0:00

So when we consider acute trauma of the pelvis,

0:04

we'll gonna consider him into three main categories,

0:07

pelvic fractures, acetabular fractures,

0:10

and hip fracture dislocations.

0:14

So with regards to pelvic fractures,

0:15

there is this rigid ring concept

0:18

where there's three components.

0:20

You have the sacrum in the centered,

0:23

and then two paired lateral components which are made up

0:26

of the ileum, isum, and pubis.

0:29

In addition to the bony injuries,

0:31

we can think about the associated injuries

0:33

that involve the urinary bladder

0:35

and urethra as part of the GU structures

0:37

or genital urinary structures.

0:40

We can also think of vascular injuries,

0:42

which may be venous plus or minus arterial.

0:45

You can have life-threatening hemorrhage

0:47

that most commonly occurs from the superior glu to artery

0:51

that's associated with pelvic fractures.

0:54

So in terms of the pelvic fractures, we have fractures

0:58

of individual bones without a break.

1:01

In the pelvic ring, you can have a single break across the

1:04

pelvic ring, double breaks in the pelvic ring,

1:08

and then acetabular fractures.

1:10

And this is based on cane's adaptation of the key

1:14

and conwell classification system.

1:17

So with regards to disruption in the pelvis,

1:19

when there's a single break,

1:21

that's typically considered a stable lesion,

1:24

which may not have much displacement,

1:26

whereas double breaks now

1:28

and you have disruption in two different portions

1:30

of the pelvis allow for greater displacement

1:33

and are considered unstable lesions.

1:36

So why classify pelvic fractures while it aids in predicting

1:40

hemodynamic instability?

1:42

Vis-A-vis the vascular injuries,

1:45

it aids in predicting associated visceral

1:47

and genital urinary injuries.

1:49

It aids in predicting pelvic instability, whether

1:52

that's rotational or vertical,

1:54

and hence the need for surgical treatment.

1:57

It aids in the understanding mechanism of injury force,

2:00

vector of injury, and potential

2:03

surgical tactics for reduction.

2:06

So how do we define pelvic instability?

2:08

Well, you can have rotational instability

2:10

where there's this opening and closing of the pelvis.

2:13

So the hemi pelvis is able to rotate into either

2:16

internal external rotation

2:18

around intact posterior ligamentous structures

2:21

and vertical displacement is resisted.

2:24

You can also have vertical instability

2:26

where the vertical forces that are transmitted to the pelvis

2:29

by axial loading from the lower extremities then allow

2:33

for disruption of that posterior

2:36

sacroiliac ligament complex.

2:38

The hemi pelvis is then free to rotate internally

2:41

or externally and to potentially migrate proximally.

2:45

This is considered globally unstable

2:47

and has a higher association with neurovascular injury.

2:51

Now there are a couple

2:52

of main classification systems that are applied.

2:56

I will briefly review them and their concepts.

2:59

So in the Young Burgess classification system,

3:03

there are several key characteristics that relate

3:06

to the type of injury.

3:07

The type of injury is shown in the left column here,

3:11

and we can consider them

3:12

as whether it's lateral compression type injury

3:17

and interop posterior

3:18

or AP compression type injury, a vertical sheer injury

3:23

or some combination thereof.

3:26

So the morphologic characteristics

3:29

with lateral compression injuries,

3:31

we typically have transverse overlapping

3:34

ator ring fractures.

3:36

They may be associated with other injuries,

3:39

whether it's head injuries, vascular injuries,

3:41

or bladder injuries.

3:43

In the type one lateral compression,

3:46

you have a sacral impaction or a buccal,

3:49

and the ligaments remain intact

3:51

and that's considered stable.

3:54

In the type two injury, there's a iliac crest fracture,

3:59

and this may be rotationally unstable,

4:03

but considered vertically stable.

4:05

And then in the type three we have a lateral compression,

4:09

that's type one or type two on one side,

4:13

and then an AP compression injury

4:15

on the contralateral or opposite side.

4:18

And because of those two concomitant injuries,

4:20

it's considered globally unstable.

4:23

So now let's move into AP compression.

4:26

So this is characterized by some diastasis

4:29

of the pubic synthesis without an anterior fracture.

