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• Pelvic injuries are a major cause of
mortality and morbidity in multiple
• The close proximity of osteoligamentous
structures to pelvic
organs, neurovascular, hollow
viscera, and urogenital structures may
lead to wide range of severe complications
and late sequel if not diagnosed and
• Fatalities are due to uncontrolled
• Disabilities are due to anatomic
disruption the pelvic ring. ( low back
discrepancies, dyspareunia, impotence,
difficulties with child bearing).
• Pelvic fractures can be particularly
lethal when occur in combination with
significant injuries to other major organ
• The bony pelvis is divided into the so-
called true and false pelvises, with the line
of demarcation formed by the pelvic brim
• The true pelvis contains the pelvic organs
the bladder, urethra, and rectum, and the
uterus and vagina in females, and the
prostate gland in men whereas the false
pelvis forms the lower part of the
• Vertically oriented ligaments resist
vertical displacement of the pelvis.
• These include:
• long posterior SI,
• lateral lumbosacral ligaments.
• (The strongest of these and the most
important with regard to pelvic stability
are the short and long posterior SI
• The Greater Sciatic Foramen
• Seven Nerves Three Vessel Sets
Sciatic nerve Superior gluteal artery/vein
Superior gluteal nerve Inferior gluteal artery/vein
Inferior gluteal nerve Internal pudendal artery/vein
Internal pudendal nerve
Posterior femoral cutaneous nerve One Muscle
Nerve to quadratus femoris Piriformis
Nerve to obturator externus
•The obturator foramen:
separating pubis from
ischium, is covered by a
membrane, deficient only on
top to allow the obturator
vessels and nerves to escape
from the pelvis. At this point
they are vulnerable and may
be torn in pelvic trauma.
• Diamond shaped space b/w inf. Pubic rami
And sacrotuberous liga.
Anterior half is urogenital triangle
Contains – deep perineal muscles
• the urethral sphincter muscle, and (in
women) the vaginal orifice.
• Deep to this lie the muscles of the pelvic
pubococcygeus, iliococcygeus, and
• The anterior two, pubococcygeus and
iliococcygeus, wrap around the rectum to
form a kind of sling, and are termed levator
• posterior to the pelvic diaphragm muscles
lie the obturator internus and piriformis
Genitourinary • The bladder lies posterior to the pubis Its
proximity to the rami puts it at risk for
damage, because fractured rami may
spear the bladder at the time of injury.
• In males - the urethra
The intrapelvic male sex
organs, the seminal vesicles and
ejaculatory and deferent ducts just above
• In females - the urethra
uterus lies between the bladder
• fallopian tubes
• ovaries, which are connected to the
uterine body through the ovarian
• final segment of the large intestine
• anal canal
Principal Sites of Hemorrhage
after a Pelvic Fracture
•The floor of the pelvis
comprises the coccygeal
and levator ani muscles.
•The urethra, rectum and
vagina transverse the floor
of the pelvis & can be
during pelvic ring
(Age affects bone structure)
(Pelvic fracture occurs in elderly with less violent force, and associated
with less soft tissue disruptions than young patients).
( Males: more associated injuries to the urethra compared to females).
( Females: vaginal tear).
3- Mechanism of injury:
Low energy - domestic falls , avulsion injury ,post menopausal , steroid induced,
metabolic bone diz
High energy - MVA, FALL from height , crush injury , sport injury , gun shots
projectile ,industrial accidents
4- Associated injuries:
( Is important to determine the amount of trauma on the pelvis).
• Evaluation should begin eith ABC
• Initiate resucitation
• Evaluate injuries to head , chest , abdomen and spine
• * Unexplained hypotension may be the only initial indication of
major pelvic disruption with instability in the posterior
( The patient must be completely
Open wounds , abrasions , ecchymosis
( Position of contusions and abrasions
may indicate direction of the injurious
3- Bleeding genitalia:
(In men, blood from urethra suggests a
in women, blood from urethra or vagina
suggests an occult open fracture of the
4- Displacement of pelvis or lower
(If there is no other fracture in the
leg, its degree of rotation and shortening
suggest what type of pelvic fracture is
( Shortening appreciated as leg length
discrepancy happens as a result of
muscular pull on the unstable hemipelvis).
- If the extremity is obviously
shortened, internally rotated, and
displaced at the posterior iliac spine, it is
mostly a lateral compression injury with
- If the extremity is externally rotated and
shortened, it indicates mostly a severe
unstable vertical shear type
( Careful manual palpation of the pelvis
may reveal crepitus or abnormal motion
in the hemipelvis, either one indicative of
( Repeated examination for pelvic
instability should be avoided in unstable
situations to prevent further induction of
•Palpation of posterior aspect may reveal
1- Test for anterior defects:
Direct palpation of symphysis pubis may
reveal a gap or ecchymosis, indicating a
2- Test for rotational instability:
Grasping the iliac crests and pushing
the unstable hemipelvis inward and
outward (compression – distraction
3- Test for vertical instability:
Can be appreciated when movement of
the hemipelvis is detected as manual
compression and traction are applied
through an extended uninjured lower
(Palpating the posterior iliac spine &
tubercle while pushing and pulling the
•Rectal & Vaginal examination:
( Both are essential for complete
- Very often the fracture can be palpated
by either of these routes to further assess
the stability of the pelvic ring.
