Pelvic Fracture Classification and Management : Simplified

Before proceeding to this topic, it would be wise to go through the topics listed below:

1. Pelvis X-ray : Simplified Approach | Epomedicine
2. Ligaments of Pelvis | Epomedicine

Tile/AO Classification

Tile classification divides pelvic fractures into three basic types according to stability based on the integrity of the posterior sacroiliac complex. Here is a mnemonic that can be used to remember tile classification.

Tile A: Anterior arch only (Posterior arch intact)

1. Avulsion injury (3 spines – ASIS, AIIS or pubic spine)
2. Anterior arch or Ala of ilium (Iliac wing)
3. Across (transverse fracture) the Ala of sacrum or coccyx

Tile B: Borderline stable (Posterior arch – incomplete disruption)

1. Book (Open): External rotation – Pubic diastasis > 2.5 cm +/- SI joint widening
2. Book (Closed): Internal rotation – Lateral compression injury
3. Book – Bilateral B injuries

Type C: Completely unstable (Complete disruption of posterior arch)

1. One side C
2. One side B, One side C
3. Both side C

Young Burgess Classification

It is based on injury mechanism.

Type	Fracture characteristics	Ligaments disrupted	Treatment	Key concepts
	Anterior-Posterior Compression (APC)
APC1	Pubic diastasis <2.5 cm	Stretched anterior SI, sacrospinous, sacrotuberous ligaments	Nonsurgical Protected WB	Tile A
APC2	Pubic diastasis >2.5 cm with widening of anterior SI joint	Disrupted anterior SI, sacrospinous, sacrotuberous ligaments	ORIF anterior pelvis (symphyseal plate)	Tile B
APC3	Pubic diastasis with widening of both anterior and posterior SI joint	+ Posterior SI ligament disruption	Urgent pelvic sheet or binder to stabilize the pelvis ORIF of anterior pelvis with posterior fixation (SI screws or plate/screws)	Tile C Highest rate of blood loss and GU injury
	Lateral compression (LC)
LC1	Transverse pubic rami fractures Sacral impaction fracture on side of impact		Nonsurgical Proteced WB (Complete, comminuted sacral component) WBAT (Simple, incomplete sacral fractures)	Tile A
LC2	Transverse public rami fractures Crescent fracture of ilium on side of impact	Variable disruption of posterior ligamentous structures	ORIF of ilium	Tile B
LC3	LC1/2 + APC on other side (Windswept pelvis)		ORIF anterior and posterior pelvis	Tile C Windswept pelvis Associated with head, chest and abdominal trauma Most common cause of death is closed head injury
	Vertical Shear (VS)
VS	Vertical displacement of hemipelvis (malgaigne fracture)	SI ligaments, sacrotuberous ligament, sacrospinous ligaments, symphyseal ligament	Traction initially ORIF anterior and posterior pelvis	Tile C Associated with intrapelvic hemorrhage and neurologic injury
CM	Combined

WSES (World Society of Emergency Surgery) Classification

It uses Young-Burgess classification and hemodynamic stability to classify and guide pelvic fracture management. Hemodynamic stability is the condition in which the patient achieve a constant or an amelioration of blood pressure after fluids with a blood pressure >90 mmHg and heart rate <100 bpm.

Hemodynamic instability:

• Admission systolic blood pressure <90 mmHg, or > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs OR
• Admission base deficit (BD) >6 mmol/l OR
• Shock index (Pulse rate/Systolic BP) > 1 OR
• Transfusion requirement of at least 4–6 Units of packed red blood cells within the first 24 h

	WSES grade	Young-Burgess classification	Hemodynamic	Mechanic	CT-scan	First-line Treatment
MINOR	I	APC I – LC I	Stable	Stable	Yes	Conservative
MODERATE	II	LC II/III – APC II/III	Stable	Unstable	Yes	Pelvic Binder in the field ± Angioembolization (if blush at CT-scan) Operative – Anterior External Fixation
	III	VS – CM	Stable	Unstable	Yes	Pelvic Binder in the field ± Angioembolization (if blush at CT-scan) Operative – C-Clamp
SEVERE	IV	Any	Unstable	Any	No	Pelvic Binder in the field Preperitoneal Pelvic Packing ± Mechanical fixation ± REBOA (Resuscitative Endo-aortic balloon) ± Angioembolization

Further reading: Coccolini, F., Stahel, P.F., Montori, G. et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg 12, 5 (2017). https://doi.org/10.1186/s13017-017-0117-6

Denis classification for Sacral fractures

Denis type	Fracture description	Neurologic injury	Remarks
Zone 1	Lateral to foramina (Alar)	L5 root; 5%	Commonest (50%)
Zone 2	Through foramina (Transforaminal)	L5/S1/S2 root; 30%	Stable vs Unstable
Zone 3	Medial to foramina (Spinal canal)	60%	Bowel, bladder & sexual dysfunction Includes “H” or “U” type fractures

Letournel Judet classification for Acetabulum fractures

Column Concept of Acetabulum

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Associated patterns: Posterior column/posterior wall, Transverse with posterior wall, T type, Anterior column/posterior hemitransverse, Both column

Indications for surgery:

