2. Early complications (Associated conditions) Delayed complications

3. Early complications

4. Multiple trauma Skull Chest Abdomen Extremities

6. Hemorrhage The most dangerous & life threatening condition ( hypovolemic shock ) Sources : Retroperitoneal ( Bone- Small & Large vessels ) Multiple trauma (Chest- Abdomen- Long bone Fx )

7. Epidemiology Evaluating Pelvic Hemorrhage (EPH) Study – 724 consecutive pelvic fractures at Harborview 62 % male Average age = 34 Mechanism – Motor vehicle crash 57% – Car versus pedestrian 21% – Fall (>3.3 meters) 11% – Crush 5%

8. Hemodynamic shock in Emergency Dept. – Blood pressure<90 27% – Pulse>130 30% – Transfuse in ED 29% Blood requirement – Any 80% – 6 or more units 41% – Range (0 to 171 units) Death 13%

9. Sign & Symptom Back pain Abdominal pain Swelling & Echymosis (Flank – Buttock – Inguinal – Perineum ) Hypotension & Shock

10. X ray X-ray : Soft tissue shadow displacement (Int.obturator, Iliopsoas, Gluteal Fat pad Bladder, Uterus) CT scan : Hematoma Angigraphy :

12. Fx type APC & VS ( high risk) Artery & Vein Inj. Iliac – Iliolumbar – Sup.Gluteal – Internal Pudental. LC (rare) Fx site – Visceral Inj. Stable Fx (very rare)

13. Treatment Transfusion Pelvic belt Antishock garment Reduction & Fixation Angiographic embolization

14. Thromboembolism Pelvic bone trauma & Immobilization Ipsilateral or contralateral Calf – Thigh – Pelvic veins Proximal thrombosis has Greatest risk of embolism

15. Increased risk of DVT Older age Spinal cord Inj. Lower extremity Inj. History of DVT

16. Rate MR Venography 35% Thrombosis Contrast Venography 29% Dopler Sonography 9% Pulmonary Embolism 2 – 12% Fatal Pulmonary Embo. 0.5 – 10%

17. Prophylaxy Routin prophylaxis is mandatory Method is controversial Drug : Aspirin – Warfarin Low dose Heparin Low M.W.Heparin Mechanical devices : Compresion stocking Foot pump Compresion device thigh & leg Vena cava filter

18. Fat Embolism

19. Gasterointestinal Inj. Open fracture Deep pelvic infection Retroperitoneal absces Peritonitis High mortality rate

20. Gasterointestinal Inj. Wound in perineum Blood in rectum More proximal Injury (Contrast CTscan) Direct Inj. (Bone fragment) Indirect Inj. (Ext.Rot. Streching)

21. Management Irrigation & Debridment Early Colostomy Broad spectrum antibiotic

22. Gasterointestinal inj. BOWEL OBSTRACTION Paralytic Ileous Entrapment in Fx site

23. Genitourinary inj. Men > Women Overall Rate 16%

24. Bladder Contusion …………Rupture Rupture : Gross Hematuria Mortality Rate 22 – 34% 85% Extra peritoneal Vesico colic fistula Foley catheter 15% Intera peritoneal Repair & Foley catheter

25. Urethral Inj. Men > Women (Vagina & Urethra) Blunt, Avulsion Inj. Commonly Distal to Urogenital Diaphragm - Blood on meatus Triad - Distended Bladder - Inability to void Retrograde Urethrography

26. Urethral Inj. Repairing time is controversial Primary Repair …….. More Impotence rate Delayed Repair …….. More Stricture rate

27. Neurologic Inj. Lumbosacral & Sacral plexus Inj. Sciatic N. (Proneal) Inj. Post. Pelvic Ring Fx (VS 40 – 50% ) Sacral Fx (Compresion) Foraminal 28% Medial to Foramen 57% APC – VS (Traction)

29. Management Physical Examination ( Before & After Reduction ) Early Reduction & Fixation of Fx Neurolysis Repair Nerve graft ?

30. Open Fx Rate 4% Iliac crest wound Rectum & Perineum wound Vaginal wound

31. Open Fx Iliac Crest Wound Often minor & stable Fx ( mortality 0 – 5% ) Sometimes APC – VS ( mortality 25% ) Irrigation & Debridment Control of hemorrhage

32. Open Fx Rectum & Perineum Wound Mortality Rate 44 – 50% Hemorrhage (Packing – Embolization –External Fixation – Hemipelvectomy ) Sepsis (Irrigation & Debridment – Early Colestomy – Packing the wound – Debridment )

34. Open Fx Vaginal Laceration Debridment & Repair & External Fixation

36. Post Op. Infection 6% Increased Risk - Open Fx - IlioInguinal Approach - Febrile Patient Percutaneous Screw - Very Rare Open Reduction - Not Common

37. Treatment - Irrigation & Debridment - Deep Culture - Antibiotic Beeds - Leave the Hardware if possible - External Fixation

38. Fixation Failure > 1 Cm Displacement Percutaneous Iliosacral Screw 10% Sacral Fx > SI Dx Prevention : - Spinopelvic Fixation - Screw across the Sacrum to far Ileum - Multiple Screw

39. Fixation Failure Percutaneous Sup. Pubic Ramus Screw 10% - Eldery & Osteoprotic Female - Medial & Shaft Fx > Lateral Fx External Fixator - Pin Loosening - Pin Tract Infection

40. Sexual Dysfunction Urethral Vascular Neruologic Psychologic Inj. Unstable & Marked Displaced Fx

41. Men,s Sexual Dysfunction Posterior Urethral Inj. : Impotence Rate 50% Poorly Scored on Sex Drive Erection Ejaculation Satisfication Eldery > Young

42. Women,s Sexual Dysfunction Ant. Pelvic Ring Fx More Dysfunction Dyspareunia 38% ( > 5mm displacement ) Decreased Interest & Orgasm 45% Dysmenorrhea Vaginal Delivery Problem Incontinence

43. Other Complications Myositis Ossificant 20% Malunion Up to 90% in Non Operative Method Nonunion ? Ligamentous Inj. may not healed Low Back Pain SI Joint Inj. Chronic Pelvic Pain Sacral Plexus Inj.

44. Case Reports - Acute Compartment Synd. In Gluteal & Thigh comp. - Gluteal Soft Tissue Necrosis After Angiographic Embolization - Bowel Herniation - Bladder Herniation In Pub. Symphisis Diastasis - Flail Penis In Open Book Fx Due to Suspensory Lig. Inj.