- Presence or absence of vaginal or
- High riding prostate gland.
• Neurological examination
- Injury to lumbosacral
plexus, especially L5 root is
common, therefore, a careful
neurological examination is mandatory.
- Nerve injuries of all types are much
more common in shear type fractures.
- AP pelvic view is mandatory and can
provide a reliable working diagnosis in
about 90% of the cases.
- For 3 dimensional analysis, oblique
views (inlet and outlet films) are included
to evaluate anterior, posterior, cranicaudal
and rotational displacement).
- The inlet view is the best view for
disclosing posterior displacement.
• inlet view
• X-ray beam angled ~45 degrees
• adequate image when S1 overlaps
• ideal for visualizing:
• anterior or posterior translation of
• internal or external rotation of the
• widening of the SI joint
• sacral ala impaction
• outlet view
• X-ray beam angled ~45 degrees
• adequate image when pubic
symphysis overlies S2 body
• ideal for visualizing:
• vertical translation of the hemipelvis
• flexion/extension of the hemipelvis
• disruption of sacral foramina and
location of sacral fractures
• radiographic signs of instability
• > 5 mm displacement of posterior
• presence of posterior sacral fracture
• avulsion fractures (ischial spine, ischial
tuberosity, sacrum, transverse process
of 5th lumbar vertebrae)
• C T scan
• routine part of pelvic ring injury
• better characterization of posterior ring
• helps define comminution and fragment
• visualize position of fracture lines
relative to sacral foramina
• nonresponders who have been
• The Young-Burgess (1986; 1987)
system is as follows:
1. APC injury
• The hallmark of the AP compression
injury is pubic diastasis with or without
disruption of the SI joints. The location
and degree of diastasis is correlated
with the magnitude of force imparted to
the pelvis and with the amount of
resulting instability. The AP
compression causes the pelvis to open:
one or both hemipelves undergo
external rotation. According to the
Young-Burgess classification system, 3
degrees of AP compression injury are
• APC- I injuries: Less than
2.5 cm of the pubic
diastasis is noted, either at
the symphysis or through
vertically oriented rami
fractures. The SI joints and
posterior ligaments remain
intact, and stability is
• APC- II injuries: The
amount of anterior diastasis
exceeds 2.5 cm. In
addition, diastasis occurs in
1 or both of the SI joints.
This incomplete posterior
arch disruption results in
rotational instability. The
posterior ligaments are not
injured; therefore, vertical
stability is preserved.
• APC- III injuries: These injuries extend to
the posterior SI ligaments, which are
disrupted. Consequently, the pelvis is
vertically and rotationally unstable.
2. Lateral compression (LC) injury
• Lateral compression injury results in
internal rotation of the affected
hemipelvis. This internal rotation
decreases rather than increases the
pelvic volume. Consequently, pelvic
vascular injuries and resulting
hemorrhage are less common with this
injury than with other injuries. Lateral
compression injuries are associated
with brain and intra-abdominal injuries.
• The hallmarks of a lateral compression
injury include sacral buckle fractures
and horizontal pubic rami fractures. The
Young-Burgess classification system
describes 3 types of injuries.
• LC- I injuries: These involve a force
directed posteriorly to the lateral
aspect of the hemipelvis, which
results in an ipsilateral sacral buckle
fractures; ipsilateral horizontal pubic
rami fractures; or, less
commonly, disruption of the pubic
symphysis with overlap of the pubic
bones. The posterior ligaments
remain intact; therefore, the pelvis is
• LC- II injuries: These involve more
internal rotation of the hemipelvis.
As in type I injuries, ipsilateral sacral
buckle fractures and horizontal pubic
rami fractures are associated with
fracture of the ipsilateral iliac wing or
disruption of the ipsilateral posterior
SI joint. The pelvis is rotationally
unstable, but its vertical stability is
• LC- III injuries: The force continues
from the ipsilateral side across the
midline to affect the contralateral
hemipelvis. The ipsilateral
hemipelvis sustains either a type I or
type II injury with associated internal
rotation. The contralateral pelvis
undergoes external rotation.
Contralateral vertical pubic rami
fractures or disruption of the
ligaments may occur. As in type II
injuries, the pelvis is rotationally
unstable but vertically stable.
3. Vertical shear injury
• A vertically oriented force applied to a
hemipelvis, usually by the
femur, results in a vertical shear injury.
