Download G.H. - Orthopaedic Trauma Association

Anatomy, Radiographic
Evaluation, and Classification
of Pelvic Ring Injuries
Robert M. Harris MD
Medical Director of Orthopaedic Trauma
Mountain States Health Alliance
East Tenn State University Quillen School of Medicine
Revised November 2010
Created March 2004
Revised April 2007
By Kyle Dickson MD
Pelvic Ring Disruption
•
•
•
Marker for severe
injury
Overall mortality 610%
Life threatening
Magnitude of Forces
•
•
ACL injury 500-1000N
LC-I pelvic fracture 6000-9000N
Bone Anatomy



•
•
Two innominate bones
with sacrum.
Coalesce at triradiate
cartilage.
Ilium, ishium and pubis
have three separate
ossification centers that
fuse at sixteen years.
Gap in symphysis < 5 mm
SI joint 2-4 mm
Ligamentous Anatomy
•
Ligaments - posterior
ligaments are stronger
than anterior ligaments:






Posterior SI
Anterior SI
Interosseous ligaments
Pubic symphysis
Sacrotuberous
Sacrospinous
ANATOMY
Ligamentous
ASI
PSI
ST
SS
ST
Posterior Ligaments
•
•
•
•
•
Ant. SI Joint – resist external rotation
Post. SI and Interosseous – posterior stability by tension band
(strongest in body)
Iliolumbar ligaments augments posterior complex
Sacrotuberous (sacrum behind sacro-spinous into ischial tuberosily
vertically)Resists shear and flexion of SI joint
Sacrospinous – (anterior sacral body to ischial spine horizontally)
resists external rotation
Normal SI Joint Motion with Gait
•
•
•
< 6 mm of translation
< 6° rotation
Intact cadaver resist 5,837 N (1,212 lbs)
ANATOMY
Relationships
Vascular Anatomy
•
•
•
Internal iliac artery
courses medial to the vein,
splits into anterior and
posterior branches.
Posterior branch is more
likely injured (SGA is
largest branch).
Usual bleeding is from
venous plexus.
Potentially Damaged Visceral
Anatomy
•
Blunt vs. impaled by bony spike
– Bladder/urethra
– Rectum
– Vagina
Pelvic Stability
•
•
•
Strength of ring: 40%
anterior and 60%
posterior.
Vsphere = 4/3r³.
Stability – ability of
pelvic ring to
withstand physiologic
forces without
abnormal deformation
IDENTIFY THE HIGH RISK
PELVIC DISRUPTION
By Radiography
By Physical Exam
Physical Exam
•
Physical Exam-poor
sensitivity (8%) for
mechanically unstable
pelvis fractures in
blunt trauma patients
•
Shlamovitz GZ, Mower WR,
Morgan MT-Journal of Trauma
Mar 09
Radiographs
•
•
•
•
•
Anteroposterior (AP)
Inlet (40° caudad)
Outlet (40 ° cephalad)
CT scan
Judet (acetabular
fractures)
AP VIEW
If evidence of pelvic ring fracture...
INLET VIEW
Inlet (Caudad) View
•
•
•
Horizontal Plane
Rotation
Posterior
Displacement
Sacral ala
OUTLET VIEW
Outlet (Cephalad) View
•
•
•
Sacrum
Cephalad
Displacement
Sacral Foramina
CT Scan
•
•
•
•
•
Better defines posterior injury
Amount of displacement versus impaction
Rotation of fragments
Amount of comminution
Assess neural foramina
CT SCAN
3D CT
Radiographic Signs of Instability
•
•
•
Sacroiliac displacement of 5 mm in any
plane
Posterior fracture gap (rather than
impaction)
Avulsion of fifth lumbar transverse process,
