Pelvic Ring Injuries


Article Author:
Kevin Perry


Article Editor:
Brad Chauvin


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/9/2019 7:57:17 AM

Introduction

The pelvic ring forms from the sacrum and the two innominate bones each containing an ilium, ischium, and pubis. There is no inherent stability to the bony anatomy of the ring. Therefore the strong ligamentous attachments are required for maintenance of the ring structure. Pelvic ring injuries cover a broad spectrum. Simple minimally displaced fractures of the sacrum or pubis may be treated conservatively while high energy disruptions of the bony or ligamentous ring represent life-threatening injuries requiring intervention.[1][2]

Etiology

Pelvic ring injuries are usually associated with high energy trauma, including falls from height and motor vehicle collisions. Geriatric pelvic ring injuries are unique and are usually the result of a low energy fall. Anterior-posterior compression injuries occur at high frequencies following equestrian saddle horn injuries and motorcycle accidents. Lateral compression injuries often happen as the pelvis is run over by a vehicle. Vertical injuries of the pelvis usually occur as a fall or injury involving an axial load.  

Epidemiology

  • Affects all age groups
  • Most common ages 18 to 44 y/o
  • Men more frequently than women
  • Incidence of 0.82 per 100000

Pathophysiology

Due to direct trauma to the pelvis or indirect trauma through compression or distraction of the spine and/or femurs, the pelvic ring suffers disruption. The pelvic ring fails in predictable patterns as described in the classification section. Depending on the degree of injury, stabilizing ligaments of the pelvis may be disrupted requiring stabilization. 

History and Physical

Due to the high energy nature of pelvic ring injuries, associated morbidities require thorough assessment. Incidence of associated trauma includes:

  • Chest trauma 63%
  • Long bone fractures 50%
  • Head injuries 40%
  • Visceral organ damage 40%
  • Spinal fractures 25%
  • Intestinal injuries 14%
  • Genitourinary injuries 6 to 15%
  • Open fractures 5%
    • Mortality of open pelvis fractures is around 50%, urgent antibiotic administration is necessary
    • Perform a rectal and vaginal exam and look for breaks in the skin around the perineum

A pelvic ring injury can be a life-threatening injury or may be associated with a life-threatening injury, and a thorough exam is necessary.

  • Advanced trauma life support (ATLS)
  • Motor and sensory exam
  • Physical exam of the pelvis including push/pull test and lateral compression test
  • Look for leg length inequality not explained by a limb fracture
  • A high riding prostate or blood at urethral meatus may indicate genitourinary injury
  • Rectal and/or vaginal exam
  • Perineum exam may reveal swollen and/or mobile genitalia

Destot sign – Palpable hematoma in perineum above inguinal ligament or proximal thigh, may represent pelvic fracture with active bleeding.

Grey Turner sign – Flank bruising indicative of retroperitoneal bleeding.

Morel-Lavallee lesion – Internal degloving injury from skin shear at time of injury, may require intervention and may affect surgical planning, look for significant soft tissue abrasions, ecchymosis or subdermal hematoma. May also be identified on CT scan with the assessment of soft tissues.[1][2]

Evaluation

Imaging                       

  • Xrays – CXR, AP pelvis
    • Inlet view – allows evaluation of anterior or posterior translation
    • Outlet view – allows evaluation of coronal plane deformity
    • Flamingo views – for assessment of chronic pelvic ring instability
  • CT scan – should be obtained for all pelvic ring injuries
    • Helps to assess the extent of the sacral injury
  • MRI – rarely indicated in acute pelvic ring trauma

Classification

Tile Classification[1]

Type A – Stable

  • A1 – Fractures not involving the pelvic ring
  • A2 – Stable minimally displaced fractures of the pelvic ring

Type B – Rotationally unstable, vertically stable

  • B1 – Open book
  • B2 – Lateral compression ipsilateral
  • B3 – Lateral compression contralateral

Type C – Rotationally and vertically unstable

  • C1 – Unilateral
  • C2 – Bilateral
  • C3 – Associated with an acetabular fracture

Young and Burgess Classification[3]

  • Lateral Compression (LC)
    • LC1 – Anterior sacral compression fracture +/- pubic rami fractures (often a stable pattern)
    • LC2 – Crescent fracture +/- pubic rami fracture (Unstable)
    • LC3 - LC 1 or 2 with a contralateral APC injury
  • Anterior-Posterior Compression (APC)
    • APC1 – Minor symphysis widening or distracted ramus fracture
    • APC 2 – Opening of symphysis greater than 2.5 cm, disruption of sacrospinous and anterior SI ligaments, assumes posterior SI ligaments remain intact
    • APC3 – Complete disruption of symphysis and SI joint
  • Vertical Shear (VS)
    • VS – Vertical displacement of hemipelvis, represents complete instability
  • Combined Mechanism (CM)
    • CM – Any combination

