Pelvic Fractures

Published on 16/04/2015 by admin

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Last modified 22/04/2025

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17 Pelvic Fractures

Anatomy of the Pelvic Skeleton

image

Bony Pelvis and Ligaments

Coxal Bones (Os Coxae; 2)

Ilium: Parts and Landmarks

• Crest, ala (wing), fossa (of false pelvis), articular surfaces
• Posterior superior iliac spine (at posterior part of articular surface)
• Iliac tuberosity: posterior sacroiliac ligament insertion
• Anterior superior iliac spine (ASIS): sartorius, inguinal ligament insertions
• Anterior inferior iliac spine (AIIS): rectus femoris, tensor fasciae latae, iliofemoral ligament (hip joint capsule) insertions
• Greater sciatic notch: sciatic nerve, piriformis muscle, pudendal neurovascular bundle exit here
• Ilium often used for cortical and cancellous bone grafts

Ischium: Parts and Landmarks

• Ischial spine: sacrospinous (SS) ligament insertion
• Body
• Ischial tuberosity: sacrotuberous (ST) ligament, hamstring insertions
• Ischial ramus: fuses with pubic ramus to form medial rim of obturator foramen

Pubis: Parts and Landmarks

• Tubercle: medial attachment of inguinal ligament (external oblique aponeurosis)
• Superior public ramus: pecten pubis (pectineal line), along inner superior ridge
• Symphysis: midline fibrous joint of superior pubic rami
• Inferior pubic ramus
• Arch: formed by inferior pubic and ischial rami
• Acetabulum formed by portions of all three bones

image Parts: articular surface, notch, limbus (margin)
image Should fuse by age ~20 years

• Arcuate line: medial ridge running from ilium (near superior sacroiliac joint) to pecten pubis
• Linea terminalis

image Bony upper border of the true pelvis, lower border of false pelvis
image Sacral promontory to iliopectineal line: arcuate line + pectineal line

Sacrum

• Parts and landmarks: ala, sacroiliac articular surfaces, lumbosacral articular (disc) surface, promontory, fused bodies (5), anterior and posterior foramina, coccyx (~4 segments)
• Sacral canal: continuation of vertebral canal with meninges and roots of spinal cord
• Posterior: median and lateral sacral crests, superior articular facet (to L5 inferior facet), sacral hiatus (end of sacral canal, ref. for caudal anesthesia)
• Posterior and anterior sacrococcygeal ligaments

Pelvic Joints

• Sacroiliac (SI)

image Synovial joints with minimal movement
image Posterior pelvis stability, weight-bearing

• Pubic symphysis: anterior pelvis
• Coxal

image Ilium, ischium, and pubis intersect in acetabular fossa.
image Typically fused by age 20 years

Pelvic Ligaments

• Sacroiliac

image Anterior and posterior (more extensive)
image Support SI joints

• Sacrotuberous; lower border of lesser sciatic foramen
• Sacrospinous: lower border of greater sciatic foramen, anterior to coccygeus fibers
• Anterior longitudinal

image Runs on anterior aspect of vertebral bodies onto sacrum
image Prevents hyperextension of lumbar spine

• Supraspinous and interspinous

image Run between vertebral spines and onto median sacral crest
image Prevent hyperflexion of lumbar spine

Neurovascular Supply

Nerves of the Pelvis

• Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles
• Sciatic nerve: anterior rami of L4, L5 (lumbosacral trunk), S1-S4, collect as trunk and pass out of greater sciatic foramen
• Sacral plexus

image Portions of anterior rami of S1-S4 supply pelvic floor muscles and regional sensation.
image Sciatic nerve motor and sensory to majority of lower limb
image Parasympathetic preganglionic fibers from S2-4 lateral column neurons to viscera (pelvic splanchnics; nervi erigentes)
image Sympathetic fibers from inferior mesenteric ganglion to pelvic viscera via hypogastric nerves and hypogastric plexus, running anterior to sacral bodies; also, contributions from sacral ganglia

• Pudendal nerve (S2-S4, sacral plexus branch)

image Motor to perineum and pudenda
image Sensory to perineum and pudenda

• Obturator nerve

image Traverses lateral wall of lesser pelvis, exits through obturator foramen
image L2-L4 supply to thigh adductors

image

Arteries and Veins of Pelvis

Arteries of the Pelvis

• Common iliac arteries and their internal and external iliac branches supply bones and viscera within the pelvic cavity.
• Common iliac branches: internal, external, middle sacral
• External iliac branches: inferior epigastric, deep circumflex iliac arteries
• Internal iliac branches

image Posterior: iliolumbar, lateral sacral, and superior gluteal arteries
image Anterior: umbilical, superior vesical, obturator, inferior vesical, prostatic or uterine/vaginal, internal pudendal, middle rectal, and inferior gluteal arteries

• Internal pudendal artery

image Passes out through greater sciatic foramen, around ischial spine, into lesser sciatic foramen
image Trauma can compromise perineal and cavernosal supply.

Venous Drainage

• Pelvic walls and viscera drain largely into branches of internal and external iliac veins (caval venous return).
• Visceral plexuses interconnect.

image Vesical, uterine/vaginal or prostatic, rectal
image Drain mainly into internal iliac veins

• Rectal plexus blood also drains into inferior mesenteric vein via superior rectal vein (portal venous return).
• Lateral and middle sacral veins drain into internal and common iliac veins, respectively (anterior sacral region).
• Iliolumbar veins drain into common iliac veins (iliac fossa region).
• Deep circumflex iliac and inferior epigastric veins drain into external iliac (anterior greater pelvis region).

Clinical Correlates

Pelvic Fractures

Mechanisms

• High-energy force

image Lateral more common, as in motor vehicle accidents
image Other injuries may be life-threatening, requiring emergency treatment.
image About 50% mortality with open fracture and GI or genitourinary injuries
image Intact posterior sacroiliac ligament key to stability

• Minor trauma

image Fall, with osteoporosis
image Single ramus fracture, stable

• Stable avulsion fracture

image ASIS: sartorius tendon avulsion
image AIIS: rectus femoris tendon avulsion
image Ischial tuberosity: hamstring tendon avulsion

Associated Injuries

• Open wounds
• Massive bleeding with internal blood loss (symptoms: flank swelling, ecchymoses)
• Bleeding from pelvic venous plexuses: vesicular, prostatic, vaginal, uterine, rectal
• Urethral, rectal, or vaginal injuries
• Anterior fractures: venous bleeding more likely
• Posterior fractures: arterial bleeding more likely
image

Classification of Pelvic Fractures (Young and Burgess)

image

Fractures of Pelvis without Disruptions of Pelvic Ring

Young and Burgess Classification

• Anterior and posterior compression (APC)

image I: Sacral compression, rami fractures; stable
image II: Rami fractures, posterior sacroiliac ligament disruption; stable
image III: Complete disruption of sacroiliac joint, pubic symphysis; unstable

• Lateral compression (LC)

image I: Sacral compression with rami fractures
image LC-II: Ramus fracture, posterior SI ligament disrupted, stable
image III: II + contralateral APC-III, unstable

• Vertical shear

image Anterior and posterior pelvic displacement injury
image Vertically unstable

Acetabular Fractures

• Typically from extreme force transmitted by femoral head (e.g., motor vehicle accident)
• May be associated with life-threatening injuries: stabilize airway, breathing, heart, and other trauma

Judet-Letournel Classification

• 5 elementary patterns of acetabular fractures: anterior wall, posterior wall, anterior column, posterior column, transverse
• Associated fractures may include more than one type.
image

Acetabular Fracture Fixation

image

Anterior Posterior Compression Fracture

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