lateral border of sacrum (sacrotuberous
ligament), or ischial spine (sacrospinous
ligament)
Translational Deformities
•
•
•
X axis – Diastasis or impaction
Y axis – Caudad or cephalad displacement
Z axis – Anterior or posterior displacement
Rotational Deformities
•
•
•
X axis – Flexion or extension
Y axis – Internal rotation or external
rotation
Z axis – Abduction or adduction
Classification
•
•
•
•
Aids in predicting hemodynamic instability
Aids in predicting visceral and g.u. injuries
Aids in predicting pelvic instability
Aids in understanding mechanism of injury,
force vector of injury, and surgical tactic for
reduction
Classification Systems
•
•
•
•
Anatomical (Letournel)
Stability & Deformity (Pennal, Bucholz,
Tile)
Vector force and associated injuries (Young
& Burgess)
OTA-research
Anatomical Classification
(Letournel)
Where The Pelvis Breaks
Anterior
•
•
Rami fractures
Symphyseal disruption
Posterior
•
•
•
•
•
Iliac wing fracture
Iliac wing/sacroiliac
(SI) joint
(crescent
fracture)
SI joint
Sacrum/SI joint
Sacrum fracture
Pennal, 1961
•
Magnitude and
direction of forces
– Lateral posterior
compression (LC)
– Anterior posterior
compression (APC)
– Vertical shear (VS)
Bucholz, 1981 Tile, 1988
•
Added stability to the
classification
Tile Classification
•
•
•
Type A: Stable fracture.
Type B: Rotationally unstable, but vertically stable.
Type C: Rotationally and vertically unstable.
OTA/AO – Pelvic Injury
Classification
•
•
•
61A – Lesion sparing (or with no
displacement of ) posterior arch
B – Incomplete disruption at posterior arch;
partially stable
C – Complete disruption of posterior arch;
unstable
A Fractures – Ring Intact
•
•
•
A-1 – Fracture of innominate bone; avulsion
A-2 – Fracture of innominate bone; direct
blow
A-3 – Transverse fracture of sacrum and
coccyx
B-Ring Injury – Partially stable
•
•
•
B-1 – Unilateral partial
disruption of posterior
arch, external rotation
(“open book” injury)
B-2 – Unilateral, partial
disruption of posterior
arch, internal rotation
(lateral compression
injury)
B-3 – Bilateral, partial
lesion of posterior arch
C – Complete Disruption Posterior
Arch, Unstable Pelvis
•
•
•
C-1 – Unilateral,
complete disruption of
posterior arch
C-2 – Bilateral,
ipsilateral complete,
contralateral
incomplete
C –3 – Bilateral,
complete disruption
Young-Burgess Radiology 1986
•
•
•
Based on mechanism of injury
Predictive of associated local & distant injury
Useful for planning acute treatment
MECHANISM OF INJURY (MOI)
•
Do initial radiographs agree with MOI in
pelvic ring disruptions- Linnau KF, Blackmore
CC, Routt ML, Mock CN-J Ortho Trauma Jul
2007
•
more reliable for LC than AP mechanisms
MECHANISM OF INJURY
•
Lateral compression (implosion)
•
AP compression (external rotation)
•
Vertical shear
•
Combined injury
Young-Burgess Classification

LATERAL COMPRESSION







LC -I Compression fracture of anterior sacrum
LC -II Iliac wing fracture posteriorly (unstable)
LC -III Windswept pelvis (contralateral SI injury)
ANTERIOR-POSTERIOR COMPRESSION