Denis Classification of Sacral Fractures[2]

  • Zone 1 – Lateral to the sacral foramen
  • Zone 2 – Entering sacral foramen
  • Zone 3 – Medial to sacral foramen – Highest incidence of neurologic injury including nerve root or cauda equina

Lumbopelvic Dissociation[4]

  • Fracture pattern which renders the base of the spine discontinuous with the pelvis requiring fixation
  • Beyond the scope of this activity
  • Bilateral sacral fractures have a high incidence of lumbopelvic dissociation, and CT scan should be reviewed carefully for coronal plane sacral disruptions

Treatment / Management

Recognize that a pelvic ring injury may represent a life-threatening emergency and work as a team to rapidly resuscitate critically injured patients

  • ATLS first
  • If a patient has a pelvic ring injury, do not assume they do not have another source of hemorrhage
  • A pelvic ring injury should remind all practitioners of high energy trauma and to perform a thorough assessment of all body systems
  • Exclude thoracic and abdominal bleeding before assuming a patients hemorrhage is from a pelvic ring injury

Hemorrhage associated with high energy trauma and pelvic ring disruption[3]

Pelvic ring injuries can have significant blood loss from sources, including:

  • Internal iliac system
  • Pelvic venous plexus
  • Osseous blood supply including nutrient arteries

Pelvic Binder/Circumferential Sheet Placement[5]

  • Temporary intervention to partially reduce the displacement of a pelvic ring injury. Adding stability will help with clot formation within the pelvis and limit hemorrhage. It is controversial whether this actually changes the pelvic volume.
    • Indications
      • Hemodynamically unstable pelvic ring injuries including APC and VS injuries
      • LC injuries treated with binder may be over compressed and may cause harm to other structures in the pelvis            
    • Contraindications
      • Acetabular fractures
  • May mask an injury from being identified
    • If the patient is hemodynamically stable on arrival without radiographic evidence of a pelvic ring injury, remove the binder and obtain repeat imaging[6]

 Angiography/Embolization[7]

  • Pelvic ring injuries which remain hemodynamically unstable despite transfusion and binder placement should undergo further intervention. At most centers, the next step is angiography and embolization. External fixation and open pelvic packing are the next steps at some centers; however, this is controversial.

 External Fixation[8]

  • Temporary or definitive fixation of pelvic ring injuries
  • Pin positions: Gluteal pillar, supraacetabular, or subcristal

Anterior Subcutaneous Pelvic Fixator (INFIX)[9]

  • New technique to avoid complications associated with pelvic external fixation including pin site infection   

Diverting Colostomy

  • May be necessary for open pelvic ring injury with perineal trauma

Open Reduction Internal Fixation[10]

  • Plates and screws across the symphysis can support the anterior ring.
  • Parasymphyseal pubic ramus fracture is treatable with open plating or percutaneous screw fixation.
  • SI dislocation or sacral fracture can be treated with sacroiliac, transiliac transacral or transiliac screws percutaneously. A thorough understanding of pelvic ring osseous fixation pathways is necessary to perform these techniques safely. Sacral dysmorphism is common and can complicate safe percutaneous fixation of the posterior pelvic ring.[11]
  • Open plating of SI joints or sacral fractures may be necessary if a closed reduction is unobtainable or the fracture pattern is not amenable to percutaneous fixation.

 Triangular Osteosynthesis[4]

  • Lumbosacral pedicle screw fixation combined with sacroiliac fixation for management of lumbopelvic discontinuity.
  • Absolute indications are still unclear.

Differential Diagnosis

Differential Diagnosis:

  • The pelvic ring should never be unstable without an injury
  • The only exception is in pregnant women who may have pelvic ring instability or widening temporarily around the time of parturition

Pertinent Studies and Ongoing Trials

Sagi et al 2011 JOT[12][13]:

  • Dr. Sagi and colleagues evaluated pelvic ring injuries under dynamic fluoroscopy in the operating room and found a subset of pelvic ring injuries to be more unstable than predicted by fracture pattern alone. 
  • Which patients require examination under anesthesia (EUA) still requires clarification.
  • Can use EUA during fixation of pelvic ring injuries to determine how much fixation is required.

