Pelvic Disruption: Assessment and Classification

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Number 151September, 1980 Pelvic Disruption Assessment 15reduction. In trauma as complicated aspelvic disruption, not all injuries can beclassified precisely, but nevertheless, apattern does evolve as described. In eachof the three major forces, the anterior lesionmay be through the symphysis pubis orthrough the pubic rami. The posteriorlesion may be through the sacrum, throughthe sacroiliac joint with a marginal fractureof the ilium, or through the ilium itself.Also, and this must be stressed, theanteroposterior compression and lateralcompression fractures may be associatedwith a stable or unstable hemipelvis; bydefinition, the vertical shear fractures areall grossly unstable (Fig. 6). The degree ofinstability, indicated best by the disruptionand posterior displacement at the sacroiliacarea, is of extreme importance as aprognostic indicator for the general resuscitationof the patient.Those patients with gross posterior instabilityapparent on the original X-rayrequired 2% times as much blood replacementand had four times the m~rtality.~The patterns of injury are described inmore detail below.ANTEROPOSTERIOR COMPRESSIONOpen-book rype. Anterior compressionagainst the anterior superior spines pro-FIG. 4A. Tangential projection: the beam isdirected from the foot to the symphysis at anangle of 40" to the plate.duces a typical fracture pattern with separationat the symphysis pubis and a correspondingdegree of separation at bothsacroiliac joints anteriorly (Figs. 7A and7B). This has been produced experimentally;'the findings indicate that separationat the symphysis of more than 2.5 cm mustbe associated with a significant degree ofseparation at one or both sacroiliac joints.Experimental testing also revealed thatrupture of the sacrospinous ligament oravulsion of the ischial spine associatedwith pelvic ring disruption resulted inmarked instability. A ligamentous injuryFIGS, 4B and 4C. (Left) Anatomic appearance. (Right) Radiologic appearance in the tangentialprojection.
16 Pennal, et al.Clinical Orthopaedicsand Related ResearchAFIG. 6. The posterior lesion may be unstablewhen these ligaments making up the so-called“tension band of the pelvis” are ruptured.FIG. 5. Tomogram showing gross disruptionof the sacrum and an avulsion fracture of thetransverse process of L,, an important indicatorof pelvic instability. The patient sustained anL, nerve root avulsion.may be apparent on the initial X-ray as anavulsion of the ischial spine, and occasionallylater as calcification in the ligament.While, in the open-book type, the anteriordisruption is almost always a massivediastasis of the symphysis, the posteriorTABLE 1. Classification of PelvicDisruption Based on Directionof ForceAnteroposterior compressionLateral compressionA. Ipsilateral anterior and posterior lesionB. Contralateral anterior and posterior lesion(bucket-handle)C. Four-rami and posterior lesionD. MiscellaneousVertical shearlesion may occasionally consist of a fracturethrough the ilium.Most fractures of the open-book typemaintain the integrity of the posterior aspectof the pelvic ring, that is, the posteriorsacroiliac ligaments. Occasionally, however,the posterior ligaments may ruptureand render the hemipelvis unstable.Four-rami fracture. Isolated bilateral fracturesof the anterior rami can result fromeither anterior or lateral compressive forces.This so-called straddle fracture is usuallycaused by a lateral compressive force,described below. Rarely, it may be causedby a direct blow on the anterior pubic rami.The displacement of the floating fragmentis usually posterior and superior and maypersist by the pull of the rectus abdominismuscles. On one occasion, we were attemptingto reduce the pelvic disruptionwith a floating anterior segment, the patientcoughed on intubation. We were watchingthe image intensifier, and noted the floatingsegment migrate almost to the level of theumbilicus because of spasm in the rectusabdominis muscle. Rarely, displacement maypersist because of the unopposed pull of thismuscle, if the patient is not managed in
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Pelvic Disruption: Assessment and Classification

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