Pelvic Fractures and Associated Injuries Dr Huw Williams MB BCh MCEM.

Pelvic Fractures and

Associated InjuriesDr Huw Williams MB BCh MCEM

1o Survey A

B

C

D

E

2o Survey

3o Survey

Pelvic Injuries in Trauma

Pelvic Anatomy

1. Sacrum

2. Innominate bones

3. Ligamentous complex

Pelvic Anatomy

Pelvic # in approx. 9% of all major traumas

All age mortality rate = 5-to-16%

Age > 65 years mortality rate = 20%

Some mortality quotes up to 45% ?

Pelvic Fractures in Trauma

Pelvic # in approx. 9% of all major traumas

All age mortality rate = 5-to-16%

Age > 65 years mortality rate = 20%

Some mortality quotes up to 45% ?

What does this mean?

? isolated pelvic injury (without an abdominal injury)

Pelvic #s = increased risk of death

Pelvic Fractures in Trauma

Where can we bleed from?

Where can we bleed from?

1. Pelvic venous plexus

2. Pelvic arterial injury

3. Fracture bone surfaces

4. Any visceral injury

Remember: extra-pelvic injuries

How much blood can we lose into our pelvis ?

1 litre ?

2 litres ?

3 litres ?

4 litres ?

5 litres ?

How much blood can we lose into our pelvis ?

‘Haemorrhage from pelvic fracture is essentially bleeding into a free space, potentially capable of accommodating the patient’s entire blood volume without gaining sufficient pressure-dependent tamponade’

(Suzuki et al., 2008)

Mechanism of Injury and Classification

Three mechanisms

i. AP Compression Injury

ii. Lateral Compression Injury

iii. A Shear Force Injury

Mechanism of Injury and Classification

Three mechanisms four patterns



iii. A Shear Force Injury

iv. A Combination

How:

RTC (car vs. peadestrian / motor-cycle crash)

direct crush injury

fall (>12ft)


How:

RTC (car vs. peadestrian / motor-cycle crash)

direct crush injury

fall (>12ft)

What Happens:

symphysis pubis brakes

tearing of posterior ligamentous complex

(may rupture venous plexus / internal iliac artery)

AP Compression (‘open book pelvis’)Frequency = 15 to 20 %


How:

RTC (motor-cycle crash)

Direct compression / crush


How:

RTC (motor-cycle crash)

Direct compression / crush

What Happens:

internal rotation of hemi-pelvis

fractures around pubis

genitourinary system injury

(life threatening haemorrhage is less common)

Lateral Compression (‘closed pelvis’)Frequency = 60 to 70 %


How:

falling from a height onto one limb

RTC

iii. Shear Force Injury

How:

falling from a height onto one limb

RTC

What Happens:

high-energy applied in a vertical plane

major instability of pelvisVertical Shear

Frequency = 5 to 15%

iii. Shear Force Injury

Tile Classification

Young Classification

Ross Classification

iv. Combination

iv. Combination


? major haemorrhage of the venous plexus / internal iliac artery

ii. Lateral Compression

injury to bladder/urethra/other / ↓ pelvic volume therefore ? ↓ haemorrhage

iii. A Shear Force

high-energy / major instability

Assessing the Pelvis

‘Springing the Pelvis’

‘Springing the Pelvis’


Direct Peritoneal Lavage


PR for ? high-riding prostate


Inspect flanks, scrotum, peri-anal area ?blood at meatus / ?swelling / ?bruising / ?deep laceration

Major disruption

Leg length discrepancy

Distending Abdomen

Signs


Tachycardia

Hypotension

Abdominal Pain

Pelvic Pain

Symptoms


Plain film PXR BONE

eFAST BLOOD

CT BONE / BLOOD

Angiography / CT angiography BLOOD

Imaging


AP Compression Injury

Lat. Compression Injury

A Shear Force Injury

A Combination

Normal

PELVIC X-RAY PLAIN FILM

-VE FAST

FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA

+VE FAST

FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA

Plain film CT Scan CT 3D reconstruction

CT

Angiography / CT Angiography

Managing the Pelvis in the ED

Sheet

Pelvic binders / splints

? Bend knees & tie ankles (internal rotation)

Scoops (not boards)

Large IV lines / ?permissive hypotensive

resuscitation / ? haemorrhage protocol

Definitive Management of the Pelvis

Surgery stem bleeding / fix pelvis / pack pelvis

Angiography plus iatrogenic embolization

Conclusion

Assume there is not a isolated pelvic injury

Assume the worst

Early intervention / minimal pelvis movement once splinted

Thankyou

Any Questions?

1. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36:1.

2. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 2005; 87:2.

3. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005; 190:830.

4. Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008; 64:449.

5. Cannada LK, Taylor RM, Reddix R, et al. The Jones-Powell Classification of open pelvic fractures:. J Trauma Acute Care Surg 2013; 74:901.

6. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 2007; 63:875.

7. Dechert TA, Duane TM, Frykberg BP, et al. Elderly patients with pelvic fracture: interventions and outcomes. Am Surg 2009; 75:291.

8. Sathy AK, Starr AJ, Smith WR, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am 2009; 91:2803.

9. Schulman JE, O'Toole RV, Castillo RC, et al. Pelvic ring fractures are an independent risk factor for death after blunt trauma. J Trauma 2010; 68:930.

10.Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002; 195:1.

References

Pelvic Fractures and Associated Injuries Dr Huw Williams MB BCh MCEM.

Documents

Transcript of Pelvic Fractures and Associated Injuries Dr Huw Williams MB BCh MCEM.