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Pelvic Fractures ICU Fellowship Training Radboudumc Classification Young-Burgess system • Three main patterns of injury AP compression Lateral compression Vertical shear AP compression • External rotation of one or both hemipelves • Iliac wings move outward - pubic diastasis • Associated injuries - sacroiliac joint diastasis and less commonly sacral fractures • Increased pelvic volume - spontaneous tamponade of hemorrhage unlikely AP compression • AC1 - pubic diastasis < 2.5 cm = stable • AC2 - pubic diastasis > 2.5 cm + anterior SIJ disruption = vertical stable but rotational unstable (classic open book) • AC3 - pubic diastasis > 2.5 cm + anterior and posterior SIJ disruption = vertical + rotational unstable S.J. Slater, D.A. Barron / European Journal of R AC2 fracture Fig. 4. AC type 2 fracture. Note pubic diastasis but intact posterior ligaments. This is an ‘open book’ fracture. Lateral compression • Most common type of pelvic fracture • Internal rotation of hemipelvis with coronal ramal fractures, contralateral SIJ disruption and central ace tabular fractures • High incidence of sacral fractures (80 - 90%) • Reduction in pelvic volume Lateral compression • LC 1 - Ipsilateral „buckle” sacral and coronal pubic rami fractures = stable • LC2 - LC1 + ipsilateral iliac wing # or posterior SIJ disruption = rotational unstable but vertical stable • LC3 - LC2 + external rotation of conttralateral hemipelvis ± contralateral saggital ramal fractures = rotational unstable but vertical stable s . - l - LC2 Fracture Right sided pubic rami # Ipsilateral sacral buckle # Vertical shear fractures • Vertically and rotationally unstable due to disruption of posterior ligaments • Vertical force is often the femur with ramal fractures anteriorly and ligamentous jury posteriorly • Hemipelvis shifted cranially • High rate of associated injuries to torso and spine and often hemodynamic instability re as in ly drs sk an 6% Vertical shear fracture Fig. 6. Vertical shear fracture. Vertically orientated pubic rami fractures and cranial Sacral fractures Is high rate of neurologic injury • Zone 1 - sacral ala lateral to sacral foramina (L5 nerve root impingement with 6% sustained injury) • Zone 2 - neuroforamina with unilateral sacral anesthesia (no involvement of central sacral canal) • Zone 3 - body of sacrum (up to 50% neurological compromise including cauda equina syndrome) high intensity 22 S.J. Slater, D.A. Barron / European Journal of Radiology 74 (2010) 16–23 of associate is low. The nerve root Rarely, t this involve and a trans ation. As a injury. In the pr picion for a identify mo tified on M 15. Conclu Pelvic fr associated early detec mistake in pelvic fract vides a relia unstable pa fracture. CT edge of pel and remin tions. Fig. 8. Coronal STIR sequence MRI. ‘Honda sign’ (arrows) demonstrating sa insufficiency fractures in an elderly female. Note the typical verticalReferences and horizo high intensity in the sacral ala bilaterally. Sacral fracture [1] American manual. 8 2008. [2] Hilty of associated neurological injury, whereas the risk below thisMP, le adiminish is low. These fractures can cause intraspinal and intraforami [3] Guillamo trauma r nerve root compromise (Fig. 7a and b). [4] Eastridge Rarely, there may be a U-shaped sacral fracture. Highlytherapeu unstab ring disru this involves longitudinal fractures through the foramina bilatera [6] Huber-W Fig. 7. (a and fracture in anfracture alcoholic man who subsequent sat down too hard! This andb) aSacral transverse with spino-pelvic disso trauma r low energy mechanism of injury raises concern for underlying osteopenia. These 2009;373 ation. As a result, there is a high rate of associated neurolog fractures can be difficult to detect on AP views, but this particular injury was more [7] Cerva Jr General management • Recognition of life-threatening injuries (ATLS) • Recognition of acute injuries • Fracture classification (suspicion for undetected injuries) Severe pelvic # in 80% associated with at least 2 other injuries CT-scan versus pelvic radiograph Multiple # pubic rami, sacrum and right femur Left epidural hematoma with intracranial air Complicated liver injury with active contrast extravasation 90% [7]. Three sources of bleeding are recognised in pelvic fractures, arterial, venous and bleeding from