Yoyos Dias Ismiarto, dr., SpOT(K), M.Kes, FICS., CCD.

Epidemiology•The overall incidence of pelvic ring

injuries is estimated at about 3% of all fractures (AO).– Among the polytrauma patients, the

incidence has risen to 25%.– Mortality is about 6 - 50%.– 39% due to bleeding (early).– 30% due to sepsis & multi-organ failure

(late).

Anatomy of PelvisPelvis contains one pair of fused bone

Each half contains: ilium, pubis, and ischium

Joined together in posterior by sacrum

Joined in anterior by symphysis pubis

Ilium

Sacrum

Male Pelvis Female Pelvis

Pubis

Ischium

Symphysis Pubis

Anatomy Around Pelvis Organs near pelvis

Parts of digestive systemReproductive organsBladder and urethra

Blood vessels run through and aroundRight and left iliac arteries from off aortaRight and left iliac veins returning from legsBlood vessels supplying pelvis and tissues

around pelvis

Function of PelvisPelvis bears weight of upper body

Balances weight for legs when standing

Protect blood vessels and organs

Also serves as connection point for numerous leg muscles

Common Fractures of PelvisPelvic ring fractures

Pelvic ring is likely to separate in more than one location

Iliac crest fracturesFractures to upper wing of

ilium

Pelvic FracturesCommon mechanisms of pelvic injury

result from high energyex. MVC, significant falls, skiing accident

Those at risk for pelvic fracturesGrowing teens (especially those involved in

sports)

Elderly patients (osteoporosis)

Risks of Pelvic FacturesIliac Crest fracture

Typically pelvis still stableLittle blood loss

Pelvic Ring fractureInternal organ damageSignificant blood loss (up to 4 liters)

• Hypovolemic shockUnstable pelvisRisk of death (Mortality of 3.4%-42%)

Pelvic Ring StabilityStability defined as patient ability to

support physiologic load

Physiologic load may be sitting, side lying, or standing, as dictated by patient needs else consider as unstable

Pelvic Ring StabilityPosterior ring integrity is important in

transferring load from torso to lower extremities

Pelvic Ring StabilityLoss of posterior ring integrity leads to

instabilityLoss of anterior ring integrity may contribute

to instability, and may be a marker to posterior ring injury

Young and burgess classification will guide us for stability issues

Young & Burgess Classification

PathologyThe poor prognosis of pelvic fractures Fracture and vascular injury can cause the

formation of hematoma in the pelvis and retroperitoneum 4 liters of blood

90% bleeding venous disruption or cancellous bone

10% bleeding an arterial injury

Assessment ATLS Approach Check Stability :

MechanicHaemodynamic

Assessment cont. Pelvis specific assessment

Check for bruising, deformity, or abrasions

Listen/Feel for crepitus Check limb length

Assessment cont. Check stability of pelvis (DON’T REPEAT)

1) Apply gentle medial pressure with palms by pressing inward on iliac crests

2) With patient supine, apply gentle posterior pressure by pressing downward on iliac crests

3) Apply gentle downward pressure on pubis to check pelvic ring stability

1) Medial pressure 2) Posterior iliac pressure 3) Posterior pubis pressure

Diagnosis1. General: abrasion, contusion, hematoma,

over bony prominence of pelvis, scrotal, vulvar hematoma.

2. PE3. X-ray4. FAST5. DPL6. CT

Radiographic Evaluation• X-Ray AP view:

– Anterior lesions: pubic rami fractures

– Symphysis displacement

– Sacroiliac joint and sacral fractures

– Iliac fractures– L5 transverse

process fractures

Radiographic Signs of Instability• Broken ‘Ring’• Symphysis gap > 2.5 cm• Sacroiliac displacement of 5 mm in any

plane.• Avulsion of the 5th lumbar transverse

process, the lateral border of the sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous ligament).

TreatmentTreat for life threatening injuriesTreat for possible shock

OxygenIntravenous infusion

Splinting / WrapPain controlRAPID TRANSPORT!!!

Palients with hemorrhagic shock and unstable pelvic fractures have four potential sources of bloodloss : (1) fractured bone surfaces(2) pelvic venous plexus(3) pelvic arterial injury, and(4) extrapelvic sources.

The pelvis should be temporarily stabilized or "closed" using an available commercial compression device or sheet to decrease bleeding.

• In the presence of unstable pelvic ring disruption and a positive abdominal study, stabilization of the pelvis should be undertaken before laparatomy.

• If hemodynamic stability is not achieved after placement of the external fixator, arteriography should then be performed.

Non-Operative Management(haemodinamically stable )

Lateral impaction type injuries with minimal (< 1.5 cm) displacement

Pubic rami fractures with no posterior displacement

Minimal gapping of pubic symphysis

Operative ManagementOperative

indications Pelvic unstable

symphysis diastasis > 2.5 cm SI joint displacement > 1 cmsacral fracture with displacement > 1 cmdisplacement or rotation of hemipelvisopen fracture

Hemodynamically unstable

Operative ManagementHemodynamically unstable

Reduce pelvic volume : promote blood clot as well as reducing blood volume from inside bleeding

TechniqueFirst aid : pelvic wrapNext : Ex fix/ C clamp

Haemodynamic StatusOptions for immediate hemorrhage control • Military antishock

trousers (MAST): Typically applied in the field.– No impact on survival

rate.– Severe complications

reported (compartment syndrome, extremity loss)

Haemodynamic StatusOptions for immediate hemorrhage control

Pelvic binder (pelvic wrap):

• This is wrapped circumferentially around the pelvis.

C-Clamp

Posterior ring structure is important

Goal : restoration of anatomy and enough stability to maintain reduction during healing

Anterior ring fixation may provide structural protection of posterior fixation

Operative Management

Anterior Fixation of Pelvic

Posterior Fixation of Pelvic

Haemodynamic StatusOptions for immediate hemorrhage control

•Anterior external fixator: – In the acute phase many

advocate external fixation as a temporary device to achieve stabilization of the fracture and a positive effect on haemorrhage.

External fixation1. AdvantagesIt helps tamponade bleeding from bone

edges .Stabilizing the clots and the bone.Could be done in 20 min.2. DisadvantagesCan’t stop arterial bleeding. Delay the

embolization for ongoing arterial hemorrhage.Degrade the quality of CT and angio.

Complications• Infection•Thromboembolism•Non-Union•Malunion

SummaryPelvic fracture High morbidity and mortality

Multiple trauma Team work (ATLS Approach)

Check stability (Mechanic and Haemodynamic)

Early immobilization Pelvic Wrap

Diagnostic tools

Definitive treatment