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Radiographic Evaluation, Anatomy, and Classification of Pelvic Ring Injuries

Radiographic Evaluation, Anatomy, and Classification of Pelvic Ring Injuries. Kyle F. Dickson, MD Chief of Orthopaedics, Charity Hospital Director of Orthopaedic Trauma Tulane University Created March 2004 Reviewed April 2007. Palpable Bony Landmarks. Symphysis Pubis

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Radiographic Evaluation, Anatomy, and Classification of Pelvic Ring Injuries

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  1. Radiographic Evaluation, Anatomy, and Classification of Pelvic Ring Injuries Kyle F. Dickson, MD Chief of Orthopaedics, Charity Hospital Director of Orthopaedic Trauma Tulane UniversityCreated March 2004Reviewed April 2007

  2. Palpable Bony Landmarks • Symphysis Pubis • Anterior Superior Iliac Spine (ASIS) • Iliac Wing • Posterior Superior Iliac Spine (PSIS)

  3. Pelvic Ring • 2 innominate bones • 1 Sacrum • Gap in symphysis < 5 mm • SI joint 2-4 mm

  4. Important Stabilizing Ligaments • Posterior Iliosacral • Anterior Iliosacral • Sacrospinous • Sacrotuberous • Symphyseal

  5. Important Muscles • Gluteus Maximus • Iliopsoas • Rectus Abdominus

  6. Possible Arterial Bleeders in Pelvic Injuries • Iliolumbar artery • Superior gluteal artery • Lateral sacral artery • Internal iliac artery • Internal pudendal (active bleeding most commonly found)

  7. Neurologic Damage • L5 & S1, most common • L2 to S4 possible • Dependent on location of fracture and amount of displacement

  8. Denis, CORR 1988 • Sacral Fractures – Neurologic Injury • Lateral to foramen – 6% injury • Through foramen – 28% injury • Medial to foramen – 57% injury

  9. Pohlemann, CORR 1994 • Amount of displacement move important then location

  10. Potentially Damaged Visceral Anatomy • Blunt vs. impaled by bony spike • Bladder/urethra • Rectum • Vagina

  11. Pelvic Ring • No inherent stability • Ligaments give the pelvis stability

  12. Symphyseal Ligaments • Resist external rotation in double-leg stance • Rami act as struts to resist compressive and internal rotation in single leg stance • Sectioning causes little pelvic instability

  13. Ghanayem, J Trauma 1995 • Abdominal wall contributes to pelvic stability (laparotomy increased pelvic displacement in cadaveric model)

  14. SI Joint Transfers Load from Appendicular to Axial Skeleton

  15. Sacrum • Inlet View Reverse keystone where compression forces displace sacrum anteriorly • Outlet View True keystone compression locks sacrum into pelvic ring • Small rotating movements during gait

  16. Posterior Ligaments • Ant. SI Joint – resist external rotation • Post. SI and Interosseous – posterior stability by tension band (strongest in body) • Iliolumbar ligaments augments posterior complex

  17. Sacrotuberous (sacrum behind sacro-spinous into ischial tuberosily vertically) Resists shear and flexion of SI joint Sacrospinous – (anterior sacral body to ischial spine horizontally) resists external rotation

  18. Normal SI Joint Motion with Gait • < 6 mm of translation • < 6° rotation • Intact cadaver resist 5,837 N (1,212 lbs)

  19. Nachemson, Acta Orthop Scand 1966 • Sitting 710 N (160 lbs) at each Si joint • Lying 196 N (44 lbs) • Lateral decubitus 686 N (154 lbs) • Standing 980 N (220 lbs)

  20. Sitting or Double Leg Stance • Pubic rami tension and compression posteriorly • External rotation injury – displaces in sitting or double leg stance

  21. Single Leg Stance • Tension shear posteriorly and compression of rami • Will displace internal rotation injury

  22. Direction of Force • Anteroposterior • Lateral compression • Vertical shear

  23. Stability – ability of pelvic ring to withstand physiologic forces without abnormal deformation

  24. Translational Deformities • X axis – Diastasis or impaction • Y axis – Caudad or cephalad displacement • Z axis – Anterior or posterior displacement

  25. Rotational Deformities • X axis – Flexion or extension • Y axis – Internal rotation or external rotation • Z axis – Abduction or adduction

  26. Deformity of Pelvis • Defined from an anatomically positioned pelvis in space • Deformity a combination of rotational & translational deformities

  27. Deformity of Pelvis (cont.) • Does not deform around a single point but can be represented as a vector from a normally positioned pelvis • Acute deformity difficult to measure but direction often able to be determined

  28. Pelvic Instability • These injuries which will have worsening deformity • Physical exam and radiographic evaluation

  29. Determining Stability • Integrity of posterior bone and ligament, unstable = vertical plane displacement • Some partial instability in rotation

  30. Physical Exam • Symmetrical palpable ASIS, iliac wing, and symphysis • ASIS compression test • Iliac wing compression test

  31. Radiographic Evaluation • Anteroposterior view (AP) • Inlet view (40° caudad) • Outlet view (40 ° cephalad) • CT

  32. Good Quality Radiographsare Essential

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