pelvis injury Taiz University,faculty of medicine and health sciences By Dr : Afrah Alalemi

1. Anatomy of the pelvis

2. Anatomy of the pelvis
The pelvic ring is made up of the twoinnominate
bones and the sacrum, articulating in front at the symphysis
pubis (the anterior or pubic bridge) and posteriorly
at the sacroiliac joints (the posterior or sacroiliac
bridge).

3. Anatomy of the pelvis

5. Ligaments of the Pelvic
Girdle

6. PELVIS FRACTURE

7. Introduction
Fractures of the pelvis account for less than 5 per cent
of all skeletal injuries, but they are particularly important
because of the high incidence of associated soft tissue
injuries and the risks of severe blood loss, shock,
sepsis and adult respiratory distress syndrome
(ARDS). Like other serious injuries, they demand a
combined approach by experts in various fields.
About two-thirds of all pelvic fractures occur in
road accidents involving pedestrians; over 10 per cent
of these patients will have associated visceral injuries,
and in this group the mortality rate is probably in
excess of 10 per cent.

8. Mechanism of injury
Low-Energy Fractures
Pelvic fractures resulting from low-energy mechanisms are
usually fractures of individual bones of the pelvic ring
that do not damage the true integrity of the ring
structure.
Example:postmenposaul,steroid
induced,postirradation,congenitialand metabolic bone
disease, fall from ground level.
High-energy trauma also results in more severe injury to
the pelvic ring, associated soft tissues, and viscera.
Although high-energy mechanisms can produce isolated
fractures, they most often result in two or more
fractures of the pelvic ring.
Example:motor vehical accidient,industrial
incident,sporting event;fall from the hight
greaterthan6ft ,crashing injery, gun shotinjery.

9. High-energy trauma
ASSOCIATED HEMORRHAGEAND IMPLICATIONS FOR
THERAPEUTIC INTERVENTION
At the time of a traumatically induced pelvic fracture, some
degree of hemorrhage is inevitable.The principal sites of
bleeding are outlined inTable 1.The anticipated sites of major
hemorrhage correlate with the region of the pelvis fracture,
the vector of the provocative blow, and the magnitude of
pelvic displacement.

10. High-energy trauma
Principal Sites of Hemorrhage after a
Pelvic Fracture
Interossoeuos vasseles
Periosteal sub capsulare , adjecent intra
mascular vasseles
Intrapelvic
Gulteal vasseles
Obturatorvassles
Pudendal
hypogastric
External and internal illiac
Common illiac and aorta
Intra abdominal bleeding
Visceral bleeding
Majer abdominal bleeding

11. High-energy trauma

12. NEUROLOGIC INJURIES WITH PELVIC TRAUMA
Lumbosacral plexus
Presacral plexus
Sciatic nerve
Femral nerve
Other motor nerve around the
pelvis(eg:gulteal,pudendal,obturator)
Lateral femoral cutaneuse nerve of the thigh
Genitofemoral,illioinguinal nerve
Lumbosacral nerve root

13. NEUROLOGIC INJURIES WITH PELVIC TRAUMA

14. VISCERAL INJURIES WITH PELVIC TRAUMA
Intraabdominal
Intrapelvic:
Small and larg bowel.
Urinary:urethera and bladder25%
Genital:vaginal,occasionally other

15. Pelvic stability
The crucial stabilizing ligaments extend from the sacrum, across
the sacroiliac (SI) joints and posterior; they transmit weight-
bearing forces either across the hip joints, into the lower
extremities for ambulation, or into the ischial tuberosities for
sitting.The crucial posterior SI ligaments stabilize the SI joints,
along with the iliolumbar,
sacrospinous, and sacrotuberous ligaments.With its ring-like
configuration, the pelvis is intrinsically highly stable and
resistant to
deforming forces.

16. Pelvic stability

17. Pelvic instability
If the pelvis can withstand weightbearing loads without
displacement, it is stable; this situation exists only
if the bony and key ligamentous structures are intact.

18. Pelvic instability
Pelvic instability
If the pelvis can withstand weightbearing loads without
displacement, it is stable; this situation exists only
if the bony and key ligamentous structures are intact.
Determinants of Pelvic Instability
The characteristic patterns of pelvic disruption correlate with the vector and magnitude of the provocative
blow and the strength of the pelvic ring . Subtle changes in the force vector markedly alter the pattern
of the disruption.A direct lateral blow on the posterior ilium usually causes a stable lateral compression
injury with impaction of the sacral ala, and accompanying unilateral or bilateral ramus fractures. A blow
to the anterior portion of the lateral ilium results in an internal rotational moment that creates an
unstable injury in which the ilium sustains a vertical or crescent fracture with the sacral ala acting as a
fulcrum (69).With the rotational deformity of the ipsilateral hemipelvis, the sharp edges of the ramus
fractures can impale the bladder or occasionally the bowel.

