10/09/2013

HR-6000L
Justification, Optimisation
and Interpretation in Medical
Imaging
Pelvis

Introduction

Review anatomy
Pelvic ring fractures
Acetabular fractures
Other types of pelvic fractures

Gary Culpan

Gary Culpan

Anatomy review

Ossification

Innominate bones

Eight ossification centres

Iliac crest does not fuse until age 25
Innominate bone formed by three bones

Ilium
Ischium

Pubis
Sacrum
Joints

Ilium
Ischium
Pubis

Symphysis pubis
Sacroiliac
Hip

Fuse at triradiate cartilage

Gary Culpan

Gary Culpan

Ossification
centres

Apophyses
Four separate ossification centres

Primary

Ilium
Ischium
Pubis

Secondary

Anterior inferior iliac spine

Iliac crest
Ischial tuberosity
Inferior pubic ramus

Appear by puberty
Fuse by age 25

Acetabulum
AIIS
Ischial tuberosity
Symphysis pubis
Iliac crest

Important not to confuse these with avulsion

injuries
Gary Culpan

Gary Culpan

10/09/2013

Related
vessels and
nerves

Avulsion fractures
Anterior superior iliac spine
Anterior inferior iliac spine
Ischial tuberosity

Important
considerations
Vascular injury

Need to compare injured side with

uninjured apophysis

Interactive Hip
2000 Primal
Pictures Ltd.
Gary Culpan

Supporting
ligaments anterior

Gary Culpan

Supporting
ligaments posterior
Strong ligaments
Attach sacrum and
innominate bones
Sacroiliac ligament
(long & short) attach
to PSIS
Long Sacroiliac
Ligament joins to
sacrotuberous
ligament

Create stability
Resist rotational
forces
Withstand
weightbearing

Gary Culpan

Gary Culpan

Joints

Associated injuries

SIJ

In up to 40% of pelvic fractures

Intra-abdominal source of bleeding
Contributes to mortality and morbidity after
blunt trauma

Inferior articular and synovial

Superior fibrous and ligamentous

Symphysis pubis

Retroperitoneal haemorrhage

Hyaline cartilage
Fibrocartilage
Fibrous tissue
Separation no more than 2.5 cm
If wider suspect disruption of sacrospinous
ligaments

Gary Culpan

May be massive arterial

Bony fragments sharp
Lacerated blood vessels
Insidious venous bleeding
Coagulopathy
Exsanguination
Gary Culpan

10/09/2013

Pelvic bleeding

Pelvic fractures

Why is it important?

Significant bleeding - difficult to find and treat

Patient can exsanguinate
Source of haemorrhage needs to be found
Control of haemorrhage needs to undertaken
Mortality of pelvic fracture 5-10%
Morbidity of pelvic fracture 5%

Associated injuries
Intraperitoneal
Genitourinary tract

Detection of fractures
Further investigation
Change patient management

Gonzalez et al 2002

Is the AP pelvis film enough?

Gary Culpan

Gary Culpan

How good is the AP pelvis?

FAST

Clinical examination is also useful!

Gonzalez et al (2002) showed that in
the awake and alert patient:
Clinical examination 93% sensitive for pelvic #
AP pelvis 87% sensitive

Positive rate for injury on AP film 4%

13% miss rate
Most missed fractures were acetabular
Majority of misses on clinical exam were also
acetabular

F
A
S
T

Focussed
Assessment
for the
Sonographic
assessment of the
Trauma
patient

Gary Culpan

Can it replace pelvis x-ray?

Gary Culpan

Alternatives?

FAST is designed to look for blood or free fluid

Survey includes pericardial sac and peritoneal
recesses
Can detect as little as 100ml of blood
Utilised in blunt trauma
Less useful to identify hollow viscus perforation

DPL = Diagnostic Peritoneal Lavage

Intra-operative procedure

CT abdomen
Ionising radiation
Can pick up unsuspected injuries
e.g. pelvic fractures, retroperitoneal bleeding

Unless there is associated haemorrhage

Gary Culpan

Gary Culpan

10/09/2013

Can you see intrabdominal

bleeding on pelvis x-ray?

What if there is a pelvic fracture?

Need to be stabilised

May see soft tissue mass above bladder

To staunch blood loss

Manual compression

Needs 100-150 ml
Good quality images

Rotate legs internally

Pressure bandage around patient and table!

In high energy trauma patient may be

bleeding elsewhere

Surgical compression
Pelvic screws in A&E!

