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Pelvic Trauma Epidemiology Account for 3% of fractures; present in 30% multitrauma; 50% require blood transfusion; mostly MVA / falls; 5-20% mortality; 50% mortality if BP OA; 30% mortality if open Complications Vascular: common iliac artery divides at SIJ internal iliac (intrapelvic); if posterior ring involvement 2-3x blood requirement; can lose up to 4-6L blood; 15iu for APC, 9iu for VS, 3.5iu for LC; major cause of death; treat with pelvic sling (may pelvic vol by up to 10%) or mechanical fixation; bleeding from multiple sources in 60%, bilateral in 50%; most bleeding is low pressure venous bleeding and bleeding from bone edges; 10-15% are arterial (usually from internal iliac; especially sup gluteal and obturator); shock and death usually due to arterial; if bleeding is refractory to resus, likely arterial and hence angiography should be persued Neural: lumbar and sacral plexus; S1-2 nerve roots commonly involved in post element fractures, associated with sacral injury; impotence in 1/6th sacral fractures; lumbar root associated with SIJ dislocation or fracture GU: bladder or urethral in 16%; urethral in 5%; usually in anterior bulbous urethra; vaginal laceration in 4% (techinically open if present); high fetal death rate; possible obstetric problems; if suspect, do retrograde urethrography before placing IDC GI: rectal injury uncommon (usually associated with urinary injury and ischial fracture) Other: ruptured diaphragm Young Classification System Usually pubic symphysis breaks 1st sacrospinous ligament and sacrotuberous ligament anterior SI ligament Single break = stable injury; 2 breaks = unstable with risk of displacement Suggestive of LC: Horizontal #’s; SIJ diastasis and crush # of sacrum; central hip dislocation Suggestive of AP: vertical #’s; posterior hip dislocation Suggestive of VS: vertical #’s with vertical displacement Lateral Compression Fracture I Fracture of sacrum on side of impact + pubic ramus fracture Most common (50%); stable; 4% bladder rupture II Fracture of iliac wing near SIJ (may enter SIJ) + pubic ramus fracture 7%; unstable to internal rotation; stability depends on degree of SIJ involvement; 36% severe haemorrhage, 7% bladder rupture III Ipsilateral LC I/II + contralateral AP compression injury 10%; unstrable; 60% svere haemorrhage, 20% bladder rupture, 20% urethral injury AP Compression Fracture Vertical Shear Fracture Mixed 20-25% 25% I Symphysis diastasis widening of SIJ; ligaments stretched but intact 8% bladder rupture, 12% urethral injury II Disruption of sacrotuberous, sacrospinous and anterior SI ligaments; intact posterior ligaments widening of anterior SIJ open book injury 10%; 28% severe haemorrhage, 10% bladder rupture, 23% urethral injury III Complete disruption of hemipelvis with lateral displacement but without vertical displacement; all ligaments disrupted 4%; 75% severe haemorrhage; 15% bladder rupture; 25% urethral rupture 5% Hemipelvis displacement superiorly (usually through SIJ); need ant and post SI ligament disruption for vertical instability: usually SIJ, vertical sacral # or ilial wing #, or complete ligament disruption through PS/PR, interosseous + posterior SI ligaments; may have L5 transverse process # 75% severe haem, 15% bladder rupture, 25% urethral rupture 50% Other Pelvic Fractures Avulsion Fracture ASIS (sartorius; pain on flexion + abduction); Ischial tuberosity (hamstrings; non-union common; OT needed); AIIS (rectus femoris; can’t flex hip); Post spine (erector spinae); Iliac crest (direct violence) Acetabular Fracture 20%; transmission of force through femoral head via posterior / central / anterior dislocation; usually due to MVA; CT better than XR; Usually treated with traction, but may need OT especially if displaced associated with sciatic and femoral nerve injury, femoral fracture, knee injury Pelvic Ring Fracture Posterior fractures have higher incidence of vascular and neurological complications Assessment Haematuria (blood at meatus, high riding prostate, boggy mass on PR), rectal, PV