Initial Management of Pelvis Fractures - COA · Key Points •Three categories of pelvis fractures...
Transcript of Initial Management of Pelvis Fractures - COA · Key Points •Three categories of pelvis fractures...
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Initial Treatment of Pelvis Fractures
COAMonterey
June 1, 2014Michael Bellino
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Key Points
• Three categories of pelvis fractures
• Get involved
• Recognize injury patterns that require immediate treatment
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Elderly Low Energy
• Complete sacral fx with bilateral rami fx displaced 68%
• Incomplete sacral fx with ispilateral rami injury had no displacement
Bruce, et al, JOT 2011
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Non Structural Ring Disruption
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Structural Ring Disruption
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Pelvic Ring Injuries
• High Energy Injury
• High Rate
Associated Injury
• Life Threatening
– Mortality 6-12%
– < 4 hours injury
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Associated Injury
• Hemorrhage
• Neurologic
• Urologic
• Gynecologic
• Gastrointestinal
• Soft Tissue
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Associated Injury
• Hemorrhage
• Neurologic
• Urologic
• Gynecologic
• Gastrointestinal
• Soft Tissue
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Physical Exam - Skin
• Perineal Lacerations
• Scrotal/Labial Swelling
• Flank Ecchymosis
• Abrasions/crush
• Morel-Lavalle degloving
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Physical Exam - Skin
• Perineal Lacerations
• Scrotal/Labial Swelling
• Flank Ecchymosis
• Abrasions/crush
• Morel-Lavalle degloving
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Physical Exam - Provocative
• AP Compression
• Lateral
Compression
• One Positive
Exam Only!
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AP Pelvis
Provides the majority of information
Guides further studies
Essential in the initial evaluation of the trauma patient
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AP Pelvis
Provides the majority of information
Guides further studies
Essential in the initial evaluation of the trauma patient
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S1 body, sacral alaAnterior /posterior displacementAnterior ring morphologyHorizontal plane rotation
Inlet
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Sacral morphologySacral foraminaSI jointCranial displacement
Outlet
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Volume Rendered
Conventional Plain radiographs
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CT ScanConformation of plain film assessmentDetects posterior ring injury missed on plain filmEssential for pre-operative planning reduction and fixation
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CT Surfaced Rendered
Beware loss of subtle detail-computer averagingUtility as an overview, final confirmation
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Mechanism of Injury
Young-Burgess
• Anterior-Posterior Compression
• Lateral Compression
• Vertical Shear
• Combined Mechanical
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Young and Burgess:
Anterior Posterior Compression Injuries
APC-1 APC-2 APC-3
< 2 cm diastasis Anterior SI Joint
SS/ST Ligaments
Posterior SI Ligaments
No cephalad translation
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Young and Burgess:
Lateral Compression Injuries
LC-1 LC-2 LC-3
Anterior sacral
compression
Posterior
sacroiliac fracture
dislocation
Associated contralateral
SI joint ER injury
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Young and Burgess:
Vertical Shear Injury Patterns
• Cephalad or postero-cephalad migration
• Unstable
VS
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Letournel (Anatomical)
Posterior Pelvis
• Sacrum
• SI Joint
• Crescent
• Iliac
Acetabulum
Anterior Pelvis
• Ramus
• Pubic Symphysis
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Mechanism of Injury
• Acute Care
• Fracture Mechanism Correlates with:
– Blood Loss
– Associated Injuries
– Multisystem Morbidity
– Mortality
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Blood Replacement vs Mechanism
• Lateral Compression 3.6
• Combined Mechanical 8.5
• Vertical Shear 9.2
• AP Compression 14.8
Burgess et al, J
Trauma 1990
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Mortality
• APCIII 37%
• APC II 25%
• VS 25%
• LCIII 14%
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ASSOCIATED INJURIES
Lateral Compression:
• Abdominal visceral injury
• Head injury
• Few pelvic vascular injuries
AP Compression:
• Urologic injury
• Hemorrhage/pelvic vascular
injury:
APC2-10%, APC3-22%
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Hemodynamic Instability
• SBP < 90mmHg
• Unresponsive to fluids/blood
• Mortality: – Shock on admission associated with pelvic
fracture is the most reliable predictor of ISS, transfusion requirement and death (40%)
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Hemodynamic Instability
• Consider Other Bleeding Sources
• Intrathoracic / Intraperitoneal
• Open Fractures / Closed Fractures
• Retroperitoneal Bleeding
• Consider other causes of hypotension
• Cardiogenic
• Spinal shock
• Hypothermia
• Terminal brain injury
Correct Coagulopathy
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Sources of Pelvic Bleeding
• Fracture Surfaces
• Pre-Sacral Venous
Plexus
• Local Arterial Injury
• Major Vessel Injury
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Hemorrhage - Treatment
• Laparotomy with direct vessel ligation
• Laparotomy with retroperitoneal packing
• Pelvic Binder
• External Fixation/C-clamp
• Angiography/Embolization
• Acute ORIF pelvic ring
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External FixationTheories
• Decrease pelvic
volume
(Tamponade)
• Prevents gross
motion, clot
disruption
• Improves comfort
• Reduces cancellous
bony bleeding
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External FixationAdvantages
• Easy, rapid
application
• Useful in various
patterns of injury
• Can be
maintained for
extended time
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External FixationDisadvantages
• Induces additional
deformity
• Poor control of
posterior pelvic
ring
• Pin tract
infections
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External FixationDisadvantages
• Induces additional
deformity
• Poor control of
posterior pelvic
ring
• Pin tract
infections
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‘Posterior’ External Fixation
‘C-clamp’• posterior pins ilium
• rationale:
– Improved posterior
compression
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‘Posterior’ External Fixation
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‘Posterior’ External Fixation
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Pelvic Binder / Sheet
• Easily Applied during resuscitation
• Portable
• Versatile
• Convert to ExFix, ORIF
• May hide injuries– Skin/Bone
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Pelvic Sheet
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Traction
• Alone or in combination with anti-shock sheeting/ Ex Fix
• Particularly useful for vertical shear injuries
• Prevent ongoing neurologic injury
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Angiographic Embolization
• Nonresponders
• Persistent
Hypotension
– Fluid resuscitation
– Mechanical
Stabilization
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Open Fractures
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Open Pelvic FracturesMortality
• Literature 4.8% to 50%
• Hemorrhagic complications
– Ave 16 U acute resuscitation
– Ave 29 total transfusion req• Brenneman, et al, J Trauma 1997
• Septic complications
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Mortality
• 1972-1993, Hannover
• 1899 pelvic fxs, 1029
polytrauma
• Mortality 17.7%
• Open fxs 48% to 30%
Pohlemann et al, CORR
1994
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Treatment Algorithm
• Obtain appropriate radiographs
• Identify High-risk fracture patterns– Hemorrhage
– Associated Injuries
– Open fractures
• Identify High-risk patients– Shock
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Treatment Algorithm
• Apply binder
sheet during initial
resuscitation
• Exclude other
sources of
bleeding
• Consider
Angiography
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Thank You