Pelvic Fractures and Associated Injuries
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Transcript of Pelvic Fractures and Associated Injuries
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Pelvic Fractures and
Associated InjuriesDr Huw Williams MB BCh MCEM
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1o Survey A
B
C
D
E
2o Survey
3o Survey
Pelvic Injuries in Trauma
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1o Survey A
B
C
D
E
2o Survey
3o Survey
Pelvic Injuries in Trauma
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Pelvic Anatomy
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1. Sacrum
2. Innominate bones
3. Ligamentous complex
Pelvic Anatomy
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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
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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
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Where can we bleed from?
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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
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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
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How much blood can we lose into our pelvis ?
1 litre ?
2 litres ?
3 litres ?
4 litres ?
5 litres ?
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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)
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Mechanism of Injury and Classification
Three mechanisms
i. AP Compression Injury
ii. Lateral Compression Injury
iii. A Shear Force Injury
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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
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How:
RTC (car vs. peadestrian / motor-cycle crash)
direct crush injury
fall (>12ft)
i. AP Compression Injury
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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
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How:
RTC (motor-cycle crash)
Direct compression / crush
ii. Lateral Compression Injury
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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
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How:
falling from a height onto one limb
RTC
iii. Shear Force Injury
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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
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Tile Classification
Young Classification
Ross Classification
iv. Combination
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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
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Assessing the Pelvis‘Springing the Pelvis’
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‘Springing the Pelvis’
Assessing the Pelvis
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Direct Peritoneal Lavage
Assessing the Pelvis
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Direct Peritoneal Lavage
Assessing the Pelvis
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PR for ? high-riding prostate
Assessing the Pelvis
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PR for ? high-riding prostate
Assessing the Pelvis
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Inspect flanks, scrotum, peri-anal area ?blood at meatus / ?swelling / ?bruising / ?deep laceration
Major disruption
Leg length discrepancy
Distending Abdomen
Signs
Assessing the Pelvis
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Tachycardia
Hypotension
Abdominal Pain
Pelvic Pain
Symptoms
Assessing the Pelvis
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Plain film PXR BONE
eFAST BLOOD
CT BONE / BLOOD
Angiography / CT angiography BLOOD
Imaging
Assessing the Pelvis
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
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-VE FAST
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
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+VE FAST
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
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Plain film CT Scan CT 3D reconstruction
CT
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Plain film CT Scan CT 3D reconstruction
CT
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CT
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Angiography / CT Angiography
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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
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Definitive Management of the Pelvis
Surgery stem bleeding / fix pelvis / pack pelvis
Angiography plus iatrogenic embolization
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Conclusion
Assume there is not a isolated pelvic injury
Assume the worst
Early intervention / minimal pelvis movement once splinted
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Thankyou
Any Questions?
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1. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36:1.
2. 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.
3. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005; 190:830.4. Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury
register. J Trauma 2008; 64:449.5. Cannada LK, Taylor RM, Reddix R, et al. The Jones-Powell Classification of open pelvic fractures:. J Trauma Acute Care Surg 2013;
74:901.6. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom
perspective. J Trauma 2007; 63:875.7. 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
and outcomes. J Am Coll Surg 2002; 195:1.
References