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Copyright 1981by The Journal of Bone and Joint Surgery. incorporated
The Pathological Anatomy of
Malgaigne Fracture-Dislocations of the Pelvis
BY ROBERT
W.
BUCHOLZ,
From the Division of Orthopedic Surgery,
ABSTRACT: Despite
@
renewed
interest
tributory
cause
and dislocations
of death
and disability
techniques
. Advancements
are a major con
in the victims
in blood
of
replace
ment, external counter-pressure
suits, and angiography
with embolization of bleeding sites have been especially
important
in preventing
fatal hemorrhage.
The morbidity rates associated with various pelvic in
juries never have been studied well . Long-term follow-up
studies have been few9'18. Slätisand Huittinen reported on
late follow-ups of sixty-five of 163 Malgaigne fracture
dislocations. Unexpectedly, they noted a 46 per cent mci
dence of late sequelae, including oblique inclination of the
pelvis on sitting, pelvic limp, disabling sacro-iliac pain,
signs of persistent
damage
to the lumbosacral
plexus , and
low-back pain. Many of these late complications
tributable
to inadequate
reduction
were at
of the dislocation
hemipelvis.
Since the original description
of the
of fracture-dislocation
of the hemipelvis by Malgaigne in the nineteenth century,
traditional treatments
have involved combinations
of bed
rest, traction, closed reduction,
mobilization.
In an attempt
mortality
rate of patients
mobilization
* Division
of Orthopedic
slings, and spica-cast im
to decrease further the
with multiple
out of bed,
many centers
Surgery,
University
ence Center, 5323 Harry Hines Boulevard,
400
trauma
by rapid
recently
of Texas
Health
Dallas, Texas 75235.
TEXAS
utilized external fixation devices for the stabilization
in the reduc
motor-vehicle accidents. The mortality rates for patients
with treated pelvic injuries have decreased due to early
recognition of the potential complications and improved
therapeutic
DALLAS,
University of Texas Health Science Center, Dallas
tion and external fixation of pelvic disruptions,
anatomical studies of such injuries are lacking. Of 150
consecutive victims of multiple trauma examined at au
topsy, forty.seven (31 per cent) were found to have a
pelvic injury. Twenty-six of the thirty-two cadavera
that were examined radiographically and dissected had
a double break in the pelvic ring (Malgaigne pattern).
An anatomical classification based on the degree of pos
tenor injury to the ring is proposed. Anatomical re
duction of the posterior fracture-dislocation
by exter
nal manipulation was impossible in the majority of
cadavera because of either ligamentous or osseous in
terposition, or both, in the sacro-iliac joint, or because
of triplane displacement of the hemipelvis.
Pelvic fractures
M.D.*,
have
Sci
pelvic
of
injuries5'13'15'7.
The theoretical advantages of early mobilization of
the patient with pelvic injuries have been realized, but
success in attaining satisfactory reduction of the pelvic
fracture-dislocation
has been variable. Karaharju and
Slätis,and Grosse, reported ‘¿
‘¿good'
‘¿
reductions but they
did not define their results clearly. Johnston, as well as
Riska et al. , recognized the inherent difficulties of obtain
ing and holding anatomical reduction of an unstable Mal
gaigne fracture-dislocation by closed manipulation and cx
ternal fixation,
series. Interest
these displaced
some
and noted only “¿fair―
reductions in their
in open reduction and internal fixation of
fractures therefore has been revived by
The accuracy
of reduction
of major fracture
dislocations of the hemipelvis appears to be of central im
portance in the avoidance of late disability from these in
juries. If reduction with external or internal fixation is to
be successful, a thorough understanding of the pathologi
cal anatomy of the injury is imperative . The purpose of
this study was to analyze the anatomical and radiographic
patterns of Malgaigne fracture-dislocations
of the pelvis.
Methods
One hundred and fifty consecutive victims of fatal
motor-vehicle accidents were examined at the time of
medicolegal autopsy at the Dallas County Medical Exam
iner's Office. Only victims who had died at the scene of
the accident or in an emergency room prior to any diag
nostic procedures were included. Details of the accident
were available in all cases.