fracture of anterior ring plus:
APC - I Partial disruption
APC - II Posterior sacroiliac ligaments intact
APC - III Posterior sacroiliac ligaments disrupted
VERTICAL SHEAR cephlad and posterior displacement
COMBINED MECHANISM (LC & VS most common)
CLASSIFICATION
Mechanism and direction of injury
DISRUPTED PELVIC RING
•
Posterior/SI injury is a
marker for associated
vascular injuries
•
Tamponade efforts and
fluid resuscitation may be
rendered useless
Resuscitation
•
Young and Burgess
classification:
–
–
–
–
–
LC III
APC II
APC III
VS
CM
RESUSCITATION REQUIREMENTS
40
35
30
units blood 25
20
1st 24 hours
15
10
5
0
35.4
2.3
3.1
LC-I
LC-II
7.4
9.4
7.6
LC-III
VS
AP-II
AP-III
Mortality
20%
Deaths
:
6.60%
0%
LC
VS
APC
Interobserver Reliability of the
Young/Burgess and Tile classifications
•
Koo H, Leveridge M, McKee,MD, Schemitsch EH, J Ortho Trauma
Jul 2008
– Young/Burgess –Kappa .72-better for the training
surgeon
– CT-improved assessment of stability
•
Furey AJ, O”Toole RV, Turen C, Ortho June 2009
– Interobserver – moderate degree of agreement
– Intraobserver- moderate for Tile
• Substantial for Burgess
LATERAL COMPRESSION
LC I: Sacral compression
Lateral Compression
•
•
•
•
Most common pattern.
LC1 – stable, load to posterior ring.
LC2 – load to anterior ring, posterior ligaments
injured, ST and SS intact.
LC3 – LC2 + external rotation injury of the
other side.
LC-I
LATERAL COMPRESSION
Common anterior pattern
LATERAL COMPRESSION
LC I: Sacral compression
What Constitutes a LCI
•
Lefaivre KA, Padalecki JR, Starr AJ- J Ortho Trauma Jan 2009
•
LC I-Spectrum of injuries
•
Complete sacral disruptions
– Denis classification
– Predicted by severity of anterior pelvic ring disruption
– Abdominal AIS
– Rami fracture location
– ISS
LATERAL COMPRESSION
LC II: Iliac wing fracture
LC-II
LC-II
LC III: “ Windswept pelvis”
LC III
LC III
LC III
Anteroposterior Compression
•
•
•
APC1- stable injury, anterior ligament injury.
APC2 – SS and anterior SI injury, possibly ST.
APC3 – anterior and posterior injury, completely
unstable.
ANTEROPOSTERIOR COMPRESSION
AP I: Hockey player
AP I
•
Note that the
ligaments are
stretched, and not
torn
ANTEROPOSTERIOR COMPRESSION
APII: Open book pelvis
AP II
•
APC-2 – Sacrotuberous,
sacrospinous, and
anterior SI joint
ligaments disrupted (post
SI ligaments intact)
•
Note: pelvic floor
ligaments are violated,
as well as anterior SI
ligaments
AP-II
AP II
Ligamentous pathology
AP II
These anterior SI ligaments are disrupted...
But these posterior SI ligaments remain intact
ANTEROPOSTERIOR COMPRESSION
APC III: Complete iliosacral dissociation
•APC-3
– Complete SI joint disruption
•(usually not vertically displaced)
AP III
APC-III
AP III
ASSOCIATED INJURIES
Lateral Compression:



Abdominal visceral injury
Head injury
Few pelvic vascular injuries
AP Compression:


Urologic injury
Hemorrhage/pelvic vascular injury:
APCII-10%, APCIII-22%
Vertical Shear
•
•
•
Always unstable
Ant. symphsis or vertical rami fracturespost. Injury variable
Vertical displacement
VERTICAL SHEAR
Vertically unstable –
often due to a unilateral injury.
Similar to APC3.
VERTICAL SHEAR
COMBINED MECHANICAL INJURY
Combined vectors
occasionally 2 separate
injuries (ejection/landing)
Often LC/VS, or AP/VS
COMBINED MECHANICAL INJURY
CLASSIFY INJURY (Young-Burgess)
LC-I, AP-I
Conservative
Treatment
AP-II
AP-III, VS
Anterior
Stabilization
Anterior and
Posterior Stabilization
Surgeon variability in the treatment
of pelvic ring injuries
•
Furey AJ, O”Toole RV, Nascone JW, Sciadini MF- Ortho Oct 2010
•
Young and Burgess, and Tile Classifications
Kappa Value-
•
– Intraobserver- 0.56 moderate agreement
– Interobserver- 0.47 moderate agreement
•
Consistent treatment for certain patterns
References
•
Surgeon variability in the treatment of pelvic ring injuries.
Furey AJ, O'Toole RV, Nascone JW, Copeland CE, Turen C, Sciadini MF. Orthopedics. 2010 Oct 11;33(10)
•
. Classification of pelvic fractures: analysis of inter- and intraobserver variability using the Young-Burgess and
Tile classification systems.
Furey AJ, O'Toole RV, Nascone JW, Sciadini MF, Copeland CE, Turen C. Orthopedics. 2009 Jun;32(6):401
•
Interobserver reliability of the young-burgess and tile classification systems for fractures of the pelvic ring.
Koo H, Leveridge M, Thompson C, Zdero R, Bhandari M, Kreder HJ, Stephen D, McKee MD, Schemitsch EH.
Division of Orthopaedic Surgery; and daggerMartin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto,
Ontario, Canada. J Orthop Trauma. 2008 Jul;22(6):379-84
•
Fracture of the pelvis: current concepts of classification.Young JW, Resnik CS.Department of Radiology,
University of Maryland Medical System/Hospital, Baltimore 21201. AJR Am J Roentgenol. 1990 Dec;155(6):116975.
•
Do initial radiographs agree with crash site mechanism of injury in pelvic ring disruptions? A pilot study.
Linnau KF, Blackmore CC, Kaufman R, Nguyen TN, Routt ML Jr, Stambaugh LE 3rd, Jurkovich GJ, Mock
CN.Department of Radiology, Harborview Medical Center, Seattle, Washington 98104-2499, USA. J Orthop
Trauma. 2007 Jul;21(6):375-80.
References
•
How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in
blunt trauma patients? Shlamovitz GZ, Mower WR, Bergman J, Chuang KR, Crisp J, Hardy D, Sargent M, Shroff
SD, Snyder E, Morgan MT. Department of Emergency Medicine and Traumatology, Hartford Hospital, UCONN
School of Medicine, University of Connecticut, Hartford, Connecticut, USA. J Trauma. 2009 Mar;66(3):815-20
•
What constitutes a Young and Burgess lateral compression-I (OTA 61-B2) pelvic ring disruption? A
description of computed tomography-based fracture anatomy and associated injuries. Lefaivre KA, Padalecki
JR, Starr AJ. Department of Orthopaedics Surgery, University of Texas Southwestern Medical Center, Dallas, TX,
USA. J Orthop Trauma. 2009 Jan;23(1):16-21.
•
Predicting blood loss in isolated pelvic and acetabular high-energy trauma. Magnussen RA, Tressler MA,
Obremskey WT, Kregor PJ. Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Nashville, Tennessee
37232-8774, USA. Orthop Trauma. 2007 Oct;21(9):603-7
•
Pelvic disruption: assessment and classification. Pennal GF, Tile M, Waddell JP, Garside H. Clin Orthop Relat Res.
1980 Sep;(151):12-21
•
Pelvic fractures: value of plain radiography in early assessment and management. Young JW, Burgess AR,
Brumback RJ, Poka A. Radiology. 1986 Aug;160(2):445-51
•
Pelvic ring disruptions: effective classification system and treatment protocols.
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ.
Shock Trauma Center, Maryland Institute for Emergency Medical Services Systems, Baltimore J Trauma. 1990
Jul;30(7):848-56
See Emergent Management of
Pelvic Injuries for Application of
Classification to Treatment
Acknowledgment
Andy Burgess and Kyle Dickson for the
use of their slides
If you would like to volunteer as an author for
the Resident Slide Project or recommend
updates to any of the following slides, please
send an e-mail to [email protected]
E-mail OTA
about
Questions/Comments
Return to
Pelvis
Index