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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
  • Symphysis Pubis
  • Anterior Superior Iliac Spine (ASIS)
  • Iliac Wing
  • Posterior Superior Iliac Spine (PSIS)
pelvic ring
Pelvic Ring
  • 2 innominate bones
  • 1 Sacrum
  • Gap in symphysis < 5 mm
  • SI joint 2-4 mm
important stabilizing ligaments
Important Stabilizing Ligaments
  • Posterior Iliosacral
  • Anterior Iliosacral
  • Sacrospinous
  • Sacrotuberous
  • Symphyseal
important muscles
Important Muscles
  • Gluteus Maximus
  • Iliopsoas
  • Rectus Abdominus
possible arterial bleeders in pelvic injuries
Possible Arterial Bleeders in Pelvic Injuries
  • Iliolumbar artery
  • Superior gluteal artery
  • Lateral sacral artery
  • Internal iliac artery
  • Internal pudendal (active bleeding most commonly found)
neurologic damage
Neurologic Damage
  • L5 & S1, most common
  • L2 to S4 possible
  • Dependent on location of fracture and amount of displacement
denis corr 1988
Denis, CORR 1988
  • Sacral Fractures – Neurologic Injury
    • Lateral to foramen – 6% injury
    • Through foramen – 28% injury
    • Medial to foramen – 57% injury
pohlemann corr 1994
Pohlemann, CORR 1994
  • Amount of displacement move important then location
potentially damaged visceral anatomy
Potentially Damaged Visceral Anatomy
  • Blunt vs. impaled by bony spike
    • Bladder/urethra
    • Rectum
    • Vagina
pelvic ring1
Pelvic Ring
  • No inherent stability
  • Ligaments give the pelvis stability
symphyseal ligaments
Symphyseal Ligaments
  • 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
  • Abdominal wall contributes to pelvic stability (laparotomy increased pelvic displacement in cadaveric model)
  • 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
  • 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

normal si joint motion with gait
Normal SI Joint Motion with Gait
  • < 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
  • 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
  • Pubic rami tension and compression posteriorly
  • External rotation injury – displaces in sitting or double leg stance
single leg stance
Single Leg Stance
  • Tension shear posteriorly and compression of rami
  • Will displace internal rotation injury
direction of force
Direction of Force
  • 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
  • X axis – Diastasis or impaction
  • Y axis – Caudad or cephalad displacement
  • Z axis – Anterior or posterior displacement
rotational deformities
Rotational Deformities
  • X axis – Flexion or extension
  • Y axis – Internal rotation or external rotation
  • Z axis – Abduction or adduction
deformity of pelvis
Deformity of Pelvis
  • Defined from an anatomically positioned pelvis in space
  • Deformity a combination of rotational & translational deformities
deformity of pelvis cont
Deformity of Pelvis (cont.)
  • 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
  • These injuries which will have worsening deformity
  • Physical exam and radiographic evaluation
determining stability
Determining Stability
  • Integrity of posterior bone and ligament, unstable = vertical plane displacement
  • Some partial instability in rotation
physical exam
Physical Exam
  • Symmetrical palpable ASIS, iliac wing, and symphysis
  • ASIS compression test
  • Iliac wing compression test
radiographic evaluation
Radiographic Evaluation
  • Anteroposterior view (AP)
  • Inlet view (40° caudad)
  • Outlet view (40 ° cephalad)
  • CT
inlet caudad view
Inlet (Caudad) View
  • Horizontal Plane Rotation
  • Posterior Displacement
  • Sacral ala
outlet cephalad view
Outlet (Cephalad) View
  • Sacrum
  • Cephalad Displacement
  • Sacral Foramina
placement of wires show
Placement of Wires Show
  • Ant. SI joint lateral to post. SI
  • Radiographic brim does not always correlate with anatomical brim
ct scan
CT Scan
  • 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
  • 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)
  • 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
  • Anatomical (Letournel)
  • Stability & Deformity (Pennal, Bucholz, Tile)
  • Vector force and associated injuries (Young & Burgess)
  • Iliac wing fracture
  • Iliac wing/sacroiliac (SI) joint (crescent fracture)
  • SI joint
  • Sacrum/SI joint
  • Sacrum fracture
  • Rami fractures
  • Symphyseal disruption
pennal 1961
Pennal, 1961
  • Magnitude and direction of forces
    • Lateral posterior compression (LC)
    • Anterior posterior compression (APC)
    • Vertical shear (VS)
bucholz 1981 tile 1988
Bucholz, 1981 Tile, 1988

Added stability to the classification

ota ao pelvic injury classification
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
a fractures ring intact
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
b ring injury partially stable
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
c complete disruption posterior arch unstable pelvis
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
further classification
Further Classification
  • A.1 – Location of avulsion
  • A.2 – Type of fracture anteriorly
  • A.3 – Amount of displacement sacrum
further classification cont
Further Classification (cont.)
  • B – Location of fracture
further classification cont1
Further Classification (cont.)
  • C – Location of fractures – iliac wing, SI joint, and sacrum
young and burgess rad 1986
Young and Burgess, Rad 1986
  • 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
  • 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

LC I: Sacral compression

patient wh
Patient WH
  • 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

LC II: Iliac wing fracture

lc cont
LC (cont.)
  • 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)
anteroposterior compression
Anteroposterior Compression
  • Diastasis anteriorly through symphysis pubis or vertical Rami fractures
  • Posteriorly usually through SI joint – amount of displacement defines subset
anteroposterior cont
  • APC-1 – 1-2 cm symphysis diastasis and minimal SI diastasis anteriorly (external rotation of hemipelvis – stable pelvis).
  • Note that the ligaments are stretched, and not torn
anteroposterior cont1
Anteroposterior (cont.)
  • 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
  • Note: pelvic floor ligaments are violated, as well as anterior SI ligaments
anteroposterior compression1

Anteroposterior Compression

APC III: Complete Iliosacral Dissociation

vertical shear
Vertical Shear
  • Always unstable
  • Ant. symphsis or vertical rami fractures-post. Injury variable
  • Vertical displacement
patient nj
Patient NJ
  • 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 vectors occasionally 2 separate injuries (ejection/landing)
  • Often LC/VS, or AP/VS
patient lc
Patient LC
  • Combination LC and VS
  • Treated conservatively initially
  • Required 3 stage pelvic reconstruction to restore ischial height

Joel Matta, Phil Kregor, and Mark

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