A complete autopsy, including evisceration of all
pelvic organs, was performed. Pelvic fracture-dislocations
were identified on examination by compression and dis
traction of the pelvis in all planes to elicit motion, and by
intrapelvic palpation of the superior pubic ramus and pos
terior aspects of the pelvic ring to localize defects . An an
teroposterior radiograph of the pelvis was made in approx
imately two-thirds of the cadavera.
In those cadavera in which pelvic injury was iden
tified, the osseous and ligamentous structures were care
fully dissected to delineate the pathological anatomy.
Based on my availability at the time of autopsy, thirty-two
of the forty-seven injured pelves were completely dissec
ted and the anatomical findings were correlated with the
radiographs. A separate posterior incision was used in
THE JOURNAL
OF BONE AND JOINT SURGERY
PATHOLOGICAL
ANATOMY
OF MALGAIGNE
401
FRACTURE-DISLOCATIONS
FIG. 1
FIG. 2
Fig. 1: Radiographically,
Group-I injuries show only anterior disruption of the pelvic ring but on dissection all have either a non-displaced vertical
fracture of the sacrum or slight tearing of the anterior sacro-iliac ligament.
Fig. 2: In addition to anterior injury to the pelvic ring, Group-I! injuries show complete tearing or avulsion ofthe anterior sacro-iliac ligament from the
sacrum, with sparing of the posterosuperior sacro-iliac ligament complex.
displaced hemipelvic injuries to properly visualize the pos
tenor aspect of the sacro-iliac joint. These thirty-two
pelves form the basis of the present study.
In all Malgaigne-type fractures , reduction was at
tempted under direct visualization. All autopsies were per
between the group with pelvic injury and the group with
out pelvic injury except for two areas. Rupture of the
formed
locations
within
eight hours of the time of death and in no
cadaver did the degree of rigor mortis appear to be an im
portant variable in preventing reduction. Longitudinal
traction with lateral compression or distraction of the iliac
thoracic aorta occurred in 45 per cent (twenty-one)
of the
group with pelvic injury but in only 15 per cent (fifteen of
103) of the group without pelvic injury. Fractures and dis
of the extremities
also were more common
in as
sociation with the pelvic injuries (8 1 per cent versus 36 per
If these maneuvers
were un
cent in the cadavera without pelvic injury). The higher in
cidence of both of these associated
findings may merely
reflect the greater number of pedestrian
victims of au
successful in securing an anatomical reduction,
reduction
tomobile accidents and the frequent crushing mechanism
crests was applied
was attempted
manually.
by direct manipulation
of the pelvis
at the
site of the fracture. The accuracy of reduction as judged by
complete visualization
of the posterior aspect of the pelvis
was correlated with the various anatomical patterns of in
jury.
of the 150 multiple-trauma
pelvic fractures
victims had
or dislocations,
or both.
The victims' ages ranged from twelve to eighty-five years
and averaged thirty-four years. Male cadavera outnum
bered female cadavera by 2.3 to 1. Statistically there was
no significant difference in age or sex distribution between
the group with pelvic injury and the group without pelvic
injury.
Of the 150 victims, ninety-three (62 per cent) were
drivers or passengers of an automobile,
thirty-four (23 per
cent) were pedestrians who were struck by an automobile,
and twenty-three ( 15 per cent) were motorcyclists . The
subgroup of forty-seven victims with pelvic injuries in
cluded a larger percentage of pedestrian victims of au
tomobile accidents: 60 per cent (twenty-eight) were driv
ers or passengers,
declared
34 per cent (sixteen)
were pedestrians,
and 6 per cent (three) were motorcyclists . Nearly one-half
(sixteen of thirty-four) of all pedestrian victims had pelvic
fractures.
The complete autopsy revealed no statistically sig
nificant differences in the frequency of associated injuries
VOL. 63-A, NO. 3, MARCH 1981
injury.
by the medical
examiner
to be the sole cause of
death. Forty-five per cent of the entire series of multiple
trauma victims had positive levels of blood alcohol, most
Anatomical
General Findings
Forty-seven
with pelvic
In no cadaver was hemorrhage from the pelvic injury
of which were above the legal level of intoxication.