19. defination
pelvic Stable:lesion sparing the pasterior arch;pelvic floor intactand
able to withstand normal physiological stresses without displacement.
Partially Stable:pasterior osteoligamentous integrity partially maintained
and pelvic floor intact
Unstable :complete loss of osteoligamentous integrity and pelvic floor
disrupted
Pelvic ring:has tow arch(a)pasterior arch is behind acetabular surface
includes sacrum’sacroilliac
joint and ther ligament and pasterior illium
(b)Anterior arch infrot of acetabular surface and includes pubic rami bone
and symphseal joint

20. Classification
PENNALANDTILE CLASSIFICATION
Pennal and associates (50) classify the principal pelvic ring disruptions
based on the direction of the injuring force
and the degree of pelvic disruption
TYPE A Stable
A1—Fractures of the pelvis not involving the
ring
A2—Stable, minimally displaced fractures of the
ring
TYPE B Rotationally unstable, vertically stable
B1—Open book
B2—Lateral compression: ipsilateral
B3—Lateral compression: contralateral (bucket-
handle)
TYPE C Rotationally and vertically unstable
C1—Rotationally and vertically unstable
C2—Bilateral
C3—Associated with an acetabular fracture

21. TYPE A Stable
A1—Fractures of the pelvis
not involving the ring
(1)Avulsion fractures
A piece of bone is pulled off by violent muscle contraction;
this is usually seen in sportsmen and athletes.
The sartorius may pull off the anterior superior iliac
spine, the rectus femoris the anterior inferior iliac
spine, the adductor longus a piece of the pubis, and
the hamstrings part of the ischium

22. Rectus femoris
Addactor longus

23. managment
All are essentially
muscle injuries, needing only rest for a few days and
reassurance.
Pain may take months to disappear and, because
there is often no history of impact injury, biopsy of
the callus may lead to an erroneous diagnosis of a
tumour. Rarely, avulsion of the ischial apophysis by
the hamstrings may lead to persistent symptoms, in
which case open reduction and internal fixation is
indicated

24. Direct fractures
 Fracture of the ilium
 Fracture of the ischium
 Fracture of the pubic ramus

25. ANTEROPOSTERIOR COMPRESSION (APC)
INJURIES
‘open book’
(1)APC-I injuries:
there may be only slight (less
than 2 cm) diastasis of the symphysis; however,
although invisible on x-ray, there will almost certainly
be some strain of the anterior sacroiliac ligaments.
The pelvic ring is stable.

27. (2)APC-II injuries
diastasis is more marked and the
anterior sacroiliac ligaments (often also the
sacrotuberous
and sacrospinous ligaments) are torn. CT
may show slight separation of the sacroiliac
joint on
one side. Nevertheless, the pelvic ring is still
stable.

28. APC-III injuries
the anterior and posterior
sacroiliac ligaments are torn. CT shows a shift or separation
of the sacroiliac joint; the one hemi-pelvis is
effectively disconnected from the other anteriorly and
from the sacrum posteriorly.The ring is unstable.

29. (b2)LATERAL COMPRESSION (LC) INJURIES
Type B2-1: Lateral compression (internal
rotation) force implodes hemipelvis. Rami
may fracture anteriorly, and posterior
impaction of sacrum may occur, with some
disruption of posterior structures, but
partial stability is maintained by intact
pelvic floor and compression of sacrum.

30. LC-I injury. The ring is stable.

31. LC-II injury
is more severe; in addition to the
anterior fracture, there may be a fracture of the iliac
wing on the side of impact. However, the ring
remains stable.

33. LC-III injury
is worse still.
Due to lateral compression force on one iliac wing
results in an opening anteroposterior force on the
opposite ilium, causing injury patterns typical for that
Mechanism.

35. vertical shear injury
With a vertical shear injury, the iliolumbar
ligaments, along with the posterior SI
ligaments, are disrupted .With vertical
displacement of the pelvis, the ipsilateral
lower lumbar transverse processes are
fractured.

37. Diagnosis
History
Suspected in high energy injury
The main symptom
 Numbness or tingling in the groin or legs
 abdominal pain
 Groin pain (get warse when walking or moving)
 Difficulty urinating
 Difficulty walking
 Unable to stand
 Blood at the external meatus


38. Diagnosis
 look:
 My reveal ecchymosis or abrasions of the pelvis, back and
buttocks
 Grey Turner's sings:
A discoloration of the flanks is indicative of
retroperitoneal hematoma.
 Destot's sign:
A hematoma over the inguinal ligament, proximal thigh,
perianal or scrotal areas.
 When inspecting the perineum may note the presence of
blood at the anus or urethral meatus

40.  feel:
The bone pelvis my demonstrate tenderness or instability. A
palpable fracture line or pelvis hematoma
 Pelvic springing:
is performed by applying alternative compression and
distraction forces to the iliac wings in order to detect
crepitance or instability.
 The presence of blood on rectal and vagina examination is
important, as displaced fracture me cause mucosal
disruption.
 Perineal butterfly hematoma:
 Presence of haematoma highly specific for urethral
disruption.

