Dr Huw Williams MB BCh MCEM Pelvic Fractures and Associated Injuries Dr Huw Williams MB BCh MCEM
Pelvic Injuries in Trauma 1o Survey A B C D E 2o Survey 3o Survey
Pelvic Injuries in Trauma 1o Survey A B C D E 2o Survey 3o Survey
Pelvic Anatomy
Pelvic Anatomy Sacrum Innominate bones Ligamentous complex
Pelvic Fractures in Trauma Pelvic # in approx. 9% of all major traumas All age mortality rate = 5-to-16% Age > 65 years mortality rate = 20% Some mortality quotes up to 45% ?
Pelvic Fractures in Trauma Pelvic # in approx. 9% of all major traumas All age mortality rate = 5-to-16% Age > 65 years mortality rate = 20% Some mortality quotes up to 45% ? What does this mean? ? isolated pelvic injury (without an abdominal injury) Pelvic #s = increased risk of death
Where can we bleed from?
Where can we bleed from? Pelvic venous plexus Pelvic arterial injury Fracture bone surfaces Any visceral injury Remember: extra-pelvic injuries
Where can we bleed from? Pelvic venous plexus Pelvic arterial injury Fracture bone surfaces Any visceral injury Remember: extra-pelvic injuries
How much blood can we lose into our pelvis ? 1 litre ? 2 litres ? 3 litres ? 4 litres ? 5 litres ?
How much blood can we lose into our pelvis ? ‘Haemorrhage from pelvic fracture is essentially bleeding into a free space, potentially capable of accommodating the patient’s entire blood volume without gaining sufficient pressure-dependent tamponade’ (Suzuki et al., 2008)
Mechanism of Injury and Classification Three mechanisms AP Compression Injury Lateral Compression Injury A Shear Force Injury
Mechanism of Injury and Classification Three mechanisms four patterns AP Compression Injury Lateral Compression Injury A Shear Force Injury A Combination
i. AP Compression Injury How: RTC (car vs. peadestrian / motor-cycle crash) direct crush injury fall (>12ft)
AP Compression (‘open book pelvis’) i. AP Compression Injury How: RTC (car vs. peadestrian / motor-cycle crash) direct crush injury fall (>12ft) What Happens: symphysis pubis brakes tearing of posterior ligamentous complex (may rupture venous plexus / internal iliac artery) AP Compression (‘open book pelvis’) Frequency = 15 to 20 %
ii. Lateral Compression Injury How: RTC (motor-cycle crash) Direct compression / crush
Lateral Compression (‘closed pelvis’) ii. Lateral Compression Injury How: RTC (motor-cycle crash) Direct compression / crush What Happens: internal rotation of hemi-pelvis fractures around pubis genitourinary system injury (life threatening haemorrhage is less common) Lateral Compression (‘closed pelvis’) Frequency = 60 to 70 %
iii. Shear Force Injury How: falling from a height onto one limb RTC
iii. Shear Force Injury How: falling from a height onto one limb RTC What Happens: high-energy applied in a vertical plane major instability of pelvis Vertical Shear Frequency = 5 to 15%
iv. Combination Tile Classification Young Classification Ross Classification
iv. Combination AP Compression Injury ? major haemorrhage of the venous plexus / internal iliac artery Lateral Compression injury to bladder/urethra/other / ↓ pelvic volume therefore ? ↓ haemorrhage A Shear Force high-energy / major instability
Assessing the Pelvis ‘Springing the Pelvis’
Assessing the Pelvis ‘Springing the Pelvis’
Assessing the Pelvis Direct Peritoneal Lavage
Assessing the Pelvis Direct Peritoneal Lavage
PR for ? high-riding prostate Assessing the Pelvis PR for ? high-riding prostate
PR for ? high-riding prostate Assessing the Pelvis PR for ? high-riding prostate
Assessing the Pelvis Signs Inspect flanks, scrotum, peri-anal area ?blood at meatus / ?swelling / ?bruising / ?deep laceration Major disruption Leg length discrepancy Distending Abdomen
Assessing the Pelvis Symptoms Tachycardia Hypotension Abdominal Pain Pelvic Pain
Assessing the Pelvis Imaging Plain film PXR BONE eFAST BLOOD CT BONE / BLOOD Angiography / CT angiography BLOOD
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
PELVIC X-RAY PLAIN FILM AP Compression Injury Lat. Compression Injury A Shear Force Injury A Combination Normal
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA -VE FAST
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA +VE FAST
Plain film CT Scan CT 3D reconstruction
Plain film CT Scan CT 3D reconstruction
CT
Angiography / CT Angiography
Managing the Pelvis in the ED Sheet Pelvic binders / splints ? Bend knees & tie ankles (internal rotation) Scoops (not boards) Large IV lines / ?permissive hypotensive resuscitation / ? haemorrhage protocol
Definitive Management of the Pelvis Surgery stem bleeding / fix pelvis / pack pelvis Angiography plus iatrogenic embolization
Conclusion Assume there is not a isolated pelvic injury Assume the worst Early intervention / minimal pelvis movement once splinted
Thankyou Any Questions?
References Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36:1. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 2005; 87:2. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005; 190:830. Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008; 64:449. Cannada LK, Taylor RM, Reddix R, et al. The Jones-Powell Classification of open pelvic fractures:. J Trauma Acute Care Surg 2013; 74:901. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 2007; 63:875. Dechert TA, Duane TM, Frykberg BP, et al. Elderly patients with pelvic fracture: interventions and outcomes. Am Surg 2009; 75:291. Sathy AK, Starr AJ, Smith WR, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am 2009; 91:2803. Schulman JE, O'Toole RV, Castillo RC, et al. Pelvic ring fractures are an independent risk factor for death after blunt trauma. J Trauma 2010; 68:930. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002; 195:1.