Pelvic Ring Disruptions

Pelvic ring disruptions are a major cause of mortality and morbidity in

multiply injured patients. Whereas fatalities result from uncontrolled
retroperitoneal hemorrhage and other associated injuries, disabilities
such as low back pain, leg-length discrepancies, dyspareunia,
difculties with
childbearing, and impotence are caused by the anatomic disruption of
the pelvic ring. Pelvic fractures can be particularly lethal when they
occur in
combination with signifcant injuries to other major organ systems.!!"
#ecause of the high force necessary to disrupt the pelvic ring in young
patients, it
is not surprising that up to $%& of these patients have additional
musculoskeletal injuries. 'ortality rates in the patient with high-energy
pelvic ring
injuries are appro(imately !)& to *)&. +hese deaths are generally a
result of the injuries commonly associated with this injury pattern.
'ortality
increases nearly !, times when the patient presents with hypotension.
When combined with either a head or an abdominal injury that re-uires
surgical
intervention, the mortality increases to )%&. When both procedures
are necessary, mortality increases to .%&.
Classifcation
/rthopedic surgeons and traumatologists broadly classify pelvic ring
disruptions into two major groups0 stable and unstable. 1 stable pelvis
is defned
as one that can withstand normal physiologic forces without displacing.
+his stability depends on the integrity of bony and ligamentous
structures 2 3ig.
*!4. 5. Instability is generally divided into rotational and vertical
components 2 3ig. *!4!% 5. +hese displacements can be appreciated on
the initial
anteroposterior screening radiograph. 6table injuries include
nondisplaced fractures of the pelvic ring and anterior displacements of
less than *.) cm.
7otational instability is characteri8ed by widening of the symphysis
pubis or displacement of pubic rami fractures of greater than *.) cm.
6uperior
translation of a hemipelvis through fractures of the sacrum or ilium and
disruption of the sacroiliac joint by more than ! cm constitute vertical
instability. 6erial sectioning studies reveal that division of the
symphyseal ligaments alone leads to diastasis of *.) cm or less,
maintaining stability.!*"
3urther sectioning of the anterior sacroiliac ligaments and sacrospinous
and sacrotuberous ligaments 2pelvic 9oor5 permits rotational instability.
:ertical
instability results only after the posterior sacroiliac ligaments are also
sectioned. ;isplaced fractures 2superior and inferior pubic rami
fractures, sacral or
iliac wing fracture5 can also result in similar instability patterns.
#ecause the pelvis is a true ring structure, a signifcant anterior
displacement must be
accompanied by a corresponding posterior disruption. ;isruptions in
the pelvic ring are usually a combination of fractures and ligamentous
injuries.
<arly recognition of unstable pelvic ring disruptions is essential
because they are more likely to be associated with fatal hemorrhage.
=ikewise, these
injuries re-uire stabili8ation to restore the pelvic ring anatomy and
decrease late disability. ;etermination of the stability of the injured
hemipelvis must
be established through a combination of physical e(amination and
review of the anteroposterior radiograph. 1n anterior defect can
sometimes be
detected by palpation at the symphysis pubis. 7otational instability can
be appreciated by manually compressing and distracting the pelvis
through the
anterior iliac spines. #ecause repeated manipulation can cause
iatrogenic injury, this should be performed a limited number of times.
:ertical instability
may be appreciated when movement of the hemipelvis is detected as
manual compression and traction are applied through an e(tended,
uninjured lower
e(tremity. +he screening anteroposterior radiograph is then e(amined.
>n .%& of cases, this is sufcient to assess stability and guide initial
treatment.
1nterior injuries are easily identifed on this projection. 'ost unstable
posterior injuries can also be appreciated. 1vulsion fractures at the =)
transverse
process and the ischial spines indicate ligamentous disruption and are
usually identifable. =arge posterior gapping or displacement of the
hemipelvis
superiorly by more than ! cm indicates complete posterior disruption
and instability.!*"
;etailed classifcation systems have been developed based on the
direction of force, stability of the pelvis, location of fracture, or whether
it is an open
or closed injury. +he ?omprehensive Pelvic ;isruption classifcation of
the 1rbeitsgemeinschaft fur /steosynthesefragen 21/5 combines the
mechanism of injury with the degree of pelvic instability. +ype 1 injuries
preserve the integrity of the posterior ligamentous and bony
structures. +hese
injuries maintain a stable pelvic ring and usually re-uire no further
treatment unless neurologic injury is associated with a sacral fracture.
+ype #
injuries represent incomplete disruption of the posterior pelvis. +hese
injuries result in rotational instability of the pelvis. 1 varying degree of
sacroiliac
joint or sacral disruption is characteristic. +hese injuries occur with
both anterior and lateral compression mechanisms. >n type ? pelvic
injuries, the
hemipelvis is vertically, rotationally, and posteriorly unstable.
