Download Pelvic Fractures

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