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Trauma

An overview of pelvic ring disruption

Anand K Garlapati and Neil Ashwood Trauma 2012 14: 169 originally published online 25 January 2012 DOI: 10.1177/1460408611434375 The online version of this article can be found at: http://tra.sagepub.com/content/14/2/169

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Trauma 14(2) 169178 ! The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1460408611434375 tra.sagepub.com

An overview of pelvic ring disruption

Anand K Garlapati and Neil Ashwood

Abstract Pelvic ring disruption after trauma is uncommon, occurring in 2037/100,000 people in the general population. However, in high velocity poly trauma up to 20% of cases have this injury contributing significantly to morbidity and mortality. The management of pelvic and acetabular trauma has become a subspecialty within the orthopaedic trauma care. The injury patterns are now better understood, there is agreement on a classification system and operative stabilisation has become a viable treatment option.

Keywords Pelvic dislocati\on, pelvic injuries, pelvic ring

Surgical anatomy
The pelvic ring is made up of the two innominate bones and the sacrum, articulating in front at the symphysis pubis and posteriorly at the sacroiliac joints. This basin-like structure transmits weight from the trunk to the lower limbs and provides protection for the pelvic viscera, vessels and nerves. The stability of the pelvic ring depends upon the rigidity of the bony parts and the integrity of the strong ligaments that bind the three segments together across the symphysis pubis and the sacroiliac joints. The strongest and the most important of the tethering ligaments are the sacroiliac and the iliolumbar ligaments. These are supplemented by the sacrotuberous and sacrospinous ligaments and the ligaments of the symphysis pubis. As long as the bony ring

and the ligaments are intact, load-bearing is unimpaired. The major branches of the common iliac arteries and the nerves of the lumber and sacral plexus are at risk with posterior pelvic injuries. The bladder lies behind the symphysis pubis. The prostate lies between the bladder and the pelvic oor. In severe pelvic injuries the membranous urethra is damaged when the prostate is forced backwards whilst the urethra remains static.

Department of Orthopaedics, Queens Hospital, Burton upon Trent, UK Corresponding author: Anand K Garlapati, Department of Orthopaedics, Queens Hospital, Belvedere Road, Burton upon Trent, Staffordshire DE13 0RB, UK. Email: anand.garlapati@burtonh-tr.wmids.nhs.uk

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Pelvic biomechanics
1. The pelvis is a ring structure, and if the ring is broken in one area and the fragments displaced, then there must be a fracture or dislocation in another portion of the ring. 2. The stability of the pelvic ring depends upon the integrity of the posterior weight-bearing sacroiliac complex, with the major sacroiliac, sacrotuberous and sacrospinous ligaments. The extremely strong posterior sacroiliac ligaments maintain the normal position of the sacrum in the pelvic ring and the entire complex has the appearance of a suspension bridge. The sacrospinous ligaments join the lateral edge of the sacrum to the ischial spine and resist external rotation of the hemipelvis, whereas the sacrotuberous ligaments resist both rotational forces and shearing forces in the vertical plane. 3. The major traumatic forces acting upon a hemi-pelvis are external rotation, internal rotation (compression from the lateral side) and vertical shear. In some complex high energy injuries, the forces may defy detailed description. External rotation is caused by a direct blow on the posterior iliac spines or more commonly by forced external rotation of the legs, and produces an open-book type of injury. This is characterised by disruption of the symphysis pubis, and as the force continues, by rupture of the anterior sacroiliac and sacrospinous ligaments. An end point is reached when the posterior ilium abuts against the sacrum, but if the force continues the hemipelvis may be sheared o, resulting in gross instability. Internal rotation (lateral compression) may be caused by a direct blow on the lateral aspect of the iliac crest or an indirect force through the femoral head. This produces compression fractures of the posterior complex, and fractures of the rami anteriorly. The posterior and anterior lesions may either be on the same side of the pelvis (ipsilateral type) or on opposite sides (bucket handle type). This latter type is associated