At the anterior aspect, vertically
oriented fractures of the pubic rami
occur. Posteriorly, the ipsilateral SI joint
(or occasionally the contralateral SI
joint) and its associated ligaments are
• The affected hemipelvis is displaced in
a cranial direction. Complete disruption
of the posterior ligaments yields a
rotationally and vertically unstable
• Associated injuries seen in the vertical
shear pattern are similar to those
encountered in type III AP compression
1. Early management
• Treatment should not await for full and
• Doctor should move according to the
priority of life saving measures with the
already available information.
• ATLS PROTOCOL
• Airway , breathing , circulation , disability
• The system is based on a three-stage
• 1. Primary survey and simultaneous
resuscitation – a rapid assessment and
treatment of life-threatening injuries.
• 2. Secondary survey – a detailed, head-to-
to evaluation to identify all other injuries.
• 3. Definitive care – specialist treatment of
Management of severe bleeding
Treatment of shock.
2. Pelvic binder
3. External fixation to close the book.
Management of genito urinary injury
Management of GI injuries
•Reduction and stabilization of the pelvis can
be achieved by a variety of mechanical
- Bind the pelvis by
a rolled sheet.
- Apply pneumatic
- Pelvic c – clamps.
- External fixator.
• pelvic binder/sheet
• risk of over-rotation of hemipelvis
and hollow viscus injury (bladder) in
pelvic fractures with internal rotation
• centered over greater trochanters to
effect indirect reduction
• do not place over iliac
• prolonged pressure from binder
or sheet may cause skin necrosis
•Pneumatic antishock garments (PASGs).
(It functions by compressing the pelvis, and if applied it should not
be deflated until the patient is actively being resuscitated in the trauma
Advantages: reduce displacement of APC INJURY
- Easy to use, applicable in the field, & reusable.
Disadvantage: Increase displacement of LC INJURY
- It blocks access to the patient and restricts excursion of the
- Gluteal & thigh compartment syndromes after its extended use in
•Pelvic C- clamps:
(recently developed devices that
can be rapidly applied to reduce and
provisionally stabilize the pelvis in
the emergency department).
- The design allows for
compression of the pelvis through
percutaneously inserted pins applied
to the outer surface of the ilium. Care
must be taken because serious
complications can result from
misplacement of the pins.
• General guidelines
• MINIMALLY DISPLACED LC 1 AND APC 1 –
PROTCATED WEIGHT BEARING AND
• DICRUPTION OF ANT. RING WITHOUT COMPELETE
POST. RING DISRUPTION
APC 2 , LC 1 WITH DISPLACEMENT –
REDUCTION AND STABILIZATION
• COMPLETE DISRUPTION OF POST RING
LC 2 , LC 3 , APC 3 , VS - STABILIZATION OF BOTH
ANT AND POST PELVIC RING
Non operative treatment
• Pubic rami fractures with no post.
• Gapping of pubic symphysis < 2.5 cm
• Lateral impaction type with minimal
Protected weight bearing
• Open pelvic fractures associated with
• Open book and verticaly unstable fractures
• Symphyseal diastasis > 2.5 cm
• SI joint displacement > 1 cm
• Leg length discrepancy > 1.5 cm
• Rotational deformity
• Sacral fracture displacement > 1 cm
• External fixation – ant. Ex fix
• Ganz fixation
• ORIF of pubic symphysis with plates
• Posterior ring fixation with plates
• Posterior SI "tension" plating
• Percutaneous iliosacral screw fixation for
• Percutaneous fixation of sup. Pubic rami
• Transiliac rod fixation of sacral fractures
•Management of open pelvic
- Isolated iliac wing fractures
are managed like open fractures
in other areas of the body with
aggressive debridement &
stabilization of fractured
- Aggressive debridement and
packing of the wound to prevent
continuous bleeding and possible
- Perineal lacerations and wounds that communicate with
the rectum or colon require early diverting colostomy
(preferably at transverse colon to provide uncontaminated
skin around the pelvis).
- Early detection and repair of vaginal lacerations to
minimize subsequent pelvic abscesses.
• Other advisable damage control
procedures at an early stage
include suprapubic urine catheter
drainage, insertion of a
transurethral catheter, and suture of
the bladder after urological injuries.
•Anterior external fixator:
( The standard method for
controlling pelvic hemorrhage).
- Proper application should
provide stability to the pelvis and
hematoma, while allowing
access to the abdomen for
- Although it can be applied in
the emergency department, it is
frequently deferred until O.T.
Pr e o p e r a t i v e ( A ) a n d p o st o p e r a t i v e
( B) x - r a y s d e m o n st r a t i n g o p e n
r e d u c t i o n a n d i n t e r n a l
f i x a t i o n o f t h e a n t e r i o r r i n g o f t h e
p e l v i s.
Ri g h t i l i a c w i n g f r a ct u r e . B.
Ma n a g e d co n se r v a t i v e l y .
Fr a ct u r e ca l l u s i s p r e se n t a t
St a b i l i za t i o n t e ch n i q u e i n ce n t r a l
a n d / o r b i l a t e r a l sa cr u m f r a ct u r e s: