PELVIC FRACTURES Fractures of the adult pelvis, exclusive of the acetabulu, !e"erall# are either stable fractures resulti"! fro lo$%e"er!# traua, such as falls i" elderl# patie"ts, or fractures caused b# hi!h%e"er!# traua that result i" si!"ifica"t orbidit# a"d ortalit#& As is trueof fractures of other bo"es, lo$%e"er!# traua to the pelvis !e"erall# produces stable fractures that ca" be treated s#ptoaticall# $ith crutch% or $al'er%assisted abulatio" a"d that ca" be expected to heal u"eve"tfull# i" ost patie"ts& (i!h%e"er!# pelvic fractures ofte" are a"a!ed operativel#, $ith the treate"t ethod deteri"ed b# the de!ree of pelvic stabilit# reai"i"! after the i")ur#& This sectio" focuses o" these hi!h%e"er!# i")uries, their a"a!ee"t i" both the resuscitative a"d reco"structive phases, a"dtheir pote"tial coplicatio"s&(i!h%e"er!# pelvic fractures result ost coo"l# fro otor vehicle accide"ts, falls, otorc#cle accide"ts, autoobile%pedestria" e"cou"ters, a"d i"dustrial crush i")uries& The pote"tial coplicatio"s of hi!h%e"er!# pelvic fractures i"clude i")uries to the a)or vessels a"d "erves of the pelvis *Fi!& +,%,+- a"d the a)or viscera, such as the i"testi"es, the bladder, a"d the urethra& .e!lovi"! i")uries to the surrou"di"! soft tissues, both ope" a"d closed, also a# accopa"# these fractures a"d coplicate their treate"t& Reportedortalit# fro severe pelvic fracture ra"!es fro /01 to as hi!h as +01 i" soe earlier series of ope" pelvic fractures& 2illila"d et al& a"d others sho$ed that ris' factors for i"creased ortalit# i"clude the patie"t3s a!e a"d i")ur# severit# score, associated head or visceral i")ur#, blood loss, h#pote"sio", coa!ulopath#, a"d u"stable or ope" pelvic fractures& Earl# ortalit# ost coo"l# results fro heorrha!e or closed head i")ur#4late ortalit# occurs fro sepsis or ultiple s#ste or!a" failure&

Fig. 53-35I"ter"al iliac plexus of arteries a"d vei"s& (Redrawn from Tile R: Anatomy of the pelvic ring. In Tile M, Helfet DL, ellam !", ed#: "ract$re# of the pelvi# and aceta%$l$m, &rd ed, 'hiladelphia, ())&, Lippincott *illiam# + *il,in#.- Initial Management The acute a"a!ee"t of a patie"t $ith a pelvic fracture a"d u"rele"ti"! heorrha!e reai"s a challe"!e to the orthopaedic sur!eo"& A ultidiscipli"ar# approach $ith orthopaedic sur!eo"s, !e"eral sur!eo"s, a"d a"esthesiolo!ists is critical to optii5i"! outcoes& The i"itial traua $or'up, i"cludi"! CT sca" of the chest a"d abdoe", supraubilical perito"eal lava!e, a"d abdoi"al ultrasou"d, ust rule out other sources of bleedi"!& 6" reco!"itio" of a" u"stable pelvic ri"! i")ur#, $e routi"el# appl# a circufere"tial pelvic bi"der *Fi!& +,%,7-& First described i" the literature b# Routt et al&, the tech"i8ue e"copasses $rappi"! a bed sheet *or coerciall# available bi"der- arou"d the pelvis a"d !reater trocha"ters& After circufere"tial ti!hte"i"!, the sheet is claped& 9i"di"!, li'e exter"al fixatio", theoreticall# reduces pelvic volue, stabili5es ra$ fracture surfaces, a"d e"coura!es tapo"ade& :e prefer circufere"tial pelvic bi"di"! to exter"al fixatio" i" the acute resuscitatio" sta!e because of its ease a"d rapid"ess of applicatio"& 6"ce i" the co"trolled e"viro"e"t of the operati"! roo, a" exter"al fixator ca" be applied to ai"tai" stabilit# of the pelvis $hile allo$i"! access to the abdoe" a"d peri"eu& ;ore"o et al&, 9ur!ess et al&, a"d others "oted a reductio" i" the tra"sfusio" re8uiree"ts of patie"ts $ith u"stable pelvic fractures $ho $ere treated $ith iediate exter"al fixatio" copared $ith those $ho did "ot u"der!o iediate fixatio"& I")uries $ith si!"ifica"t posterior displacee"t a# be"efit fro a C%clap t#pe of exter"al fixator, ideall# applied i" the operati"! roo $he" the situatio" allo$s *see Tech"i8ue +,%,-&

Fig. 53-36A, I"itial a"teroposterior radio!raph of ope"%boo' pelvic fracture& B, After applicatio" of pelvic bi"der *C-& TECHNIQUE 53-3Ganz et al.

:ith the patie"t supi"e, palpate the posterior superior iliac spi"e a"d dra$ a" ia!i"ar# li"e bet$ee" it a"d the a"terior superior iliac spi"e& I"sert the "ail o" this li"e, approxiatel# , to < fi"!erbreadths a"terolateral to the posterior superior iliac spi"e *Fi!& +,%+0A

Fig. 53-50Applicatio" of 2a"5 fixator *see text-& A, =ail i"sertio" site& B, Stei"a"" pi"s are i"serted, a"d free slidi"! of side ar is e"sured& C, Pi"s are drive" approxiatel# / c i"to bo"e& , .rivi"! threaded bolts i"$ard applies copressio" to close diastasis a"d stabili5e posterior pelvic ri"!& E, Crossbarca" be rotated to allo$ laparoto# or access to proxial feur& (.o$rte#y of R. /an0, MD.- -& .o "ot a'e the e"tr# poi"t too distal to avoid e"da"!eri"! the !luteal vesselsor the sciatic "erve&

;a'e a !e"erous stab $ou"d over each e"tr# poi"t, i"sert the Stei"a"" pi"s, a"d a'e sure the side ar ca" slide freel# *Fi!& +,%+09-&

Adva"ce the pi"s u"til bo"e is co"tacted, a"d the" use a haer to drive the pi"s approxiatel# / c i"to the bo"e *Fi!& +,%+0C-&

Slide the t$o side ars ediall# to$ard o"e a"other u"til the e"ds of the threaded bolts, slidi"! over the pi"s, coe i"to co"tact $ith the bo"e&

.rive the threaded bolts i"$ard $ith a $re"ch to appl# copressio" to the u"stable heipelvis& This closes the diastasis a"d stabili5es the posterior pelvic ri"! *Fi!& +,%+0.-&

Correct cra"ial displacee"t of the heipelvis b# placi"! tractio" o" the ipsilateral le! before appl#i"! copressio"&

Correct dorsal displacee"t b# a"ual tractio" usi"! the T%ha"dle applied to a Scha"5 pi" placed i" the a"terior superior iliac spi"e& Carr# out other "ecessar# a"ipulatio"s i" a siilar a""er&

Chec' the reductio" a"euvers radio!raphicall#, or if other procedures are "ecessar# iediatel#, obtai" a radio!raph as soo" as possible&

The device ca" be applied i" a" obli8ue co"fi!uratio" b# placi"! the Stei"a"" pi" o" the side of the stable heipelvis i" the a"terior superior iliac spi"e& :he"the bolt is ti!hte"ed, o"e copo"e"t of the force vector o" the u"stable side is directed a"teriorl#, $hich helps reduce a posteriorl# displaced heipelvis&

6"ce the clap is i" place, additio"al dia!"ostic or therapeutic procedures ca" be perfored& If a laparoto# is re8uired, rotate the crossbar arou"d the fixed axis of the Stei"a"" pi"s a$a# fro the abdoe" so that it lies distall# o" the thi!hs& If a procedure o" the proxial feur is re8uired, rotate the crossbar cephalad so that it rests o" the abdoe" *Fi!& +,%+0E-&

Leave the clap i" place u"til defi"itive i"ter"al fixatio" ca" be perfored& 6"ce the posterior fracture has bee" exposed a"d reductio" claps or pi"s are i"place, reove the C%clap&

If heorrha!e is "ot co"trolled after applicatio" of the a"terior exter"al fixator or pelvic clap, a"!io!raphic evaluatio" is i"dicated& I" approxiatel# /01 of patie"ts, a a)or arterial i")ur# ca" be ide"tified a"d treated b# eboli5atio"& Althou!h it is "ot !e"erall# advocated i" this cou"tr#, Pohlea"" et al& recoe"ded retroperito"eal exploratio" a"d pac'i"! to co"trol bleedi"! i" these patie"ts&The patie"t $ith a pelvic ri"! i")ur#, persiste"t h#pote"sio" after circufere"tial pelvic bi"di"!, a"d "o other source of bleedi"! should be co"sidered for arterio!raph#& (eorrha!e fre8ue"tl# results fro fracture surfaces a"d sall vessels i" the retroperito"eu& 6"l# +1 to /01 of patie"ts $ith pelvic fractures bleed fro arterial sources ide"tified b# a"!io!raph# a"d are treated $ith eboli5atio"& (i!her rates of arterial bleedi"! i" the !eriatric populatio" have bee" "oted b# (e"r# et al& A" al!orith b# 639rie" a"d .ic'so" *Fi!& +,%,>- has bee" proposed4 ho$ever, the authors recoe"ded that each i"stitutio" develop its o$" protocol, depe"di"! o" resources a"d facilities& ;ore rece"tl#, Sith et al& reported retroperito"eal pac'i"! a"d exter"al fixatio" $ith earl# favorable results&

Fig. 53-3!I"itial evaluatio" a"d a"a!ee"t of patie"t $ith pelvic ri"! fracture& Protocols should be i"dividuali5ed accordi"! to resources a"d facilities& ("rom 123rien '!, Dic,#on ": 'elvic fract$re#: eval$ation and ac$te management. In Tornetta ' III, 3a$mgaertner M, ed#: 1rthopaedic ,nowledge $pdate, tra$ma &, Ro#emont, Ill, ())4, American Academy of 1rthopaedic 5$rgeon#.- 6pe" pelvic fractures are extreel# difficult i")uries to a"a!e, $ith reported ortalit# rates of up to +01& If the retroperito"eal space is ope", "o tapo"ade effect occurs to preve"t excessive bleedi"!& Sepsis caused b# fecal co"tai"atio" is a a)or cause of ortalit# $ith this i")ur#, a"d iediate diverti"! colosto# is i"dicated i" patie"ts $ithperi"eal $ou"ds& Fari"!er et al& a"atoicall# classified ope" pelvic $ou"ds i"to 5o"es a"d recoe"ded selective fecal diversio" for patie"ts $ith ope" $ou"ds i"volvi"! the rectu or a"us, soft%tissue $ou"ds close to the a"us, or lar!e avulsio" flaps $ith associated ischeic pelvic tissue *Fi!& +,%,?-&

Fig. 53-3"Three 5o"es of i")ur# that !uide decisio"s re!ardi"! "eed for colosto# i" ope" pelvic fractures, accordi"! to Fari"!er et al& @o"e I i")uries ofte" re8uire colosto#, $hereas diversio" is rarel# re8uired for 5o"e III $ou"ds& @o"e II i")uries are diverted selectivel#, $ith $ou"ds i"to subcuta"eous fat of a"terior !roi" or edial thi!h possibl# re8uiri"! colosto#& ("rom "aringer 'D, M$llin# R!, "eliciano 'D, et al: 5elective fecal diver#ion in comple6 open pelvic fract$re# from %l$nt tra$ma, Arch 5$rg 7(8:849, 788:.- Routi"e va!i"al a"d rectal exai"atio"s should be perfored i" patie"ts $ith ope" pelvicfractures because fracture fra!e"ts ca" pe"etrate these structures, $ith devastati"! co"se8ue"ces if tiel# a"d appropriate dAbridee"t is "ot perfored& Exter"al fixatio" ca" i"ii5e fracture otio" a"d further soft%tissue i")ur#&Anat#m$ 9uchol5, Pe""al et al&, Bou"! a"d 9ur!ess, a"d others have exte"sivel# evaluated the a"ato# a"d pathoecha"ics of pelvic ri"! disruptio"s, a"d their $or' has added !reatl# to our u"dersta"di"! of these i")uries& The pelvis is coposed a"teriorl# of the ri"! of thepubic a"d ischial rai co""ected $ith the s#ph#sis pubis& A fibrocartila!i"ous disc separates the t$o pubic bodies& Posteriorl#, the sacru a"d the t$o i""oi"ate bo"es are )oi"ed at the sacroiliac )oi"t b# the i"terosseous sacroiliac li!ae"ts, the a"terior a"d posterior sacroiliac li!ae"ts, the sacrotuberous li!ae"ts, the sacrospi"ous li!ae"ts, a"d the associated iliolubar li!ae"ts *Fi!& +,%,CA-& This li!ae"tous coplex provides stabilit# to the posterior sacroiliac coplex because the sacroiliac )oi"t itself has"o i"here"t bo"# stabilit#& Tile has copared this relatio"ship of the posterior pelvic li!ae"tous a"d bo"# structures to a suspe"sio" brid!e $ith the sacru suspe"ded bet$ee" the t$o posterior superior iliac spi"es *Fi!& +,%,C9-&

Fig. 53-3%A, ;a)or posterior stabili5i"! structures of pelvic ri"! *posterior a"d sa!ittal vie$s-& B, Tile copares relatio"ship of posterior pelvic li!ae"tous a"d bo"# structures to suspe"sio" brid!e, $ith sacru suspe"ded bet$ee" t$oposterior superior iliac spi"es& ("rom Tile M: Ac$te pelvic fract$re#. I. .a$#ation and cla##ification, ! Am A##oc 1rthop 5$rg ::7:&, 788;.- Pelvic stabilit# is deteri"ed b# li!ae"tous structures i" various pla"es& The priar# restrai"ts to exter"al rotatio" of the heipelvis are the li!ae"ts of the s#ph#sis, the sacrospi"ous li!ae"t, a"d the a"terior sacroiliac li!ae"t& Rotatio" i" the sa!ittal pla"e is resisted b# the sacrotuberous li!ae"t& Vertical displacee"t of the heipelvis is co"trolled b# all the e"tio"ed li!ae"tous structures, but if other li!ae"ts are abse"t, it a# be co"trolled b# i"tact i"terosseous sacroiliac a"d posterior sacroiliac li!ae"ts alo"! $ith the iliolubar li!ae"t& Fre8ue"tl#, a rotatio"all# u"stable heipelvis a# reai" verticall# stable because of these i"tact li!ae"tous structures& This has si!"ifica"t iplicatio"s i" classificatio", pro!"osis, a"d treate"t&Cla&&i'i(ati#n 9uchol5, i" a classic stud# of /+0 co"secutive victis of fatal otor vehicle accide"ts, fou"d pelvic fractures i" ,/1& (e separated the i"to three !roupsD !roup I had displaced a"terior ri"! i")uries $ith i"iall# displaced, stable sacral fractures or i"coplete teari"! of the a"terior sacroiliac li!ae"t4 !roup II had a"terior i")uries associated $ith a rotatio"al ope"i"! of the sacroiliac )oi"t $ith disruptio" of o"l# the a"terior sacroiliac li!ae"ts, spari"! the posterosuperior sacroiliac li!ae"t coplex4 a"d !roup III had coplete disruptio" of the a"terior a"d posterior heipelvis&Pe""al et al& developed a echa"istic classificatio" i" $hich pelvic fractures are described as a"terior%posterior copressio" i")uries, lateral copressio" i")uries, or vertical shear i")uries& Tile odified the Pe""al s#ste to a'e it a" alpha"ueric s#ste i"volvi"! three !roups based o" the co"cept of pelvic stabilit# *9ox +,%/-D A, stable4 9, rotatio"all# u"stable but verticall# stable4 a"d C, rotatio"all# a"d verticall# u"stable& This classificatio" is $idel# used i" the curre"t literature&B#) 53-*Cla&&i'i(ati#n #' +el,i( -ing .e&i#n& T$/e A0 1ta2le 3+#&te4i#4 A4(5 Inta(t6A/ Avulsio" i")ur#AE Iliac $i"! or a"terior arch fracture caused b# a direct blo$A, Tra"sverse sacrococc#!eal fractureT$/e B0 +a4tiall$ 1ta2le 3In(#m/lete i&47/ti#n #' +#&te4i#4 A4(569/ 6pe" boo' i")ur# *exter"al rotatio"-9E Lateral copressio" i")ur# *i"ter"al rotatio"-9E%/ Ipsilateral a"terior a"d posterior i")uries9E%E Co"tralateral *buc'et%ha"dle- i")uries9, 9ilateralT$/e C0 Un&ta2le 3C#m/lete i&47/ti#n #' +#&te4i#4 A4(56C/ U"ilateralC/%/ Iliac fractureC/%E Sacroiliac fracture%dislocatio"C/%, Sacral fractureCE 9ilateral, $ith o"e side t#pe 9, o"e side t#pe CC, 9ilateral"rom Tile M: Ac$te pelvic fract$re#. I. .a$#ation and cla##ification, ! Am A##oc 1rthop5$rg ::7:&, 788;.T#pe A *stable- fractures are further divided i"to three !roups& T#pe A/ fractures do "ot i"volve the pelvic ri"!, such as avulsio" fractures of the iliac spi"es or the ischial tuberosit# a"d isolated fractures of the iliac $i"!& T#pe AE fractures are stable fractures of the pelvic ri"! $ith i"ial displacee"t, such as coo"l# result fro lo$%e"er!# falls i" elderl# patie"ts& T#pe A, fractures are tra"sverse lesio"s of the sacru a"d cocc#x4 these are co"sidered spi"al i")uries rather tha" pelvic ri"! disruptio"s&T#pe 9 fractures are rotatio"all# u"stable& T#pe 9/ fractures i"clude Fope" boo'G fractures or a"terior copressio" i")uries i" $hich the a"terior pelvis ope"s throu!h a diastasis of the s#ph#sis or throu!h a fracture of the a"terior pelvic ri"! *Fi!& +,%