 710 N (160 lbs) at each Si joint

  • Lying 196 N (44 lbs)

  • Lateral decubitus 686 N (154 lbs)

  • Standing 980 N (220 lbs)


Sitting or double leg stance
Sitting or Double Leg Stance Pelvic Ring Injuries

  • Pubic rami tension and compression posteriorly

  • External rotation injury – displaces in sitting or double leg stance


Single leg stance
Single Leg Stance Pelvic Ring Injuries

  • Tension shear posteriorly and compression of rami

  • Will displace internal rotation injury


Direction of force
Direction of Force Pelvic Ring Injuries

  • Anteroposterior

  • Lateral compression

  • Vertical shear


Stability ability of pelvic ring to withstand physiologic forces without abnormal deformation
Stability – ability of pelvic ring to withstand physiologic forces without abnormal deformation


Translational deformities
Translational Deformities physiologic forces without abnormal deformation

  • X axis – Diastasis or impaction

  • Y axis – Caudad or cephalad displacement

  • Z axis – Anterior or posterior displacement


Rotational deformities
Rotational Deformities physiologic forces without abnormal deformation

  • X axis – Flexion or extension

  • Y axis – Internal rotation or external rotation

  • Z axis – Abduction or adduction


Deformity of pelvis
Deformity of Pelvis physiologic forces without abnormal deformation

  • Defined from an anatomically positioned pelvis in space

  • Deformity a combination of rotational & translational deformities


Deformity of pelvis cont
Deformity of Pelvis (cont.) physiologic forces without abnormal deformation

  • Does not deform around a single point but can be represented as a vector from a normally positioned pelvis

  • Acute deformity difficult to measure but direction often able to be determined


Pelvic instability
Pelvic Instability physiologic forces without abnormal deformation

  • These injuries which will have worsening deformity

  • Physical exam and radiographic evaluation


Determining stability
Determining Stability physiologic forces without abnormal deformation

  • Integrity of posterior bone and ligament, unstable = vertical plane displacement

  • Some partial instability in rotation


Physical exam
Physical Exam physiologic forces without abnormal deformation

  • Symmetrical palpable ASIS, iliac wing, and symphysis

  • ASIS compression test

  • Iliac wing compression test


Radiographic evaluation
Radiographic Evaluation physiologic forces without abnormal deformation

  • Anteroposterior view (AP)

  • Inlet view (40° caudad)

  • Outlet view (40 ° cephalad)

  • CT


Good quality radiographs are essential

Good Quality Radiographs physiologic forces without abnormal deformationare Essential


Inlet caudad view
Inlet (Caudad) View physiologic forces without abnormal deformation

  • Horizontal Plane Rotation

  • Posterior Displacement

  • Sacral ala


Outlet cephalad view
Outlet (Cephalad) View physiologic forces without abnormal deformation

  • Sacrum

  • Cephalad Displacement

  • Sacral Foramina


Placement of wires show
Placement of Wires Show physiologic forces without abnormal deformation

  • Ant. SI joint lateral to post. SI

  • Radiographic brim does not always correlate with anatomical brim


Ct scan
CT Scan physiologic forces without abnormal deformation

  • Better defines posterior injury

  • Amount of displacement versus impaction

  • Rotation of fragments

  • Amount of comminution

  • Assess neural foramina


Radiographic signs of instability
Radiographic Signs of Instability physiologic forces without abnormal deformation

  • 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)


Classification
Classification physiologic forces without abnormal deformation

  • 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


Classification systems
Classification Systems physiologic forces without abnormal deformation

  • Anatomical (Letournel)

  • Stability & Deformity (Pennal, Bucholz, Tile)

  • Vector force and associated injuries (Young & Burgess)


Anatomical classification letournel
Anatomical Classification physiologic forces without abnormal deformation(Letournel)

Where The Pelvis Breaks


Posterior
Posterior physiologic forces without abnormal deformation

  • Iliac wing fracture

  • Iliac wing/sacroiliac (SI) joint (crescent fracture)

  • SI joint

  • Sacrum/SI joint

  • Sacrum fracture


Anterior
Anterior physiologic forces without abnormal deformation

  • Rami fractures

  • Symphyseal disruption


Pennal 1961
Pennal, 1961 physiologic forces without abnormal deformation

  • Magnitude and direction of forces

    • Lateral posterior compression (LC)

    • Anterior posterior compression (APC)

    • Vertical shear (VS)


Bucholz 1981 tile 1988
Bucholz, 1981 physiologic forces without abnormal deformationTile, 1988

Added stability to the classification


Ota ao pelvic injury classification
OTA/AO – Pelvic Injury Classification physiologic forces without abnormal deformation

  • 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


A fractures ring intact
A Fractures – Ring Intact physiologic forces without abnormal deformation

