CT Case 053

There is pubic symphysis diastasis and left sacroiliac joint widening.

There is also prominent surgical emphysema, this is most obvious within the pelvis, however it can also be seen to extend above and below the pelvis.

The case demonstrates pelvic ring fracture with features in keeping with a Type 3 Anteroposterior Compression fracture (also known as an “open book” fracture).

There is pubic diathesis and bilateral sacroiliac (SI) joint widening.

There are various systems for classifying pelvic fractures. The Young-Burgess classification system is one of the most widely used. It is particularly useful in the ED as it is based on the mechanism, and it also helps in determining stability of the fracture.

Based on the Young-Burgess classification, fractures are divides into;

• Anteroposterior compression (APC)
• Lateral compression (LC)
• Vertical shear (VS)
• Combined mechanism fractures

APC fractures are further categorised into types 1, 2 and 3 depending upon the degree of pubic diathesis and widening of the SI joints;

An ‘open book’ fracture is associated with high risk of associated injuries to the genitourinary and perineal structures. They are also often associated with vascular injury with arterial dissection, pseudoaneurysm, transection or arteriovenous fistula formation.

Active bleeding in the pubic symphysis and pubic rami region indicate injury to the internal pudendal artery, obturator artery and inferior epigastric artery, whereas bleeding at the iliac wing and sacroiliac joint region could indicate injury of the gluteal artery, iliolumbar artery and sacral arteries.

This extensive surgical emphysema seen in this case should raise concern for a hollow viscus perforation. Indeed, the intra-operative findings reveals a large rectal injury extending into the scrotum, perineum, anus and anteromedial thigh. There was also near complete bladder avulsion.

Intra-operative management involved open repair of the bladder (to achieve urinary tract integrity necessary for urinary drainage).

The pelvic fracture was managed with closed reduction and external-fixation of the anterior pelvis and bilateral distal femur skeletal traction due to the unstable bilateral SI joints.

• Nickson C. Classification of Pelvic Fractures. LITFL
• Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56.
• Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Pelvic ring fractures: what the orthopedic surgeon wants to know. Radiographics. 2014 Sep-Oct;34(5):1317-33.
• Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg. 2013 Aug;21(8):448-57 [PDF]