Pelvic Fractures Presented By: Fadel Naim M.D. Orthopedic Surgeon Faculty of Medicine IUG

Introduction Only 3-8% of all fractures Occurs in 25% of multiply injured patient Associated blunt, soft-tissue injury Mortality as high as 20%-25% Open pelvic fracture = 30-50% mortality

Classification 1. Vectors of injury Lateral compression AP-direction Vertical shear 2.Young and Burgess’s classification scheme—prediction of pelvic fracture related hemorrhage .

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Primary Assessment Primary Survey Airway Maintenance with cervical spine protection Breathing and Ventilation Circulation with hemorrhage control Disability: Neurologic status Exposure/Environment Control: Undress patient but prevent hypothermia

Resuscitation Intravenous lines Crystalloid Solution Blood Administration 50-69% of unstable pelvic fractures require 4 or more units of blood 30-40% require 10 or more units

Physical Examination Bimanual compression and distraction of the iliac wings Assess for rotational stability Manual leg traction aids in determining vertical stability Rectal examination Palpate prostate – urethral injury Palpate sacrum assess for fracture

Physical Examination Vaginal examination Perineal skin evaluation Bleeding or laceration indicate open fractures Perineal skin evaluation Laceration may indicate open fracture; laceration may be caused by hyper-abduction of the leg

Associated injuries

Associated Injuries Vascular Neurologic Visceral Urologic Rectal/Gastrointestinal Gynecologic Degloving - Moral-Lavalle

Vascular Hemorrhage occurs in up to 75% of pelvic fractures Three source of bleeding Osseous Vascular Visceral Intra-abdominal source is present in 40% of patients with pelvic fractures

Possible Bleeders Iliolumbar artery Lateral sacral artery Internal iliac artery Internal pudendal Sacral venous plexus Superior gluteal artery the most commonly injured vessel

Retroperitoneal Veins

Vascular Major source of bleeding is the venous plexus Retroperitoneal space holds up to 4 L of blood Arterial source of bleeding is present in only10-15% of patients

Neurologic Fracture of sacrum or dislocation of SI joint can lead to injury to lumbosacral plexus L5 & S1, most common L2 to S4 possible Amount of displacement more important than location

Visceral Injury Blunt vs. impaled by bony spike Bladder/urethra Rectum Vagina Prostate

Urologic 15-17% of pelvic fractures Scrotal/labial swelling Urethral 15% of men Urethral injury rare in women Indicators: Blood in meatus High-riding prostate Straddle-type fracture Retrograde Urethrogram

Ruptured Urethra Classical Triad Blood on external meatus Distended bladder Inability to void

Rectal/Gastroinstestinal Occurs in less than 1% Laceration of rectum or perforation of small and/or large bowel Rectal tears accompany perineal wounds Requires diverting colostomy

Gynecologic Laceration of the vagina Results from dislocation or fractures of the pubic rami Large laceration may involve perineum and rectum Inferior rami fracture that causes impingement may require operative intervention

Morel–Lavalle’ Lesion Closed degloving injury Greater trochanter pelvic and acetabular fx Shear injury Subcutaneus tissue torn Cavity of hematoma/liquefied fat Not initially apparent/overlooked Infected in 1/3 of cases

Hemodynamically Unstable Patient Causes of bleeding/hypovolemia: Hemothorax Intrabdominal injury Intracranial/Spinal injury Closed/Open fractures Coagulopathies (hypothermia, low calcium, acidosis) PELVIC FRACTURE

Hemodynamically Unstable Patient Intra-abdominal Bleeding Assess: Abdominal CT Scan Peritoneal Lavage Ultrasound Pelvis AP Pelvis Physical exam Pelvic CT Scan

Imaging AP pelvis can identify 90% of pelvic injuries It can guide the surgeon to additional imaging needs, such as CT scan AP pelvis during early phase of resuscitation is useful to determine presence or absence of unstable pelvic fracture

Inlet and Outlet Views Inlet View 45 degree caudal tilt True AP projection of the pelvic brim Evaluates for posterior displacement Evaluates for rotation of ilium and sacral impaction injuries

