pelvic ring injuries: stability and reduction techniques
TRANSCRIPT
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
Pelvic Ring Injuries
Young-BurgessLateral Compression (LC 1-3)
Anterior-Posterior Compression (APC 1-3)
Vertical Shear (VS)
Combined Mechanism of Injury (CMI)
Pelvic Ring Injuries
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
Pelvic Ring Injuries
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)
Pelvic Ring Injuries
TileMay be more helpful determining need for surgery (front, back, front
& back) based upon classification
Difficult to visualize fracture pattern based upon classification
Pelvic Ring Injuries
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
Pelvic Ring Injuries
LC-1
Pelvic Ring Injuries
LC-1
Pelvic Ring Injuries
LC-2
Pelvic Ring Injuries
LC-2
Crescent fracture
Pelvic Ring Injuries
LC-3
Pelvic Ring Injuries
LC-3
Pelvic Ring Injuries
APC-1
Floor ligaments stretched, not torn
Pelvic Ring Injuries
APC-2
Floor ligaments and anterior SI ligaments disrupted
Pelvic Ring Injuries
APC-2
SI involvement may be subtle, even on CT
Pelvic Ring Injuries
Neutral IR stress ER stress
APC-2
Pelvic Ring Injuries
APC-3: Complete iliosacral dissociation
Pelvic Ring Injuries
APC-3
Pelvic Ring Injuries
Vertical shear
Pelvic Ring Injuries
Vertical shear
Pelvic Ring Injuries
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
Pelvic Ring Injuries: Surgical Indications
Example: “Bad” LC-1Complete sacral fracture
Internal rotation deformity
Potential for vertical instability
Pelvic Ring Injuries: Surgical Indications
“Bad” LC-1
Pelvic Ring Injuries: Surgical Indications
“Bad” LC-1
Pelvic Ring Injuries: Surgical Indications
Intermediate LC-1: Complete sacral fracture, minimal rotational deformity, ? Risk of vertical migration
Pelvic Ring Injuries: Surgical Indications
Pelvic Ring Injuries: Surgical Indications
“Bad” LC-2: Rotationally and vertically unstable, almost but not quite involving the acetabulum
Pelvic Ring Injuries: Surgical Indications
“Bad” LC-2
Pelvic Ring Injuries: Surgical Indications
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
Pelvic Ring Injuries: Reduction
Unstable InjuriesDisplaced
Rotationally
Vertically
Both
Anteriorly
Posteriorly
Both
Pelvic Ring Injuries: Reduction
ReductionOpen
Closed
Combination
Determined by degree of displacement/instablilty
Pelvic Ring Injuries: Reduction
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
Pelvic Ring Injuries: Reduction
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
Pelvic Ring Injuries: Reduction
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
Pelvic Ring Injuries: Reduction
Anterior injuriesRami fractures
Often amenable to closed reduction and control with anterior external fixator
Intramedullary rami screws may also be effective
Difficult trajectory
? fixation
Pelvic Ring Injuries: Reduction
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