  • A-1 – Fracture of innominate bone; avulsion

  • A-2 – Fracture of innominate bone; direct blow

  • A-3 – Transverse fracture of sacrum and coccyx


B ring injury partially stable
B-Ring Injury – Partially stable physiologic forces without abnormal deformation

  • 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


C complete disruption posterior arch unstable pelvis
C – Complete Disruption Posterior Arch, Unstable Pelvis physiologic forces without abnormal deformation

  • C-1 – Unilateral, complete disruption of posterior arch

  • C-2 – Bilateral, ipsilateral complete, contralateral incomplete

  • C –3 – Bilateral, complete disruption


Further classification
Further Classification physiologic forces without abnormal deformation

  • A.1 – Location of avulsion

  • A.2 – Type of fracture anteriorly

  • A.3 – Amount of displacement sacrum


Further classification cont
Further Classification (cont.) physiologic forces without abnormal deformation

  • B – Location of fracture


Further classification cont1
Further Classification (cont.) physiologic forces without abnormal deformation

  • C – Location of fractures – iliac wing, SI joint, and sacrum


Young and burgess rad 1986
Young and Burgess, Rad 1986 physiologic forces without abnormal deformation

  • Increases clinicians diagnosis of frequently missed lesions

  • Predictive index for associated injuries

  • Helps clinicians to select treatment based on probable pathology and hemodynamic status


Lateral compression
Lateral Compression physiologic forces without abnormal deformation

  • LC-1 – Ant. superior inf. rami or symphysis and compression of sacrum same side

  • LC-2 - LC-1 – anteriorly and posteriorly crescent fracture near anterior border at SI joint  Ileum rotated internally


Lateral compression1
Lateral Compression physiologic forces without abnormal deformation

LC I: Sacral compression


Patient wh
Patient WH physiologic forces without abnormal deformation

  • Progressive IR deformity that became fixed

  • Required anterior release & post sacral osteotomy followed by external rotation

  • Pre-& postop, AP and inlet, and 2 year follow-up


Lateral compression2
Lateral Compression physiologic forces without abnormal deformation

LC II: Iliac wing fracture


Lc cont
LC (cont.) physiologic forces without abnormal deformation

  • LC-3 – Windswept pelvis – LCI or II on one side of the pelvis and open book (APC) on contralateral side (roll over mechanism by IR on LC side and ER on contralateral side)


Lc iii windswept pelvis
LC III: “Windswept pelvis” physiologic forces without abnormal deformation


Lc iii
LC III physiologic forces without abnormal deformation


Anteroposterior compression
Anteroposterior Compression physiologic forces without abnormal deformation

  • Diastasis anteriorly through symphysis pubis or vertical Rami fractures

  • Posteriorly usually through SI joint – amount of displacement defines subset


Anteroposterior cont
Anteroposterior physiologic forces without abnormal deformation(cont.)

  • APC-1 – 1-2 cm symphysis diastasis and minimal SI diastasis anteriorly (external rotation of hemipelvis – stable pelvis).


AP I physiologic forces without abnormal deformation

  • Note that the ligaments are stretched, and not torn


Anteroposterior cont1
Anteroposterior (cont.) physiologic forces without abnormal deformation

  • APC-2 – Sacrotuberous, sacrospinous, and anterior SI joint ligaments disrupted (post SI ligaments intact)

  • APC-3 – Complete SI joint disruption (usually not vertically displaced)


Ap ii
AP II physiologic forces without abnormal deformation

  • Note: pelvic floor ligaments are violated, as well as anterior SI ligaments


Anteroposterior compression1

Anteroposterior Compression physiologic forces without abnormal deformation

APC III: Complete Iliosacral Dissociation


Vertical shear
Vertical Shear physiologic forces without abnormal deformation

  • Always unstable

  • Ant. symphsis or vertical rami fractures-post. Injury variable

  • Vertical displacement


Vertical shear1
Vertical Shear physiologic forces without abnormal deformation


Patient nj
Patient NJ physiologic forces without abnormal deformation

  • VS initially attempted to be treated with anterior plate and ex-fix with hardware failure

  • 3 stage pelvic reconstruction ( ant.  post ant. 2 yr follow-up – Auburn football player)


Combined
Combined physiologic forces without abnormal deformation

  • Combined vectors occasionally 2 separate injuries (ejection/landing)

  • Often LC/VS, or AP/VS


Combined mechanical injury
Combined Mechanical Injury physiologic forces without abnormal deformation


Patient lc
Patient LC physiologic forces without abnormal deformation

  • Combination LC and VS

  • Treated conservatively initially

  • Required 3 stage pelvic reconstruction to restore ischial height



Acknowledgment
Acknowledgment of Classification to Treatment

Joel Matta, Phil Kregor, and Mark

Vrahas for the use of their slides

If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected]

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