SUMMARY

• Ilium fractures are high energy pelvic fractures that are often unstable and typically progress from the iliac crest to the greater sciatic notch.

• Diagnosis can made with pelvis radiographs but frequently require pelvic CT scan for full characterization.

• Treatment may be nonoperative or operative depending on fracture displacement, associated pelvic ring instability and patient activity demands.

EPIDEMIOLOGY

• Associated injuries

  • Iliac wing fractures have high incidence of associated injuries

    • open injuries 

    • bowel entrapment

    • soft tissue degloving

ANATOMY

• Osteology

  • pelvic girdle is comprised of 

    • sacrum

    • 2 innominate (coxal) bones 

      • each formed from the union of 3 bones: ilium, ischium, and pubis

  • ilium

    • 2 important anterior prominences

      • anterior-superior iliac spine (ASIS)

        • origin of sartorius and transverse and internal abdominal muscles

      • anterior-inferior iliac spine (AIIS)

        • origin of direct head of rectus femoris and iliofemoral ligament (Y ligament of Bigelow)

    • posterior prominences

      • posterior-superior iliac spine (PSIS)

        • located 4-5 cm lateral to the S2 spinous process

      • posterior-inferior iliac spine (PIIS)

IMAGING

• Plain radiographs

  • standard set of AP pelvis, inlet/outlet, and judet views

    • helpful for evaluating the iliac wing in addition to pelvic stability and possible acetabular involvement

• CT scan

  • carefully assess CT scan for signs of bowel entrapment

  • evaluate for presence of gas or air in the soft tissues which can be associated with open injury or bowel disruption

CLASSIFICATION

• No specific classification for iliac wing fractures

• Generally described as specific subtypes of more common classification systems

  • Tile Classification

  • Tile Classification
    Stable (intact posterior arch)
    	A1-1: iliac spine avulsion injury
    	A1-2: iliac crest avulsion
    	A2-1: iliac wing fractures often from a direct blow
    Partially stable (incomplete disruption of posterior arch)
    	B2-3: incomplete posterior iliac fracture
    Unstable (complete disruption of posterior arch)
    	C1-1: unilateral iliac fracture

TREATMENT

• Nonoperative

  • mobilization with an assist device

    • indications

      • nondisplaced fractures

      • isolated iliac wing fractures

• Operative

  • open reduction and internal fixation

    • indications

      • displaced fractures of ilium

TECHNIQUES

• Wound Management

  • evaluate all wounds for

    • soft tissue disruption or internal degloving injury

    • possible soft tissue or bowel entrapment in the fracture site

  • prophylactic antibiotics as appropriate

  • serial debridements as necessary

• Open Reduction Internal Fixation

  • approach

    • posterior approach 

    • ilioinguinal approach 

    • Stoppa approach (lateral window) 

  • recommend early reconstruction

    • single pelvic reconstruction plate or lag screw along the iliac crest

    • percutaneous screws and reduction techniques possible as well  

    • supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim or sciatic buttress

  • coordination with trauma team

    • injury to bowel may require diversion procedures

    • plan surgical intervention with trauma team to minimize recurrent trips to the operating room

COMPLICATIONS

• Malunion with deformity of the iliac wing

• Internal iliac artery injury

• Bowel perforation

• Lumbosacral plexus injury