=ateral compression as well as vertical shear-type fractures are
associated with intra-abdominal and head injuries. +he most common
cause of death in a
lateral compression injury to the pelvis is associated closed head
trauma.," +he anteroposterior compression-type injuries have the
greatest risk for
retroperitoneal hemorrhage. >ntrapelvic visceral injuries are also more
common in the anteroposterior patterns. 'ortality in anteroposterior
compression-type injuries relates to a combination of retroperitoneal
bleeding and visceral injuries.,"
547
Figure 21-9 Pelvic stability. A, +he intact ligamentous bony structures of the pelvis
maintain its integrity with regard to stability. +he posterior hinge, consisting of the
posterior
sacroiliac ligaments and the iliolumbar ligaments, is imperative to maintain vertical
stability. +he sacrospinous prevents rotation, and the sacrotuberous prevents vertical
migration. 1s
long as these, the anterior sacroiliac, and the symphysis are intact, the pelvis will
remain stable. >f, however, the anterior symphysis is separated or the sacrum is
crushed posteriorly,
as seen in B and C, the posterior hinge remains intact and the pelvis is usually stable
vertically. +he sacrospinous ligaments are intact, and rotatory abnormalities are thus
prevented.
(A to C, From Kellam JF, Mayo K: Pelvic ring disruptions. In Browner B, Jupiter !B,
"evine #M, !ra$ton P% &eds': ()eletal !rauma, *rd ed. P+iladelp+ia, ,B (aunders,
-..*./
e!orr"age in Pelvic Fracture
+he usual cause of hemorrhage in pelvic fractures is from the posterior
pelvic venous ple(us and bleeding cancellous bone surfaces. 7arely, in
less than
!%& of cases, it may be caused by bleeding from a named artery 2 3ig.
*!4!! 5.!," !@" !)" #leeding from a larger artery is even less fre-uent. +wo
large
series!A" demonstrated rates of bleeding from femoral or iliac vessels in
!& and %& of patients. >n light of these studies, initial treatment
should focus on
the control of venous bleeding. 7eduction and stabili8ation of the
displaced pelvic ring help achieve this. 7eduction leads to a decrease
in pelvic volume
and tamponade of the bleeding vessels through compression of the
viscera and pelvic hematoma. 6tabili8ation maintains the reduction
and avoids
movement of the hemipelvis, reducing pain and limiting the disruption
of organi8ing clots. 6ince reduction and stabili8ation alone usually
control
venous bleeding, patients who do not respond to these maneuvers are
more likely to have arterial bleeding.
#ta$ili%ation
7eduction and stabili8ation of the pelvis can be achieved by a variety
of mechanical means 2 3ig. *!4!* 5. When feld personnel detect
unstable pelvic
ring disruptions on physical e(amination, they can begin treatment by
binding the pelvis with a rolled sheet or applying pneumatic antishock
garments
2P16Bs5. =ike the air splints applied to the e(tremities, the garment
functions by compressing the pelvis. >f applied in the feld, P16Bs
should not be
de9ated until the patient is actively being resuscitated in the trauma
room. +he P16B has as its advantages ease of use, application in the
feld, and
reusability. Cowever, it blocks access to the patient and restricts
e(cursion of the diaphragm, and there have been reports of gluteal
and thigh
compartment syndromes developing after its e(tended use in
hypotensive patients.
+he standard method for controlling pelvic hemorrhage has been the
application of an anterior e(ternal f(ation frame. Proper application of
an anterior
pelvic
54&
Figure 21-1' A, ;ivision of the symphysis pubis will allow the pelvis to open to
appro(imately *.) cm with no damage to any posterior ligamentous structures. B,
;ivision of the
anterior sacroiliac and sacrospinous ligaments, either by direct division of their fbers
2rig+t5 or by avulsion of the tip of the ischial spine 2le$t5, allows the pelvis to rotate
e(ternally
until the posterior superior iliac spines abut the sacrum. Dote, however, that the
posterior ligamentous structures 2e.g., the posterior sacroiliac and iliolumbar
ligaments5 remain intact.
+herefore, no displacement in the vertical plane is possible. C, ;ivision of the
posterior tension band ligaments, that is, the posterior sacroiliac, as well as the
iliolumbar, depicted here
on the left side, plus an avulsion of the transverse process of =) causes complete
instability of the hemipelvis. Dote that posterior displacement is now possible. (A to
C, From Kellam
JF, Mayo K: Pelvic ring disruptions. In Browner B, Jupiter !B, "evine #M, !ra$ton P%
&eds': ()eletal !rauma, *rd ed. P+iladelp+ia, ,B (aunders, -..*./
Figure 21-11 >nternal aspect of the pelvis shows the great vessels in the
lumbosacral ple(us as well as the pelvic 9oor and the pelvic contents, bladder, and
rectum. (From Kellam JF,
Mayo K. Pelvic ring disruptions. In Browner B, Jupiter !B, "evine #M, !ra$ton P%
&eds': ()eletal !rauma, *rd ed. P+iladelp+ia, ,B (aunders, -..*./
549
Figure 21-12 1lgorithm of pelvic fracture management. ?+, computed tomographyE
<.F.1., e(amination under anesthesiaE /.7.>.3., open reduction and internal f(ationE
6l,
sacroiliac. (From Kellam JF, Mayo K: Pelvic ring disruptions. In Browner B, Jupiter !B,
"evine #M, !ra$ton P% &eds': ()eletal !rauma, *rd ed. P+iladelp+ia, ,B (aunders,
-..*./
e(ternal f(ator should provide stability to the pelvis and hematoma,
while allowing access to the abdomen for surgical procedures. 'ultiple
studies
have shown that outcomes can improve with their routine use.!@" !)" !G"
1lthough this device can be applied in the emergency department, it is
fre-uently
deferred until the patient is brought to the operating suite. >n these
circumstances, the pelvis can remain displaced for many hours with
venous bleeding
continuing uncontrolled. >f an e(ternal f(ator cannot be applied
e(peditiously, another method of provisional stabili8ation must be
employed. 7ecently,
devices called pelvic ?-clamps have been developed that can be
rapidly applied to reduce and provisionally stabili8e the pelvis in the
emergency
department. +he design allows for compression of the pelvis through
percutaneously inserted pins applied to the outer surface of the ilium.
+hey provide
ade-uate stabili8ation and easy access to the abdomen or e(tremities
without removal of the device 2 3ig. *!4!, 5. +he ?-clamps can remain
in place
throughout the resuscitation phase and then be replaced by defnitive
stabili8ation methods when the patient is able to undergo these
procedures. ?are
must be taken in the
55'
Figure 21-1( Pelvic ring disruption with massive hemorrhage. A, 1nteroposterior
21P5 radiograph of the pelvis shows disruption of the symphysis pubis and the
sacroiliac joint. B,
1P view of the pelvis following reduction by application of the pelvic stabili8er. C and
D, Patient with the pelvic stabili8er in the standard position and elevated to allow
access to the
perineum or the hips to be 9e(ed into the lithotomy position.
application of these clamps because serious complications can result
from misplacement of the pins. 1ccordingly, these devices are utili8ed
only in
rotationally and vertically unstable pelvic ring disruptions and not in
stable injury patterns.
+he role of angiography in the diagnosis and management of pelvic
hemorrhage is controversial. =arge series have demonstrated the
incidence of
arterial hemorrhage amenable to emboli8ation to be appro(imately
!%&.!," !@" 3urthermore, it is even less common for the bleeding to be
the result of an
injury to a large or named artery. >n these cases, arteriography with
emboli8ation can be lifesaving. Cowever, catheteri8ation and
emboli8ation of
vessels in the pelvis are technically difcult and time consuming. +he
use of these techni-ues should be reserved for those cases when all
other methods
of control of hemorrhage have been e(hausted.!,"
)anage!ent Algorit"!s
1lgorithms for management of the hypotensive patient with a pelvic
fracture all should begin with a search for the cause of the shock 2 3ig.
*!4!@ 5. 1ll
possible causes of bleeding are e(plored. 1uscultation of the chest and
review of the chest radiograph determine the presence of hemothora(
and the
need for thoracostomy. /nce the hemothora( is either ruled out as a
cause of shock or is controlled by chest tubes, a diagnostic peritoneal
lavage or
ultrasound of the abdomen is performed. <(amination of the pelvis is
performed as described previously. 1ny wounds are noted around the
pelvis and
in the perineum. #leeding from the rectum, vagina, or urethral meatus
is noted. ;igital vaginal and rectal e(aminations are performed, feeling
for tears
and fracture fragments.
551
Figure 21-14 1lgorithm for resuscitation after pelvic disruption. ? spine, cervical
spineE <7, emergency room, 3(, fractureE >:s, intravenous linesE /7, operating roomE
P16B,
pneumatic antishock garmentE 7PC, retroperitoneal hematomaE 7H/, rule out. (From
Kellam JF, Mayo K.: Pelvic ring disruptions. In Browner B, Jupiter !B, "evine #M,
!ra$ton
P% &eds': ()eletal !rauma, *rd ed. P+iladelp+ia, ,B (aunders, -..*./
552
>n the presence of an unstable pelvic ring disruption and a positive
abdominal study, stabili8ation of the pelvis should be undertaken
before laparotomy.
