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Joshua L. Gary, MD
February 2016
Radiographic Evaluation and Classification of Pelvic Ring
Disruptions
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• Open? • Closed? • Tile? • Young-
Burgess? • AO/OTA? • Letournel?
How do we classify this?
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It all goes back to ANATOMY!
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Osteology
• Sacrum
• Iliac WIng
• Acetabulum
• Pubis
• Ischium
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Ligamentous Anatomy
• Pubic Symphysis • Anterior
Sacroiliac Ligaments
• Posterior Sacroiliac Ligaments
• Sacrospinous Ligaments
• Sacrotuberous Ligaments
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External Iliac System
Internal Iliac System – Posterior
Division – Anterior
Division
Vascular Anatomy
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• L4/L5 nerve roots – Anterior sacrum
• Sciatic nerve
– Greater sciatic notch
• Obturator nerve – Lateral obturator
foramen
Nervous Anatomy
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• Screening AP Pelvis
• Circumferential compression changes appearance
Imaging
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• General idea – Stable – Unstable
• Immediate interventions if needed – Circumferential
compression – Reduction of hip
dislocation
AP Pelvis
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Inlet
Anterior / Posterior Displacement
Internal / External Rotation
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Outlet
Cranial / Caudal Displacement
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CT Scan
Study SOFT TISSUE WINDOWS 1st!!!! Look at bony injury last.
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CT Scan – Soft Tissue Windows
Hematoma=Morel-Lavallee
Air Densities = Open Fracture
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CT Scan – Inguinal Hernia
• Impacts open approaches
• May preclude
percutaneous implant placement
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CT Scan – Lumbar Hernia
• Detachment of abdominal wall from iliac wing
• Repair with iliac
window approach
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CT Scan – Hematoma
• Look for “midline shift”
• Associated vascular
injury?
Bladder
Hematoma
Femoral vein abnormality
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CT Scan – Posterior Ring
Iliac Fracture Sacral Fracture SI joint Disruption
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Posterior Ring – Iliac Fracture
• Displaced or
nondisplaced? • Internal or external
rotation mechanism?
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Posterior Ring – SI Joint Disruption
• Complete or
Incomplete? • Anterior sacral
crush?
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Posterior Ring – Sacral Fractures
• Complete or Incomplete?
• Extraforaminal,
transforaminal, or median?
• Intraforaminal
debris?
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Posterior Ring – Bilateral Sacral Fractures
• Lumbosacral dissociation – “U”, “Y”, and “H” patterns
• Sagittal Images to look
for transverse component of fracture
• Spinal canal
compromise
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Paradoxical Inlet
AP view
Lumbosacral kyphosis leads to an “inlet” appearance on AP View
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Posterior Ring – Sacral Dysmorphism
• Residual upper sacral disk
• Acute alar slope • Mammillary processes • “Tongue-in-groove”
articulation • Noncircular upper
sacral foramina • Fixation implications
for SI screws
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CT Scan – Anterior Ring
• Symphyseal disruption and/or rami fractures?
• Unilateral or bilateral? • Horizontal or vertical
pattern? • Isthmic diameter of
superior ramus for fixation
• Associated acetabular
injury?
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Magnetic Resonance Imaging
• Shows ligamentous injury
• Role undefined
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Classification
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Tile Classification
A: Stable B: Partially stable C: Completely
unstable
• Based on cadaveric sectioning
• Posterior ring only! }
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Tile Classification • A: Stable • B: Rotationally
unstable, vertically stable
• C: Rotationally and vertically unstable
A1: Avulsion injury A2: Iliac wing or anterior ring
from direct blow A3: Transverse sacrococcygeal
fracture
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Tile Classification • A: Stable • B: Rotationally
unstable, vertically stable
• C: Rotationally and vertically unstable
B1: Open book (external rotation) B2: Lateral compression injury
(internal rotation) B2-1: Ipsilateral anterior and
posterior injuries B2-2: Contralateral (bucket-
handle) injuries B3: Bilateral
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Tile Classification • A: Stable • B: Rotationally
unstable, vertically stable
• C: Rotationally and vertically unstable
C1: Unilateral C1-1: Iliac fracture C1-2: Sacroiliac fracture-
dislocation C1-3: Sacral fracture C2: Bilateral, with one side type B,
one side type C C3: Bilateral
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Young and Burgess Classification
• Grouped by mechanism of injury
Lateral Compression (LC) Anteroposterior Compression
(APC) Vertical Shear (VS) Combined Mechanism of Injury
(CMI)
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Young-Burgess Lateral Compression
• LC
1: Sacral + superior/inferior pubic rami fractures (unilateral or bilateral
2: Crescent (± sacral) +
superior/inferior rami fractures
3: LC1 or 2 with
contralateral SI joint injury (windswept pelvis
Crescent fragment
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Young-Burgess Anteroposterior Compression
• APC
1: Pubic symphysis rupture 2: PS + Anterior SI ligament
rupture a: SS and ST intact b: SS or ST disrupted 3: PS + ASI + Posterior SI
ligament rupture
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Young-Burgess Vertical Shear
• Shearing mechanism rather than external rotation
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Young-Burgess Combined Mechanism of Injury
• Doesn’t fit other classifications
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LeTournel Classification
Describe injuries Simple!!
• Left complete SI dislocation • Pubic symphysis disruption • Displaced right transverse
acetabular fracture • Right complete SI
dislocation
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Open Pelvic Fractures
• Jones Classification – I: Stable pelvic ring – II: Rotationally or vertically
unstable pelvis without rectal or perineal wound
– III: Rotationally or vertically unstable pelvis with rectal or perineal wound
• Gustilo-Anderson doesn’t apply
– Originally devised for tibia fractures
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Summary Case
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19 yo female thrown from horse
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19 yo female thrown from horse
Displaced Sacral Fracture Minimally Displaced
Anterior Column Acetabular Fracture
Inferior Ramus Fracture
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Computed Tomography
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Computed Tomography
L4 and L5 Nerve Roots run here
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Visualize and protect nerve roots prior to reduction!
PROXIMAL
LATERAL
DISTAL
MEDIAL L4 Root
L5 Root
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Remove anterior fragment prior to reduction!
DISTAL
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Postoperative Result
DISTAL
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Summary
• Anatomic knowledge = POWER! • Proper Imaging = PLANNING! • Classification = UNDERSTANDING!
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• For questions or comments, please send to [email protected]