pelvic fractures and associated injuries dr huw williams mb bch mcem
TRANSCRIPT
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?
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 ?
‘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
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
What Happens:
high-energy applied in a vertical plane
major instability of pelvisVertical Shear
Frequency = 5 to 15%
iii. Shear Force Injury
iv. Combination
i. 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
Inspect flanks, scrotum, peri-anal area ?blood at meatus / ?swelling / ?bruising / ?deep laceration
Major disruption
Leg length discrepancy
Distending Abdomen
Signs
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
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
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
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References