4:33

However, because of the diastasis, there is a risk

4:37

of substantial hemorrhage associated

4:39

with this type of injury.

4:41

So AP compression also has three types.

4:45

So in type one we have less than 2.5 centimeters

4:49

of pubic diastasis.

4:51

And so if it's under 2.5 centimeters, it's considered stable

4:56

if it's greater than 2.5 centimeters.

5:00

And often with widening of the anterior portion

5:03

of the SI joint, this is considered rotationally unstable,

5:07

but vertically stable.

5:09

And in the type three it's often massive

5:13

where you have greater than five centimeters

5:15

of pubic diastasis.

5:17

And because of that tremendous amount of separation

5:20

of the pubic synthesis, there is often concomitant widening

5:23

of both the anterior and posterior components

5:26

of the SI joints.

5:28

And that produces a situation that's globally unstable.

5:32

The next type of injury considers a vertical shear where

5:36

this has some vertical displacement component

5:39

of the hemi pelvis fractures of the pubis,

5:43

and then may have involvement of the SI joint.

5:45

These are considered unstable lesions with association

5:49

of visceral injuries.

5:51

So we reviewed the main three types

5:53

of injuries in the Young Burgess classification,

5:56

and they can be combined.

5:58

So that could produce a complex fracture

6:00

with combined elements of the AP compression,

6:03

lateral compression, and vertical shear.

6:05

And when you have any combination of those different types

6:08

of injuries, the stability will be variable depending on the

6:12

most severe injury.

6:14

So one of the reasons that the Young Burgess classification

6:17

is utilized is

6:19

because the classification of injury can have implication

6:22

for the type of treatment.

6:24

So if we go through our diagram here, starting on the left

6:28

lateral compression, type one

6:30

or anterior compression type one

6:35

have conservative treatment, anterior compression type two

6:39

may require anterior stabilization, whereas type three

6:44

lesions or ones that are variable may require both anterior

6:48

and posterior stabilization.

6:51

Now compared to the Young Burgess classification,

6:54

what's also commonly employed is the tile classification.

6:58

So the tile classification separates pelvic disruption into

7:02

three different types known as type A, B, and C.

7:06

So type A is considered stable,

7:09

whereas A one is fractures of the pelvis

7:12

but not involving the bony ring.

7:16

A two is stable fracture

7:18

with minimally displaced fractures of the ring.

7:21

The next is type B,

7:23

which is considered rotationally

7:25

unstable, but vertically stable.

7:28

So B one is our open book fracture.

7:33

B two is where you have lateral compression on a

7:36

ipsilateral side.

7:39

B three is lateral compression,

7:41

but on the contralateral side, also known

7:44

as a bucket handle lesion.

7:45

And then the third type is type C,

7:49

where you have rotationally

7:50

and vertically unstable components.

7:53

And C one is when it's unilateral, C two is bilateral.

7:58

And then C3 is when either of those are associated

8:01

with an acetabular fracture.

8:04

So here's the diagram showing what's known

8:06

as a dever fractures,

8:09

and these are isolated fractures that involving portions

8:12

of the iliac wing and these are considered stable lesions.

8:17

Here's a drawing that depicts what's known as uh,

8:21

MAGA injury, which is a complex unstable pelvic fracture

8:25

involving one side of the pelvis and both anterior

8:30

and posterior disruption of the pelvic ring.

8:33

And in this case, the lateral fragment contains the

8:36

acetabulum and this is considered an unstable lesion.

8:40

With regards to the demographics for acetabular fractures,

8:44

about 10% of pelvic fractures will involve the acetabulum.

8:48

More often in younger patients

8:50

where there's a high energy trauma

8:51

as the primary cause, moderate or minimal trauma

8:54

May be increasing the account for fractures

8:56

of the acet in patients over 35

8:59

or if they have underlying osteoporosis.

9:02

And these acet fractures, as we mentioned,

9:05

are commonly associated with other fractures,

9:07

especially fractures of the lower extremity as well

9:10

as pelvic ring disruption.

9:12

The images on the right show a radiograph

9:15

and a CT slice demonstrating a both column,

9:19

right acetabular fracture with a traumatic protrusion

9:23

that is a indentation of the joint

9:26

or medialization of the joint

9:28

and a right femoral inter enteric fracture shown here.