Anatomy of the pelvis

Anatomy of the pelvis

The pelvic ring is made up of the two innominate

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).

Anatomy of the pelvis

Ligaments of the Pelvic Girdle

PELVIS FRACTURE

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.

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,steroidinduced,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,industrialincident,sporting event;fall from the hight

greaterthan6ft ,crashing injery, gun shot injery.

High-energy trauma

ASSOCIATED HEMORRHAGE AND 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 in Table 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.

High-energy trauma

Principal Sites of Hemorrhage after a Pelvic Fracture

Interossoeuos vasselesPeriosteal sub capsulare , adjecent intra mascular vasselesIntrapelvicGulteal vasselesObturatorvasslesPudendalhypogastric

External and internal illiacCommon illiac and aortaIntra abdominal bleedingVisceral bleedingMajer abdominal bleedingExternal bleeding through open wound

High-energy trauma

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

NEUROLOGIC INJURIES WITH PELVIC TRAUMA

VISCERAL INJURIES WITH PELVIC TRAUMA

Intraabdominal

Intrapelvic:

Small and larg bowel.

Urinary:urethera and bladder25%

Genital:vaginal,occasionally other

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.

Pelvic stability

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.

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 ramusfractures can impale the bladder or occasionally the bowel.

defination

pelvic Stable:lesion sparing the pasterior arch;pelvic floor intactandable 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

Classification

PENNAL AND TILE CLASSIFICATION

Pennal and associates (50) classify the principal pelvic ring disruptions based on the direction of the injuring forceand 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

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

Sartorius

Rectus femoris

Addactor longus

managment

All are essentiallymuscle injuries, needing only rest for a few days andreassurance.Pain may take months to disappear and, becausethere is often no history of impact injury, biopsy ofthe callus may lead to an erroneous diagnosis of atumour. Rarely, avulsion of the ischial apophysis bythe hamstrings may lead to persistent symptoms, inwhich case open reduction and internal fixation isindicated

Direct fractures

Fracture of the ilium

Fracture of the ischium

Fracture of the pubic ramus

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.

(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.

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.

(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.

LC-I injury. The ring is stable.

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.

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.

vertical shear injury

With a vertical shear injury, the iliolumbarligaments, along with the posterior SI ligaments, are disrupted . With vertical displacement of the pelvis, the ipsilaterallower lumbar transverse processes are fractured.

Diagnosis

HistorySuspected 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

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

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.

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 groinpain when they place the ipsilateral foot on thecontralateral knee and the ipsilateral hip is Flexed,Abducted and Externally Rotated. .examination of visceral injury

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.

Plain Pelvic X-rays

AP views

90% of all

traumatic

injuries to the

bony pelvis were

diagnosed on

Anteroposterior

veiw alone

Inlet view

Caudal view in

the 40-degree

inlet. The inlet

view demonstrates

rotational

deformity or

anteroposterior

displacement of

one hemipclvis

Outlet view:

Cephalic view

in 40-degree

outlet views

the outlet view

demonstrates

vertical

displacement of

a hemipelvis

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.

Management of major pelvic fracture:

You have to call orthopaedic surgeon, a urologist, a vascular surgeon, a colo-rectal surgeon and (sometimes) a gynaecologist!

Management I

1. Prehospital- transport with bed sheet, MAST, pelvic clumps.

)

3..

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

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.

minor fracture [ stable ] bed rest,PainkillerPhysical therapyHealing take 8-21 wk

Severe injuries

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

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.

Fracture reduction and stabilization

with external fixation

Timing of surgery

Reduction may be

easiest in first 24-48

hoursMay aid in percutaneus reduction

Reduction tools

Traction

Pelvic manipulator (e.g. femoral

distractor)

Specialized clamps

Reduction and Fixation:SI Joint Dislocation

SI screw

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

Genitourinary GU complications occur in up to 37% of patients with pelvic ring injuries.65 The

most common GU complications occurring with pelvic ring injuries are bladderdisruptions 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.

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.

Thank you for listening