Pelvic Fractures and Associated Injuries

Pelvic Fractures and Associated Injuries Dr Huw Williams MB BCh MCEM

Pelvic Injuries in Trauma • 1o Survey A • B • C • D • E • 2o Survey • 3o Survey

Pelvic Anatomy

Pelvic Anatomy Sacrum Innominate bones Ligamentous complex

Pelvic Fractures in Trauma • 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 • 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

Where can we bleed from?

Where can we bleed from? • Pelvic venous plexus • Pelvic arterial injury • Fracture bone surfaces • Any visceral injury • Remember: extra-pelvic injuries

How much blood can we lose into our pelvis ? 1 litre ? 2 litres ? 3 litres ? 4 litres ? 5 litres ?

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)

Mechanism of Injury and Classification • Three mechanisms  • AP Compression Injury • Lateral Compression Injury • A Shear Force Injury

Mechanism of Injury and Classification • Three mechanisms four patterns • AP Compression Injury • Lateral Compression Injury • A Shear Force Injury • A Combination

i.AP Compression Injury • How: • RTC (car vs. peadestrian / motor-cycle crash) • direct crush injury • fall (>12ft)

i.AP Compression Injury • 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 %

ii.Lateral Compression Injury • How: • RTC (motor-cycle crash) • Direct compression / crush

ii.Lateral Compression Injury • 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 %

iii.Shear Force Injury • How: • falling from a height onto one limb • RTC

iii.Shear Force Injury • How: • falling from a height onto one limb • RTC • What Happens: • high-energy applied in a vertical plane  • major instability of pelvis Vertical Shear Frequency = 5 to 15%

iv.Combination Tile Classification Young Classification Ross Classification

iv.Combination • AP Compression Injury  • ? major haemorrhage of the venous plexus / internal iliac artery • Lateral Compression  • injury to bladder/urethra/other / ↓ pelvic volume therefore ? ↓ haemorrhage • A Shear Force  • high-energy / major instability

Assessing the Pelvis ‘Springing the Pelvis’

Assessing the Pelvis Direct Peritoneal Lavage

Assessing the Pelvis PR for ? high-riding prostate

Assessing the Pelvis Signs • Inspect flanks, scrotum, peri-anal area • ?blood at meatus / ?swelling / ?bruising / ?deep laceration • Major disruption • Leg length discrepancy • Distending Abdomen

Assessing the Pelvis Symptoms • Tachycardia • Hypotension • Abdominal Pain • Pelvic Pain

Assessing the Pelvis Imaging • Plain film PXRBONE • eFASTBLOOD • CT BONE / BLOOD • Angiography / CT angiography BLOOD

PELVIC X-RAY PLAIN FILM • AP Compression Injury • Lat. Compression Injury • A Shear Force Injury • A Combination • Normal

FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA -VE FAST

FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA +VE FAST

CT Plain film CT Scan CT 3D reconstruction

Angiography / • CT Angiography

Pelvic Fractures and Associated Injuries