Results
either detectable
of injury found in the group
Findings
Of the thirty-two dissected cadavera, twenty-two had
a unilateral double vertical break (Malgaigne pattern) in
jury to the pelvic ring, while four fractures were bilateral.
The other six pelvic injuries included two so-called strad
die fractures (bilateral fracture of the superior and inferior
pubic rami) , two unilateral
the acetabulum,
of the
central
fracture-dislocations
of
one bilateral central fracture-dislocation
acetabulum,
and
one
unilateral
fracture
of the
superior and inferior pubic rami. The thirty Malgaigne
pattern injuries (twenty-two unilateral and four bilateral)
could be classified
into three distinct
anatomical
groups.
Group I (fourteen cadavera): Radiographically these
cadavera showed anterior injury only to the pelvic ring but
on dissection all had either a non-displaced vertical frac
ture of the sacrum or slight tearing of the anterior sacro
iliac ligament (Fig . 1).
Group II (five cadavera): In addition to anterior in
jury to the pelvic ring, there was radiographic
evidence of
partial disruption of the sacro-iliac joint. Dissection dem
onstrated complete tearing or avulsion of the anterior
sacro-iliac ligament from the sacrum, with sparing of the
402
R. W.
BUCHOLZ
Axial view
FIG. 3-A
FIG. 3-B
Figs. 3-A and 3-B: Group-Ill injuries.
Fig. 3-A: Complete disruption of all sacro-iliac ligaments allowed triplane displacement of the hemipelvis
radiograph shows superior displacement.
Fig. 3-B: The axial radiograph shows posterior and external rotation displacement of the hemipelvis.
posterosuperior
Group
sacro- iliac ligament complex (Fig . 2).
III (eleven
cadat'era):
Complete
disruption
definition of injuries to the lumbosacral
of
all sacro-iliac ligaments allowed triplane displacement of
the hemipelvis on the sacrum in these cadavera. The
hemipelvis most frequently was displaced cephalad, pos
teriorly, and in external rotation (Figs. 3-A and 3-B).
Anterior injury to the pelvic ring was quite variable.
There were twelve cases of bilateral fracture of either the
pubic or ischial ramus, or both; eight cases of unilateral
fracture of either the pubic or ischial ramus, or both; six,
of pure diastasis of the symphysis pubis; and four combi
nations of fracture and symphyseal disruption. Comminu
tion of the fractures was common.
Posterior injuries to the pelvic ring included nineteen
pure sacro-iliac disruptions, six sacral fractures, one verti
cal fracture of the ilium, and four fractures of the sacrum
or ilium with extension into the sacro-iliac joint. Ten of
the nineteen cadavera with sacro-iliac disruptions had
multiple avulsion fractures of the anterior surface of the
sacrum which was firmly attached to the anterior sacro
iliac ligament. In the other nine cadavera the anterior
sacro-iliac ligament was torn in its mid-portion. All poste
nor sacro-iliac ligaments were ruptured in the eleven
cadavera in Group III.
All but one of the six sacral fractures extended verti
cally through the sacral foramen.
Displacement of the fracture fragments was minimum
in the Group-I injuries. The anterior sacro-iliac ligament
most commonly was attenuated in its mid-portion but oc
casionally it was avulsed off the sacrum or ilium for sev
eral centimeters. Sacral fractures in the Group-I cadavera
were invariably
non-displaced
(Figs. 4-A and 4-B). In all
Group-Il cadavera, the hemipelvis was rotated externally
with the intact posterior sacro-iliac ligament acting as the
hinge of the so-called oyster shell. Although the triplane
displacement
of the Group-Ill
injuries was usually
cephalad, posterior, and in external rotation, the amount
of displacement in each plane varied (Figs. 5-A and 5-B).
Due to the autopsy
to evaluate
associated
technique
used, it was not possible
urological
injuries.
on the sacrum. The anteroposterior
Precise
was not feasible.