Treatment Planning

The sequence of Events for Treating a Pelvic Ring Injury

On arrival:

  • ATLS
    • Two large bore IVs
    • Foley catheter
      • Contraindicated if blood at the urethral meatus
      • Indications for a retrograde cystourethrogram
        • Male patients with symphysis disruptions, hematuria, blood at meatus, inability to void, ecchymosis or hematoma of the perineum, high-riding or boggy prostate
    • Rectal and vaginal exam
    • Hemodynamic instability treated with fluids vs. immediate blood products
  • CXR
    • High energy trauma may also have widened mediastinum or pneumothorax
  • AP Pelvis
    • Try to decipher between APC and LC/VS/CM injury patterns
      • If the symphysis has significantly widened its likely an APC pattern
        • If the symphysis is wide and the patient is hemodynamically unstable, apply a pelvic binder or circumferential sheet
      • If the pelvis is broken/disrupted, but it is not clearly an APC pattern, consider other interventions before a pelvic binder
        • Traction for a VS injury 
  • CT head, neck, chest, abdomen and pelvis
    • Fine cuts (2 mm) of the pelvis
    • Look for other injuries including head/neck/chest/abdominal/pelvic hemorrhage
  • If the patient remains hemodynamically unstable
    • Identifiable source of bleeding outside of pelvis:
      • Control by other means per general surgery recommendations
    • No other source of bleeding identified other than pelvic ring injury: 
      • Interventional radiology embolization
        • Best next step in most centers
      • Emergent pelvic external fixation and pelvic packing
        • Controversial
  • Once the patient is hemodynamically stable
    • Inlet and outlet X-rays of the pelvis
      • For surgical planning
    • If the patient has polytrauma, it indicates a reason for the delay of definitive surgical intervention
      • Temporary external fixation per damage control orthopedic principles
    • If the patient is stable (lactate corrected)
      • Definitive fixation

Prognosis

Young-Burgess Classification predicts mortality[14]

  • Combine the classification into stable (LC1, APC1) vs. unstable (LC2,3 APC 2,3)
    • Stable – mortality of 7.9%
    • Unstable – mortality 11.5%

Reduction of the posterior ring within 1 cm improves long term outcomes.

Return to work rate is highly variable with the majority of patients reporting some form of persistent impairment.[15]

  • 24% lose a job
  • 34% returned to work but changed duties
  • 46% unable to perform pre-injury duties

Male gender and older age have higher mortality.

Females with symphysis fixation can still have safe vaginal deliveries.[16][17]

  • As long as the front and back of the pelvis are not both restrained by fixation

Complications

Malunion[18]

  • Controversial how to define or measure displacement and malunion
  • Patient with anatomic reductions have better outcomes, but displacement less than 1 cm are often tolerable
  • Sometimes difficult to discern stable patterns from unstable patterns
  • May consider manipulation under anesthesia to determine stability in select cases or to guide treatment during surgery
  • Complete sacral fractures with ipsilateral rami fractures treated nonoperatively will displace over time 39% of the time
  • Complete sacral fractures with bilateral rami fractures treated nonoperatively will displace over time 68% of the time

Hardware Failure[19]

  • Micromotion is present even in a well aligned and healed pelvic ring. Therefore, there is a high rate of hardware failure over time. If the pelvic ring has healed, there should be no displacement if and when the hardware fails; this is not an indication for hardware removal
  • Plating across the symphysis has a hardware failure rate of 43% at one year
  • 97% of hardware failures were asymptomatic

 Neurologic Dysfunction

  • Denis 3 fractures of the sacrum have approximately 50% rate of neurologic dysfunction of lumbosacral nerve roots.

 Sexual Dysfunction[20][21]

  • Erectile dysfunction occurs in 46% of males after pelvic ring injury
  • Dyspareunia occurs in 56% of females after pelvic ring injury, 91% with APC injuries, and 79% of patients treated with symphysial plating

 Chronic Pain and Disability

  • See prognosis section

Infection[22]

  • As high as 16% with a posterior approach to the sacrum
  • Obesity increases the risk of complications and reoperation

DVT/PE[23]

  • Pelvic ring injury may require IVC filter

Postoperative and Rehabilitation Care

Depending on injury and method of treatment, the patient may require a period of weight bearing restrictions to one or both extremities. Nursing and therapy will be necessary to assist with a patients return to function. DVT prophylaxis postoperatively is paramount. 

