Pelvic Fracture

1. Pelvic Fracture 2nd Affiliated Hospital, School of Medicine, Zhejiang University orthopedics department Li Hang

2. Pelvis is a bone structure which joins the bear lord, truncus and lower limbs, and in which there are some organs including important great vessels, rectum, bladder, urethra and so on.

3. Epidemiology Anatomy Imaging Classification Treatment Complications Outline

4. 2-3% in fracture Most are high energy injuries The severity depends on the energy of trauma( It is more common young people are more with high energy, while elderly people are more with fall for osteoporosis). In complex pelvic fractures, 50% <30 years old, 77% <50 years old, and M:F=3:1. Serious high-energy pelvic fractures are more resulted from crush accident, fall, occupational injury. Epidemiology

5. The pelvis is a ring-like structure composed of sacrum and two innominatums. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis). Anatomy

6. The pelvicring makes up to three joints. The stability depends on not integrity of bone, but also circumjacent ligaments, especially sacroiliac ligament, sacrotuberous ligament, sacrospinous ligament, which are the key ligament for pelvic stability.

8. 1Extrusion violence before and after Injury Mechanism Anterior is pubic symphysis separation, and posterior is sacroiliac joint dislocation.

9. 2 Lateral extrusion violence Anterior is pubis fracture, and posterior is sacral fractures .

10. 3 Vertical shear violence Result in upward shift of ilium, sacroiliac joint or sacral.

11. 4 Mixed violence Result in the diversity of fractures and dislocations.

12. 1 Injury history of high energy 2 Pain 3 Deformity 4Hemodynamic instability or shock 5 The urethra and bladder injury 6 Lumbar di nerve damage 7 The injury of anus and rectum 8 Complicated with other parts of the fractures Clinical Manifestations And Diagnosis

13. High-energy injuries can induce serious complications, in which peritoneal hematoma takes up 75%, injuries of urinary system takes up 12%, lumbar di nerve damage takes up 8%, and incidence of vascular injury was 8 times of in low-energy injury.

14. Don't only simply examine the pelvic situation in pelvic fracture. Examine carefully from head to toe. It is implied to be open pelvic fractures when complicated with injury of bladder, urethra, anus and rectum damage.

16. X-ray 1 AP view X-ray CT

17. Inlet view

18. Inlet view Judgebefore and after the shift, iliac pronation or supination, and sacrum and sacral wing fractures.

19. OUTLET VIEW

20. Judge Sacrum upward shift and sacral foramina.

21. CT is an important examination for pelvic fracture, which could judge the stability of the posterior pelvic ring, rotation of the pelvis, sacral fractures, and by a small fracture of the sacral foramina, relationship between pubic bone fracture and acetabulum, and so on. Three-dimensional reconstruction of CT can present the pelvis completely, intuitively and stereoscopically, which is of guiding significance to treatment. （Attention: CT exam should be take after hemodynamic stable.） CT

22. The common classification of pelvic fracture is based on the main site of pelvic fracture, damage the direction of violence, and the stability of the pelvis. Classification of pelvic fracture

23. 1 According to the direction of the violence of the injury-Younghe Burgess classification（1987）

24. Lateral compression Type LC-1: Pubis fracture + sacral compression Ligament is integrated , and the pelvis is stable.

25. LC-Ⅱ:iliac ring fracture Ligament rupture pelvic is instable, but the vertical is stable.

26. LC-Ⅲ（windswept pelvic) Ligament is rupture, and pelvic is multi-direction instable.

28. Anterior posterior compression (APC) 1 APC-TypeⅠ Pubic symphysis is separated, but the pelvic ring is stable.

29. APC-TypeⅡ Pubic symphysisseparation or pubic bonefracture; ligament rupture; pelvis rotation instability.

30. APC-Type Ⅲ Pelvic rotation and vertically unstable

31. Vertical shear injury(VS) Pelvic bone structure and ligament is injury, and pelvis is upward shift.

33. CM Mixture ofAPC, LC and VS

34. Tile classificationbased on the stability of the pelvis Type A stable type

35. Type B（The vertical stability and the rotatory instability）

36. Type C（Rotation and vertical instability）

37. Sacral fracture classification Denis classification

38. Treatment

39. Mortality5%-42% Arterial injury 10% hematoma Vein and fracture end90% Retroperitoneal hematoma

40. Fracture pattern associated with risk of vascular injury (Young & Burgess) External rotation and vertical shear injury patterns at higher risk for a vascular injury than internal rotation patterns APC & VS (antero-posterior compression and vertical shear) at increased risk of hemorrhage Pelvic Fractures & Hemorrhage

41. Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control Disability: Neurologic status Exposure/environment control: undress patient but prevent hypothermia Advance trauma life support(ATLS)

42. Pelvic stability and volume control Sheet Pelvic girdle External fixator Vascular thrombosis (Small arteries injuries) Retroperitoneum filling (Bleeding of small arteries, veins and fracture end) Abdominal aortic balloon blocking method（Vascular injury） Laparotomy: Higher failure rate Hematoma control

43. Sterilization

45. Pelvic girdle

46. External fixator

48. Vascular thrombosis

49. Retroperitoneum filling

50. Vessel detection Balloon occlusion of the abdominal aorta