MANAGEMENT OF PELVIC AND ACETABULAR
Management of Pelvic and Acetabular
The mortality associated with pelvic
fractures has decreased significantly over
the past 30 years, due to improvements in
early patient rescue, rapid transport from
the site of injury and vigorous
The early management of any pelvic injury
includes proper resuscitation, search for
other systemic injuries which may be a
threat to life/ limb/ critical organ systems
and damage control interventions to address
such problems (eg. Tension pneumothorax,
cardiac tamponade, actively bleeding
injuries, intra-cranial injuries).
As the patient’s general condition is being
stabilised, mechanical stability of the
pelvic ring should to be assessed Clinically
and radiologically. An AP radiograph of the
pelvis in conjunction with the hemo-dynamic
status is enough to make a decision on
emergency pelvic stabilisation. A CT scan
though better, may not always be possible in
Classification of the pelvic injury
(according to Tile) helps to differentiate
the Stable (A), Partially Stable (B) and
Completely Unstable (C) injuries.
There are other classification systems too –
notably the Young and Burgess System which
is a mechanistic classification depending on
the nature of the initial injury.
Emergency management of the pelvic injury
includes measures for external reduction of
pelvic volume which leads to compression of
fracture surfaces and the open venous
plexuses resulting in stoppage of bleeding.
This can be achieved by an external fixator,
a C-clamp, pelvic binder (regular/
pneumatic). Care is taken to see that there
are no fractures where the pins are
External tamponade by such measures may not
be enough and a laparotomy to attend to
intra- abdominal injuries and packing of the
bleeders in the pelvis may be necessary.
Nowadays, with advancement of interventional
(pin- hole surgery), embolisation of active
bleeders is a minimally invasive
alternative, in sselected cases.
Not all pelvic fractures require internal
fixation. The fractures that need to be
Displaced and unstable fractures/
dislocations of the posterior ring -
sacrum/ilium/ sacro-iliac joint
Markedly displaced fractures of the
It is necessary to time the definitive
fixation depending on other injuries and the
patient’s general status to avoid the
“second hit” and multi-organ dysfunction.
If both the anterior and posterior ring
fixation is required, the posterior injury
has to bee estabilised first. In some cases,
posterior fixation alone is enough. However,
anterior fixation alone, except in mild
“open book” injuries will fail and is not
recommended. Whichever segment is operated,
reduction is more important and is sometimes
more difficult than fixation.
Posterior Ring Fixation
The sacro-iliac joint can be reduced by
The sacral fractures are approached by a
para-median or midline incision, posteriorly.
Fractures of the posterior ilium are exposed
by an incision along the iliac crest.
Sacro-iliac Joint by percutaneous ilio-
Ilium - small contourable plates along crest
Anterior Ring Fixation
After a diagnosis of acetabular fracture is
made, classification of the fracture
(according to Letournel and Judet) is done
with the aid of AP, obturator oblique and
iliac oblique views +/- CT scan, to
determine further treatment.
In acetabular fractures, minor malreductions
are less tolerated than in the pelvic ring.
Even so, not all fractures need surgery. The
following can be treated non-operatively:
undisplaced, stable fractures
<20% of posterior wall involved, without
low anterior column fractures
Transverse fractures with an adequate roof
In associated both column fractures,
secondary congruence with poor general
condition of patient
Patient factors (Relative):
soft tissue injuries
Closed reduction of dislocations of the hip
is to be undertaken as soon as possible.
Skeletal traction is applied if the hip
joint is unstable due to the fracture.
Operative treatment of acetabular fractures:
Internal fixation is almost always
electively undertaken, except in
post-reduction nerve palsies, open injuries
or with associated pelvic fractures which
Anterior column with Posterior
Associated Both Column : Ilio-inguinal
(mostly), Extensile approach
At MIOT Hospitals, the preferred line of
Percutaneous ilio-sacral screw after open
reduction by posterior approach or
Anterior SI joint plate with plate for
anterior ring, if indicated, through an
Kocher - Langenbeck for all posterior
fractures, Most transverse fractures,
Transverse +posterior wall, some
Ilio-inguinal for all anterior fractures,
most Both column fractures, anterior
Combined for T-shaped and some Both column
The frequency of combined approaches has
diminished over time and single approaches
are enough in most cases.