Pelvic Fractures
AOCP National CourseBelfast City Hospital
11th June 2010
D Swain BSc; FRCSI; FRCS (Orth.)
Who’s this bloke?
• Consultant orthopaedic surgeon – RVH
• Trained in Belfast, England and Toronto
• Interests - pelvic and acetabular trauma
- hand surgery
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
Acute Pelvic Fracture ?
D Swain BSc; FRCSI; FRCS (Orth.)
High Energy Pelvic Fractures
• Occur in 10-20% of polytrauma victims
• Mortality varies with associated injuries
• Age, ISS and severe haemorrhage are best predictors of mortality
D Swain BSc; FRCSI; FRCS (Orth.)
Polytrauma Mortality
• Pelvic-related mortality ~ 7-18%
• Pelvic # + intracranial mass (a) ~ 50%
+ intra-peritoneal injury (b) ~ 50%
+ (a) + (b) > 90%
• Pelvic # + thoracic / urological / musculoskeletal
~ 20%
D Swain BSc; FRCSI; FRCS (Orth.)
Pelvic - related Mortality
• Mostly due to bleeding
• Bleeding may occur from venous or arterial injury or from the cancellous bone surfaces
• Different sources of bleeding require different interventions
“If at first you don’t succeed….”
• 16 year old male,scooter vs. lorry
• Transient responseto : - resuscitation
- external fixation- embolisation- Novo 7
• No response to laparotomy
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
Pelvic – related mortality
• The key is to differentiate transient and non-responders
• Clinical - unstable fractures- open fractures
• X-ray - unstable fractures- evidence of pelvic floor disruption- fractures extending into sciatic notch
• ? Physiological response to resuscitation
D Swain BSc; FRCSI; FRCS (Orth.)
Assessment
A pelvic fracture:
• should be suspected from the history
• may not be clinically obvious
• confirmed by plain radiographs of the pelvis.
In addition to plain anteroposterior films two 45-degree oblique films should be obtained, the pelvic inlet and the pelvic outlet view.
D Swain BSc; FRCSI; FRCS (Orth.)
Examination
• Instability can be assessed by compressing the ASIS, pulling on the leg and looking for evidence of damage to posterior structures (bruising or localised tenderness).
D Swain BSc; FRCSI; FRCS (Orth.)
Radiographs
Trauma series• c-spine• chest• pelvis
• (if there is an injury to one part of the pelvis x-ray the whole pelvis)
• ? spine
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
A.P. pelvis
D Swain BSc; FRCSI; FRCS (Orth.)
Inlet view
D Swain BSc; FRCSI; FRCS (Orth.)
Outlet view
D Swain BSc; FRCSI; FRCS (Orth.)
CT
• Not necessary in acute situation- unless surgeons want one
• Useful to assess posterior damage
• Useful to assess reduction
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
Contrast studies
N.B.
• Signs of urethral damage
• Urethrogram
• If in doubt – suprapubic
catheter
D Swain BSc; FRCSI; FRCS (Orth.)
Angiography / embolisation
• Has been used for
> 20 years
• Indications and / or
timing controversial
• Availability may be
an issue
D Swain BSc; FRCSI; FRCS (Orth.)
Young and Burgess
• LATERAL COMPRESSION
• AP COMPRESSION
• VERTICALLY UNSTABLE
D Swain BSc; FRCSI; FRCS (Orth.)
Lateral compression
• I - sacral impaction, stable
• II - disruption of posterior structures, vertically stable
• III - injury to contralateral hemipelvis
D Swain BSc; FRCSI; FRCS (Orth.)
A.P. compression
• I - less than 2.5cm diastasis, no posterior injury
• II - greater than 2.5cm, opening of sacroiliac joint, vertically stable
• III - complete disruption, unstable
D Swain BSc; FRCSI; FRCS (Orth.)
Vertical shear
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
Pelvic - related Haemorrhage
Options to try and control haemorrhage include:
• Mechanical stabilization
• Angiography / embolisation
• Pelvic packing
Pelvic binding
• Rapid and easily
applied
• Effective
• Can produce skin necrosis
D Swain BSc; FRCSI; FRCS (Orth.)
External fixation
• Many variations
• Poor control of posterior pelvic injuries
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)
Inlet view
Outlet view
D Swain BSc; FRCSI; FRCS (Orth.)
Pelvic clamps
• Attempt to address
posterior pelvic
displacement
• High rate of
complications
D Swain BSc; FRCSI; FRCS (Orth.)
Open pelvic fractures
“Pelvic “ volume is now unlimited
D Swain BSc; FRCSI; FRCS (Orth.)
Open pelvic fractures
D Swain BSc; FRCSI; FRCS (Orth.)
D Swain BSc; FRCSI; FRCS (Orth.)AP pelvis
Outlet
view
Inlet
view
D Swain BSc; FRCSI; FRCS (Orth.)
Future developments
• Identify the fracture patterns likely to continue to bleed
• Identify features which guide treatment choice
• Pharmacological manipulation
D Swain BSc; FRCSI; FRCS (Orth.)