41.  mesure
 Leg length:
 Examination of the leg is an important part of the physical
 examination in pelvis fracture.

 Adduction/abduction of the hip internal/external hip rotation that
demonstrates instability.
 Pain or crepitus indicates involvement at or near acetabulum.
 FABER test:
for the pubic ramus fracture patients experience groin
pain when they place the ipsilateral foot on the
contralateral knee and the ipsilateral hip is Flexed,
Abducted and Externally Rotated.
 .examination of visceral injury

42. Radiographs:
 Every poly trauma patient should have
 Lateral c-spine
 Chest
 AP Pelvis
 AP pelvis is done to detect major (and potentially life-
threatening) pelvic injury.

43. Plain Pelvic X-rays
AP views
90% of all
traumatic
injuries to the
bony pelvis were
diagnosed on
Anteroposterior
veiw alone

44. Inlet view
Caudal view in
the 40-degree
inlet. The inlet
view demonstrates
rotational
deformity or
anteroposterior
displacement of
one hemipclvis

45. Outlet
view:
Cephalic view
in 40-degree
outlet views
the outlet view
demonstrates
vertical
displacement of
a hemipelvis

46. CT scan
 Is an essential part of the evaluation in pelvis
fracture.
 It allows evaluation of the posterior portion of the
pelvic ring that may be poorly appreciated on
standard roentgenograms.
 Before the widespread use of CT scanning. many pelvic
fractures were assumed. to be purely anterior
injuries, although isolated anterior lesions actually
are rare.
 CT scanning demonstrates rotational and
anteroposterior displacement much better than plain
roentgenograms, although vertical dispiacement is
still better appreciated on roentgenograms than on
axial CT images.
 Magnetic Resonance Imaging (MRI)
 Indicate that magnetic resonance imaging may provide
clinically useful information with regard to
genitourinary tract injuries.

47. Management of major pelvic fracture:
 You have to call orthopaedic surgeon, a
urologist, a vascular surgeon, a colo-rectal
surgeon and (sometimes) a gynaecologist!

48. Management I
 1. Prehospital- transport with bed sheet, MAST,
pelvic clumps.
)
3..

49. Initial management in the ER:
 Safe life
 Made during primary survey.
 Airway with c-spine control.
 Breathing (oxygen).
 Circulation
 IV access
 Crystalloid
 Control external loss
 Evaluation of intra-abdominal bleeding
 Look for major pelvic injury

50. Safe the limp
The objectives of treatment for pelvic ring
injuries include:
 Restoring bony anatomy.
 Preventing deformity.
 Minimizing discomfort.
 Facilitating return of' mobility and
function.

51. minor fracture [ stable ]
 bed rest,
 Painkiller
 Physical therapy
 Healing take 8-21 wk

52. Severe injuries
These injuries often require
 extensive surgery
 as well as lengthy physical therapy
 and rehabilitation .

53. External fixation
1. Advantages
 It helps tamponade bleeding from bone edges .
 Stabilizing the clots and the bone.
 Could be done in 20 min.
2. Disadvantages
 Can’t stop arterial bleeding. Delay the embolization for ongoing
arterial hemorrhage.
 Degrade the quality of CT and angiograghy.

54. Fracture reduction and stabilization
with external fixation

55. Timing of surgery
Reduction
may be
easiest in
first 24-48
hoursMay aid in percutaneus reduction

56. Reduction tools
Traction
Pelvic manipulator
(e.g. femoral
distractor)
Specialized clamps

57. Reduction and Fixation:
SI Joint Dislocation
SI screw

60. Complications of high-energy pelvic
fractures
Complication of pelvis fracture result from
associated injury the most complications:
 Pulmonary distress syndrome.
 Sciatic nerve injury
 Fat embolism
 Pneumonia
 Urinary tract infection
 Wound infection
 sepsis
 Coagulopathy and pulmonary embolism
 Paralytic ileus

61. Genitourinary
 GU complications occur in up to 37% of patients with pelvic ring injuries.65The
most common GU complications occurring with pelvic ring injuries are bladder
disruptions and ureteral disruptions, particularly in male patients.
 Less commonly, the ureters and kidneys may be injured.Dyspareunia and
erectile dysfunction occur in approximately 29% of patients with pelvic ring
injuries.
 Dyspareunia usually is caused by a displaced ramus fracture, causing pressure
on the vaginal vault
 . Erectile dysfunction can have many causes, including vascular injury,
neurologic injury, and psychological stress.
 A patient with erectile dysfunction should be referred to a urologist for
evaluation and treatment.

62. Post operative complication
Bed sores
 DVT
prophylaxis is important postoperatively and should be
managed aggressively.
Mechanical methods, such as support stockings, work to
decrease venous stasis, thereby decreasing the risk of DVT
formation.

63. Thank you for listening