Transcript Pelvic Fractures 2nd Northern Trauma Network Conference

Pelvic Fractures
2nd Northern Trauma
Network Conference
P Fearon
Consultant Orthopaedic Trauma Surgeon - RVI
Overview
• Identify the priorities of life saving, limb
saving, and disability-limiting surgery
• Outline the general and local factors affecting
decision-making
• Importance of teamwork
• Orthopedic and trauma surgeons naturally
concentrate on the fracture
• It is vital to realise that there are other factors
that may dominate decision making in the
management of a particular fracture
Injury
Patient
Care team
Resources
Injury
• Fracture
• Vascular injury
• Compartment syndrome
• Open wound
• Crush injury
• Nerves
Care Team
• Surgeon
• Assistants
• Anesthesia
• Other specialties
• OR nurses
• Postoperative
• Rehabilitation
• Social supports
Patient
• Previous Condition
• Age (physiologic)
• Diagnoses
• Medications!
• Other injuries
• Physiologic response
• Expectations/needs
Resources
• OR
• Instruments
• Implants
• Imaging
• ICU
• (Other Patients)
Classification systems
Survivors
Non-survivors
Non-survivors
Early Death
Haemorrhage
Brain injury
Late Death
Sepsis
MOF
Bleeding
# bones, venous plexus, arterial injury, extra-pelvic sources
Survivors
•
•
•
•
•
•
•
Mental health problems
Chronic pain
Pelvic obliquity
Leg length discrepancy
Gait abnormalities
Sexual & urological dysfunction
Long term unemployment
Pre-Hospital
• Goals:– Early suspicion
– Identification – no need to spring/log roll
– Management
Pelvic immobilisation should be routine
MOI
Symptoms
Clinical findings
– deformity, bruising or swelling over the bony prominences, pubis, perineum or
scrotum.
– Leg length discrepancy or rotational deformity of a lower limb (without fracture
in that extremity) may be evident.
– Wounds over the pelvis or bleeding from the patient's rectum, vagina or urethra
may indicate an open pelvic fracture.
– Neurological abnormalities may also rarely be present in the lower limbs after a
pelvic fracture.
Ease of application
Access for intervention
Shown just as good as external fixators
• Prevent re-injury from pelvic motion (clot
disruption)
• Tamponade bleeding pelvic bones & vessels
• Decrease pain
• Decrease pelvic volume (lesser)
ED
• Resuscitation / Management
• MHP
• WBCT – trauma series
– TEAM
– TEAM
TEAM TEAM
Illustrated case
•
•
•
•
•
•
•
29 yr female
Motor cyclist
GCS 14/15
BP 90/40
Hr 110
PV bleeding
Binder applied
Pathway
• Resuscitation on going
via CT scanner
All bets off!
Team Huddle – Senior Decision making
Modify Plan
• Aorta stented
• Evaluation of coeliac
– Common hepatic
– Left hepatic
• Both internal iliac
– Left pudendal branch
embolised (anterior
division of internal iliac)
•
•
•
•
•
•
•
•
•
•
•
•
•
Prehospital
ED
ITU & anaesthetics
Ortho
Gen Surg
HBP
CT/radiology
Interventional radiology
Urology
Rehab
Pain team
Sexual dysfunction clinic
Clinical psychology
Holistic Approach
Improve disability
How much blood loss from pelvic #?
• WBV
– (true pelvic vol 1.5L, but ↑ with disruption)
– Retroperitoneal space 5L
– Loose tamponade effect/disruption parapelvic
fascia
– Escape into peritoneum & thighs
? Arterial Bleeding
• MOI
Head on collisions
Jumpers
•
•
•
•
Open fractures
Elderly patients (gluteal injuries)
Sacrum/SIJ, symphyseal separation–gluteal, pudendal
CT scan – vascular blush/large haematoma≡sig bleed
Binder
MHP
Trauma CT
Urology
Coordinated
Team
Approach
Surgery
Pelvic fixation
Holistic Rehab
• Isolated haemodynamically unstable pelvic
trauma uncommon
– Associated injuries due to high MOI
• Resuscitation/intervention team based with
better understanding & cooperative team
working
– surgeons included
Thank you