Hemorrhage
plexus similarly
at the sites of fracture
and
dislocation was more a function of the severity of as
sociated visceral injuries to the chest and abdomen than of
the degree of local pelvic trauma. The multiple-trauma
victims who died instantaneously often demonstrated mm
imum retroperitoneal hemorrhage despite severe pelvic
disruption.
Reduction of the posterior displacement of the pelvic
ring was attempted in all cadavera. Success in reducing a
given fracture-dislocation correlated well with its anatom
ical grouping. All Group-I injuries were basically non
displaced and showed no tendency to displace with axial or
posteriorly directed force applied to the hemipelvis. Two
of the five Group-I! injuries were reducible by lateral
compression to the iliac crest. In the other three Group-LI
injuries, anatomical reduction was prevented by in-folding
of the anterior sacro-iliac ligament or interposition of the
sacral avulsion fracture fragments into the sacro-iliac
joint. After excision of the ligament and avulsion fracture
fragments, reduction was attained easily.
Reduction by traction and external manipulation of
the pelvis was impossible in all eleven Group-Ill injuries.
Rupture
of the posterosuperior
sacro-iliac
ligament
corn
plex resulted in posterior displacement of the hemipelvis
with the cadaver lying supine. Cephalad and rotatory dis
placement were variable. By placing a bone hook into the
sciatic
notch
and
lifting
anteriorly,
reduction
of
the
hemipelvis could be approximated. Interposition of osse
ous and ligamentous tissue into the sacro-iliac joint, how
ever, prevented anatomical reduction. The undulations of
the opposing articular surface of the sacro-iliac joint were
not prominent
enough in any Group-Ill
pelvis to afford
stability once a reduction had been attained. Even when in
terposed ligaments and bone fragments were removed and
accurate reduction was possible,
ently stable.
no reduction was inher
Discussion
Pelvic fractures or dislocations
were sustained by 31
THE JOURNAL OF BONE AND JOINT SURGERY
PATHOLOGICAL
ANATOMY
OF MALGAIGNE
403
FRACTURE-DISLOCATIONS
FIG. 4-A
FIG. 4-B
Figs. 4-A and 4-B: Typical Group-I cadaver.
Fig. 4-A: Anteroposterior radiograph showing an apparent isolated straddle injury to the pelvis.
Fig. 4-B: Drawing of injuries detected at time of dissection, demonstrating the presence of a non-displaced
left in addition to the anterior pubic fractures.
vertical fracture of the sacrum on the
per cent of the victims of multiple trauma in this series.
juries
The actual incidence
of pelvic injuries may have been
slightly greater because of failure to detect minor pelvic
disruptions
by inspection
alone in the one-third
of the
cadavera that were not studied radiographically.
The high
frequency
of pelvic injury in pedestrian
victims of au
tomobile accidents corresponded
closely with the findings
The vast majority of cadavera with so-called straddle frac
of Garland et al. and of Braunstein et al. In contradistinc
the pelvic ring in truth had radiographically
tion to the conclusions
that Braunstein
et al . drew from
their series of 200 pedestrian victims of automobile
acci
dents, hemorrhage
from a pelvic injury was not found to
be the sole cause of death in any of the 150 cadavera in the
present study. Severe, fatal injuries to other organ systems
nor disruption.
Gertzbein and Chenoweth performed bone
scans on six patients with diagnosed isolated anterior frac
tures of the pelvic ring. All six demonstrated
increased up
take posteriorly
at sites of injury that were not evident
radiographically.
With a high level of suspicion by the cx
were
aminer
present
in all of the cadavera
in this
series.
The extent of pelvic injuries invariably has been un
derestimated
by radiographic
evaluation.
In their anatomi
cal study of injury to the hypogastric
artery secondary to
pelvic fracture, Huittinen and Slätis reported that twenty
six of their twenty-seven
cadavera had a Malgaigne pattern
of pelvic injury. Skeletal damage to the pelvic ring in their
series frequently
was found to far exceed the impression
gained from radiographs.