1. >2 mm displacement
2. Posterior wall fracture >/= 20% of wall (20-40% and unstable under stress EUA)
3. Roof arc angle <45 degrees
4. Incongruity of hip joint (absence of secondary congruence)
5. Incarcerated fragments/loose bodies
6. Marginal impaction
7. Irreducible fracture-dislocations

Roof arc angle of Matta: It is the estimation of amount of weight bearing dome (WBD) involved. It is the angle measured between a line from dome to geometric center of femoral head and another line from fracture to the geometric center in following 3 views:
a. AP view: Medial roof arc angle
b. Obturator oblique view: Anterior roof arc angle
c. Iliac oblique view: Posterior roof arc angle

Roof arc angle <45 degrees in any view (Matta et.al.) signifies unstable fracture requiring fixation.
Roof arc angle <45 degrees in AP, <25 degrees in obturator oblique and <70 degrees in iliac oblique view (Varhas et.al.) signifies unstable fracture requiring fixation.

It is not applicable to isolated posterior wall fracture and both column fractures.

Important points on management of pelvic ring fractures

1. Pelvic binder/sheet: Applied at the level of greater trochanter (GT)

2. Anterior stabilization with external fixator (Ganz): Decreases pelvic volume; Consider partial closed reduction 1st

• High route: Iliac crest (3-5 cm posterior to ASIS); Place atleast 2 pins on each side
  • Place at junction of lateral 2/3rd and medial 1/3rd of iliac crest
  • Aim: 30-45 degrees from lateral to medial (towards the hip joint)
  • Fluoroscopy: Outlet-oblique view
• Low route: Supra-acetabular (AIIS); Single pin
  • Fluoroscopy:
    • 30/30 outlet/obturator oblique view (to confirm entry location and direction)
    • Iliac oblique (to confirm location above sciatic notch)
    • Inlet/obturator oblique (to confirm depth)
  • Direction: 30 degrees cephalad (towards SIJ) to avoid greater sciatic notch
  • Provides better stabilization than high route
  • Risk: lateral femoral cutaneous nerve

3. Posterior stabilization with C-clamp:

• Entry point: Intersection of femoral axis line and a perpendicular line dropped from ASIS to bed

4. Pre-peritoneal pelvic packing:

• 6-8 cm midline longitudinal incision from pubic symphysis
• Divide midline fascia, leave peritoneum intact
• Retract bladder
• Place 3 lap pads on each side of bladder, into true pelvis below the pelvic brim
• Close fascia and skin
• Pack removal 24-48 hours later

5. Traction for vertical shear fractures:

• Bilateral upper tibial skeletal traction
• A heavy weight (upto 20 kg) may be required to achieve reduction
• After 3 weeks, weight is reduced to 10 kg
• Traction is removed after 6-8 weeks

6. Percutaneous ilio-sacral screws:

• Safe zone: S1 vertebral body
• Inlet view: guides antero-posterior screw placement
• Outlet view: guides superior-inferior screw placement
• Complication: L5 nerve root injury

7. Surgical approaches:

Approach	Interval	Access	Acetabular fracture indications	Risks
Ilioinguinal	1. Medial window: Medial to external iliac vessels 2. Middle window: Between external iliac vessels and iliopsoas muscle 3. Lateral window: Lateral to iliopsoas muscle	1. Pubic rami, iliac fossa, anterior SIJ 2. Pelvic brim, quadrilateral plate 3. Quadrilateral plate, SIJ, Iliac wing	Both column Anterior wall Anterior column Anterior column-posterior hemi transverse Some T-type and transverse types	Obturator artery/nerve Corona mortis Femoral nerve/vessels Lateral femoral cutaneous nerve Spermatic cord, round ligament
Kocher-Langenbeck	Split gluteus maximus; detach short external rotators 1 cm from insertion Quadratus femoris left intact to protect femoral head blood supply	Outer table of ilium Sciatic notch Ischium Posterior wall	Posterior wall Posterior column Transverse	Sciatic nerve Superior gluteal artery Medial femoral circumflex artery Heterotopic ossification
Iliofemoral	Extensile approach	Posterior and anterior acetabulum Inner and outer table of ilium	High anterior column Both column T-type Fractures >3 weeks old	Heterotopic ossification High complication rates
Stoppa	Behind iliopectineal fascia to enter true pelvis Can use “lateral” window of ilioinguinal approach	Pubic symphysis Pelvic brim Quadrilateral plate	Anterior column Anterior wall Transverse T-type Both column Anterior column-posterior hemitransverse	Corona mortis Obturator nerve

Cause of hemorrhage:

1. Stable pelvic fractures: ~70% due to associated injuries and 30% due to pelvic fracture
2. Unstable pelvic fracture: ~70% due to pelvic fractures and 30% due to associated injuries

Superior gluteal artery is the most common artery to be damaged. Internal pudendal artery yields the most symptomatic bleeds.

Further reading: Montmany S, Rebasa P, Luna A, Hidalgo JM, Cánovas G, Navarro S. Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability. Cir Esp. 2015 Aug-Sep;93(7):450-4. English, Spanish. doi: 10.1016/j.ciresp.2015.01.011. Epub 2015 Mar 21. PMID: 25804517.