with major rotational deformities and may result in malunion. In some instances, a lateral compression force may stop short of rupture of the posterior structures, but in others rupture will occur. Vertical shearing forces act across the main trabecular pattern of the pelvis, causing marked displacement of bone with disruption of soft tissues. There is generally no end point to damage by this force and a traumatic hemipelvectomy may result (Tile, 1984). The injury occurs in two forms: 1. Dislocation of the sacro-iliac joint 2. Fracture of the ilium or sacrum adjacent to the sacro-iliac joint. In both types there is separation of the symphysis pubis, or fracture of both pubic rami. In both varieties there is displacement of one-half of the pelvis outwards, or outwards and upwards. Associated with this displacement there is often rotation of the large pelvic fragment in the sagittal plane.

Mechanism of injury and displacement

It has been cogently argued that, because of the rigidity of the pelvis, a break at one point in the ring must be accompanied by the disruption a second point. Exceptions are fractures due to direct blows and also ring fractures in children, whose symphysis and sacroiliac joints are more elastic. The basic mechanisms of pelvic ring injury are anterior-posterior compression, lateral compression, vertical shear and combinations of these. Anteroposterior compression injury is most commonly caused by a frontal collision between a pedestrian and a car. The pubic rami are fractured or the innominate bones are sprung apart and externally rotated, with disruption of the symphysis the so called open book injury. The anterior sacroiliac ligaments are partially torn, or there may be a fracture of the posterior part of the ilium.

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Lateral compression or side-to-side compression of the pelvis causes the ring to buckle and break. This is usually due to a side-on impact in a road accident or a fall from a height. Anteriorly the pubic rami on one or both sides are fractured, and posteriorly there is a severe sacroiliac strain or a fracture of the sacrum or ilium, either on the same side as the fractured pubic rami or on the opposite side of the pelvis. If the sacroiliac injury is much displaced, the pelvis is unstable. Vertical shear injury causes the innominate bone on one side is displace vertically, fracturing the pubic rami and disrupting the sacroiliac region on the same side. This occurs typically when someone falls from a height onto one leg. These are usually severe, unstable injuries with gross tearing of the soft tissues and retroperitoneal haemorrhage. In severe injuries there may be a combination of the above.

Classification
Fracture classication schemes should help clinicians and researchers identify and describe an injury, plan treatment, and predict outcome. The most popular schemes in use today are the Tile system and YoungBurgess system. The Tile system combines directional patterns of the pelvic disruption with the radiographic signs of stability or instability. The Young Burgess system seeks to link the direction of the force that created the injury to the fracture pattern seen radiographically.

Figure 1. Open Book Injury Type B1. The diagram shows wide separation of the symphysis, avulsion of the sacrospinous ligaments and disruption of the anterior sacroiliac ligaments. The intact posterior ligaments allow external rotational instability, but prevent vertical instability. The radiograph shows wide anterior opening of the sacroiliac joints with no posterior displacement. Reproduced with permission and copyright of the British Editorial Society of Bone and Joint Surgery (Tile, 1998).

B3. Lateral compression; contralateral (buckethandle) (Figure 2) Type C: Rotationally and vertically unstable: C1. Rotationally and vertically unstable (Figure 3) C2. Bilateral C3. Associated with an acetabular fracture

Tiles classification of pelvic disruption

Type A: Stable: A1. Fractures of pelvis not involving the ring A2. Stable, minimally displace fractures of the ring Type B: Rotationally unstable, vertically stable: B1. Open book (Figure 1) B2. Lateral compression; ipsilateral

YoungBurgess system
LC: Transverse fracture of pubic rami, ipsilateral or contralateral to posterior injury: 1. Sacral compression on side of impact 2. Iliac wing fracture on side of the impact 3. LC1 or LC-2 injury on the side of the impact; contralateral open book (APC) injury

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Figure 2. Bucket Handle Lateral Compression Injury Type B3. The diagram shows the typical appearance of a bucket handle injury, with the left hemi-pelvis internally and superiorly rotated by 40. The radiograph shows internal rotation of the left hemi-pelvis with fracture of all four pubic rami. Reproduced with permission and copyright of the British Editorial Society of Bone and Joint Surgery (Tile, 1998).

