Pelvic Fractures 2 nd Northern Trauma Network Conference

1. Pelvic Fractures2nd Northern Trauma Network Conference P Fearon Consultant Orthopaedic Trauma Surgeon - RVI

2. Overview • Identify the priorities of life saving, limb saving, and disability-limiting surgery • Outline the general and local factors affecting decision-making • Importance of teamwork

4. Orthopedic and trauma surgeons naturally concentrate on the fracture • It is vital to realise that there are other factors that may dominate decision making in the management of a particular fracture

5. Injury Patient Care team Resources

6. Injury • Fracture • Vascular injury • Compartment syndrome • Open wound • Crush injury • Nerves • Patient • Previous Condition • Age (physiologic) • Diagnoses • Medications! • Other injuries • Physiologic response • Expectations/needs • Resources • OR • Instruments • Implants • Imaging • ICU • (Other Patients) • Care Team • Surgeon • Assistants • Anesthesia • Other specialties • OR nurses • Postoperative • Rehabilitation • Social supports

7. Classification systems Survivors Non-survivors

8. Non-survivors Early Death Late Death Haemorrhage Brain injury Sepsis MOF Bleeding # bones, venous plexus, arterial injury, extra-pelvic sources

9. Survivors • Mental health problems • Chronic pain • Pelvic obliquity • Leg length discrepancy • Gait abnormalities • Sexual & urological dysfunction • Long term unemployment

10. Pre-Hospital • Goals:- • Early suspicion • Identification – no need to spring/log roll • Management

13. Pelvic immobilisation should be routine MOI Symptoms Clinical findings • deformity, bruising or swelling over the bony prominences, pubis, perineum or scrotum. • Leg length discrepancy or rotational deformity of a lower limb (without fracture in that extremity) may be evident. • Wounds over the pelvis or bleeding from the patient's rectum, vagina or urethra may indicate an open pelvic fracture. • Neurological abnormalities may also rarely be present in the lower limbs after a pelvic fracture.

14. Ease of application Access for intervention Shown just as good as external fixators

15. Prevent re-injury from pelvic motion (clot disruption) • Tamponade bleeding pelvic bones & vessels • Decrease pain • Decrease pelvic volume (lesser)

16. ED • Resuscitation / Management • MHP • WBCT – trauma series • TEAM • TEAM TEAM TEAM

17. Illustrated case • 29 yr female • Motor cyclist • GCS 14/15 • BP 90/40 • Hr 110 • PV bleeding • Binder applied

18. Pathway • Resuscitation on going via CT scanner

20. All bets off! Team Huddle – Senior Decision making Modify Plan

21. Aorta stented • Evaluation of coeliac • Common hepatic • Left hepatic • Both internal iliac • Left pudendal branch embolised (anterior division of internal iliac)

24. Prehospital • ED • ITU & anaesthetics • Ortho • Gen Surg • HBP • CT/radiology • Interventional radiology • Urology • Rehab • Pain team • Sexual dysfunction clinic • Clinical psychology Holistic Approach Improve disability

25. How much blood loss from pelvic #? • WBV • (true pelvic vol 1.5L, but ↑ with disruption) • Retroperitoneal space 5L • Loose tamponade effect/disruption parapelvic fascia • Escape into peritoneum & thighs

26. AttachmentSize ? Arterial Bleeding • MOI • Open fractures • Elderly patients (gluteal injuries) • Sacrum/SIJ, symphyseal separation–gluteal, pudendal • CT scan – vascular blush/large haematoma≡sig bleed Head on collisions Jumpers

27. Binder MHP Trauma CT Urology Coordinated Team Approach Surgery Pelvic fixation Holistic Rehab

28. Isolated haemodynamically unstable pelvic trauma uncommon • Associated injuries due to high MOI • Resuscitation/intervention team based with better understanding & cooperative team working – surgeons included

29. Thank you