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Pelvic Ring Fractures

Pelvic Ring Fractures. Christy Johnson. Outline. Background Anatomy and Function Assessment Radiology Classification Treatment. Background. Mechanism: high energy blunt trauma Mortality rate: 15-25% for closed fractures Up to 50% for open fractures

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Pelvic Ring Fractures

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  1. Pelvic Ring Fractures Christy Johnson

  2. Outline • Background • Anatomy and Function • Assessment • Radiology • Classification • Treatment

  3. Background • Mechanism: high energy blunt trauma • Mortality rate: • 15-25% for closed fractures • Up to 50% for open fractures • Hemorrhage is the leading cause of death overall • Venous (80%) > arterial • Have a high index of suspicion for injury of internal iliac vessels or lumbosacral plexus

  4. Background • Associated injuries: • Chest injury (63%) • Long bone fracture (50%) • Head and abdominal injury (40%) • Spine fractures (25%) • Urogenital injuries in 12-20% • Survivors: 1.89 additional injuries • Non-survivors: 2.95 additional injuries • Only 2 in 14 deaths (14%) are directly attributable to pelvic injury

  5. Ilium Sacrum Pubis Femur Ischium Anatomy: Osteology

  6. Osteology • Ring structure made up of the sacrum and two innominate bones • No inherent osseous stability

  7. Iliacus Piriformis Pectineus Sartorius Rectus femoris Adductor longus Adductor brevis Adductor magnus Anatomy: Muscles

  8. Ligaments • Anterior structures: provide 40% of stability • Posterior structures: provide 60% of stability

  9. Sacrospinous Ligament: Resist ER Pelvic Stabilizers Iliolumbar: Augment posterior stability • Posterior interosseous sacroiliac ligaments are the strongest in the body Sacrotuberous Ligament: Resist ER and Vertical shear

  10. Assessment • Primary Survey • Airway • Breathing • Circulation • Disability • Exposure • Secondary Survey • Pelvis assessed by compression/distraction • Skin evaluation • Smith/Johnson/Cothren et al Journal of Trauma 2007

  11. Resuscitation/ Hemorrhage • 2 large-bore IVs • 2L crystalloid on arrival • Hct/Hgb does NOT correspond to EBL • Hypotension = 30-40% EBL • Patients presenting in shock (SBP<90) have mortality rates up to 10 times that of normotensive patients • Starr et al JOT 2002

  12. Sites of Hemorrhage • External bleeding controlled by direct pressure • Thoracic cavity evaluated by CXR for hemothorax: chest tube if necessary • Abdominal cavity evaluated by a FAST or CT scan in stable patients or ex-lapin unstable patients • If other causes eliminated, then EBL likely from pelvis • Blood replacement as indicated by response to fluid resuscitation • Ratio of FFP: PRBC/ 1:1.5 associated with decreased mortality and transfusion requirements • Injury 2010

  13. Physical Exam • Test stability by placing gentle rotational force on each iliac crest • Perform ONCE • Look for external rotation of lower extremity +/- limb-length discrepancy

  14. Physical Exam (continued) • Neurologic exam • L5 and S1 injuries most common • Rectal exam to evaluate sphincter tone and perirectal sensation • Urogenital exam • Concomitant urologic injury 12% of the time • Catheter placement should be preceded by rectal exam, evaluation of meatus, vaginal exam • 57% of men with urethral injury show no signs • Vaginal injuries missed in up to 50% of cases • Vaginal and rectal exams • Mandatory to rule out occult open fracture

  15. Radiographs • Inlet • Outlet • AP Pelvis Oblique/Judet • Obturator oblique • Iliac oblique

  16. Mechanisms of Pelvic Injury • Anterior Compression • Lateral Compression • Vertical Shear • Combined mechanism • Young and Burgess, Rad 1986 • Young and Burgess J Trauma 1989

  17. AP Compression

  18. Anteroposterior Compression

  19. Lateral Compression

  20. Lateral Compression

  21. Vertical Shear

  22. Vertical Shear • Associated with the highest risk of hypovolemic shock, mortality • Usually result from falls from height • Posterior and superior directed force • APCIII + vertical displacement

  23. Mortality from Pelvic Injuries • Hemodynamic instability + pelvic fracture = 40% mortality • Major cause of death: Hemorrhage (15%) • Major cause of death LC injuries: closed head injuries • Major cause of death APC: combined pelvic and visceral injuries • Hemorrhage in pelvic injuries • Venous bleeding more common than arterial bleeding • Superior gluteal artery (most common arterial injury in APC) • Internal pudendal artery (most common in LC) • Metz et al OrthopClin N Am 2004 • Smith et al J Trauma 2007

  24. Circumferential Pelvic Antishock Sheeting • Rapid, inexpensive, temporary means of decreasing pelvic volume • Indications: initial management of an unstable ring injury • Risk of bladder injury in pelvic fractures with internal rotation component (i.e. LC injuries) • Technique: center over greater trochanters (NOT iliac crest/abdomen)

  25. External Fixation • Advantages: • Decreases pelvic volume • Stabilization of pelvis • Indications: • Pelvic ring injuries with an external rotation component (APC, VS) • Unstable ring injury w/ ongoing blood loss • Contraindications • Ilium fracture that precludes safe application • Acetabular fracture • Technique: Iliac wing or supra-acetabular pins • EgbersOrthopade 1992

  26. Angiography/ Embolism • Small percentage of pelvic fractures have significant arterial injuries amendable to angio (10%) • Must have stabilized pelvis (pattern or ex-fix) because most bleeding is venous which will tamponade • Eliminate other sources of bleeding • Successful in 70-90% of cases but takes 3-4hrs

  27. Treatment Overview • Nonoperative • Indicated for mechanically stable pelvic ring injuries • LC1: anterior impaction fracture of sacrum and oblique ramus fx with <1cm of posterior ring displacement • APC1: widening of symphysis <2.5 cm with intact posterior pelvic ring • Isolated pubic ramus fx • Operative • Anterior ring stabilization: Symphyseal fixation • Posterior ring stabilization • Anterior or posterior SI joint fixation • Sacral bar • Iliac wing fixation

  28. Treatment Comparison

  29. Tenets of Fixation • Complete instability of posterior ring: • Anterior fixation alone is inadequate for maintaining reduction • Complete instability of posterior ring with vertical (cephalad) displacement • Posterior fixation should be supplemented with anterior stabilization • Posterior injury is regarded as the more critical and in need of accurate reduction with stable fixation • Reduction generally proceeds from back to front

  30. Summary • Pelvic ring injuries are highly associated with other injuries • Evaluation of pelvic stability is critical and requires an understanding of mechanism of injury, a careful examination, and scrutiny of radiographic imaging • Management requires an interdisciplinary approach and may be life saving

  31. Questions? • Thanks to: • Dr. Helfet • Matt Griffith • Chris Mattem • Milton Little

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