CASE 23 pelvic ring injuries (APC)

A 65-year-old male presents to the trauma bay with Young–Burgess APC type II pelvic ring injury.

This specific injury pattern includes which of the following pelvic ligaments?

1. Iliolumbar

2. Sacrospinous

3. Posterior Iliosacral

4. Inguinal

 

Discussion

The correct answer is (B). The APC II injury pattern will include pubic diastasis

>2.5 cm with anterior widening of the sacroiliac joints. Anatomically this correlates with injury to the pubic symphyseal ligaments, pelvic floor ligaments (sacrotuberous and sacrospinous), and the anterior sacroiliac ligaments. The iliolumbar ligaments are primarily involved in vertical shear or Tile C type injury patterns. Posterior iliosacral ligaments are involved in APC III type injuries. Inguinal ligament injury is not classically described in any of the Young–Burgess fracture patterns.

Approximately what percentage of patients who undergo preperitoneal packing

for hemodynamic instability in the setting of pelvic ring fracture (without another obvious hemorrhage source) will require subsequent angiography for continued hemorrhage?

1. 3%

2. 17%

3. 35%

4. 50%

 

Discussion

The correct answer is (B). Cothren et al. describe the efficacy of preperitoneal packing for recalcitrant hemorrhage in pelvic trauma in their 2007 JOT series. All patients with hemodynamic instability in the setting of pelvic fracture underwent external fixation with concomitant preperitoneal packing. Only 16.7% of patients temporized with these measures required further intervention.

The decision is made to stabilize the patients posterior pelvic ring injury with percutaneous instrumentation.

What radiographic landmark on the lateral pelvic view represents the anterior margin of the “safe zone” for percutaneous sacroiliac screw placement?

1. Iliac wing cortical density

2. Anterior cortex of S1

3. Superior endplate of S1

4. Anterior cortex of S2

 

Discussion

The correct answer is (A). Miller et al. describe the radiographic safe zones for percutaneous sacroiliac screw placement in their 2012 JAAOS review article. The anterior iliac cortical density (seen in Fig. 6–29) represents the anterior extent of the safe zone to ensure appropriate hardware location within the SI articulation. These images must still be correlated with AP, outlet, and inlet views to ensure no other forms of dysmorphism prior to screw placement.

 

 

Figure 6–29

 

This patient has up to a 90% chance of developing which long-term sequelae following his displaced APC type pelvic ring injury?

1. Fecal incontinence

2. Ipsilateral abductor weakness

3. Dyspareunia

4. Erectile dysfunction

 

Discussion

The correct answer is (D). Collinge et al. describe increasing age and APC-type fracture patterns as significant risk factors for recalcitrant postinjury erectile dysfunction in males. Choices A to C are all associated with APC type injuries however with lower reported prevalence rates.

 

Objectives: Did you learn...?

 

The Young-Burgess classification of pelvic ring injuries (APC)?

 

Anatomic landmarks associated with safe percutaneous iliosacral screw placement?

 

Long-term complications associated with APC pelvic ring injuries?