APC: Symphyseal diastasis or longitudinal rami fractures: 1. Slight widening of the symphysis pubis or anterior SI joint; stretched but intact anterior SI, scarotuberous, and sacrospinous ligaments intact posterior SI ligaments 2. Widened anterior SI joint; disrupted anterior SI, scarotuberous, and sacrospinous ligaments intact posterior SI ligaments 3. Complete SI joint disruption with lateral displacement, disrupted anterior SI, scarotuberous, and sacrospinous ligaments, disrupted posterior SI ligaments VS: Symphyseal diastasis or vertical displacement anteriorly and posteriorly, usually through the SI joint, occasionally through the iliac wing or sacrum CM: Combination of other injury patterns, LC/ VS being the most common

Figure 3. Unstable Vertical Shear Injury Type C. The shearing forces cause massive disruption of the pelvic ring, its soft tissues and surrounding structures. The radiograph shows the unstable nature of this injury and this was stabilised surgically. Reproduced with permission and copyright of the British Editorial Society of Bone and Joint Surgery (Tile, 1998).

Evaluation and resuscitation

The most common mechanism of injury resulting in pelvic fracture is road trac collision frequency of injury (2066%). There is an increased if the patient is sitting in the front of the vehicle in head on collisions on the struck side. Pelvic fractures resulting from pedestrian collisions (1459%) and motorcyclist collisions (59.3%) are also common (Papadopoulos et al., 2006; Tile, 1988; Talbot et al., 1989). Falls from heights, or from a low level by elderly

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Figure 4. Symphysis diastasis widening with pubic ramus fracture following motorcycle injury an open book type of pelvic injury. Reproduced with permission and copyright of the British Editorial Society of Bone and Joint Surgery (Tile, 1998).

patients with osteoporosis are also implicated in the aetiology and, more rarely, crush injuries. The mortality from pelvic fractures in patients who reach hospital is reported to be between 7.6% and 19% (Papakostidis et al., 2009; Resnik et al., 1992). Although exsanguinating haemorrhage from pelvic fracture is of concern, studies suggest that the associated injuries to the contents of the abdomen and pelvis from the considerable energy transfer are as signicant a cause of death and morbidity in these patients. The mortality from open pelvic fractures is much higher and approaches 50% according to Lee and Porter (2007). The prehospital practitioner rst needs to assess the mechanism of injury to be able to predict a potential pelvic fracture. The initial evaluation and resuscitation of the injured patient begin at the accident scene and continue in the hospital with airway control, predictable ventilation, and adequate circulation. Large-diameter intravenous catheters are inserted, and volume resuscitation is initiated by the paramedics. The patients core temperature is optimized by covering the patient with warm blankets, using heat

lamps, and providing warmed intravenous uids. The goal of the primary survey is to identify and begin treatment of the immediately lifethreatening injuries. Alerting features suggestive of signicant pelvic injury during examination include deformity, bruising or swelling over the bony prominences, pubis, perineum or scrotum. Leg-length discrepancy or rotational deformity of a lower limb (without fracture in that extremity) may be evident. Wounds over the pelvis or bleeding from the patients rectum, vagina or urethra may indicate an open pelvic fracture. Neurological abnormalities may also rarely be present in the lower limbs after a pelvic fracture. Discrete rectal or vaginal bleeding or a high-riding prostate will not be detected in the prehospital environment. In the alert, orientated, cooperative patient with no distracting injury, it will be possible for the prehospital practitioner to ask the patient about the presence of pain in the pelvic area, including the lower back (assessing the sacroiliac joint), groin and hips. Any positive reply should call for routine immobilisation of the pelvis. In the case of the unresponsive trauma patient, the pelvis should not be palpated for tenderness or instability. A pelvic fracture should be assumed to be present and routinely immobilised. Traditional teaching encourages the practice of springing the pelvis as part of this assessment to identify tenderness or instability as an indicator of pelvic fracture and therefore a source of internal haemorrhage. Macleod and Powell (1997) report a variety of methods of springing the pelvis are described in the literature, most involving compression or distraction of the fracture site. However, the current belief is that this is an unreliable test, which will only detect major pelvic disruption and is dangerous in that clots may be dislodged promoting further blood loss. Pneumatic antishock garments, also known as antishock trousers or MAST, may be used to provisionally stabilise pelvic fractures during prehospital transport and during early evaluation after arrival at the hospital. This device

