Joshua L. Gary, MD February - PowerPoint Presentation

Slide1

Joshua L. Gary, MDFebruary 2016

Radiographic Evaluation and Classification of Pelvic Ring DisruptionsSlide2

Open?Closed?Tile?Young-Burgess?AO/OTA?Letournel?How do we classify this?Slide3

It all goes back to ANATOMY!Slide4

OsteologySacrumIliac

WIng

Acetabulum

Pubis

IschiumSlide5

Ligamentous AnatomyPubic SymphysisAnterior Sacroiliac Ligaments

Posterior Sacroiliac Ligaments

Sacrospinous Ligaments

Sacrotuberous LigamentsSlide6

External Iliac SystemInternal Iliac SystemPosterior DivisionAnterior DivisionVascular AnatomySlide7

L4/L5 nerve rootsAnterior sacrumSciatic nerveGreater sciatic notchObturator nerveLateral obturator foramenNervous AnatomySlide8

Screening AP PelvisCircumferential compression changes appearanceImagingSlide9

General ideaStableUnstableImmediate interventions if neededCircumferential compressionReduction of hip dislocationAP PelvisSlide10

InletAnterior / Posterior Displacement

Internal

/

External RotationSlide11

OutletCranial / Caudal DisplacementSlide12

CT ScanStudy

SOFT TISSUE WINDOWS 1

st

!!!!

Look at bony injury last. Slide13

CT Scan – Soft Tissue Windows

Hematoma=Morel-

Lavallee

Air Densities = Open FractureSlide14

CT Scan – Inguinal Hernia

Impacts open approaches

May preclude percutaneous implant placementSlide15

CT Scan – Lumbar HerniaDetachment of abdominal wall from iliac wingRepair with iliac window approachSlide16

CT Scan – HematomaLook for “midline shift”Associated vascular injury?

Bladder

Hematoma

Femoral vein abnormalitySlide17

CT Scan – Posterior RingIliac FractureSacral Fracture

SI joint DisruptionSlide18

Posterior Ring – Iliac FractureDisplaced or nondisplaced?Internal or external rotation mechanism?Slide19

Posterior Ring – SI Joint DisruptionComplete or Incomplete?Anterior sacral crush?Slide20

Posterior Ring – Sacral Fractures

Complete or Incomplete?

Extraforaminal

,

transforaminal

, or median?

Intraforaminal

debris?Slide21

Posterior Ring – Bilateral Sacral FracturesLumbosacral dissociation – “U”, “Y”, and “H” patternsSagittal Images to look for transverse component of fractureSpinal canal compromiseSlide22

Paradoxical Inlet

AP view

Lumbosacral

kyphosis

leads to an “inlet” appearance on AP ViewSlide23

Posterior Ring – Sacral DysmorphismResidual upper sacral diskAcute alar slopeMammillary processes“Tongue-in-groove” articulation

Noncircular upper sacral foramina

Fixation implications for SI screwsSlide24

CT Scan – Anterior RingSymphyseal disruption and/or rami fractures?Unilateral or bilateral?Horizontal or vertical pattern?Isthmic

diameter of superior ramus for fixation

Associated acetabular injury?Slide25

Magnetic Resonance ImagingShows ligamentous injuryRole undefinedSlide26

ClassificationSlide27

Tile ClassificationA: StableB: Partially stableC: Completely unstable

Based on cadaveric sectioning

Posterior ring only!

}Slide28

Tile ClassificationA: StableB: Rotationally unstable, vertically stableC: Rotationally and vertically unstable

A1: Avulsion injury

A2: Iliac wing or anterior ring from direct blow

A3: Transverse

sacrococcygeal

fractureSlide29

Tile ClassificationA: StableB: Rotationally unstable, vertically stableC: 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: BilateralSlide30

Tile ClassificationA: StableB: Rotationally unstable, vertically stableC: 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: BilateralSlide31

Young and Burgess ClassificationGrouped by mechanism of injuryLateral Compression (LC)Anteroposterior Compression (APC)Vertical Shear (VS)

Combined Mechanism of Injury (CMI)Slide32

Young-Burgess Lateral CompressionLC1: 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 fragmentSlide33

Young-Burgess Anteroposterior CompressionAPC1: Pubic symphysis rupture2: PS + Anterior SI ligament rupture a: SS and ST intact

b

: SS or ST disrupted

3: PS + ASI + Posterior SI ligament ruptureSlide34

Young-Burgess Vertical ShearShearing mechanism rather than external rotationSlide35

Young-Burgess Combined Mechanism of InjuryDoesn’t fit other classificationsSlide36

LeTournel ClassificationDescribe injuries  Simple!!

Left complete SI dislocation

Pubic symphysis disruption

Displaced right transverse acetabular fracture

Right complete SI dislocationSlide37

Open Pelvic FracturesJones ClassificationI: Stable pelvic ringII: Rotationally or vertically unstable pelvis without rectal or perineal woundIII: Rotationally or vertically unstable pelvis with rectal or perineal

wound

Gustilo-Anderson doesn’t apply

Originally devised for tibia fracturesSlide38

Summary CaseSlide39

19 yo female thrown from horseSlide40

19 yo female thrown from horse

Displaced Sacral Fracture

Minimally Displaced Anterior Column Acetabular Fracture

Inferior Ramus FractureSlide41

Computed TomographySlide42

Computed Tomography

L4 and L5 Nerve Roots run here Slide43

Visualize and protect nerve roots prior to reduction!Proximal

lateral

distal

Medial

L4 Root

L5 Root Slide44

Remove anterior fragment prior to reduction!distalSlide45

Postoperative ResultdistalSlide46

SummaryAnatomic knowledge = POWER!

Proper Imaging = PLANNING!

Classification = UNDERSTANDING!Slide47

For questions or comments, please send to ota@ota.org