Inlet and Outlet Views Outlet View 45 degree cephalad tilt Evaluates for vertical shift of pelvis Visualizes Sacral foramen

CT Scan Best visualization for Sacrum and SI joint Rotational and posterior displacement can be easily assessed 3-D reconstruction may be helpful in determining overall displacement of the pelvic fracture

Angiography Useful in assessing and embolization of arterial injury Can determine patency of superior gluteal artery for viability of large surgical exposures Disadvantage: Source of arterial bleeding is identified in only 10-15% of patients with severe pelvic disruption Does not address venous bleeding

Open Pelvic Fractures High mortality rate (30% - 50%) Potential for major vascular injury with hemorrhage High incidence of associated gastrointestinal and genitourinary injuries Diverting colostomy may be required Requires aggressive multidisciplinary treatment

Assessment of ‘stability’: Mechanical: Based on clinical examination and radiographs. Haemodynamic: Normal. Stable (maintaining P/BP/urine output by continuous infusion of fluid = on-going bleeding somewhere). Unstable (failure to maintain P/BP/urine output despite continuous infusion of fluid).

Type I injuries: Mechanically stable (usually lateral compression). Haemodynamically stable. No emergency treatment for pelvic lesion. Obtain CT scan.

Type II injuries: Mechanically unstable Haemodynamically stable. No emergency treatment for pelvic lesion. Careful haemodynamic monitoring. Obtain CT scan.

Type III injuries: Mechanically stable Haemodynamically unstable. Pelvis already closed/stable – no need for emergency treatment for pelvic lesion. Look for bleeding elsewhere (chest/abdomen). If none found, consider: Angiography/embolisation. Laparotomy/pack pelvis.

Type IV injuries: Mechanically unstable Haemodynamically unstable. Look for bleeding elsewhere (chest/abdomen). Reduce pelvic fracture and stabilise with anterior external fixator or C-clamp. If laparotomy indicated, apply external fixator BEFORE abdomen opened.

Type IV injuries: After external fixation, careful haemodynamic monitoring. If continuing haemodynamic instability: Angiography/embolisation Laparotomy/simple anterior plate fixation/maintain external fixator/pack pelvis.

Type V injuries: Mechanically unstable Haemodynamically unstable. Patient in extremis. Dying despite aggressive fluid resuscitation. Immediate operation required to save life.

Type V injuries: Apply simple anterior external fixator or C-clamp. Laparotomy and deal with any intra-abdominal bleeding. If still haemodynamically unstable, simple anterior plate fixation/maintain external fixator/pack pelvis.

Acute Intervention Stabilization of Pelvic Hemorrhage Traction Sheet/Pelvic Binder Anti-shock Garment Pelvic clamp/External fixator Angiographic embolization

Sheet Sheet can be wrapped around iliac wings and held with towel-clamp or knot Hips slightly flexed and internally rotated

Pelvic Binder

Anti-shock Garment MAST (Military antishock trousers) Uncommon Limits access for examination Decreases lung function Can contribute to lower extremity compartment syndrome

External Fixator Indicated in the unstable patient who does not respond to initial fluid resuscitation Stabilizes pelvis, preventing redisruption of Clot ? May decrease pelvic volume Not adequate for posterior pelvic disruption

External fixation 1. Advantages 2. Disadvantages It helps tamponade bleeding from bone edges . Stabilizing the clots and the bone. Could be done in 20 min. 2. Disadvantages Can’t stop arterial bleeding. Delay the embolization for ongoing arterial hemorrhage. Degrade the quality of CT and angio.

Pelvic C-clamp Applied to the posterior ilium in line with sacrum Requires fluoroscopy and expertise Higher risk of iatrogenic injury Not available in many institutions Good for stabilizing posterior disruption

Definitive Fixation Anterior External fixator Plate fixation (ORIF) Posterior Iliosacral screw Plate fixation Combined

Non-Operative Management bed to chair mobilization WBAT with support serial xray after mobilization monitor for subsequent displacement posterior ring displacement > 1cm: STOP WBAT Very unstable patients: require prolonged immobility (poor results)