Deterrence and Patient Education

CLinicians need to address patient expectations early. Discussing reasonable outcomes and understanding some degree of chronic discomfort may be unavoidable. Also, discussion of some intimate issues like erectile dysfunction or dyspareunia is important to patient well-being and making necessary referrals to OBGYN or urology as necessary. 

Enhancing Healthcare Team Outcomes

Patients with pelvic ring injuries are typically very sick and will require the assistance of multiple providers. It is imperative that each provider discuss their role with other providers and the patient. In complex scenarios, there may be multiple teams working on a single patient, and interprofessional communication is essential. Because of the complexity of these injuries, the number of organs injured, and the high morbidity and mortality, it is imperative that an interprofessional team be involved in the care of the patient. The brief roles of the interprofessional team are as follows:

The urologist may be required if there is a urethral injury; since these patients require suprapubic catheterization. Further, it is imperative that the catheter not be placed in the way of a diverting ileostomy for the general surgeon or a pelvic incision for the orthopedic surgeon. Diverting ileostomy/colostomy or suprapubic catheters should be placed as cephalad as possible to avoid interfering with the surgical incisions needed to operate on the pelvis.

A general surgeon may be required to divert the fecal flow by creating a diverting ileostomy or colostomy.

The radiologist is essential for localizing the injuries and their extent. Also, an interventional radiologist may be necessary for arterial embolization in cases of uncontrolled hemorrhage.

These patients are often managed in the trauma or surgery ICU and need close monitoring by the nurses. These patients also need DVT and pressure sore prophylaxis. Since most patients cannot eat an oral diet for a few days or weeks, a dietary consult for TPN may be required. If the patient has a stoma, a stoma nurse needs to educate the patient and the family about stoma care, the necessary changes in diet and maintaining hygiene around the appliance, and report back to the physicians of any issues encountered.

Pain control and antimicrobial therapy may be necessary, and the pharmacist should oversee medication reconciliation and dosing, and let the team know of any potential interactions or dosing issues.

Because these patients are often bedridden for prolonged periods, physical and occupation therapy must be involved to exercise the muscles and maintain function. They can inform the team as to the progress or lack thereof as the patient moves through the stages of rehabilitation.

A mental health nurse should see the patient prior to discharge as depression and anxiety are common after pelvic trauma. The road to recovery is long and unpredictable, causing extreme stress in many patients. These findings should go to the managing physician(s) as well as the nursing team.

Most patients require extensive rehabilitation after discharge and may need to follow up with many specialists, including the nurse practitioner.

 

In summary, as can be seen above, pelvic ring injuries/fractures require an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]

Outcomes

Pelvic trauma is a significant event, and despite optimal care, it correlates with very high morbidity. Many patients remain disabled after the injury and are not able to return to work. Most have difficulty performing daily living activities and often require assistance with ambulation. The long term prognosis for most of these patients is guarded.


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Pelvic Ring Injuries - Questions

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An 18-year-old male arrives in the trauma bay after a rollover motor vehicle accident. He is unconscious and hemodynamically unstable. The emergency department staff intubates the patient to protect the airway. ATLS is initiated. The FAST scan is negative. Chest x-ray shows no pneumothorax. The pelvis x-ray shows pubic diastasis of 5 cm. Resuscitation with blood products is initiated. Which of the following is the next best step in the management of this patient?



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A 36-year-old female was involved in a motor vehicle accident and stuck in the driver side door. She is brought to the emergency department and stabilized in the trauma bay. Her pelvis radiographs show a left-sided crescent fracture, bilateral pubic rami fractures, and a right-sided sacroiliac widening. What is the Young and Burgess Classification of this injury, and the appropriate management?



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A patient presents with a Young and Burgess APC 2 pelvic ring injury. Based on this injury classification, which pelvic ligaments have most likely been disrupted?



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A 65-year-old male is being evaluated in the emergency department for recurrent kidney stones. On the radiographic evaluation of the patient's abdomen, a plate is visualized crossing the pubic symphysis. The plate appears to be broken at the pubic symphysis, and two screws appear to have toggled out of the plate. The patient reports pelvic trauma at age 18 but no recent pelvic pain with ambulation. Which of the following is the next best step in the management of this patient?



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A 22-year-old female presents to the clinic for a routine prenatal care visit at 24 weeks gestation. This is her first pregnancy. She admits to the provider that she had a pelvic fracture at age 16, which required surgery in the front of her pelvis. She would like to know if she can have a vaginal delivery despite her prior trauma. What is the most appropriate recommendation?



