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Pelvic Fracture Complications

Pelvic Fracture Complications. E arly complications (Associated conditions) D elayed complications. E arly complications. Multiple trauma. S kull C hest A bdomen E xtremities. Hemorrhage. The most dangerous & life threatening condition

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Pelvic Fracture Complications

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  1. Pelvic FractureComplications Early complications (Associated conditions) Delayed complications

  2. Early complications

  3. Multiple trauma Skull Chest Abdomen Extremities

  4. Hemorrhage The most dangerous & life threatening condition ( hypovolemic shock ) Sources : Retroperitoneal ( Bone- Small & Large vessels ) Multiple trauma (Chest- Abdomen- Long bone Fx )

  5. Epidemiology • Evaluating Pelvic Hemorrhage (EPH) Study – 724 consecutive pelvic fractures at Harborview • 62 % male • Average age = 34 • Mechanism – Motor vehicle crash 57% – Car versus pedestrian 21% – Fall (>3.3 meters) 11% – Crush 5%

  6. • Hemodynamic shock in Emergency Dept. – Blood pressure<90 27% – Pulse>130 30% – Transfuse in ED 29% • Blood requirement – Any 80% – 6 or more units 41% – Range (0 to 171 units) • Death 13%

  7. Sign & Symptom Back pain Abdominal pain Swelling & Echymosis (Flank – Buttock – Inguinal – Perineum ) Hypotension & Shock

  8. X ray X-ray : Soft tissue shadow displacement (Int.obturator, Iliopsoas, Gluteal Fat pad Bladder , Uterus) CT scan : Hematoma Angigraphy :

  9. Fx type APC & VS ( high risk) Artery & Vein Inj. Iliac – Iliolumbar – Sup.Gluteal – Internal Pudental. LC (rare) Fx site – Visceral Inj. Stable Fx (very rare)

  10. Treatment Transfusion Pelvic belt Antishock garment Reduction & Fixation Angiographic embolization

  11. Thromboembolism Pelvic bone trauma & Immobilization Ipsilateral or contralateral Calf – Thigh – Pelvic veins Proximal thrombosis has Greatest risk of embolism

  12. Increased risk of DVT Older age Spinal cord Inj. Lower extremity Inj. History of DVT

  13. Rate MR Venography 35% Thrombosis Contrast Venography 29% Dopler Sonography 9% Pulmonary Embolism 2 – 12% Fatal Pulmonary Embo. 0.5 – 10%

  14. Prophylaxy Routinprophylaxis is mandatory Method is controversial Drug: Aspirin – Warfarin Low dose Heparin Low M.W.Heparin Mechanical devices : Compresion stocking Foot pump Compresion device thigh & leg Vena cava filter

  15. Fat Embolism

  16. Gasterointestinal Inj. Open fracture Deep pelvic infection Retroperitoneal absces Peritonitis High mortality rate

  17. Gasterointestinal Inj. Wound in perineum Blood in rectum More proximal Injury (Contrast CTscan) Direct Inj. (Bone fragment) Indirect Inj. (Ext.Rot. Streching)

  18. Management Irrigation & Debridment Early Colostomy Broad spectrum antibiotic

  19. Gasterointestinal inj. BOWEL OBSTRACTION Paralytic Ileous Entrapment in Fx site

  20. Genitourinary inj. Men > Women Overall Rate 16%

  21. Bladder Contusion …………Rupture Rupture : Gross Hematuria Mortality Rate 22 – 34% 85% Extra peritoneal Vesico colic fistula Foley catheter 15% Intera peritoneal Repair & Foley catheter

  22. Urethral Inj. Men > Women (Vagina & Urethra) Blunt , Avulsion Inj. Commonly Distal to Urogenital Diaphragm - Blood on meatus Triad- Distended Bladder - Inability to void Retrograde Urethrography

  23. Urethral Inj. Repairing time is controversial Primary Repair …….. More Impotence rate Delayed Repair …….. More Stricture rate

  24. NeurologicInj. Lumbosacral & Sacral plexus Inj. Sciatic N. (Proneal) Inj. Post. Pelvic Ring Fx (VS 40 – 50% ) Sacral Fx (Compresion) Foraminal 28% Medial to Foramen 57% APC – VS (Traction)

  25. Management Physical Examination ( Before & After Reduction ) Early Reduction & Fixation of Fx Neurolysis Repair Nerve graft ?

  26. Open Fx Rate 4% Iliac crest wound Rectum & Perineum wound Vaginal wound

  27. Open FxIliac Crest Wound Often minor & stable Fx ( mortality 0 – 5% ) Sometimes APC – VS ( mortality 25% ) Irrigation & Debridment Control of hemorrhage

  28. Open Fx Rectum & Perineum Wound Mortality Rate 44 – 50% Hemorrhage (Packing – Embolization –External Fixation – Hemipelvectomy ) Sepsis (Irrigation & Debridment – Early Colestomy – Packing the wound – Debridment )

  29. Open FxVaginal Laceration Debridment & Repair & External Fixation

  30. Delayed Complication

  31. Post Op. Infection 6% Increased Risk - Open Fx - IlioInguinal Approach - Febrile Patient Percutaneous Screw - Very Rare Open Reduction - Not Common

  32. Treatment - Irrigation & Debridment - Deep Culture - Antibiotic Beeds - Leave the Hardware if possible - External Fixation

  33. Fixation Failure> 1 Cm Displacement Percutaneous Iliosacral Screw 10% Sacral Fx > SI Dx Prevention: - Spinopelvic Fixation - Screw across the Sacrum to far Ileum - Multiple Screw

  34. Fixation Failure Percutaneous Sup. Pubic Ramus Screw 10% - Eldery & Osteoprotic Female - Medial & Shaft Fx > Lateral Fx External Fixator - Pin Loosening - Pin Tract Infection

  35. Sexual Dysfunction Urethral Vascular Neruologic Psychologic Inj. Unstable & Marked Displaced Fx

  36. Men,s Sexual Dysfunction Posterior Urethral Inj. : Impotence Rate 50% Poorly Scored on Sex Drive Erection Ejaculation Satisfication Eldery > Young

  37. Women,s Sexual Dysfunction Ant. Pelvic Ring Fx More Dysfunction Dyspareunia 38% ( > 5mm displacement ) Decreased Interest & Orgasm 45% Dysmenorrhea Vaginal Delivery Problem Incontinence

  38. Other Complications Myositis Ossificant 20% Malunion Up to 90% in Non Operative Method Nonunion ? Ligamentous Inj. may not healed Low Back Pain SI Joint Inj. Chronic Pelvic Pain Sacral Plexus Inj.

  39. Case Reports - Acute Compartment Synd. In Gluteal & Thigh comp. - Gluteal Soft Tissue Necrosis After Angiographic Embolization -Bowel Herniation - Bladder Herniation In Pub. Symphisis Diastasis -Flail Penis In Open Book Fx Due to Suspensory Lig. Inj.

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