pelvic ring injuries: stability and reduction techniques

Pelvic Ring Injuries:Stability and Reduction Techniques

Pelvic Ring Injuries

Classification of Pelvic Ring InjuriesYoung-Burgess

Based upon mechanism of injury

Tile Based upon stability of pattern


Young-BurgessLateral Compression (LC 1-3)

Anterior-Posterior Compression (APC 1-3)

Vertical Shear (VS)

Combined Mechanism of Injury (CMI)


TileType A: Stable

A1: Not involving ring

A2: Minimally displaced ring fracture

A3: Transverse fractures of sacrum/coccyx

Type B: Partially stable (rotationally unstable, vertically and posteriorly stable) B1: External rotation instability, open book

B2: Internal rotation instability, lateral compression

B3: Bilateral rotational instability

Type C: Unstable (rotationally, vertically and posteriorly unstable) C1: Unilateral injury

C2: Bilateral injury, one side rotationally unstable one side vertically unstable

C3: Bilateral injury, both sides completely unstable


Young-BurgessWidely utilized

Characteristic fracture patterns can be visualized based on classification

Inter-observer variability

Wide variations in stability and need for surgery within single level of classification (LC-1, LC-2, APC-2)


TileMay be more helpful determining need for surgery (front, back, front

& back) based upon classification

Difficult to visualize fracture pattern based upon classification


Treatment in many cases controversial Important to understand that there are fractures that could be

classified as ANY of the Young-Burgess or Tile types for which surgical treatment may be indicated

Since Tile classification is based upon stability, may be less susceptible to confusion

Controversy still exists regarding indications for surgery in certain fracture patterns


LC-1


LC-2


LC-2

Crescent fracture


LC-3


APC-1

Floor ligaments stretched, not torn


APC-2

Floor ligaments and anterior SI ligaments disrupted


APC-2

SI involvement may be subtle, even on CT


Neutral IR stress ER stress

APC-2


APC-3: Complete iliosacral dissociation


APC-3


Vertical shear

Pelvic Ring Injuries: Surgical Indications

IndicationsPosteriorly unstable fractures

Vertically unstable fractures

Rotationally unstable fractures

Which are these?LC-3, APC-3, VS

Some LC-1

Some LC-2

Some CMI

? APC-2

Assessment of stability independent of Young-Burgess classification


Example: “Bad” LC-1Complete sacral fracture

Internal rotation deformity

Potential for vertical instability


“Bad” LC-1


Intermediate LC-1: Complete sacral fracture, minimal rotational deformity, ? Risk of vertical migration


“Bad” LC-2: Rotationally and vertically unstable, almost but not quite involving the acetabulum


“Bad” LC-2


APC-2Treatment may be controversial

Identical injury may be treated with symphyseal plating only, symphyseal plating plus iliosacral screw, or nothing

More dependent upon surgeon than injury

No good data to direct treatment

Pelvic Ring Injuries: Reduction

Stable InjuriesGenerally non- or minimally-displaced

Reduction not usually an issue

Intermediate and “bad” LC-1 fractures? Correction of internal rotation deformity

May not be necessary depending upon degre

Closed reduction, external fixation adequate


Unstable InjuriesDisplaced

Rotationally

Vertically

Both

Anteriorly

Posteriorly

Both


ReductionOpen

Closed

Combination

Determined by degree of displacement/instablilty


Early traction and/or binder!Very important, if indicated

Can reduce need for open reduction at time of definitive fixation

Patients with pelvic ring injuries often sick

Definitive fixation delayed

If left significantly displaced for even a few days, open reduction may become necessary


Anterior injuriesSympyseal disruption

Pfannenstiel incision

May be approached via standard midline as well

Placement of tenaculum on pubic tubercles

Use of pelvic reduction clamp attached to screws may be necessary

Allows for correction of rotational deformity as well as diastasis


Anterior injuriesAnterior reduction aids posterior reduction

Usually address symphysis first with reduction, +/- instrumentation

Address SI joint second, if necessary

Rami fractures Often amenable to closed reduction and control with anterior external fixator

Intramedullary rami screws may also be effective

Difficult trajectory

? fixation


Anterior injuriesRami fractures

Often amenable to closed reduction and control with anterior external fixator

Intramedullary rami screws may also be effective

Difficult trajectory

? fixation


Posterior Injuries SI disruption

Closed reduction easiest if performed early

Massive displacement requires open reduction

May be approached anteriorly via lateral window or posteriorly via direct approach to SI joint

Posterior ilac fractures (crescent fractures) Closed reduction if not widely displaced

Open reduction

Anterior via lateral window if fracture/dislocation of SI joint

Direct posterior approach via outer table

45 yo Female, T-Bone MVA, Front Seat 45 yo Female, T-Bone MVA, Front Seat PassengerPassenger

Currently Hemodynamically StableCurrently Hemodynamically Stable Pelvic DeformityPelvic Deformity Grossly Unstable Pelvic Ring InjuryGrossly Unstable Pelvic Ring Injury Left Foot Insensate And 0/5 Motor FunctionLeft Foot Insensate And 0/5 Motor Function

Case Discussion

Post Injury Day # 4Post-Injury Day 4

pelvic ring injuries: stability and reduction techniques

Documents

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acetabulumpelvic ring

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surgical indicationsbad

vssome lc

surgical indicationsexample

surgical treatment