cancellous bone. Management of these different sources varies greatly. It is generally accepted that venous and cancellous bleeding is managed by initial stabilisation of the fracture to facilitate tamponade. In such cases, close monitoring is advised as young patients in particular can appear stable or metastable despite ongoing arterial haemorrhage. Arterial bleeds are commonly from the superior gluteal and the internal pudendal arteries. The greater sciatic foramen is a common exit pathway for many pelvic vessels and any fracture involving this area incurs a higher risk of bleeding. The superior gluteal artery is at risk of laceration from the sharp fascia of the piriformis muscle as it enters the greater sciatic foramen. The internal pudendal artery also exits the pelvis here but re-enters through the lesser sciatic foramen. It is injured in anterior–posterior compression fractures where there are inferior pubic rami fractures or fractures involving the lesser sciatic foramen. Therefore the fracture location can be used to predict which artery has been injured. Major risk - bleeding • Mortality up to 60% in case of haemodynamic instability • Bleeding: arterial, venous or from cancellous bone • Injured artery related to fracture site Most common Artery injured Fracture site Superior gluteal Greater sciatic foramen, ischial spine or tuberosity AP compression fracture involving lesser sciatic foramen, inferior pubic ramus Superior obturator foramen, superior pubic ramus, pubic acetabulum Acetabulum, injured posterior to inguinal canal Sacral foramina or posterior trans-sacral fracture Posterior fracture involving ilium or anterior SIJ’s Internal pudendal Obturator Femoral Lateral sacral Iliolumbar - a a Identifying other organ injuries earlyit Reducing the number of unnecessarya fo w th u 5. Vascular injuries In pelvic fractures, the most comm cation is bleeding. Where there is haem fractures are reported to have a high m (Fig. 2a–c). CT can quickly and accura absence of haemorrhage with an accur 90% [7]. Three sources of bleeding are reco arterial, venous and bleeding from can of these different sources varies greatly.fo venous and cancellous bleeding is man in of the fracture to facilitate tamponadeo [8 toring is advised as young patients in pp or metastable despite ongoing arterialv Arterial bleeds are commonly fromact internal pudendal arteries. The greaterin s exit pathway for many pelvic vessels ana q area incurs a higher risk of bleeding. Th at risk of laceration from the sharp fascire D it enters the greater sciatic foramen. Th ra also exits the pelvis here but re-entero Fig. 2. (a–c) Unstable pelvic fracture (a, arrows) with contrast extravasation on CT Arterial bleeding - therapy • Depends on several factors including associated injuries - hemodynamic instability - reaction to external fixation/pelvic packing • Angiography very effective (85 - 100%) in isolated injury when performed early • Proposed management algorithm should incorporate early CT scanning if possible e228 C. Arvieux et al. Anatomical and physiological fundamental and management principles Anatomy of pelvic and perineal injuries Vascular injuries The pelvis is characterized by its abundant and complex vascularization. Three potential bleeding sources (arterial, venous and cancellous bone) can co-exist to various degrees, which explain the magnitude and initial severity of bleeding in pelvic and perineal trauma (PPT). The quantity of blood loss depends equally on the mechanism of fracture according to Tile’s classification [2]: type C fractures (vertical shear) and type A (anteroposterior compression) injuries have the highest risk of severe bleeding. Other local and locoregional injuries Urinary tract and digestive tract lie in close proximity to bony structures [3], explaining the frequent association of bony and visceral injuries. The pelvic organs are contained within the rigid bowl of the bony pelvis: a pelvic fracture attests to high energy transfer and is frequently associated with distant injuries: severe pelvic fractures are associated with at least two other traumatic injuries in 80% of cases [4]. Moreover, neurologic structures that control the bladder and anal sphincters and sexual functions must be considered in management to minimize postoperative urinary and fecal incontinence and sexual disorders. Surgical