pelvic fracture

1. Classification of Pelvic
Fractures
Zahid Askar
FCPS(Ortho), FRCS (Ortho)
Prof of Orthopaedics & Trauma
Khyber Medical College, Peshawer

2. Value Of classification
• Mechanism of injury
• Treatment options
• Prognosis
• Records/communications
It should also be :-
Easily Reproducible
Have good Intra- & Interobservor reliability
Easily remembered/applied

3. Historical Background
• First attempt by Malgaigne in 1859
– Described without radiographs of the so-called
“double vertical fracture”
Malgaigne I. F.: Traite des Fractures et des
Luxations, Paris, J. B. Bailliere, 1855.

4. Historical classification
• Watson-Jones
• Connolly & Hedberg
• Huttinen & Slatis
• Trunkey
• Looser & Crombie

5. • Present classification systems started with
the ground-breaking work by Pennal
• Classified Injuries as APC/LC/VS
Pennal GF, Sutherland GO. Fractures of the
Pelvis. Park Ridge, IL: American Academy of
Orthopedic Surgeons, 1961.
Pennal, G. F., and Sutherland, G. 0.: Fractures
of the Pelvis. Motion picture in AAOS film
library, 1961.

6. Classification Systems
• Letournel
• Bucholz,
• Tile
• Young & Burgess
• OTA/AO -research
Commonly used Classification systems:-
Tile Classification
Young & Burgess Classification

7. Tile classification
• Modification of Pennal Idea
• Tile et al added the concept of stability
The Tile classification system is mainly
based on the integrity of the posterior
sacroiliac complex
Which Tile ???

8. Original Tile Classification
Pennal GF, Tile M, Waddell JP, et al. Pelvic
disruption: assessment and classification. Clin
Orthop Relat Res 1980;151:12-22.
Type A: Pelvic Ring Stable
A1: fractures not involving the ring (i.e., avulsions, iliac wing, or
crest fractures)
A2: stable minimally displaced fractures of the pelvic ring
Type B: Pelvic Ring Rotationally Unstable, Vertically Stable
B1: open book
B2: lateral compression, ipsilateral
B3: lateral compression, contralateral, or bucket-handle-type injury
Type C: Pelvic Ring Rotationally and Vertically Unstable:
C1: unilateral
C2: bilateral
C3: associated with acetabular fracture

9. C1: Unilateral
C1-1: iliac fracture
C1-2: sacroiliac fracture-dislocation
C1-3: sacral fracture
C2: Bilateral with one side type B and one side type C
C3: Bilateral with both sides type C
B - Rotationally unstable, vertically stable
B1: Open book injury (external rotation)
B2: Lateral compression injury (internal rotation)
B2-1: Ipsilateral ant. and post. Injuries
B2-2: Contralateral ant. and post. Injuries (bucket-handle injury)
B3: Bilateral
A: stable
A1: fracture not involving the ring (avulsion or iliac wing fracture)
A2: stable or minimally displaced fracture of the ring
A3: transverse sacral fracture (Denis zone III sacral fracture)
Modified Tile Classification
Tile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg Br
1988;70:1-12.

10. • Comprehensive Classification

11. Type A: Stable (Posterior Arch Intact)
A1 Avulsion injury
A1.1—Iliac spine A1.2—Iliac crest A1.3—Ischial tuberosity
A2 Iliac wing or anterior arch fracture caused by a direct blow
A2.1—Iliac wing fractures A2.2—Unilateral fracture of anterior arch
A2.3—Bifocal fracture of anterior arch
A3 Transverse sacrococcygeal fracture
A3.1—Sacrococcygeal dislocation A3.2—Sacrum undisplaced
A3.3—Sacrum displaced
Type B: Partially Stable (Incomplete Disruption of Posterior Arch)
B1 Open book injury (external rotation)
B1.1—Sacroiliac joint, anterior disruption B1.2—Sacral fracture
B2 Lateral compression injury (internal rotation)
B2-1 Ipsilateral anterior and posterior injuries B2-2 Contralateral
(bucket-handle) injuries
B3 Bilateral
B3.1—Bilateral open book B3.2—Open book, lateral compression
B3.3—Bilateral lateral compression
Type C: Unstable (Complete Disruption of Posterior Arch)
C1 Unilateral
C1.1 Iliac fracture C1.2 Sacroiliac fracture-dislocation C1.3 Sacral fracture
C2 Bilateral,
with one side type B, one side type C
C3 Bilateral

12. Modified Tile Classification
Tile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg Br
1988; 70:1-12.

13. Tile Type A fractures
• The SI Joint is completely stable( Rotationally & vertically)
• Fractures are outside the pelvic ring !!A: stable
A1: fracture not involving the ring (avulsion or iliac
wing fracture)
A2: stable or minimally displaced fracture of the ring
A3: transverse sacral fracture (Denis zone III sacral
fracture)

