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Pelvic Fractures and
Associated InjuriesDr Huw Williams MB BCh MCEM
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 Injuries in Trauma
Pelvic Anatomy
1. Sacrum
2. Innominate bones
3. Ligamentous complex
Pelvic Anatomy
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
Pelvic Fractures in Trauma
Where can we bleed from?
Where can we bleed from?
1. Pelvic venous plexus
2. Pelvic arterial injury
3. Fracture bone surfaces
4. Any visceral injury
Remember: extra-pelvic injuries
Where can we bleed from?
1. Pelvic venous plexus
2. Pelvic arterial injury
3. Fracture bone surfaces
4. 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
i. AP Compression Injury
ii. Lateral Compression Injury
iii. A Shear Force Injury
Mechanism of Injury and Classification
Three mechanisms four patterns
i. AP Compression Injury
ii. Lateral Compression Injury
iii. A Shear Force Injury
iv. A Combination
How:
RTC (car vs. peadestrian / motor-cycle crash)
direct crush injury
fall (>12ft)
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 %
i. AP Compression Injury
How:
RTC (motor-cycle crash)
Direct compression / crush
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 %
ii. Lateral Compression 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 pelvisVertical Shear
Frequency = 5 to 15%
iii. Shear Force Injury
Tile Classification
Young Classification
Ross Classification
iv. Combination
iv. Combinationi. AP Compression Injury
? major haemorrhage of the venous plexus / internal iliac artery
ii. Lateral Compression
injury to bladder/urethra/other / ↓ pelvic volume therefore ? ↓ haemorrhage
iii. A Shear Force
high-energy / major instability
Assessing the Pelvis‘Springing the Pelvis’
‘Springing the Pelvis’
Assessing the Pelvis
Direct Peritoneal Lavage
Assessing the Pelvis
Direct Peritoneal Lavage
Assessing the Pelvis
PR for ? high-riding prostate
Assessing the Pelvis
PR for ? high-riding prostate
Assessing the Pelvis
Inspect flanks, scrotum, peri-anal area ?blood at meatus / ?swelling / ?bruising / ?deep laceration
Major disruption
Leg length discrepancy
Distending Abdomen
Signs
Assessing the Pelvis
Tachycardia
Hypotension
Abdominal Pain
Pelvic Pain
Symptoms
Assessing the Pelvis
Plain film PXR BONE
eFAST BLOOD
CT BONE / BLOOD
Angiography / CT angiography BLOOD
Imaging
Assessing the Pelvis
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
PELVIC X-RAY PLAIN FILM
-VE FAST
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
+VE FAST
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
Plain film CT Scan CT 3D reconstruction
CT
Plain film CT Scan CT 3D reconstruction
CT
CT
Angiography / CT Angiography
Managing the Pelvis in the EDSheet
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?
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perspective. J Trauma 2007; 63:875.7. Dechert TA, Duane TM, Frykberg BP, et al. Elderly patients with pelvic fracture: interventions and outcomes. Am Surg 2009;
75:291.8. 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; 91:2803.9. 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; 68:930.10.Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries
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References