access to the pelvis The pelvic cavity forms a truncated cone with potential access from above (abdominal) or below (perineal), but the narrowness of both accesses explains why hemostasis can be difficult and complex, and accounts for the surging popularity of containment strategies, pelvic packing and the predominant role of arterial embolization [5]. Physiological consequences of bleeding Figure 1. Technique of pelvic compression with a sheet wrap. e230 Figure 3. Ganz® pelvic clamp. Suicide attempt in an 18-year-old Figu Arthrodesis at day 30 via the ilioinguinal route. At 1 year, the patient walks without crutches but with a limp. urethrography urgent attent Digestive tr In the event o early infectio agate along t tissues. Such a tion which sh drainage and mary rectal in surgical mana (bony splinte fairly simply Here again, t tates the initi Patient w admission Figure 4. for Preperitoneal packing technique: presacral and Risk rectal ischemia and the necrosis paravesical spaces are tightly packed by inserting four to eight pads Definition Urological injury • Especially with separation of pubic symphysis or fractured pubic ramus • Usually extraperitoneal • Intraperitoneal with blunt trauma to a distended bladder • CT cystography Neurological injury • 10% following pelvic fractures • Bladder, bowel and erectile dysfunction • Transverse sacral # - intraspinal and intraforaminal nerve root injury • Greater sciatic notch # or posterior acetabulum # sciatic nerve injury C. Arvieux et al. Urethra injury 20 . Ganz® pelvic clamp. Suicide attempt in an 18-year-old who threw herself under a truck. Initial management confemoral traction, insertion of a Ganz® clamp, debridement nage of the perineal injury. Colostomy and transfer to Uniospital on day 5. Removal of the clamp on day 10, insertion nal fixation (Slatis) with maintenance of femoral traction. sis at day 30 via the ilioinguinal route. At 1 year, the patient thout crutches but with a limp. S.J. Slater, D.A. Barron / European Journal of Radiology 74 (2010) 16–23 ciated injuries. Many studies have attempted to predict the r of haemorrhage according to fracture pattern [4,20]. Howev whilst unstable pelvic fractures are more frequently associa Transurethral catheterization is formally contraindicated. fracture pattern cannot be used to absolut with haemorrhage, Placement of a suprapubic catheter and performance of predict haemorrhage [10]. urethrography are critically important but should not delay Figure 5. Perineal hematoma. urgent attention to hemostasis [30]. Digestive tract involvement 9. Pelvic ring fractures In the event of traumatic rectal injury, there is major risk of The pelvis is considered to be a ring structure comprised early infection because fecal contamination and sepsis propthree bones, the agate along the anatomic planes into the surrounding softsacrum and two innominate bones. The pos rior ring includes tissues. Such an injury requires immediate surgical interven-the sacrum, SI joints and iliac bones, whilst tion which should combine hemostasis, local debridement, anterior ring is comprised of the pubic bones and symphysis. T drainage and diverting colostomy [31]. In the setting of priSI joints can be divided into anterior and posterior and are h mary rectal injury (firearm and knife wounds, impalement), by the anterior and posterior sacroiliac ligaments. T surgical management is complex. A together secondary rectal injury (bony splinter from pelvic fractures)posterior is most often treated ligaments are the strongest in the body and sacroiliac fairly simply by local wound care, drainage and colostomy. most important in maintaining pelvic stability. The sacrotubero Here again, the hemodynamic stability of the patient dicand sacrospinous ligaments provide additional support posterio tates the initial management. Conversely, the pubic symphysis anteriorly is weaker and m easily ruptured. Fig. 3. (a and b) Window cleaner who fell from a ladder. Unstable pelvic frac- Perineal wounds • Rectal examination with blood - recognition essential - otherwise mortality up to 50% • Exploration in OR < 6 hours with complete assessment and debridement • Diverting colostomy • Drainage and secondary healing (vacuum dressings) —8. Thirty-six-year-old man with crush injury pelvic fracture. At admission, the patient is in severe shock (blood p