15. Tile Type B Fractures
• Partial Instability of the SI Joint Complex
• Rotationally Unstable while Vertically stable
B - Rotationally unstable, vertically stable
B1: Open book injury (external rotation)
B2: Lateral compression injury (internal rotation)
B2-1: with anterior ring rotation/displacement
through ipsilateral rami
B2-2-with anterior ring rotation/displacement
through contralateral rami (bucket-handle
injury)
B3: Bilateral

16. Tile type B1- Open Book Injury
(External Rotation Injury)

17. APC

19. B2- Lateral Compression Injury
B2: lateral compression injury (internal rotation)
B2-1: with anterior ring rotation/displacement
through ipsilateral rami
B2-2: with anterior ring rotation/displacement
through contralateral rami (bucket-
handle injury)

22. B2: lateral compression injury (internal rotation)
B2-1: Ipsilateral Ant/Post Injuries
B2-2-Contralateral Ant/Post Injuries (bucket-handle
injury)
B2.1 B2.2

26. B2.2- Contralateral injuries

27. B3- Bilateral
The B3 bilateral injuries
can be bilateral open book type
One side B1 and one side B2 or
Bilateral B2 .

29. Type C Injuries- Unstable
C1: Unilateral
C1-1: iliac fracture
C1-2: sacroiliac fracture-dislocation
C1-3: sacral fracture
C2: Bilateral with one side type B and one
side type C
C3: Bilateral with both sides type C

30. C1- Unilateral Injuries
C1: Unilateral
C1-1: iliac fracture
C1-2: sacroiliac fracture-dislocation
C1-3: sacral fracture

33. Tile- Type C2 Injuries
Bilateral with one side type B and
one side type C

34. C3 Injuries
Bilateral with both sides type C

36. Young and Burgess Classification
• Based on the direction of forces causing
fracture, associated instability of pelvis
• Original Work of Pennal
Young JW, Burgess AR, Brumback RJ, Poka A.
Pelvic fractures: Value of plain radiography in
early assessment and management. Radiology
1986;160:445-51.
Burgess AR, Eastridge BJ, Young JW, et al.
Pelvic ring disruptions: effective classification
system and treatment protocols. J Trauma. Jul
1990;30(7):848-56.

37. Young and Burgess classification
• Four Injury Patterns
• Lateral compression (LC)
• Anteroposterior compression (APC)
(external rotation)
• Vertical shear (VS)
• Combined Mechanism (CM)

40. LC-1

41. LC-2
Crescent Fracture

42. LC-3
Windswept
Injury

43. APC

44. APC-1
Symphysis widening < 2.5 cm

45. APC-2
Symphysis widening > 2.5 cm. Anterior SI joint diastasis .
Posterior SI ligaments intact. Disruption of sacrospinous
and sacrotuberous lig

46. APC-3
Disruption of anterior and posterior SI ligaments (SI
dislocation). Disruption of sacrospinous and sacrotuberous
ligaments.

47. C-Vertical Shear Injuries

49. CM- Combined Mechanism
• Combined VS & LC
• LC &APC

50. Pelvic ring disruptions: effective classification
system and treatment protocols.
Burgess AR, et al J Trauma. 1990 Jul;30(7):848-56.

52. Which one is better ???
• Easily reproducible
• Inter observor Agreement
• Relationship to prognosis/treatment

53. Kappa values ( Agreement grades)
Poor ======= =0 to 0.20 ,
Fair =========0.21 to 0.40 ,
Moderate ====0.41 to 0.60
Substantial ===0.61 to 0.80
Perfect ====== >0.80
Intraobserver agreement
SUBSTANTIAL---- for the full Young-Burgess system ,
Average kappa value = 0.61 (95% CI 0.53, 0.69).
SUBSTANTIAL ---- without the subclasses of the Young-Burgess system ,
Average kappa value = 0.72 (95% CI 0.66, 0.78)
MODERATE ------- for the Tile system is
Average kappa value = 0.47 (95% CI 0.31, 0.64)
Andrew et al: Classification of Pelvic Fractures: Analysis of Inter- and
Intraobserver Variability Using the Young-Burgess and Tile Classification
Systems :Orthopedics June 2009 - Volume 32 · Issue 6
Interobserver Agreement
MODERATE for full Young-Burgess system
Average kappa value = 0.46 (95% CI 0.39, 0.52
MODERATE for only the 4 main fracture types
Average kappa value= 0.58 (95% CI 0.45, 0.72),.
MODERATE for Tile system,
Average kappa value = 0.47 (95% CI 0.42, 0.52).