Gary Culpan

Lines to assess

The AP Radiograph

Gary Culpan

Ilio-pubic line
Ilio-ischial line
Teardrop

Ilio-pubic line
Ilio-ischial line
Teardrop
Sacrum
Sacro-iliac joints
Symphysis pubis
Anterior and posterior acetabular rims
Rings

Sacrum
Sacro-iliac joints
Symphysis pubis
Anterior and
posterior
acetabular rims
Rings
Gary Culpan

Judet View 450 Oblique

Right Anterior Oblique (RAO)

Gary Culpan

Judet View 450 Oblique

Left Anterior Oblique (LAO)

Anterior column of RIGHT acetabulum

demonstrated

Anterior column of LEFT acetabulum

demonstrated

RIGHT anterior acetabular roof shown in

profile

LEFT anterior acetabular roof shown in profile

Posterior column of LEFT acetabulum

demonstrated

Posterior column of RIGHT acetabulum

demonstrated
Gary Culpan

Gary Culpan

10/09/2013

Alternative Plain Film Views

Pelvic Inlet

Pelvic Outlet

Tube angled 400

caudad

Tube angled 600

cephalad

Centre to umbilicus

Centre to symphysis
pubis

Cross-sectional imaging

Gary Culpan

CT uses

Gary Culpan

Trauma stable injuries

Pubic ramus fracture

Shows individual fragments

Similar population to #NoF

Assess treatment options

Pre and post surgery

Direct trauma, avulsion, stress fractures

Shows sacrum and SIJs

Difficult to assess on plain radiographs
Stress injuries in osteoporotic and metastases

Straddle fracture
Iliac wing
Avulsions related to children, adolescents,
athletes
Avulsion sites - ASIS, AIIS, ischial tuberosity,
ischial ramus, lesser trochanter

Gary Culpan

Ring structure of pelvis

Gary Culpan

Concept of Stability

Imagine POLO

Ring structure

Try to break in 1 place

Stability depends on integrity of anterior and

posterior arches

Instability result of disruption

Evaluate

Joints, ligaments or bone

Both anterior and posterior arches

Acetabulae
SIJs
Sacrum

The greater the disruption the greater

the degree of instability
Gary Culpan

Gary Culpan

10/09/2013

Stable Fractures

Unstable Fractures

66% of pelvic fractures are stable

33% of pelvic fractures are unstable

Fractures around the ring

Do not break into the ring

High risk of haemorrhage

Usually result of moderate forces

Most common

Classified by mechanism of injury

Unilateral fractures of pubic rami

Gary Culpan

Isolated Pubic Fractures

Gary Culpan

Isolated Sacral Fractures

Insufficiency fractures

Mechanism is usually fall onto sacrum

Stress fractures

Isolated fractures are usually transverse

Ischial pubic synchondroses

Can get insufficiency fractures

Compare with major trauma where fractures are vertical

Insidious symptoms
No history of trauma

Gary Culpan

Gary Culpan

Unstable Fractures

Young et al

JW Young, AR Burgess, RJ Brumback and

A Poka 1986

Mechanism of injury determines type of

pelvic ring disruption
Four patterns of force identified

Shock Trauma Center

Maryland Institute for Emergency Medical
Services

Plain film appearances are distinctive

Plain film findings correlate to soft tissue
injuries
Enables rapid surgical correction

http://radiology.rsnajnls.org/cgi/reprint/160/2/445
Gary Culpan

Gary Culpan

10/09/2013

Young et al

Mechanisms of Injury

Risk of mortality is related to type of

disruption

Lateral compression
Types 1-3 dependent upon where force applied

Anterior compression
Emphasised risk of excessive
radiological studies

Vertical shear
Complex
Gary Culpan

Lateral Compression Type 1

Gary Culpan

Lateral Compression Type 2

Fracture pattern
Bilateral superior and inferior pubic rami
Horizontally orientated

Fracture pattern
Bilateral
Superior and inferior pubic rami fractures
Folding in of iliac wing

Gary Culpan

Gary Culpan

Classification of Lateral
Compression Injuries

Lateral Compression Type 3

Fracture pattern
Bilateral, superior and inferior pubic rami
fractures
Folding in of iliac wing
Vertical fracture of sacrum +/- widening of SIJ

Gary Culpan

Type 1
Force applied to posterior part of pelvis
Fractures
Pubic rami
Sacrum - crush

Gary Culpan

10/09/2013

Classification of Lateral
Compression Injuries

Classification of Lateral
Compression Injuries

Type 2
Force applied more anteriorly
Characteristic # pubic rami
Possible sacral crush #

Type 3 severe internal rotation

Force applied anteriorly as type 2
Characteristic # pubic rami
Possible sacral crush #
Same side as force

