3. Background
• Represent 3% of all skeletal injuries
• About 25% in the polytrauma patients
• About 42% of traffic related fatalities
• Increasing mortality up to 50% with:
Hemodynamically unstable patients
Concomitant head, chest and major
abdominal injuries.
Open pelvic fractures
Age > 65
• Pelvic injury must, therefore, be looked as
an indicator of a major trauma
4. Assessment of Pelvic Injury Patient
• Assess the patient haemodynamic stability (ATLS)
• History i.e mechanism of injury
• Patient Presentation (Signs and Symptoms)
• Physical examination;Assess pelvic organs and associated injuries
• Assess the fracture
6. Primary survey: ABC’s
Airway maintenance with cervical spine
protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/environment control: undress patient
but prevent hypothemia
7. History
• Mechanism of injury (classification scheme and associated injuries)
High energy
Motorcycle accidents and motor vehicle pedestrian accidents are the
most common mechanisms
although falls, motor vehicle collisions, equestrian accidents, and
crush injuries also result in pelvic ring injuries.
A fall from standing height- elderly.
8. Importance of Mechanisms of Injury
• APC
Increased incidence in thoracic aorta injuries when compared to
patients with blunt trauma without pelvic ring fracture.
APC III injuries are associated with a high rate of circulatory shock
(67%) and greater blood loss and transfusion requirements than other
injury patterns.
In patients who are hemodynamically unstable there is a higher
incidence of acute respiratory distress syndrome (ARDS) (18.5%),
sepsis (59%), and death (37%).
9. • LC
Associated with a high incidence of head injury (50%).
The most severe, LC III, which can occur from a rollover mechanism,
is associated with a 20% risk of bowel injury, 40% incidence of
concomitant lower extremity fracture, and 60% presence of a
retroperitoneal hematoma.
10. • VS
injuries have a high risk of hypovolemic shock (63%), mortality
(25%), head injury (56.2%), lung injury (23%), and splenic injury
(25%).
• Multidisciplinary approach to effectively and efficiently manage the
multiple injuries.
11. Associated Pelvic Injuries
• chest injuries (63%),
• long bone fractures (50%),
• head injury (40%),
• solid organ injury (40%), and spinal fracture (25%).
• Intestinal injuries are also encountered in up to 14% .
12. Physical Examination
• Inspection
• Assess pelvic stability manually (once)
• Genitourinary system
• Open fractures and GIT
• Lower extremity neurologic deficits
• Other associated injuries
13. Inspection
• Scrotal swelling,labial or perineal hematoma
• Ecchymosis
• Flank hematoma
• Lacerations of perineum.
• Leg length inequality
• External rotation of one or both extremities
• Degloving injuries (Morel-lavallee lesion).
• Rectal and vagina lacerations (overlooked but indicative of severe
injury)
14.
15. • VS Injuries
Lower extremity shortening and external rotation of the affected side
• Unstable LC injuries
Internal rotation deformity of the lower extremity
• APC injuries
Scrotal edema
16. Manual Palpation
• Manual compression along iliac crests provides a tactile assessment
of pelvic stability.
• Can reveal crepitus from fractures and can assist with determination
of pelvic stability.
17. Genitourinary Tract
• Bladder and Urethral injuries occur in 6% to 15%
• Male patients have a higher incidence of urethral injury compared to
female patients.
• Anterior portion is common compared posterior portion in male.
• Posterior portion 10 to 20% associated with bladder rupture.
• Vaginal injuries: has a remarkably low incidence of injury, ranging
from 0% to 5%.
18. • Blood at the external urethral meatus
• Perineal and genital swelling
• DRE-high-riding prostate for male-urethral disruption.
• Vaginal exam
19. Bladder injury
• Extraperitoneal bladder rupture (EPBR)
common.
urine may communicate with the pelvis.
Suprapubic catheter or direct repair.
An intraperitoneal bladder rupture (IPBR), which is often caused by
compression on the distended bladder resulting in rupture of the
dome, communicates with the peritoneal cavity but will not
contaminate the pelvis.
Ex-lap and repair
20. • Bladder injuries occur in up to 10% of pelvic ring injuries, with
approximately 60% EPBR, 30% IPBR, and 10% both.
• Because the amount of force required to rupture hollow structures,
such as the bladder, is so high, the associated mortality has been
reported anywhere from 22% to 34%.
• Gross hematuria common clinical findings.
21. Open Pelvic injuries and GIT
• Fragments can penetrate soft tissues and resulting in direct
communication with external environment to open fracture 5%.
• In addition, the bony fragments may cause direct damage when in
contact with the visceral cavity.
• These open pelvic ring injuries are often contiguous with the vagina
or rectum resulting in contamination
• This can significantly increase the number of complications including
osteomyelitis, deep pelvic infection, long-term disability, and
mortality
22. • A digital rectal examination and a vaginal examination should be
performed in female patients.
• Open wounds may occur anywhere along the course of the iliac crest
or through the perineum.
• Open pelvic ring injuries with fecal contamination have been
associated with a high mortality rate of up to 50%; therefore, early
recognition and appropriate therapeutic interventions are required.
23. Neurological Exam
• Rectal examination
• Rectal tone and bulboarvenous reflex
• Peripheral nerve examination i.e L5 & S1 nerve roots (sacral
fractures)
• Foot drop
28. References:
• Purnendu Saxena, Harshal Sakale1 , Alok C. Agrawal2 Consultant
Orthopaedic Surgeon, Visharad Hospital, 1 Assistant Professor Pt.
Jawahar Lal Nehru Memorial Medical College, 2 Professor and Head
of the Department, All India Institute of Medical Sciences, Raipur,
Chhattisgarh, India.
• Ebookmedicin_2020_Rockwood
Editor's Notes
Initial evaluation
A-Airway evaluation and management:ensuring patient is adequately moving air as well as oxygenating appropriately.
B-bilateral chest movement
Circulation: ??hemorrhage sbp less than 90mmhg,sources of hemorrhage must be identified. Fast,ct,dpl
Secondary survey other injuries can be identified.
Mechanism of injury helps to elucidate associated pelvic injuries.
Help a trauma surgeon to predict other associated injuries.
The sources of bleeding include iliac vessels and their branches, low pressure venous plexus, and fractured cancellous bone surfaces
The female urethra is short and adjacent to the vagina, which protects it from injury by the pelvic ring fracture.54,276 In addition, the vagina has a remarkably low incidence of injury, ranging from 0% to 5%.277 The male urethra is divided into anterior and posterior portions, with the latter being more commonly injured from shearing forces rather than by direct laceration from bony fragments.63,314 In posterior urethral injuries, there is a 10% to 20% associated incidence of bladder rupture.
Rectam exam,rectal tone and bulbocarvenous reflex are assessed to rule out spinal cord injury.
In female:gently tugging on the foley catheter,
