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APC III

- Discusison:
    - w/ application of severe AP force, hemipelvis rotates externally until posterior iliac wing contacts posteior sacrum;
    - continued force rips posterior SI ligaments, completely dissconecting hemipelvis from the sacrum;
    - APC III have highest rate of assoc injury, including retroperitoneal bleeding;
    - by definition then, an APC III injury shows destruction of all the ligamentous constraints connecting the involved side of the
             hemipelvis to the axial skeleton and the opposite hemipelvis;
    - these types of fractures are associated with vascular injury;

- Assessment of Stability:
    - isolated division of symphysis pubis allows approx 2.5 cm of diastasis of symphysis pubis;
    - further division of anterior sacroiliac, sacrospinous, & sacrotuberous ligaments causes further instability (APC II), but complete
             instability does not occur until all of sacroiliac ligaments are disrupted (Type III);

- Radiology:

    - Push-Pull Views:
         - used to evaluate dynamic displacement of the pelvis;
         - these views are obtained as in Outlet view w/ examiner pushing on the femur for one view and pulling on it for other;
    - references: Radiological analysis, operative management and functional outcome of open book pelvic lesions: a 13-year cohort study.

- Anterior Fixation Methods:
      - anterior fixation alone is indicated for type II fractures, where as type III require anterior fixation along with posterior fixation;
      - treatment options:
            - Orthomed pelvic reduction clamps (temporary for reduction of pelvic volume)
            - External Fixation:
                    - indicated for SI diastasis or pubic ramus frx which cannot be treated by open reduction or screw fixation;
                    - such as may occur w/ suprapubic cystostomy tube or open frx;
           - Open Reduction and Plate Fixation:
                   - types of anterior plates
                   - indicated for pubic diastasis greater than 2.5 cm;
           - Retrograde Medullary Superior Ramus Screw:
                   - indicated for superior ramus fractures which occur along w/ an ustable posterior injury


Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome.