Management of pelvic fractures: the first 24 hours.
Peter Worlock
Newcastle General Hospital
Objectives:
• Review assessment of pelvic injury.• Understand concept of different types of
‘stability’.• Management algorithm.
Diagnosis:
• Made during primary survey.• Airway with c-spine control.• Breathing (oxygen).• Circulation– IV access– Crystalloid– Control external loss– Look for major pelvic injury
Assess pelvis:
• History– Suspect in high energy injury
• Examination– External bruising/wounds (anterior/posterior)– Test for vertical/horizontal instability– Rectal examination– Vaginal examination
Radiographs:
• Every polytrauma patient should have– Lateral c-spine– Chest– AP Pelvis
• AP pelvis is done to detect major (and potentially life-threatening) pelvic injury.
Inlet view:
Patient flat on trolley.XR plate under pelvis.Direct XR beam at 60 degrees to plate.Effectively ‘transverse’ section through sacrum.Will show sacral #.Will show any posterior shift of hemi-pelvis.Will show internal/external rotation of hemi-pelvis.
Outlet view:
Patient flat on trolley.XR plate under pelvis.Direct XR beam at 45 degrees to plate.Effectively true AP view of sacrum.Will show vertical shift of hemi-pelvis.Will reveal any ‘bucket-handle’ injury.Will help in assessing leg length discrepancy.
Pelvic fracture classification: Type A.
Stable.Minimally displaced.Posterior arch intact.
Pelvic fracture classification: Type B.
Can be unstable.Incomplete disruption of posterior arch.Actual or potential horizontal translation.No vertical translation.
Pelvic fracture classification: Type C.
Unstable.Complete disruption of posterior arch.Actual or potential horizontal and vertical displacement.
Type B injuries:
• B1: open book injury (external rotation). Can be mechanically unstable.
• B2: lateral compression injury (internal rotation) - includes ipsilateral and contralateral (“bucket-handle”) types. Usually mechanically stable.
• B3: bilateral Type B injuries (includes “windswept” pelvis). External rotation injury can be mechanically unstable.
Type C injuries:
• C1: unilateral complete disruption of posterior arch.
• C2: unilateral complete disruption of one posterior arch, with incomplete disruption of contralateral posterior arch.
• C3: bilateral complete disruption of posterior arch.
• All are mechanically unstable.
Management of major pelvic fracture:
• You have to be an orthopaedic surgeon, a urologist, a vascular surgeon, a colo-rectal surgeon and (sometimes) a gynaecologist!
Initial management:
• Save life.• Do not do anything to compromise definitive
reconstruction.• Most important piece of equipment to
master?
The telephone!
Open pelvic fracture:
• Wound may be external, into rectum, into vagina or into bladder.
• ALL wounds must be explored, lavaged and debrided.
• Defunctioning colostomy if any large bowel communication with fracture, with washout of distal limb.
Urethral injury:
• Pass urethral catheter only if:– No blood at meatus– No scrotal/perineal haematoma– Normal rectal examination
• Urethrogram will define injury.• Suprapubic catheter will rapidly contaminate
tissues posterior to symphysis.
Urethral injury:
• Consider urgent transfer to pelvic fracture unit for combined pelvic/urethral reconstruction as emergency.
Nerve injury:
• Careful examination as soon as possible to detect any nerve damage.
• Document clearly.• Treat expectantly.• Lumbo-sacral plexus damaged in up to 45% of
Type C injuries.
Assessment of ‘stability’:
• Mechanical:– Based on clinical examination and radiographs.
• 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).
Type I injuries:
• Mechanically stable (usually Type B lateral compression).
• Haemodynamically stable.• No emergency treatment for pelvic lesion.• Obtain CT scan.• Liaise with pelvic fracture unit re definitive
management.
Type II injuries:
• Mechanically unstable (open book and Type C injuries).
• Haemodynamically stable.• No emergency treatment for pelvic lesion.• Careful haemodynamic monitoring.• Obtain CT scan.• Liaise with pelvic fracture unit re definitive
management.
Type III injuries:
• Mechanically stable (usually Type B lateral compression).
• 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.
Type IV injuries:
• Mechanically unstable (open book and Type C injuries).
• Haemodynamically unstable.• Look for bleeding elsewhere (chest/abdomen).• Reduce pelvic fracture and stabilise with
anterior external fixator or C-clamp.• If laparotomy indicated, you MUST apply
external fixator BEFORE abdomen opened.
Type IV injuries:
• After external fixation, careful haemodynamic monitoring.
• If continuing haemodynamic instability:– Angiography/embolisation (if skills rapidly
available).– Laparotomy/simple anterior plate
fixation/maintain external fixator/pack pelvis.
Type V injuries:
• Mechanically unstable (open book and Type C injuries).
• Haemodynamically unstable.• Patient in extremis. Dying in front of you
despite aggressive fluid resuscitation.• Immediate operation required to save life.
Type V injuries:
• Apply simple anterior external fixator or C-clamp.
• Laparotomy and deal with any intra-abdominal bleeding.
• If still haemodynamically unstable, perform simple anterior plate fixation/maintain external fixator/pack pelvis.
Pelvic injury with haemodynamic instability:
• Beware of “consumption coagulopathy”.• Secondary haemorrhage can be
uncontrollable.• Start aggressive replacement of clotting
factors/platelets/calcium early (after five units of blood).
• Obsessional monitoring of clotting status.
Definitive care:
• Posterior approach to sacrum may be compromised by de-gloving of skin.
• Anterior approach to SI joint compromised by external fixator pin wounds on iliac crest.
• Anterior approach to symphysis pubis compromised by ruptured viscus and intra-peritoneal contamination.
Definitive care:
• Anterior approach to symphysis pubis compromised by suprapubic catheter for >24 hours.
• When haemodynamically stable, start prophylaxis against DVT/PE.
• Transfer early – best results come if pelvis reconstructed within 5-10 days of injury.
Summary:
• All units receiving trauma must be able to save life in major pelvic injury.
• Haemodynamically stable or unstable?• Define # pattern on XR - mechanically stable
or unstable?• The only injuries that require you to operate
as emergency are those that are mechanically and haemodynamically unstable.
Summary:
• Detect all complications of the pelvic injury.• Definitive care:– Get it right first time.– Speak to your local pelvic fracture unit ASAP.– Do not compromise definitive reconstruction by
inappropriate early care.
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