trauma, degenerative disease

1. By : Marcell Wijaya, S.Ked. MD.

2.  Combination of bones
 2 part –false and true
 Function :
 Transmit weight
 Protection for vital organs

4. Pelvic ring stability depends on :
 Rigidity of bony parts
 Strong ligaments binds the segments together
across symphysis pubis and sacroiliac joint

5.  Pelvic fractures accounts for 3% of all skeletal
fractures
 95% of pelvic injuries -> minor trauma
 Severe trauma have high mortality rate due to
hemorrhage or multiple injuries
 Hemorrhage is 80-90% venous in origin

6. Radiographic lines :
1. Iliopectineal
2. Ilioischial
3. Radiographic
tear drop /
acetabulum
4. Acetabular roof
5. Acetabulum rim
/ wall : anterior
and posterior
6. Shenton
7. Arcuate

7. Iliac = unaffected hip 45 Obturator = affected 45
Inlet = caudal 45 to inf Outlet = cephalad 45 to sup

9. Generally injuries of the pelvis is classified into 4
groups :
 Isolated fractures with an intact pelvic ring
 Sacrococcygeal fractures
 Fractures of acetabulum
 Fractures with broken ring – stable or unstable

10. Isolated fractures with intact pelvic ring
Ramus Pubic Fractures Duverney Fractures
• In general these injuries do not require
surgical treatment, unless injuries to
bladder, vagina, perineum are present
• NSAID / Pain killer, walker / stabilizer

11. Fractures of acetabulum
 Acetabular fracture may cause disruption in hip joint
integrity and dislocation / subluxation of hip joint
 When dislocation occur, emergency relocation /
reduction of the dislocation is necessary to prevent
necrosis of bone (avascular necrosis)

12. Judet and Letournell Classification

13. Pediatic Acetabular Fractures Classification
Watts Classification
1. Type A – Small fragments occuring with hip
dislocation
2. Type B – Stable linear fractures without
displacement in association with pelvic
fractures
3. Type C – Linear fractures with hip joint
instability
4. Type D – Fractures secondary to central
fracture-dislocation of the hip

14. Radiographs
 AP View
 Judet / Oblique View
 Inlet View
 Outlet View
 CT Scan
 Define fragment size and
orientation
 Marginal impaction
 Loose bodies
 Articular gaps

16.  Treatment :
 Non – operative
 Protected weight bearing 6-8 weeks
 minimally displaced fracture (< 2mm)
 < 20% posterior wall fractures
 femoral head remains congruent with weight bearing roof
(out of traction)
 both column fracture with secondary congruence (out of
traction)
 displaced fracture with roof arcs > 45 degrees in AP and
Judet views
 relative contraindications to surgery :
 Morbid obesity
 Open contaminated wound
 DVT

17.  Operative
 ORIF
 displacement of roof (>2mm)
 posterior wall fracture involving > 40-50%
 marginal impaction
 intra-articular loose bodies
 irreducible fracture-dislocation
 pregnancy is not contraindication to surgical fixation
 ORIF – Hip Arthroplasty
 significant osteopenia and/or significant comminution
 Percutaneous Fixation with column screws

18. Complication
 Post-traumatic DJD
 most common complication
 anatomic reduction essential to prevent
 treat with hip fusion or THA
 Heterotopic Ossification
 treat with
 indomethacin x 5 weeks post-op
 low dose external radiation (no difference shown in direct comparison)
 Osteonecrosis
 6-7% of all acetabular fractures
 18% of posterior fracture patterns
 DVT and PE
 Infection
 Bleeding
 Neurovascular injury
 Intraarticular hardware placement
 Abductor muscle weakness

19. Sacrococcygeal fractures
 Common in pelvic ring injury (30-45%) or after
repetitive stress / insuficiency fracture in old
age
 Fractures may damage Sacral Plexus – loss of
neurological function
 Sacrum contain :
 Lumbar Plexus (L4-S1)
 Sacral Plexus (S2-S4)
 S2-S5 controls sexual, bowel and bladder function
(parasymphatethic pathway)
 presence of a neurologic deficit is the most
important factor in predicting outcome

20. Denis classification
 Comprised of 3 zones
 Lateral to neuroforamina
 50% of patient, neurological injuries
in 6% cases, affecting L4-L5 nerve
 In neuroforamina, excluding spinal
canal
 34% of patient, neurological injuries
in 28% cases, affecting L5-S1-S2 nerve
 Extend into spinal canal
 16% of patient, neurological injuries
in 57% cases
 Highest prevalence and severity of
injuries

21.  Transverse sacral fractures
 High incidence of nerve
dysfunction
 U-type sacral fractures
 Result from axial loading
 High incidence of neurologic
complication

22. Treatment :
Operative
 Surgical fixation w/w/out
decompression
 displaced fractures >1 cm
 soft tissue compromise
 persistent pain and/or
displacement of fracture after non-
operative management
 Neurological deficit
Non – operative
 Progressive weight bearing and
orthosis
 <1 cm displacement and no
neurologic deficit
 insufficiency fractures
 Physical examination reveal :
 Soft tissue trauma around pelvis
 Pelvic ring instability
 Rectal / vaginal touche
 Radiograph : AP, Inlet, Outlet, Cross-table view, CT, MRI

23. Complication
 Venous thromboembolism
 often as a result of immobility
 Iatrogenic nerve injury
 may result from
 overcompression of fracture
 improper hardware placement
 Malreduction
 more common with vertically displaced fractures

24. Fractures with broken ring – stable or unstable
 Pelvic ring injury are categorized into 3
classification :
 Letournel and Judet’s classification
 Young and Burgess’ Classification
 Tile Classification
 Mortality rate 15-20% for closed fractures, up to
50% for open fractures
 Hemorrhage is the leading cause of death

