Pelvic Fractures 2 nd Northern Trauma Network Conference P Fearon Consultant Orthopaedic Trauma Surgeon - RVI

Overview Identify the priorities of life saving, limb saving, and disability-limiting surgery Outline the general and local factors affecting decision-making Importance of teamwork

Orthopedic and trauma surgeons naturally concentrate on the fracture It is vital to realise that there are other factors that may dominate decision making in the management of a particular fracture

InjuryPatient Care teamResources

Injury Fracture Vascular injury Compartment syndrome Open wound Crush injury Nerves Patient Previous Condition Age (physiologic) Diagnoses Medications! Other injuries Physiologic response Expectations/needs Care Team Surgeon Assistants Anesthesia Other specialties OR nurses Postoperative Rehabilitation Social supports Resources OR Instruments Implants Imaging ICU (Other Patients)

Classification systems SurvivorsNon-survivors

Non-survivors Early DeathLate Death Haemorrhage Brain injury Sepsis MOF Bleeding # bones, venous plexus, arterial injury, extra-pelvic sources

Survivors Mental health problems Chronic pain Pelvic obliquity Leg length discrepancy Gait abnormalities Sexual & urological dysfunction Long term unemployment

Pre-Hospital Goals:- – Early suspicion – Identification – no need to spring/log roll – Management

Pelvic immobilisation should be routine MOI Symptoms Clinical findings – deformity, bruising or swelling over the bony prominences, pubis, perineum or scrotum. – Leg length discrepancy or rotational deformity of a lower limb (without fracture in that extremity) may be evident. – Wounds over the pelvis or bleeding from the patient's rectum, vagina or urethra may indicate an open pelvic fracture. – Neurological abnormalities may also rarely be present in the lower limbs after a pelvic fracture.

Ease of application Access for intervention Shown just as good as external fixators

Prevent re-injury from pelvic motion (clot disruption) Tamponade bleeding pelvic bones & vessels Decrease pain Decrease pelvic volume (lesser)

ED Resuscitation / Management MHP WBCT – trauma series – TEAM – TEAMTEAMTEAM

Illustrated case 29 yr female Motor cyclist GCS 14/15 BP 90/40 Hr 110 PV bleeding Binder applied

Pathway Resuscitation on going via CT scanner

All bets off! Team Huddle – Senior Decision making Modify Plan

Aorta stented Evaluation of coeliac – Common hepatic – Left hepatic Both internal iliac – Left pudendal branch embolised (anterior division of internal iliac)

Prehospital ED ITU & anaesthetics Ortho Gen Surg HBP CT/radiology Interventional radiology Urology Rehab Pain team Sexual dysfunction clinic Clinical psychology Holistic Approach Improve disability

How much blood loss from pelvic #? WBV – (true pelvic vol 1.5L, but ↑ with disruption) – Retroperitoneal space 5L – Loose tamponade effect/disruption parapelvic fascia – Escape into peritoneum & thighs

? Arterial Bleeding MOI Open fractures Elderly patients (gluteal injuries) Sacrum/SIJ, symphyseal separation–gluteal, pudendal CT scan – vascular blush/large haematoma≡sig bleed AttachmentSize Head on collisions Jumpers

Binder MHP Trauma CT Urology Surgery Pelvic fixation Holistic Rehab Coordinated Team Approach

Isolated haemodynamically unstable pelvic trauma uncommon – Associated injuries due to high MOI Resuscitation/intervention team based with better understanding & cooperative team working – surgeons included

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