Download Pelvic Fractures

Pelvic Fractures
Dr Adam Chesters
HEMS Registrar
Background
• About 10% of blunt multi-trauma patients
• Mortality rate up to 20%
– Exsanguination
– Associated severe injuries
• Open pelvic fracture – 50% mortality
• 2/3 caused by RTC
– Positioned in the front of the vehicle
– Positioned on the struck side (especially with intrusion)
• Pedestrian collisions – around 20%
• Motorcyclists – around 10%
Classification (by a PHC doctor!)
• Pennal and Tile (1979)
• Mechanism-based classification:
1. Anteroposterior compression
2. Lateral compression
3. Vertical shear
• Anterior lesion
– Pubic symphysis or pubic rami disruption
• Posterior lesion
– Sacrum, ilium, or SI joint disruption
AP Compression Fractures
• PS diastasis(>5mm)
• Bilateral anterior SIJ
disruption (>4mm)
• ER of hemi-pelvis
• Anterior compression
force applied to ASIS
• May result in bony
instability (or not)
depending on
ligamentous disruption
Lateral Compression Fractures
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•
•
•
Account for largest proportion of fractures
Cause internal rotation of hemipelvis
May be stable or unstable
Four sub-classifications
A.
B.
C.
D.
Ipsilateral anterior and posterior injury
Contralateral injury (bucket-handle)
Four-rami with posterior disruption
Miscellaneous
Ipsilateral anterior and posterior
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•
•
•
Direct lateral blow
IR of hemi-pelvis
Ipsilateral PR fractures
Anterior sacrum or
ilium fracture
• Unstable if SI ligaments
also rupture
Bucket Handle Fractures
• Lateral compressive
force combined with
upwards rotation
• Both PR fractured on
contralateral side
• Sacrum, ilium or SIJ
fracture on same side
• Hemi-pelvis displaced
superior and medial
• Leg shortened and IR
Four-rami Posterior Disruption
• Violent lateral
compression force
• All four rami broken
• Posterior disruption
• Associated with
additional severe injury
• Displacement of
floating fragment
anterior and superior
Miscellaneous LC Fractures
• Buckling of pubic ramus
• Anterior and medial
fragment rotation into
perineum
• Fragment felt PV
• More common in
females than males
Vertical shear fractures
• Always very unstable
• Severe trauma
• Fall from height (landing
on one leg)
• High speed RTC
• Forces in vertical plane
• Significant anterior and
posterior disruption
Why bother to classify?
• Reading the mechanism
• Diagnosing the fracture in the field
• Predicting the bleeding risk
– Open book and vertical shear more likely to cause
haemodynamic instability (mostly venous)
– Lateral compression fractures more likely to cause
arterial bleeding (anterior branches of IAA)
• Dictates type of acute fixation for the surgeon
What will be on the PXR?
Lateral compression fracture (Type B)
What will be on the PXR?
Vertical shear fracture
What will be on the PXR?
AP compression fracture
Pre-hospital diagnosis of pelvic fracture
• Can I base it on the mechanism?
– Common in RTCs and motorbike collisions
– Read the wreckage and remember the anatomy!
• Should I spring the pelvis?
– Severe pain and clot disruption
– Low sensitivity and specificity
– Absolutely contraindicated!
Pre-hospital diagnosis of pelvic fracture
• Can the patient tell me if pelvis is broken?
– Alert, orientated, cooperative patient
– No distracting injury or dangerous mechanism
– Pain in back, pelvis, groin or hips
– Obtunded patient – absolutely not!
• Are there any decent clinical signs?
– Deformity, bruising and swelling
– Shortened or rotated leg
– Wounds over pelvis or bleeding (PR, PU, PV)
What should I do if I suspect a pelvic fracture?
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•
•
•
•
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•
•
•
•
Remember that they could die of bleeding
Handle the patient (pelvis) very carefully
Cut all the clothes off
Apply a pelvic splint always
Do not log roll the patient
Use the orthopaedic scoop stretcher
Give generous analgesia
Practice permissive hypotension
Take to the best hospital to deal with injuries
Be explicit in the handover of care
Why do patients with a fractured
pelvis bleed to death?
Bleeding from the pelvis
• Venous bleeding – around 90%
– Sacral venous plexus
• Arterial bleeding – around 10%
– Branches of internal iliac artery
– More common cause of haemodynamic instability
• Bleeding from disrupted bones
• Vertical shear > open book > lateral compression
• Where does the blood go?
Retroperitoneal haematoma
• Retroperitoneal space
opens up with fracture
• Volume of up to 4 litres
• Not picked up by FAST
• Potentially treatable
– Pelvic splint
– External fixation
– Surgical intervention
Pelvic Splint
• Brings pelvis back into
anatomical alignment
• Tamponades and closes
retroperitoneal space
• Prevents unstable bones
causing more pain or
damage
• May stabilise the patient
with a venous bleed
• Acts as a marker of a
suspected pelvic injury
Log rolls and spinal boards
o
150
o
90
o
90
o
Total = 330
At hospital
On Spinal Board
o
90
o
90
o
Grand Total = 510
RSI
o
o
150
Left blade in
o
10
Right blade in
10
At hospital
On scoop
o
Total = 170
Counter traction
Left blade out
Right blade out
o
0
o
Total = 170
Permissive hypotension
• Faculty of PHC consensus guidelines
– Stop external haemorrhage
– Splint all fractures
– Fluid resus (in 250ml crystalloid boluses) based on
• Absent radial pulse and verbal contact (awake patients)
• SBP <80mmHg (sedated patients)
– Cannulation en route to hospital
• Unless required for extrication analgesia
• Only two attempts
Triage
• Pelvic fractures represent significant trauma
• Often have other serious associated injuries
• These patients should be taken to a MTC
– Well-rehearsed trauma protocols
– Facilities for appropriate emergency interventions
• Blood transfusion
• Emergency surgery
• Angiography and interventional radiology
– Facilities for critical care and rehabilitation
Handover
• Standardised format to include all information
• Pelvis specific stuff:
– Mechanism and suspected pelvic fracture
– Haemodynamic instability – especially positive
response to pelvic splint (suggests venous bleed)
– Do not remove pelvic splint until investigations and
definitive plan in place
– PXR may appear normal if splint has reduced fractures
– Can x-ray through most pelvic splints
The bleeding pelvis in the ED
Post-traumatic
haemodynamic
instability in association
with pelvic fracture
1. Exclude chest,
abdomen, long bones
2. Assume
retroperitoneal
haematoma
The bleeding pelvis in the ED
• Maximise oxygen
delivery (intubate)
• Blood product
resuscitation – continue
permissive hypotension
until bleeding control
• Stop the bleeding
1. External fixation
2. Surgical control
3. Arterial embolisation
External fixation
• Emergency haemostasis
not bone reduction
• Effective for venous
bleeding (more
definitive replacement
for pelvic splint)
• Takes about 45 minutes
to apply in theatre
Surgical control of bleeding
• Surgical exploration of
vessels (for ligature)
– Bad idea!
– Accidental opening of
posterior peritoneum
– Mortality rate of 80%
• Proximal aorta x-clamp
– In extremis only
– Thoracic aorta (opening
abdomen decompresses
retroperitoneum)
Surgical control of bleeding
Damage control surgery
• Effective for arterial and
venous bleeding
• Extraperitoneal pelvic
packing with swabs
• Removed after 24-48 hrs
• Definitive surgery later
after ITU admission
• Useful if associated
abdominal bleeding (pack
pelvis before opening the
abdomen)
Arterial embolisation
• Transfer from ED if pelvis
only source of bleeding
• Arterial access on
contralateral side to
suspected injury
• Common vessels:
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–
–
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Superior gluteal
Lateral sacral
Iliolumbar
Obturator
Vesical
Inferior gluteal
Arterial embolisation
• Immediate vascular
occlusion (temporary)
• Facilitates physiological
haemostasis, thrombus
formation and healing
of dissected vessels
• Treatment of choice for
arterial lesions
• Success rate >80%
• <5% complication rate
Angiography or Surgery?
• Angiography more likely to control
haemodynamic instability in pelvic fracture
– Arterial lesions more likely to cause instability
– Up to 75% of unstable patients have arterial injury
– External fixation doesn’t work for arterial injury
• No benefit from properly applied pelvic splint
– Unlikely to benefit from surgical external fixation
• Can do both! (ideally embolise first)
Angiography or Surgery?
What about haemodynamically stable
patients with pelvic fracture?
• Whole body CT scan
– Accurately defines the fracture
– Picks up associated injuries
• Combine with contrast
– 80% sensitivity, 90% specificity for pelvic arterial bleed
• No indication for embolisation if stable
• External fixation becomes about the bone, not
about the bleeding
– Reduction of bones before internal fixation
Summary
1. Pelvic fractures are serious injuries
2. Routinely immobilise pelvis based on
mechanism or symptoms in alert patients
3. Handle very gently (no log roll, OSS)
4. Permissive hypotension resuscitation
5. Take to a trauma centre for definitive
management of bleeding
6. Have a very clear why you do what you do!