Pelvic Ring Injuries: Stability and Reduction Techniques 4/22/2017 11:55 PM Pelvic Ring Injuries: Stability and Reduction Techniques V4

Pelvic Ring Injuries Classification of Pelvic Ring Injuries Young-Burgess Based upon mechanism of injury Tile Based upon stability of pattern

Pelvic Ring Injuries Young-Burgess Lateral Compression (LC 1-3) Anterior-Posterior Compression (APC 1-3) Vertical Shear (VS) Combined Mechanism of Injury (CMI)

Pelvic Ring Injuries Tile Type 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-Burgess Widely 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 Tile May 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 SI involvement may be subtle, even on CT APC-2 4/22/2017 11:55 PM Pelvic Ring Injuries SI involvement may be subtle, even on CT APC-2 V4

Pelvic Ring Injuries APC-2 Neutral IR stress ER stress

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 Posteriorly 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-1 Complete 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-2 Treatment 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 Injuries Generally 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 Injuries Displaced Rotationally Vertically Both Anteriorly Posteriorly

Pelvic Ring Injuries: Reduction Open 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 injuries Sympyseal 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 injuries Anterior 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 injuries 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 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 Passenger Case Discussion 45 yo Female, T-Bone MVA, Front Seat Passenger Currently Hemodynamically Stable Pelvic Deformity Grossly Unstable Pelvic Ring Injury Left Foot Insensate And 0/5 Motor Function

Post Injury Day # 4 Post-Injury Day 4