54. Koo et al : Interobserver reliability of the Young-Burgess and Tile
classification systems for fractures of the pelvic ring. J Orthop
Trauma. 2008 Jul;22(6):379-84.
CONCLUSIONS:
The CT scan can improve the reliability of assessment of pelvic stability
(Pre-CT and post-CT = 0.59 and 0.93)
Investigation
(Xrays/CT scan)
Classification Type of Surgeon Average kappa
score
Xrays Young-Burgess All 0.72( Substantial)
Xrays/CT scan All 0.63(Substantial)
Xrays Tile All 0.30( Fair)
Xrays/CT scan All 0.33(Fair)
“The Young-Burgess system may be optimal for the learning surgeon.
The Tile classification system is more beneficial for specialists”

55. Osterhoff et al : Comparing the predictive value of the pelvic
ring injury classification systems by Tile and by Young and
Burgess. Injury 2014 Apr;45(4):742-7
Conclusions
“In this first direct comparison of both
classifications, we found no clinical relevant
differences with regard to
their predictive value on mortality,
transfusion/infusion requirement and
concomitant injuries.”
Predictive Value ???

56. Guthrie HC, Owens RW, Bircher MD.
Fractures of the pelvis: J Bone Joint Surg Br. 2010
Nov;92(11):1481-8
“We recommend using the Young and Burgess
classification which is derived from the initial
anteroposterior (AP) radiograph and is based
predominantly on the mechanism of injury and
severity of pelvic fracture.”

57. Classification of Pelvic Injuries
in Children
Torode and Zieg modification of Watts classification
• Type I – avulsion fractures
• Type II - Iliac wing fractures
• Type III – stable pelvic ring
injuries
• Type IV – any fracture
pattern creating a free
bony fragment (unstable
pelvic ring injuries)
Torode I, Zieg D. Pelvic fractures in children.
J Pediatr Orthop 1985;5:76-84.

58. Open pelvic fractures
Accounting for 2% to 4% of all pelvic ring fractures.
High rate of mortality (25–50%) and significant
morbidity
An open pelvic fracture is defined by a communication
to lesions of the integument or the gastrointestinal and
urogenital tracts.

59. Class 1: Stable open pelvic ring fractures (low mortality)
Class 2: Unstable open pelvic ring fractures without
rectal injury (about 33% mortality)
Class 3: Unstable open pelvic ring fractures in
combination with rectal injury (upto 50% mortality)
Jones Classification for Open Pelvic
Fractures
Jones AL, Powell JN, Kellam JF, et al. Open pelvic fractures: a
multicenter retrospective analysis. Orthop Clin North Am 1997;
28:345–350.

60. Bircher and Hargrove Classification
of Open Pelvic Fractures
Soft tissue injury was divided into three main alphanumerical
categories, which were assigned to Tile’s classification of pelvic ring
fractures. Subsets were defined by the primary skin lesion and
associated soft tissue damage.
Bircher M, Hargrove R. Is it possible to classify open
fractures of the pelvis? Eur J Trauma 2004; 30:74–79.

61. Bircher and Hargrove Classification of
Open Pelvic Fractures
Type A1: Penetrating trauma, for example, by a bullet. Tile/AO type A fracture.
Type A2: “Outside in” injury of the iliac crest, with minimal soft tissue damage.
Tile/AO type A fracture.
Type A3: “Outside in” injury of the iliac crest, with extensive soft tissue damage
requiring surgery for soft tissue coverage. Tile/AO type A fracture.
Type B1: “Inside out” injury caused by lateral compression and showing little
external damage but possible injury to the genitourinary system (i.e., tilt
fracture). Tile/AO type B2 fracture (LC).
Type B2: “Inside out” injury, caused by lateral compression and representing
moderate tissue damage. An example would be a rotationally unstable
pelvic fracture in combination with extensive degloving (Morel–Lavalle´
syndrome). Tile/AO type B2 fracture (LC).
Type B3: “Perineal split” following APC injury. Tile/AO type B1 fracture (“open
book”).

62. Type C1: “Perineal split” and/or “sacral shear/split” injury with moderate to
extensive skin loss, complete genitourinary disruption, and rectal lesions
with subsequent fecal contamination. Tile/AO type C fracture.
Type C2: “Hemipelvic destabilization” injury with severe tissue damage,
complete urogenital and bowel injury combined with extensive
contamination of all tissue layers. Tile/AO type C fracture.
Type C3: “Pelvic crush” with bilateral complex pelvic instability and massive
damage to soft tissues and intrapelvic organs. Tile/AO type C fracture.
Soft tissue injury was divided into three main alphanumerical categories,
which were assigned to Tile’s classification of pelvic ring fractures. Subsets
were defined by the primary skin lesion and associated soft tissue damage.
Bircher M, Hargrove R. Is it possible to classify open fractures of the pelvis?
Eur J Trauma 2004; 30:74–79.

63. Summary
• Tile and Burgess & Young Classifications are
the most commonly used classifications
• Burgess & Young seems to be more easily
remembered and reproduced
• The prognostic values of both are
comparable
• Certain fractures may not be classifiable in
either systems

64. Thanks for your attention !!!