1. Dr Huw Williams MB BCh MCEM
Pelvic Fractures
and
Associated Injuries
Dr Huw Williams MB BCh MCEM

2. Pelvic Injuries in Trauma
1o Survey A B C D E
2o Survey
3o Survey

3. Pelvic Injuries in Trauma
1o Survey A B C D E
2o Survey
3o Survey

4. Pelvic Anatomy

5. Pelvic Anatomy
Sacrum
Innominate bones
Ligamentous complex

6. 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% ?

7. 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

8. Where can we
bleed from?

9. Where can we bleed from? Pelvic venous plexus Pelvic arterial injury
Fracture bone surfaces
Any visceral injury
Remember: extra-pelvic injuries

10. Where can we bleed from? Pelvic venous plexus Pelvic arterial injury
Fracture bone surfaces
Any visceral injury
Remember: extra-pelvic injuries

11. How much blood can we lose into our pelvis ?
1 litre ?
2 litres ?
3 litres ?
4 litres ?
5 litres ?

12. 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)

13. Mechanism of Injury and Classification
Three mechanisms 
AP Compression Injury
Lateral Compression Injury
A Shear Force Injury  

14. Mechanism of Injury and Classification
Three mechanisms  four patterns
AP Compression Injury
Lateral Compression Injury
A Shear Force Injury  
A Combination

15. i. AP Compression Injury
How:
RTC (car vs. peadestrian / motor-cycle crash)
direct crush injury
fall (>12ft)

16. 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 %

17. ii. Lateral Compression Injury
How:
RTC (motor-cycle crash)
Direct compression / crush

18. 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 %

19. iii. Shear Force Injury
How:
falling from a height onto one limb
RTC

20. 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%

21. iv. Combination Tile Classification Young Classification
Ross Classification

22. 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

23. Assessing the Pelvis
‘Springing the Pelvis’

24. Assessing the Pelvis
‘Springing the Pelvis’

25. Assessing the Pelvis
Direct Peritoneal Lavage

26. Assessing the Pelvis
Direct Peritoneal Lavage

27. PR for ? high-riding prostate
Assessing the Pelvis
PR for ? high-riding prostate

28. PR for ? high-riding prostate
Assessing the Pelvis
PR for ? high-riding prostate

29. Assessing the Pelvis Signs Inspect flanks, scrotum, peri-anal area
?blood at meatus / ?swelling / ?bruising / ?deep laceration
Major disruption
Leg length discrepancy
Distending Abdomen

30. Assessing the Pelvis Symptoms Tachycardia Hypotension Abdominal Pain
Pelvic Pain

31. Assessing the Pelvis Imaging Plain film PXR BONE eFAST BLOOD
CT BONE / BLOOD
Angiography / CT angiography BLOOD

32. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

33. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

34. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

35. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

36. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

37. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

38. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

39. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

40. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

41. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

42. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

43. PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury  
A Combination
Normal

44. FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
-VE FAST

45. FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
+VE FAST

46. Plain film CT Scan CT 3D reconstruction

47. Plain film CT Scan CT 3D reconstruction

48. CT

50. Angiography /
CT Angiography

51. 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

52. Definitive Management of the Pelvis
Surgery  stem bleeding / fix pelvis / pack pelvis
Angiography plus iatrogenic embolization

53. Conclusion Assume there is not a isolated pelvic injury
Assume the worst
Early intervention / minimal pelvis movement once splinted

54. Thankyou
Any Questions?

55. 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.