The sacral fractures
of the
Group-I cadavera in this series were radiographically
sub
tle (Figs. 4-A and 4-B), and the minimum sacro-iliac in
in this group
were radiographically
tures were found on dissection
ment of the pelvic ring also.
undetectable.
to have posterior
involve
In his classification of pelvic fractures into minor and
major patterns, Kane expressed his belief that many of the
presumed
posterior
stable,
minor
at the time
injuries
injuries
of physical
to the anterior
examination,
may be diagnosed
The anatomical
classification
aspect
of
occult poste
many
of these
clinically.
system of this study
reflects different stages of posterior disruption of the pcI
vic ring. Non-displaced
vertical fractures of the sacrum or
radiographically
undetectable
injuries
to the anterior
sacro-iliac ligaments were found in all Group-I cadavera.
Group-Il injuries represented
the classic so-called oyster
shell pelvis. The tenuous anterior sacro-iliac
ligaments
were completely
torn or avulsed from the sacrum, with
sparing of the more substantial posterosuperior
sacro-iliac
@i
FIG. 5-A
Figs. 5-A and 5-B: Typical Group-Ill
cadaver.
Fig. 5-A: Anteroposterior
showing
Fig. 5-B: On dissection,
orly,
superiorly,
radiograph
a left Malgaigne
FIG. 5-B
fracture-dislocation
and a right fracture
of the iliac crest.
all of the left sacro-iliac ligaments were shown to be disrupted and the left hemipelvis was found to be displaced posteri
and in slight
external
VOL. 63-A, NO. 3, MARCH 1981
rotation.
404
R. W. BUCHOLZ
ligament complex. The posterior ligaments acted as a ful
crum around which the hemipelvis rotated externally.
Complete ligament disruption with or without associated
fractures characterized the Group-Ill injuries.
Huittinen and Slätisrecorded twelve of twenty-six
Malgaigne fracture-dislocations
as unstable in their series.
However, they did not provide a specific anatomical
definition of pelvic stability. Dommisse proposed that
three major anatomical factors are responsible for sacro
iliac stability. These included the concave-convex shape
of the opposing joint surfaces in every plane, the small an
terior shelf of bone on the ilium, and the posterosuperior
ligament complex . This study supports the proposal that
the posterosuperior
ligaments are the prime stabilizing
structure
of the joint.
When
these
thick
ligaments
are
compromised, the sacro-iliac joint is unstable in all planes.
The hemipelvis most frequently tends to displace posteri
orly due to its supine position, cephalad due to muscle
forces, and externally due to the transmitted forces of the
extended and externally rotated hips on the hemipelvis.
Closed reduction and external fixation quickly is be
coming the standard treatment of unstable Malgaigne
fracture-dislocations in many trauma centers. The goals of
treatment are rapid mobilization of the patient and im
proved maintenance of reduction over that possible with
traction and a pelvic sling. This study suggests that reduc
tions rarely are anatomical unless the injury is minimally
displaced on presentation. Osseous or higamentous inter
position in the sacro-iliac joint, as hypothesized by
Holdsworth
and shown
in this study,
often
may be re
sponsible for an imperfect reduction. More important,
however, is the failure to correct the triplane displacement
in the unstable Group-Ill injuries. Three threaded pins into
each iliac crest are most frequently used for the mainte
nance of reduction with external fixation. With the loss of
all inherent stability of the sacro-iliac joint in the Group-Ill
dislocations , the adequacy of purchase on the hemipelvis
to maintain a reduction in all planes is doubtful. Gunter
berg et al. assumed a perfect anatomical reduction in their
biomechanical loading of cadaver pelves with external
fixation applied. Application of their data to clinical in
juries with comminuted fractures and deficient reductions
therefore should be done with caution.
External fixation of a Malgaigne fracture-dislocation
generally does permit rapid, comfortable mobilization of
the patient. Given the current state of the technique, its
other theoretical benefits , including the restoration and
maintenance of pelvic alignment, are yet to be realized.
References
1. BRAUNSTEIN, P. W.; SKUDDER, P. A.; MCCARROLL, J. R.; MUSOLINO, ANTHONY; and WADE, P. A.: Concealed Hemorrhage due to Pelvic
Fracture. J. Trauma, 4: 832-838, 1964.