>f hemodynamic stability is not achieved after placement of the
e(ternal f(ator, arteriography should then be performed.
=ong-term, defnitive care of pelvic ring disruption is dependent on the
severity and the pattern of injury. 6table fractures or injury patterns
usually
re-uire no more than restricted weight bearing. 3or the reasons
described previously, unstable injuries often need to be defnitively
f(ed. 3re-uently,
the e(ternal f(ator can provide defnitive stabili8ation, if applied
eIectively and reduction has been maintained. >n cases when the
f(ator may be
obstructing access to the abdomen or an interim ?-clamp has been
applied, /7>3 or closed reduction and percutaneous f(ation may be
indicated. When
rotational or vertical instability is present, both the anterior and the
posterior pelvis must be stabili8ed. 1nteriorly, the symphysis is often
secured with a
plate and screws. Posteriorly, more options e(ist. +he sacroiliac joint or
sacral fractures can be secured with plates, bars, or percutaneously
inserted
cannulated screws 2 3ig. *!4!) 5.
Pelvic 3ractures
>njuries to the pelvic ring should be diIerentiated between the low-energy,
stable fractures and the high-energy, life-threatening injuries. +he former are
commonly seen in older adult osteoporotic patients who may have sustained
isolated fractures of the pubic rami or nondisplaced fractures of the acetabuli
or sacrum from a fall. +hese fractures usually do not have disruption of the
pelvic ring or weight-bearing segments and are considered stable.
Cigh-energy injuries are the result of automobile collisions, pedestrians
and cyclists being struck by motor vehicles, or falls from signifcant heights.
!!@A PAR* ++ #P,C+F+C C-.#+D,RA*+-.#
+hese injuries are caused by direct crush, either from the anterior or lateral
direction or vertical shear, or combinations of rotational stress on the iliac
wings. >nitial evaluation of pelvic injuries includes an 1P radiograph. 3urther
imaging includes inlet and outlet views. 1ssociated acetabular fractures
and lumbar spine injuries re-uire @)-degree obli-ue 2Judet5 views and 1P
and lateral radiographs of the lumbosacral spine. 'ost pelvic injuries will
also need a ?+ scan with ,-mm cuts to evaluate a posterior injury to the
pelvis. 1 ?+ scan is best used for evaluation of the sacrum and sacroiliac
joints.
?ontinued, une(plained blood loss despite fracture stabili8ation and aggressive
resuscitation is an indication for angiography. <arly recognition of
potential arterial bleeding should include early notifcation of the interventional
radiology team. 1ngiography and emboli8ation may be re-uired in up
to *% percent of 1P injuries, vertical shear injuries, and combined mechanical
injuries.
1cetabular 3ractures
1cetabular fractures are a subset of pelvic fractures that involve the acetabulum.
+hese intraarticular fractures may result in posttraumatic arthritis of the hip
and are sometimes associated with hip dislocations, which are discussed in the
ne(t section.
+horough evaluation of acetabulum fractures re-uires @)-degree obli-ue
views 2Judet views5 of the pelvis to assess the integrity of the anterior
and posterior columns and the anterior and posterior walls. 1dditionally,
?+ scans are helpful in fully delineating fracture patterns and demonstrating
the presence of intraarticular bony fragments. Dondisplaced or minimally
displaced fractures are determined after complete evaluation of the
radiographs and acetabular ?+ scans. 7adiographs should be taken with
traction removed and preferably with stress applied. 1ny degree of incongruence
involving the weight-bearing surface of the acetabulum is unacceptable
and is an indication for surgical treatment. Dondisplaced fractures
may be treated with a period of traction followed by progressive weight
bearing.
Cip ;islocation
;islocation of the hip often is caused by a force applied to the femur and
can be associated with fractures of the acetabulum or femoral head. +he most
common mechanism of injury is motor vehicles accidents. 3orce applied to
an abducted hip can result in anterior dislocation, although striking the knee
on a car dashboard with the hip 9e(ed and adducted, results in posterior dislocations.
Posterior dislocations often are associated with a fracture of the
posterior wall of the acetabulum. ;irect trauma to the greater trochanter from
a lateral direction can result in medial wall fractures or central acetabular
fracturesHdislocations.
+horough evaluation of hip dislocations often re-uires Judet radiographic
views and additional ?+ scans. 6imilar to patients with pelvic fractures, these
patients may have other major injuries and careful evaluation of the chest,
abdomen, spine, and neurologic status is necessary. Prompt reduction of hip
dislocations is essential in minimi8ing the incidence of osteonecrosis of the
femoral head.