Anatomy of the pelvis

Pelvic Fractures

Thelma Musingwini R186623F

Vongai Guta R186638S
Tanaka Samudzi R186637L
Anatomy of the
pelvis
The Pelvis
● The bony pelvis’s main function is to transmit the weight of the body from the
vertebral column to the femurs.
● In addition, it contains, supports, and protects the pelvic viscera and provides
attachment for trunk and lower limb muscles.
● The bony pelvis is composed of four bones: the two hip bones, which form the
lateral and anterior walls, and the sacrum and the coccyx,
● The two hip bones articulate with each other anteriorly at the symphysis pubis
and posteriorly with the sacrum at the sacroiliac joints.
The Pelvis
● The pelvis is divided into two parts by the pelvic brim, which is formed by:
● the sacral promontory (anterior and upper margin of the first sacral vertebra)
● False Pelvis.
● It is bounded behind by the lumbar vertebrae, laterally by the iliac fossae and
the iliacus muscles, and in front by the lower part of the anterior abdominal
wall.
● The false pelvis flares out at its upper end and should be considered as part
of the abdominal cavity. It supports the abdominal contents and after the 3rd
month of pregnancy helps support the gravid uterus.
● During the early stages of labor, it helps guide the fetus into the true pelvis.
● True Pelvis
● Knowledge of the shape and dimensions of the female pelvis is of great
importance for obstetrics, because it is the bony canal through which the child
passes during birth.
● The true pelvis has an inlet, an outlet, and a cavity
Boundaries of the true pelvis
● The true pelvis is made up of three bones
● Hip bone(ilium, pubic, and ischial bone)
● Scrum
● coccyx
● The pelvic inlet oval in shape
● Anteriorly –the symphisis pubis
● Laterally- iliopectenal line
● Posterioly-sacral promontory
Pelvic Wall
● Anterior pelvic wall
● It is shallow and is formed by the body of symphisis pubis
● Posterior Pelvic wall
● It is formed by the coccyx and piriformis muscles and their covering of parietal
pelvic fascia
● Lateral Pelvic walls
● Formed by the hip bone, obturator membrane, the sacrotuberous and
sacrospinous ligament
● Pelvic floor
● Formed by the pelvic diaphragm, which is made up of lavatories ani muscles
and a small coccygeus muscle.
Pelvic muscles
● Piriformis
● Origin: Front of sacrum
● Insertion: Greater trochanter of femur
● Obturator internus
● origin: Obturator membrane and adjoining part of hip boneI
● nsertion: Greater trochanter of femur
● Levator ani
● Origin :Body of pubis, fascia of obturator internus, spine of ischium
● Insertion: Perineal body; anococcygeal body; walls of prostate, vagina,
● r ectum, and anal canal
● Coccygeus
● Origin: Spine of ischium Lower end of sacrum;
Joints of the pelvis
Sacroiliac Joints
The sacroiliac joints are strong synovial joints and are formed between the
auricular surfaces of the sacrum and the iliac bones .
The pubic symphysis is a cartilaginous joint located between the main body of
the pubic bone in the midline. The symphysis of the pubic bone is covered with
hyaline cartilage and may have a cleft. The ligaments around the pubic
symphysis are flexible and relax during pregnancy
● The sacrococcygeal joint is a fusion of the bone between the sacrum and
coccyx. It also consists of an intervertebral disc between the two vertebrae
and several accessory ligaments
Blood supply
Fractures of the pelvis
Pelvic fractures are often described as "stable" or "unstable," based on how much
damage has occurred to the structural integrity of the pelvic ring

Stable fractures
In this type of fracture, there is often only one break in the pelvic ring and the broken
ends of the bones line up adequately.
Low-energy fractures are often stable fractures.
Example of Pelvic fractures
Unstable fractures
In this type of fracture, there are usually two or more breaks in the pelvic ring and
the ends of the broken bones do not line up correctly (displacement). This type of
fracture is more likely to occur due to a high-energy event.
Causes of pelvic fractures
High energy trauma such as car collision
Because the pelvis is in proximity to major blood vessels and organs, pelvic
fractures may cause extensive bleeding and other injuries
Bone insufficiency
Lower impact event (minor fall) in older people
Less commonly, a fracture may occur when a piece of the ischium bone tears
away from the site where the hamstring muscles attach to the bone. This type of
fracture is called an avulsion fracture and it is most common in young athletes who
are still growing
They are various classification systems which are
commonly used in pelvic fractures.
● Anatomical classification by Letournel.
● Classification based on stability and deformity.
● Orthopedic Trauma Association classification - mainly useful for research.
● Classification based on vector force and associated injuries by Young and
Burgess.
Anatomical Classification by Letournel
Letournel defined the fracture pattern on the basis of the area of pelvic bone involved.
He divided all fractures in two groups - anterior and posterior fractures