2. DOMMISSE,G. F.: Diametric Fractures of the Pelvis. J. Bone and Joint Surg. , 42.B(3): 432-443, 1960.
3. GARLAND, D. E.; GLOGOVAC, S. V.; and WATERS, R. L.: Orthopedic Aspects of Pedestrian Victims of Automobile Accidents. Orthopedics, 2:
242-244, 1979.
4. GERTZBEIN,S. D., and CHENOWETH,D. R.: Occult Injuries of the Pelvic Ring. Clin. Orthop., 128: 202-207, 1977.
5. GROSSE, ARSENE:Stabilization of Pelvic Fractures with Hoffmann External Fixation: The French Experience. In External Fixation: The Current
State of the Art, pp. 123-132. Edited by A. F. Brooker and C. C. Edwards. Baltimore, Williams and Wilkins, 1979.
6. GUNTERBERG,BJöRN;GOLDIE, IAN; and SLATIS,PAR: Fixation of Pelvic Fractures and Dislocations. An Experimental Study on the Loading of
Pelvic Fractures and Sacro-Iliac Dislocation after External Compression Fixation. Acta Orthop. Scandinavtca, 49: 278-286, 1978.
7. HOLDSWORTH,F. W.: Dislocation and Fracture-Dislocation
of the Pelvis. J. Bone and Joint Surg. , 30-B(3): 461-466, 1948.
8. HUITTINEN, V.-M., and SLATIS, PAR: Postmortem Angiography and Dissection of the Hypogastric Artery in Pelvic Fractures. Surgery, 73:
454-462, 1973.
9. HUNDLEY, J . M.: Ununited Unstable Fractures of the Pelvis. In Proceedings of The American Academy of Orthopaedic Surgeons. J. Bone and
Joint Surg. , 48-A: 1025, July 1966.
10. JENKINS,D. H. R., and YOUNG, M. H.: The Operative Treatment ofSacro-Iliac Subluxation and Disruption ofthe Symphysis Pubis. Injury, 10:
139-141, 1978.
11. JOHNSTON, RENNER: Stabilization of Pelvic Fractures with Hoffmann External Fixation: The Colorado Experience. In External Fixation: The
Current State of the Art, pp. 133-150. Edited by A. F. Brooker and C. C. Edwards. Baltimore, Williams and Wilkins, 1979.
12. KANE, W. J.: Fractures ofthe Pelvis. In Fractures, pp. 905-1011. Editedby C. A. Rockwood, Jr., and D. P. Green. Philadelphia, J. B. Lippin
coft, 1975.
13. KARAHARJU, E. 0., and SLATIS, PAR: External Fixation of Double Vertical Pelvic Fractures with a Trapezoid Compression Frame. Injury, 10:
142-145, 1978.
14. MALGAIGNE, J. F.: A Treatise on Fractures. Philadelphia, J. B. Lippincott, 1859.
15. MEARS, D. C.: The Management of Complex Pelvic Fractures. In External Fixation: The Current State of the Art, pp. 151-177. Edited
Brooker and C. C. Edwards. Baltimore, Williams and Wilkins, 1979.
16. MULLER, JOHANNES;BACHMANN,BRUNO; and BERG, HOWARD:Malgaigne Fracture of the Pelvis: Treatment with Percutaneous Pin
Report of Two Cases. J. Bone and Joint Surg. , 60-A: 992-993, Oct. 1978.
17. RISKA, E. B.; VON BONSDORFF,HENRIK; HAKKINEN, SIRKKA;JAROMA,HEIKKI; KIVILUOTO, OLLI; and PAAVILAINEN, TIM0: External
of Unstable Pelvic Fractures [abstract]. Acta Orthop. Scandinavica, 50: 362, 1979.
18. SLATIS, P., and HUITTINEN, V.-M.: Double Vertical Fractures of the Pelvis. A Report on 163 Patients. Acta Chir. Scandinavica, 138:
by A. F.
Fixation.
Fixation
799-807,
1972.
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