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prevents fracture motion and may provide enough stability to allow clot formation. Pelvic binders oer a better alternative for prehospital transport of patients with pelvic fractures. Binders can be quickly applied in the eld, do not require ination, and will not obscure the patients abdomen or lower extremities during secondary survey. An improvised method, is to use a Kendrick extrication device, slid under the patient upside down (with the head support towards the feet) and the straps secured around the waist and legs. Vermeulen et al. (1999) rst described the prehospital use of an external pelvic compression belt (Geneva belt) in a series of 19 patients. A variety of commercial material compression splints have been manufactured. Examples include the Stuart splint, the London splint, the Dallas pelvic binder and the Trauma Pelvic Orthotic Device. They are generally applied at the level of greater trochanters/symphysis pubis directly on to the patients skin. Log rolling the patient on to a spinal board should be avoided for the same reasons as compression and distraction of the pelvis in clinical examination. Circumferential pelvic sheeting is the least expensive and most readily available option. The peripheral neurologic examination is documented in alert patients. A digital rectal examination assesses the prostate gland location and the rectal mucosal surface and tests for gross and occult blood. A bimanual vaginal examination is performed in female patients. Speculum vaginal evaluations are deferred until initial pelvic stability is achieved, allowing safe placement of the patient in the lithotomy position. Lower extremity deformities are realigned carefully, then splinted. Scrotal swelling or ecchymoses and the presence of urethral meatal bleeding are delayed signs of a urethral disruption and are noted in male patients. Similarly the inability to urinate or insert a urinary catheter easily are signs of urethral disruption. In a retrospective review of 405 male patients with pelvic fractures treated at a level one trauma centre, Lowe et al. (1988) identied a 5% incidence of urethral injuries, especially in

patients with displaced pubic ramus fractures and sacroiliac joint disruptions. They found that physical signs suggesting a urethral injury were absent in 57% of the patients and were related directly to the time interval since injury. Lowe et al. (1988) also recommended that male patients with the combination of pubic ramus fractures and a sacroiliac joint disruption undergo retrograde urethrograms before urethral instrumentation. Chip Routt et al. (2002) outline the importance of prompt recognition and appropriate management of these injuries on reducing subsequent morbidity. There are three major categories of patients with pelvic fractures at risk of high mortality: patients in haemodynamic shock, elderly patients and patients with grossly unstable fractures. There is incidence of 4157% of mortality for patients with pelvic fractures who arrive with systolic blood pressure of 90 mm of Hg or less. In patients above the age of 55 years mortality ranges from 21% to 28%, compared to mortality rates in the 56% for patients aged less than 55 years. In patients with unstable and high energy injuries the mortality risk ranges from 23% to 43%.

Investigations
Resnik et al., (1992) have documented a high frequency of missed pelvic fractures on plain lms. Montana et al. (1986) in one of the larger series, reported that 20 of 70 cases of diastasis of the sacroiliac joint was not detected on plain lms, and 24 of 42 lip fractures (fractures involving the sacral or iliac surface abutting the sacroiliac joint) and 15 of 44 vertical shear fractures (sacral fractures extending into neural foramina) were missed initially. However, retrospective review of the plain radiographs in cases of vertical shear fractures yielded a 93% detection rate. Adam et Al. (1985) have noted misdiagnosis rates of sacral fractures and sacroiliac joint diastasis of 6065%.The ecacy of plain radiographs in detecting pelvic fractures in patients with acute pelvic trauma is sucient to identify virtually all clinically important

