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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.)