Tearing of posterior SI ligaments

Same side as force

Anterior part of joint is pivot, same side

Contralateral anterior SI
Sacrospinous and sacrotuberous ligament
tearing

Tearing of posterior SI ligaments

Anterior part of joint is pivot

Gary Culpan

Gary Culpan

Pelvis
Anterior Compression

Anterior Compression
Widening of the symphysis pubis

Widening of the symphysis pubis

Opening out of the iliac wings
(OPEN BOOK / SPRUNG PELVIS)

Gary Culpan

Pelvis
Anterior Compression

Gary Culpan

AP Compression Injuries
BUT!
It is possible to have up to 2.5cm
separation of the symphysis WITHOUT
disrupting the posterior ligaments

Widening of the symphysis pubis

Opening out of the iliac wings (OPEN
BOOK / SPRUNG PELVIS)

Fractures of the pubic ramus rather

than symphysis widening may be
present but they will be VERTICALLY
orientated

Tearing of the anterior sacro-iliac

ligaments
Gary Culpan

Gary Culpan

10/09/2013

Classification of AP
Compression Injuries

Classification of AP
Compression Injuries

Type 1
Widening or fracture without posterior
instability (radiological or clinical)

Type 2
Widening of symphysis with some
disruption of anterior SI ligaments

Gary Culpan

Classification of AP
Compression Injuries

Gary Culpan

Pelvis - Vertical Shear

Type 3
Widening of symphysis
Total disruption of SIJ

Mechanism of injury
Fall from height
Heavy weight on shoulders

Fracture pattern

anterior and posterior ligaments

Pubic rami
Vertical fracture of sacrum/disruption of SIJ
Superior displacement of large hemipelvic
fragment

Gary Culpan

Pelvis - Mixed Fracture Pattern

(Complex)

Pelvis - Vertical Shear

Gary Culpan

Rare ~ 5%
Can be bilateral
Best visualised on outlet view
Severe ligamentous disruption and
instability

Arises from a combination of forces

Mixed anterolateral pattern (both
AP and lateral compression) or
lateral and vertical

Gary Culpan

Gary Culpan

10/09/2013

Acetabular fractures

Acetabular fractures

Associated with hip dislocations

Posterior dislocation

Usually significant trauma

Femur pushed posterior by dashboard of car in RTA

Posterior edge of acetabulum fractured easily missed
Judets views useful

Anterior dislocation

RTA
Fall from height

Blunt force to femur

Transferred to acetabulum
Through femoral head

Pattern of acetabular injury determined by:

Uncommon
Femoral head pushed into obturator foramen

Direction and magnitude of force

Position of femoral head

Central dislocation

Elderly and osteoporotic

Fracture due to low-energy trauma
e.g. Fall from standing

Femoral head pushed into pelvic cavity

Gary Culpan

Gary Culpan

Associated injuries

Judet Classification

Major trauma so associated injuries common

Intracranial
Spinal
Intrathoracic
Intra-abdominal

Pelvic ring and extremity fractures also common

Dont usually see bladder injury or pelvic
haemorrhage unless associated pelvic ring
fracture

Based on orientation of fractures and

structures involved

Requires lateral view of acetabulum

AP and oblique (Judet) views needed
10 patterns used
5 elementary and 5 associated

Multidetector CT
New classification system proposed

Gary Culpan

Findings

References

Review questions to determine fracture pattern

Fracture of obturator ring?

Indicates t-shaped or column fracture (exception = hemitransverse type

Intact obturator ring eliminates these fractures

Ilioischial line disrupted?

Occurs in fractures involving posterior column or transverse group

Iliopectineal line disrupted?

Indicates anterior column involvement or transverse-type fractures

Iliac wing above acetabulum fractured?

Seen in fractures of anterior column

Posterior wall fractured?

Can occur in isolation

In combination with posterior column / transverse fractures

Spur sign present?

Gary Culpan

Only seen in both-column fracture

Spur = strut of bone extending from SIJ
Normally connects to articular surface of acetabulum
In both-column fracture connection is disrupted
Fragment of bone resembling spur remains
Best seen on obturator oblique view
Can also be seen on CT
Gary Culpan

Gonzalez RP, Fried PQ, Bukhalo M (2002) The utility of clinical

examination in screening for pelvic fractures in blunt trauma.
J Am Coll Surg 194 (2002) 121-125
Graf KW, Karunakar M (2006) Unstable Pelvic Fractures.
Emedicine.com
http://emedicine.medscape.com/article/1247426-overview
last accessed 10/09/13
Thornton DD (2007) Acetabulum Fractures. Emedicine.com
http://emedicine.medscape.com/article/385838-overview last
accessed 10/09/13
Young JW, Burgess AR, Brumback RJ, Poka A (1986) Pelvic
Fractures: Value of Plain Radiography in Early Assessment
and Management. Radiology, August 1986, vol 190 p445-451
Gary Culpan

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