25.  The Letournel and Judet classification of pelvic
fractures is anatomic
 A : Iliac wing fractures
 B : Ilium fractures with extension to the sacroiliac joint
 C : Trans-sacral fractures
 D : Unilateral sacral fractures
 E : Sacroiliac joint fracture–dislocation
 F : Acetabular fractures
 G : Pubic ramus fractures
 H : Ischial fractures
 I : Pubic symphysis separation

26.  Young and Burgess’ Classification is based on the mechanism
of injury
 Anterior-posterior Compression (APC)
I. Symphysis widening < 2.5 cm
II. Symphysis widening > 2.5 cm. Sacrospinous and
sacrotuberous disruption
III. Sacroilium dislocation with vascular injury
 Lateral Compression (LC)
I. Ipsilateral ramus pubis and sacral ala fracture
II. Ipsilateral ramus pubis and ilium posterior fracture; also
known as crescent fracture
III. Ipsilateral compression and contralateral APC. Ex : Run
over by car
 Vertical Shear (VS)

28.  Tile Classification is based on the integrity of posterior
sacroiliac complex
 Type A is stable injuries, outside ring and inside ring
 Type B is Rotationally unstable but vertically stable (unilateral)
or Rotationally unstable in 1 part and vertically unstable in
other part
 Type C is Rotationally and vertically unstable (Bilateral)

30. Pediatric Pelvic Injury Classification
Watts Classification modified by Torode and Zieg
1. Type I – avulsion fracture
2. Type II – Iliac wing Fractures
3. Type III – Stable pelvic ring injuries
4. Type IV – unstable pelvic ring injuries

31.  Radiographic imaging
 Cervical Spine – in suspected high-speed MVI
 Thorax – in suspected high-speed MVI
 AP pelvis
 Inlet view
 Outlet view
 CT
 Signs of Instability
 > 5 mm displacement of
posterior sacroiliac complex
 presence of posterior sacral
fracture gap
 Avulsion fractures (ischial
spine, ischial tuberosity,
sacrum, transverse process of
5th lumbar vertebrae)

32. Treatment
 Initial treatment :
 Primary Survey (ABCDE)
 Stabilize patient
 Bleeding control, fluid resuscitation
 Bleeding source :
 Arterial 20%
 Venous 80% from Venous plexus just over SI joint
 Pelvic Binder for unstable ring injury, placed in
greater trochanter area
 Ex : PASG, MAST (Military Anti Shock Trouser)

33.  Secondary survey
 Open wound in perineum, groin area
 Abnormal pelvic mobility
 Leg – length discrepancy
 Blood in urethral orifice, anus, perineum, vagina
 Neurological deficit in lower part of body

35.  External Fixation
 Indications
 pelvic ring injuries with an external rotation component
(APC, VS, CM)
 unstable ring injury with ongoing blood loss, to reduce
pelvic volume
 Contraindications
 ilium fracture that precludes safe application
 acetabular fracture
 Angiography / Embolization
 Indications
 CT angiography useful for
determining presence or absence of
ongoing arterial hemorrhage
 Can not detect venous hemorrhage
 Flush pelvic aortogram, then selected pelvic
angiography

36. Definitive treatment
 Nonoperative
 weight bearing as tolerated
 mechanically stable pelvic ring injuries including
 LC1
 anterior impaction fracture of sacrum and oblique ramus
fractures with < 1cm of posterior ring displacement
 APC1
 widening of symphysis < 2.5 cm with intact posterior
pelvic ring
 isolated pubic ramus fractures

37.  Operative
 ORIF
 symphysis diastasis > 2.5 cm
 SI joint displacement > 1 cm
 sacral fracture with displacement > 1 cm
 displacement or rotation of hemipelvis
 open fracture
 diverting colostomy
 consider in open pelvic fractures, especially with
extensive perineal injury or rectal involvement

38.  RPH : retro –
peritoneal
hematome
 R/O : rule out

40. Complication
 Neurologic injury
 DVT and PE
 Chronic instability – persistent pain
 Urogenital injury – Urethral tear, bladder
rupture
 Pelvic infection in open fractures

41. Other Disorder of Pelvis
Osteitis Pubis
 Inflammation or
degeneration of symphysis
pubis
 Repetitive microtrauma or
fracture
 Anterior pubic pain, most
commonly after trauma or
sport.
 Symphysis pubis is tender
to palpation
 Imaging : AP view
with/without inlet and
outlet view
 Treatment consist of activity
modification, NSAID and
fusion as last resort

42. Sacroilitis
 Inflammation or degeneration of sacroiliac joint
 Low back pain
 Sacro iliac joint is tender to palpation
 Imaging used is X-ray or CT-scan
 Lab report necessary is CBC, ESR, CRP if infection
is suspected
 Treatment consist of rest, NSAID, corticosteroid
local injection

43. Ischial Bursitis
 Inflammation of bursa of ischial tuberosity
 Prolonged sitting
 Buttock pain on sitting
 Ischial tuberosity is tender on palpation.
 May mimick hamstring injury, however on phys ex,
hamstring movement is not painful
 Imaging used is X-ray or MRI
 Treatment consist of Rest, NSAID and activity
modification (either to decrease seating or adding
more cushion)

45. Iliac Crest Contusion / Hip Pointer
 Usually from direct trauma to iliac crest
 More common in contact sport
 There is history of trauma or hip pain
 Iliac crest is tender to palpation
 Imaging used is X-ray
 Treatment consist of rest, NSAID, padding to
Iliac Crest and local corticosteroid injection