Anterior fractures include:

● Ramus fractures
● Symphyseal disruption
Posterior fractures include

● Iliac wing fracture

● Iliac wing/SI joint fracture (crescent fracture)
● SI joint fracture
● Sacrum/SI joint fracture
● Sacrum fracture

NB:

This classification defined the fracture pattern, but it did not mention the stability of
the fracture and therefore is not useful in deciding the management protocol or
outcome of these fractures
Classification based on stability and deformity by
Pennal, Bucholz, and Tile
Pennal et al., [9] described the fracture pattern on the basis of mechanism of
injury:

● Anteroposterior compression (APC) injury

● Lateral compression (LC) injury
● Vertical shear (VS) injury pattern

NB: All classifications prior to this are dependent on radiographs for describing the
pelvic injuries. They only give documentation of individual fracture pattern and
they were found not useful in further management of patients.
Young and Burgess classification
Four mechanisms of injury are defined in this classification.

● Lateral compression (LC) (implosion)

● Anteroposterior compression (APC) (external rotation)
● Vertical shear (VS)
● Combined injury
The LC fracture is the most common pattern in pelvic fractures.
LC-I fracture pattern

LC-I fracture pattern

The direction of force of injury is from the side and is associated with either
horizontally oriented pubic fracture and/or impacted fracture of the sacrum. Thus,
this fracture pattern is associated with impacted fracture of posterior SI complex
and may be unstable
LC II fracture pattern

With increasing lateral force on the anterior pelvis, the major fracture fragment is
rotated inwards, with anterior sacrum acting as the pivot. This gives rise to the
disruption of the posterior SI joint associated with or without oblique fracture of
posterior ilium extending lateral to the SI joint.
LC III fracture pattern

This is the most severe form of LC fracture. There is further continuation of LC

force which continues on the contralateral pelvis. This lateral force becomes a
distracting force for the contralateral hemipelvis and causes its external rotation.
This external rotation occurs due to SI, sacrotuberous, and sacrospinous ligament
disruption. This leads to unstable pelvic injury with associated hemorrhage and
neurological injury.
Anterior Posterior Compression

The direction of force is from the front of the pelvis. These forces disrupt the
anterior pelvis and as the force vector progresses there is disruption of posterior
pelvis leading to unstable pelvic injury. (young et. al)
 APC1
There is vertical fracture of pubic rami with rupture of the ligament of pubic
symphysis, associated stretching of posterior ligaments. There is less than 2.5 cm
of symphyseal diastasis
APC2
Additional anteroposterior force causes splaying of anterior pelvis with external
rotation of iliac wings. The iliac wings hinge at the posterior SI joint. There is
rupture of sacrotuberous, sacrospinous, and symphyseal ligaments with intact
posterior SI ligamentsq. Symphyseal diastasis of more than 2.5 cm is seen,
vertical stability is maintained
APC3
There is complete disruption of all ligaments associated with posterior SI ligament.
This results in rotational instability and lateral displacement of pelvis. This type of
injury pattern is highly unstable and is associated with highest rate of vascular
injuries.
Vertical Shear
This injury occurs because of fall from height on the extended lower limbs. There
is associated disruption of sacrospinous, sacrotuberous, SI, and pubic symphysis
ligaments, which leads to gross instability of the pelvis more commonly in the
cephaloposterior direction. This injury is also associated with neurovascular injury
and hemorrhage
Diagnostic Procedures
● X-rays: antero-posterior view, inlet view and outlet view
● CT scan
● Ultrasound
● Bone scans

The severity and correlated injuries can be investigated by:

● Urinalysis
● Measurement of haemoglobin and hematocrit: to measure blood loss
● Retrograde urethrography
● Arteriography
● Cystography
Differentail Diagnosis
Pelvic fractures rarely occur as a single injury
- avascular necrosis of the femoral head
- cancer
- hip dislocation
- hip fractures
- osteomyelitis
- osteoporosis
- genito-urinary injuries
- bowel injury
- muscular injuries
- neurovascular injuries
- bladder injury
Outcomes or complications of pelvic fractures
Unstable pelvic fractures sustained during high-energy incidents, such as car
accidents, may result in significant complications, including severe bleeding,
internal organ damage, and infection.
Subsequent problems, such as pain, impaired mobility, and sexual dysfunction,
may result from damage to nerves and organs that is associated with the pelvic
fracture.
Complications of pelvic fractures
● pain in the groin, hip or lower back, which may get worse when walking or
moving the legs.
● Abdominal pain
● Numbness or tingling in the groin or legs
● Bleeding from the vagina, urethra or rectum
● Difficulty urinating
● Difficulty walking or standin
● Swelling or bruising on the hip area
Medical management of the
fractures
Conservative treatment

Following indications are considered for conservative treatment:

● Most LC and anteroposterior type I injuries are treated conservatively

● Pubic symphysis diastasis less than 2.5 cm
● Pubic rami fracture with no posterior displacement.

● Patients are kept on protected weight bearing and followed up by serial

radiographs and clinical examination
Absolute indications of surgery

● APC-III, LC-III, and VS type of fracture pattern

● Open pelvic fractures
● Associated visceral injury
● Hemodynamic instability
Medical management
 Pelvic fractures should be considered in the context of a polytrauma
management
 Lately operative management has increased in the treatment of unstable pelvic
fractures.
 Operative management of pelvic fractures allows earlier mobilisation of the
patient therefore diminishing complications of immobilisation
 In emergency, the fracture will be stabilised by an external fixator (for antero-
posterior injuries) or a ‘C-clamp’ (for vertical shear injuries).
 Mostly plates or screws are used to stabilise a fracture.
 Other methods used to treat pelvic fractures are traction, spica casts, pelvic
slings, and turnbuckles.
 Open reduction and internal fixation
 Physiotherapy
management of the
fractures
Physiotherapy management

● The goals of the physical therapy program should

provide the patient with an optimal return of function
by improving functional skills, self-care skills and
safety awareness.
● The main goals are to
 improve the pain level
 strength
 flexibility
 Speed of healing
 the motion of the hip, spine and leg.
 to shorten the time needed to return to activity and
sport.
Cont...
● Low-energy injuries are usually managed with conservative care. This
includes bed rest, pain control and physical therapy.
● For high-energy injuries, after surgery physical therapy includes the same
treatment as in low-energy fractures.
● In people with surgical treatment, physical therapy starts after 1 or 2 days of
bed rest. It is initiated with training of small movements, transfers and
exercise training.
Cont....
Exercises that be done
 Knee extension in sitting or in bed
 Contraction of quadriceps(5 -10times)
 Abduction of the hip (10times)
 Planterflexion and dorsiflexion of the feet(10-15 times hourly)
Cont..
● During the non-weight bearing status the patient performs
 isometric exercises of the gluteal muscle and quadriceps femoris muscle
 range of motion exercises and upper-extremity resistive exercises (for
example shoulder and elbow flexion and extension) until fatigued
Cont.,
● Once weight-bearing is resumed, physical therapy consists of
 gait training
 resistive exercises for the trunk and extremities
 cardiovascular exercises (for example treadmill or bicycle training).
 Stabilisation exercises
 mobility training
 Aquatherapy is also good and helpful when available.
Outcome measures
We have two types of outcome measures that is disease specific and patient
specific

Disease specific
Harris hip score
Mayo hip score

Patient specific
Oxford hip scores, iHOT
Sf 36,WOMAC
Reference list
[Link]

[Link]

[Link]
[Link]
● Journal of Orthopedics, traumatology, and Rehabilitation(2014)
[Link]
7341;year=2014;volume=7;issue=1;spage=8;epage=13;aulast=Haq#ref22.
● Pennel GF, Tile M, Waddell JP, Garside H. Pelvic disruption: Assessment and
classification. Clin Orthop Relat Res 1980;151:12-21
● Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: Value of plain
radiography in early assessment and management. Radiology 1986;160:445-
51. Back to cited text no. 10[PUBMED]
● Tile M, Helfet DL, Kellan JF. Fractures of pelvis and acetabulum. 3 rd ed.
Baltimore, Lippincott Williams and Wilkins; 2003. Back to cited text no. 1
●
● Rice, Phillip L., and Melissa Rudolph. "Pelvic fractures." Emergency medicine
clinics of North America 25.3 (2007): 795-802. LOE: 4
● Pelvic fractures
physiopedia[Link]