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fractures and dislocations. Plain radiographs alone are not accurate in detecting fracture fragments within the hip joint. Pelvic inlet and outlet plain radiographs identify the major pelvic ring disruptions and their associated displacements. Most patients with pelvic ring disruptions undergo abdominal computed tomography (CT) scans, which can be reformated to provide valuable pelvic osseous and soft tissue details. Osseous pelvic CT scans consist of sequential axial images in 3-mm increments. Other helpful imaging studies include pelvic angiography, cystography, retrograde urethrography, and two-dimensional or three-dimensional pelvic CT. The angiographic image intensier can be used to visualize and quantify the pelvic instability sites during a careful manual examination under uoroscopy.Using these diagnostic tools, the orthopedic surgeon gathers an improved understanding of the injury (Chip Routt et al., 2002)

Definitive treatment
Indications for external xation of pelvic ring injuries: Type B: Vertically stable, rotationally unstable injuries: Open book to provide denitive treatment B2/B3. Lateral compression, to aid and maintain reduction Type C: Vertically unstable injuries to produce partial stability in order to reduce bleeding and relieve pain whilst aiding in nursing the patient B1.

Symphysis diastasis
The management of disruption of the pelvic ring is both complex and controversial. Although in the past most of the pelvic fractures were managed non-operatively, advances in xation techniques and a clearer understanding of biomechanics led to more aggressive

approaches11 Fixation of the anterior ring, particularly with external xators, gained an invaluable role in acute management. Riska et al. (1979) amongst other authors have advocated its use also for the denitive treatment of certain fracture types. The involvement of the posterior osseous-ligamentous elements is often underestimated, according to cadaveric and clinical studies. With the patient on the operating table, the two halves of the pelvic vice are placed opposite each other at the level of the greater trochanters. The vice consists of vertical bars held to the table by adapted toggles. At the top of each bar is a threaded rod with a padded concave plate for contact with the patient. Before surgery the vice is compressed to make skin contact only. The skin is prepared and draped so that the vice is beneath the towels and is manipulated by an unscrubbed assistant. At laparotomy any angled segments are manipulated into reasonable position with bone-holding forceps. The vice is then used to compress the two halves of the pelvis together suciently to allow internal xation. The other alternative is to use a pelvic binder to assist in reduction. The binder can be placed at the level of the proximal thigh and tightened to provide compression at the symphysis disruption. Manual compression of the iliac wings may help achieve reduction. Similarly, anterior external xator frames half pins may be used as joysticks to assist with reduction. Most symphysis disruptions are treated by open reduction and internal xation with a single plate, although biplanar plate xation is clearly stronger than single plate xation. The symphysis is approached through a Pfannenstiel exposure. Once the superior rami are exposed, the diastasis is reduced using a large reduction clamp. The clamp tines can be seated on the pubic tubercles, or in the obturator formina. Strive for perfect alignment, rotational displacement may lead to leg length discrepancy and it is essential to pain. Once reduction is obtained, alignment is veried on both inlet and outlet x-rays.

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Sacroiliac joint disruption

Little information is provided in the literature describing an ecient reduction technique for pelvic ring disruption. Thaunat et al. (2006) used transcondylar traction as a closed reduction technique for vertically unstable fracturedislocations of the sacro-iliac joint. Management of SI joint disruption is dependent on the degree of instability. If the injury is isolated to the anterior SI ligaments, and the thick posterior SI ligaments remain intact, such as occurs with APC 2 fractures, then restoration of rotational stability will suce. Reduction and stabilisation of the anterior pelvic ring injury will close the gap at the front of the SI joint. If the SI joint is completely disrupted, such as occurs with APC 3 fractures, reduction and stabilisation are needed. Reduction can be achieved either through open or percutaneous method. Open techniques commonly use either the anterior iliac fossa approach, or the posterior approach. Percutaneous xation relies on reduction with manual traction or minimally invasive techniques. The usual displacement is posterior and cephalad. The most popular being percutaneous iliosacral screw placement. Upper sacral anatomy is highly variable and may interfere with screw placement. Close examination of plain radiographic and CT scan ndings is mandatory to learn the anatomy of each individual patient.