bleeding; abnormal bony prominence on PR; altered tone on PR Destot’s sign: haematoma above inguinal ligament or in scrotum Roux’s sign: distance betweem gt trochanter and pubic symphysis unequal Earle’s sign: tender fracture line palpable on PR exam Grey-Turner’s sign: flank bruise due to retroperitoneal blood Investigation XR: 65-90% sensitivity; pelvic inlet view for anterior SIJ injury and AP displacement of ring fractures; pelvic outlet view for vertical displacement / transverse fracture through sacrum and arcuate lines; judet view for acetabular fracture CT: needed for acetabular injury, pelvic ring disruption, posterior element fracture, single rami fracture, complex fracture; extravasation of contrast 80-90% sensitive, 98% specific for need for vessel embolisation Retrograde urethrogram: inject 200-300ml contrast Bladder poorly filled with extravasation to side: extraperitoneal rupture; conservative treatment if small, OT if large Bladder doesn’t fill, extravasation to pelvic floor: membranous urethra rupture; needs cystoscopy Bladder doesn’t fill, extravasation beneath pelvic floor: bulbar urethra rupture Catheter: dry tap: intraperitoneal rupture Blood stained tap: extraperitoneal rupture Management ABC Stabilisation: doesn’t prevent arterial bleeding; may prevent dislodgement of existing clot; doesn’t support posterior pelvis; difficult if obese; assess for other causes of blood loss Pelvic sling: best if major disruption and opening of pelvic ring; contraindicated IF LC / VS injury, isolated pubic rami fracture; don’t use >24hrs External fixation: quick and can be done in ED; use if pubic diastasis >2.5cm / involvement of posterior elements Pneumatic anti-shock garment: can be used pre-hospital; works in APC; may bleeding in LC; BP if sudden removal, compartment syndrome, access to legs Conservative: fracture bilateral pubic ramus with min displacement; LC I / AP I; non-displaced # ilium Traction: acetabular and VS fracture, using femoral pins; LC I + II – bed rest and delayed ORIF External fixation within 4hrs if: APC II, III + VS, ?LC III, especially if opened >2.5cm anteriorly; effective for controlling venous bleeding (maybe pre-angio) OT vs angio Surgery Open surgery if: haemodynamically unstable + positive FAST; may need extraperitoneal packing as part of damage contro; can use as bridge for patients too unstable to survive angiography Internal fixation if: major visceral / vascular injury, ongoing blood loss, open Angio Angiography and embolisation if: continuing blood loss and other sources excluded (ie. Intra abdominal exlcuded; need for ongoing blood transfusion, haemodynamic status, certain amount of iu blood needed, positive helical CT) even if haemodynamically unstable; only CI’ed if needs laparotomy; takes 1-2hrs; bleeding successfully control in >90%; 7-10% fractures require embolisation; only useful if branches of internal and external iliac system involved (more likely if VS / APC injury as 20% have arterial haemorrhage; only 2% lateral compression fractures have arterial haemorrhage) Pros: avoids retroperitoneal probs associated with OT, preserves tamponade effect, avoids entering haematoma, more effective than OT for major arterial bleeding Cons: source of arterial bleeding only identified in 20-30% patients with severe pelvic disruption; when failure occurs, usually assoc with severe 2Y coagulopathy; complications = impotence, bladder / gluteal necrosis, sciatic / femoral nerve paralysis, emboli to normal vessels; not available in some hospitals; operator dependent; time consuming; doesn’t address venous blood loss; diagnostic and therapeutic; must not perform cystourethrography pre-angiography Management (cntd) Sacral Fracture Controversy exists about best practice; depends on facilities available but most unstable pelvic trauma should have angio over OT if there is no abdo injury causing bleeding Usually associated with pelvic ring fracture; can cause sacral nerve damange (weak legs, saddle anaesthesia, incontinence); CT more sensitive than XR Other Classication Systems