Transcript Pelvic Fractures

Presented By:
Fadel Naim M.D.
Orthopedic Surgeon
Faculty of Medicine
IUG
 Only 3-8% of all fractures
 Occurs in 25% of multiply injured
patient
 Associated blunt, soft-tissue injury
 Mortality as high as 20%-25%
 Open pelvic fracture = 30-50%
mortality
1. Vectors of injury
Lateral compression
AP-direction
Vertical shear
 2.Young and Burgess’s classification
scheme—prediction of pelvic fracture related
hemorrhage
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Primary Survey
 Airway Maintenance with cervical spine
protection
 Breathing and Ventilation
 Circulation with hemorrhage control
 Disability: Neurologic status
 Exposure/Environment Control: Undress patient
but prevent hypothermia
 Intravenous lines
 Crystalloid Solution
 Blood Administration
▪ 50-69% of unstable pelvic fractures
require 4 or more units of blood
▪ 30-40% require 10 or more units
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Bimanual compression and distraction of the iliac
wings
 Assess for rotational stability
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Manual leg traction
 aids in determining vertical stability
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Rectal examination
 Palpate prostate – urethral injury
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Palpate sacrum
 assess for fracture
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Vaginal examination
 Bleeding or laceration indicate open
fractures
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Perineal skin evaluation
 Laceration may indicate open fracture;
 laceration may be caused by hyper-
abduction of the leg
Vascular
Neurologic
Visceral
4. Urologic
5. Rectal/Gastrointestinal
6. Gynecologic
7. Degloving - Moral-Lavalle
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Hemorrhage occurs in up to 75% of pelvic
fractures
Three source of bleeding
 Osseous
 Vascular
 Visceral
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Intra-abdominal source is present in 40% of
patients with pelvic fractures
Iliolumbar artery
Lateral sacral artery
 Internal iliac artery
 Internal pudendal
 Sacral venous plexus
 Superior gluteal artery
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 the most commonly injured vessel
 Major source of bleeding is the
venous plexus
 Retroperitoneal space holds up to 4
L of blood
 Arterial source of bleeding is
present in only10-15% of patients
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Fracture of sacrum or dislocation of SI joint
can lead to injury to lumbosacral plexus
L5 & S1, most common
L2 to S4 possible
 Amount of displacement more important
than location
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Blunt vs. impaled by bony spike
 Bladder/urethra
 Rectum
 Vagina
 Prostate
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15-17% of pelvic fractures
Scrotal/labial swelling
Urethral 15% of men
 Urethral injury rare in women
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Indicators:
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Blood in meatus
High-riding prostate
Straddle-type fracture
Retrograde Urethrogram
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Blood on external meatus
Distended bladder
Inability to void
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Occurs in less than 1%
Laceration of rectum
or perforation of small
and/or large bowel
Rectal tears
accompany perineal
wounds
Requires diverting
colostomy
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Laceration of the vagina
 Results from dislocation or fractures of the pubic
rami
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Large laceration may involve perineum and
rectum
Inferior rami fracture that causes
impingement may require operative
intervention
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Closed degloving injury
 Greater trochanter
 pelvic and acetabular fx
 Shear injury
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Subcutaneus tissue torn
Cavity of hematoma/liquefied fat
Not initially apparent/overlooked
Infected in 1/3 of cases
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Causes of bleeding/hypovolemia:
1. Hemothorax
2. Intrabdominal injury
3. Intracranial/Spinal injury
4. Closed/Open fractures
5. Coagulopathies (hypothermia, low calcium,
acidosis)
6. PELVIC FRACTURE
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Intra-abdominal Bleeding
Assess:
 Abdominal CT Scan
 Peritoneal Lavage
 Ultrasound
 Pelvis
▪ AP Pelvis
 Physical exam
 Pelvic CT Scan
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AP pelvis can identify 90% of pelvic injuries
 It can guide the surgeon to additional imaging
needs, such as CT scan
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AP pelvis during early phase of resuscitation
is useful to determine presence or absence of
unstable pelvic fracture
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Inlet View
 45 degree caudal tilt
 True AP projection of the pelvic brim
 Evaluates for posterior displacement
 Evaluates for rotation of ilium and sacral impaction
injuries
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Outlet View
 45 degree cephalad tilt
 Evaluates for vertical shift of pelvis
 Visualizes Sacral foramen
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Best visualization for Sacrum
and SI joint
Rotational and posterior
displacement can be easily
assessed
3-D reconstruction may be
helpful in determining overall
displacement of the pelvic
fracture
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Useful in assessing and embolization of
arterial injury
Can determine patency of superior gluteal
artery for viability of large surgical exposures
Disadvantage:
 Source of arterial bleeding is identified in only 10-
15% of patients with severe pelvic disruption
 Does not address venous bleeding
High mortality rate (30% - 50%)
Potential for major vascular injury with
hemorrhage
 High incidence of associated
gastrointestinal and genitourinary injuries
 Diverting colostomy may be required
 Requires aggressive multidisciplinary
treatment
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Mechanical:
 Based on clinical examination and radiographs.
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Haemodynamic:
 Normal.
 Stable (maintaining P/BP/urine output by continuous
infusion of fluid = on-going bleeding somewhere).
 Unstable (failure to maintain P/BP/urine output
despite continuous infusion of fluid).
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Mechanically stable (usually lateral compression).
Haemodynamically stable.
No emergency treatment for pelvic lesion.
Obtain CT scan.
Mechanically unstable
Haemodynamically stable.
No emergency treatment for pelvic
lesion.
 Careful haemodynamic monitoring.
 Obtain CT scan.
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Mechanically stable
Haemodynamically unstable.
Pelvis already closed/stable – no need for
emergency treatment for pelvic lesion.
Look for bleeding elsewhere (chest/abdomen).
If none found, consider:
 Angiography/embolisation.
 Laparotomy/pack pelvis.
Mechanically unstable
Haemodynamically unstable.
Look for bleeding elsewhere
(chest/abdomen).
 Reduce pelvic fracture and stabilise with
anterior external fixator or C-clamp.
 If laparotomy indicated, apply external
fixator BEFORE abdomen opened.
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 After external fixation, careful
haemodynamic monitoring.
 If continuing haemodynamic
instability:
 Angiography/embolisation
 Laparotomy/simple anterior plate
fixation/maintain external fixator/pack
pelvis.
Mechanically unstable
 Haemodynamically unstable.
 Patient in extremis.
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 Dying despite aggressive fluid resuscitation.
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Immediate operation required to save
life.
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Apply simple anterior external fixator or Cclamp.
Laparotomy and deal with any intraabdominal bleeding.
If still haemodynamically unstable, simple
anterior plate fixation/maintain external
fixator/pack pelvis.
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Stabilization of Pelvic Hemorrhage
Traction
Sheet/Pelvic Binder
Anti-shock Garment
Pelvic clamp/External fixator
Angiographic embolization
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Sheet
 Sheet can be
wrapped around
iliac wings and held
with towel-clamp
or knot
 Hips slightly
flexed and
internally rotated
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MAST (Military antishock trousers)
Uncommon
Limits access for examination
Decreases lung function
Can contribute to lower extremity
compartment syndrome
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Indicated in the unstable patient who does not
respond to initial fluid resuscitation
Stabilizes pelvis, preventing redisruption of Clot
? May decrease pelvic volume
Not adequate for posterior pelvic disruption
1. Advantages
 It helps tamponade bleeding from bone edges .
 Stabilizing the clots and the bone.
 Could be done in 20 min.
2. Disadvantages
 Can’t stop arterial bleeding. Delay the
embolization for ongoing arterial hemorrhage.
 Degrade the quality of CT and angio.
Applied to the posterior ilium in line with
sacrum
 Requires fluoroscopy and expertise
 Higher risk of iatrogenic injury
 Not available in many institutions
 Good for stabilizing posterior disruption
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 Anterior
 External fixator
 Plate fixation (ORIF)
 Posterior Iliosacral screw
 Plate fixation
 Combined
bed to chair mobilization
WBAT with support
serial xray after mobilization
 monitor for subsequent displacement
 posterior ring displacement > 1cm: STOP
WBAT
 Very unstable patients: require prolonged
immobility (poor results)
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