Diastasis symphysis pubis during pregnancy

The incidence of pubic symphysis separation during delivery is 1 in 300 to 1 in 30,000 pregnancies, and it can cause a variety of problems such as pain, bladder dysfunction, and diculty ambulating. The non-pregnant gap is 45 mm but in pregnancy there will be an increase of at least 23 mm as the ligaments which surround and insert into the joint remodel under the inuence of hormones. Therefore, it is considered that a total width of up to 9 mm between the two bones is normal for a pregnant woman.

This natural extra gapping decreases within days following the delivery, although the supporting ligaments will take 3 to 5 months to fully return to their normal state. An abnormal gap is considered to be 1 cm or more, sometimes with the two bones being slightly out of alignment. If there is a complete separation, that is, a traumatic tear, the joint will be completely unstable. This tear can be felt and sometimes heard by the woman. There will be intensive pain followed by swelling and inammation. The woman is unable to move her back, trunk, hips and legs without causing severe pain. When lying on her back her legs involuntary move apart and without the ability to close them together. This type of pelvic fracture needs to be treated as such and investigations into possible involvement of the sacroiliac joints should be addressed. It is important to note that the same can happen to the sacroiliac joints, and could lead to laxity and even inammation. This involvement may involve one or both sacroiliac joints. A separation or diastasis can also be the result of traumatic forces from either an incident during the pregnancy or delivery. A diastasis of the symphysis pubis is a condition associated with pregnancy related pelvic girdle pain. An X-ray lm will show a marked gap between the pubic bones. To demonstrate instability of the joint the patient is required to stand in the amingo position, (standing with weight on one leg and the other bent). A vertical displacement of 1 cm or greater is an indicator of symphysis pubis instability. Displacement 2 cm or greater usually indicates involvement of the sacroiliac joints. Treatment is usually conservative in women of child rearing age and stabilisation may interfere with future deliveries. Injection and protected weight bearing often reduce symptoms

Summary
Disruption of the pelvic ring is a serious injury with a signicant mortality and morbidity. Early

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resuscitation and exclusion of life threatening injury is essential with the concomitant treatment of the musculoskeletal injury. The need for xation of pelvic fractures depends on many factors, and there must be clear reasons for advocating operation. Stabilisation is only required for the uncommon Type C vertically unstable pelvic disruptions and occasionally for Type B rotational instability. In Type B1 open book injury, stabilisation may be indicated to reduce the pelvic volume in the acute phase, and in the rare Type B3 lateral compression injury, external xation pins may aid in reduction. Quickly applied, simple anterior external xation has a major role in the acute phase of management of the patient with multiple injuries and either a Type C unstable vertical shear injury or a Type B1 open book injury. Most pelvic fractures, even those referred to major trauma units, are relatively stable and may be managed by simple techniques. Posterior internal xation should be reserved for those cases with a dicult vertically unstable pelvis as this often does badly with traditional methods. Treatment of the pelvic ring injuries requires an in-depth understanding of the anatomy of the pelvis and the mechanisms of injury. With this understanding and precise clinical and radiographic evaluation of the injury, appropriate management can be chosen. A determination of pelvic instability is imperative; along with assessment of displacement, pelvic stability guides the surgeon in deciding the best form of treatment. Although surgical intervention to stabilise unstable fractures is usually the best method of achieving an intact pelvic ring and ensuring a good result, not all pelvic ring disruptions require stabilisation. The complications of management of these injuries are formidable, but they can be lessened by appropriate evaluation and treatment. Successful treatment of high-energy pelvic ring disruptions relies on early intervention, accurate reduction, stable xation, and a low rate of associated injuries and complications.

Funding
This research received no specic grant from any funding agency in the public, commercial, or notfor-prot sectors.

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