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Pelvic Ring Injuries - References

References

Langford JR,Burgess AR,Liporace FA,Haidukewych GJ, Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. The Journal of the American Academy of Orthopaedic Surgeons. 2013 Aug;     [PubMed]
Berger-Groch J,Thiesen DM,Grossterlinden LG,Schaewel J,Fensky F,Hartel MJ, The intra- and interobserver reliability of the Tile AO, the Young and Burgess, and FFP classifications in pelvic trauma. Archives of orthopaedic and trauma surgery. 2019 May;     [PubMed]
Beckmann NM,Chinapuvvula NR, Sacral fractures: classification and management. Emergency radiology. 2017 Dec;     [PubMed]
Acklin YP,Zderic I,Richards RG,Schmitz P,Gueorguiev B,Grechenig S, Biomechanical investigation of four different fixation techniques in sacrum Denis type II fracture with low bone mineral density. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 2018 Jun;     [PubMed]
Ghaemmaghami V,Sperry J,Gunst M,Friese R,Starr A,Frankel H,Gentilello LM,Shafi S, Effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures. American journal of surgery. 2007 Dec;     [PubMed]
Wiley M,Black S,Martin C,Barnwell J,Starr A,Sathy A, Complications After Pelvic Arteriography in Patients With Pelvic Ring Disruptions. The Journal of the American Academy of Orthopaedic Surgeons. 2018 Nov 1;     [PubMed]
Vaidya R,Woodbury D,Nasr K, Anterior Subcutaneous Internal Pelvic Fixation/INFIX: A Systemic Review. Journal of orthopaedic trauma. 2018 Sep;     [PubMed]
Sagi HC,Coniglione FM,Stanford JH, Examination under anesthetic for occult pelvic ring instability. Journal of orthopaedic trauma. 2011 Sep;     [PubMed]
Manson T,O'Toole RV,Whitney A,Duggan B,Sciadini M,Nascone J, Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? Journal of orthopaedic trauma. 2010 Oct;     [PubMed]
Aprato A,Joeris A,Tosto F,Kalampoki V,Rometsch E,Favuto M,Stucchi A,Azi M,Massè A, Are work return and leaves of absence predictable after an unstable pelvic ring injury? Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology. 2016 Jun;     [PubMed]
Ceylan HH,Kuyucu E,Erdem R,Polat G,Yιlmaz F,Gümüş B,Erdil M, Does pelvic injury trigger erectile dysfunction in men? Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2015;     [PubMed]
Vallier HA,Cureton BA,Schubeck D, Pelvic ring injury is associated with sexual dysfunction in women. Journal of orthopaedic trauma. 2012 May;     [PubMed]
Morris SA,Loveridge J,Smart DK,Ward AJ,Chesser TJ, Is fixation failure after plate fixation of the symphysis pubis clinically important? Clinical orthopaedics and related research. 2012 Aug;     [PubMed]
Bruce B,Reilly M,Sims S, OTA highlight paper predicting future displacement of nonoperatively managed lateral compression sacral fractures: can it be done? Journal of orthopaedic trauma. 2011 Sep;     [PubMed]
Jaeblon T,Perry KJ,Kufera JA, Waist-Hip Ratio Surrogate Is More Predictive Than Body Mass Index of Wound Complications After Pelvic and Acetabulum Surgery. Journal of orthopaedic trauma. 2018 Apr;     [PubMed]
Cullinane DC,Schiller HJ,Zielinski MD,Bilaniuk JW,Collier BR,Como J,Holevar M,Sabater EA,Sems SA,Vassy WM,Wynne JL, Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. The Journal of trauma. 2011 Dec;     [PubMed]
Lucas JF,Routt ML Jr,Eastman JG, A Useful Preoperative Planning Technique for Transiliac-Transsacral Screws. Journal of orthopaedic trauma. 2017 Jan;     [PubMed]
Dashe J,Parisien RL,Pina M,De Giacomo AF,Tornetta P 3rd, Is the Caprini Score Predictive of Venothromboembolism Events in Orthopaedic Fracture Patients? Journal of orthopaedic trauma. 2019 Jun;     [PubMed]
Vallier HA,Cureton BA,Schubeck D, Pregnancy outcomes after pelvic ring injury. Journal of orthopaedic trauma. 2012 May;     [PubMed]
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Swartz J,Vaidya R,Hudson I,Oliphant B,Tonnos F, Effect of Pelvic Binder Placement on OTA Classification of Pelvic Ring Injuries Using Computed Tomography. Does It Mask the Injury? Journal of orthopaedic trauma. 2016 Jun;     [PubMed]
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