Complex pelvic trauma General Surgery Lecture

1. ‫الرحمن‬ ‫هللا‬ ‫بسم‬
‫الرحيم‬

3. IMPORTANCE
1. Complex anatomic relation,
pathway of nerves and vessels
networks.
2. Substantial force.
3. There are many organs in it.
4. Connects to abdominal and
retroperitoneal space.

6. FRACTURE PELVIS
Depending on the mechanism and
the severity of trauma to the
pelvic region , lesions may be
limited to osteo-articular
structures, or they may be
complicated by injuries to
adjacent soft tissues.

8. 1. Fractures Outside pelvic
ring
2. Single fr. of pelvic ring
3. Double fr. of pelvic ring
• ant.& post. segments
• double breaks in ant. segm
4. Lateral wall fracture
• acetabular
• segmental
PELVIC FRACTURES CLASSIFICATION

10. 1- Fracture outside
pelvic ring
i. Avulsion of
apophyses
ii. Fr. Iliac wing
iii. Fr. Sacrum
iv. Fr. coccyx
FRACTURE PELVIS ( CONT.)

12. LATERAL COMPRESSION
Sacral compression

13. LATERAL COMPRESSION
Sacral compression

14. 2- Single fr. Of pelvic
ring
• Clinical
• Local pain
• Bruising , tenderness
• Springing of pelvis is
painful
 Treatment
• Rest in bed
FRACTURE PELVIS ( CONT.)

16. 2- Single fracture
dislocation Of
pelvic ring
FRACTURE PELVIS ( CONT.)

17. 3- Double fr. Pelvic ring
Types :
i. Combined breaks in
both ant. and post.
segments
ii. Double breaks ant.
segment
FRACTURE PELVIS ( CONT.)

18. Double breaks in the anterior segment of the
pelvic ring

19. 3- Double fracture
pelvic ring
• Complications
i. Posterior urethra inj.
in male
ii. Extra-peritoneal
rupture of urinary
bladder
iii. Injury of rectum
FRACTURE PELVIS ( CONT.)

20. FRACTURE PELVIS ( CONT.)
3- Double fracture pelvic ring
• Complications
iv. The vagina
v. Nerve roots
vi. Pelvic arteries and veins , blood loss
up to 2.5 liters .

22. COMPLEX PELVIC TRAUMA
Are due to severe direct
violence or duo to force
transmitted indirectly
through the lower
extremities .

23. COMPLEX PELVIC TRAUMA
Results usually from road
traffic accidents or
 A fall from a height .

25. COMPLEX PELVIC TRAUMA
Fracture boney pelvis
Injury of important structures :
o vascular , arterial , venous ,DVT . nerves
o visceral injury , urinary bladder , urethra ,
rectum , anal canal
o paralytic ileus
o Malunion
o Secondary osteoarthrosis

26. COMPLEX PELVIC TRAUMA
The extent of associated
injuries must be
determined at once by
physical and X-ray
examinations .
Hypovolemic shock
is the most urgent
problem to investigate and
treat .

28. FRACTURE PELVIS ( CONT.)
Clinical picture
o Shock – neurogenic& hypovolemic
o Retro-peritoneal hemorrhage.
oPain around pelvis
o External rotation of one leg
oA gap in symphysis pubis

30. DIAGNOSIS
1. General: abrasion, contusion,
hematoma, over bony prominence
of pelvis, scrotal, vulvar hematoma.
2. PE: Rectal vaginal laceration
3. X-ray
4. CT for subtal fracture and or
retroperitoneal hemorrhage.

31. CT SCAN
Better defines posterior injury
Amount of displacement versus impaction
Rotation of fragments
Amount of comminution
Assess neural foramina

32. CT SCAN

33. 3D CT

35. FRACTURE PELVIS ( CONT.)
Management
o The principles and priorities of trauma management
is followed
o Correction of shock
o Treatment of soft tissues injuries .
o Treatment of fracture
• Skeletal traction on leg
• Closed reduction by pelvic sling
• Open reduction and internal fixation.

36. TRAUMA CARE PRINCIPLES
Steps
A.Airway and cervical spine control
B.Breathing
C.Circulation with haemorrhage control
D.Disability – brief neurological
assessment
E.Exposure and Environment

37. MANAGEMENT I
1. Prehospital- transport with bed
sheet, MAST, pelvic clumps.
2. ABC( 2nd -intubation, IV line,
monitor, transfusion)
3. Evaluation of intra-abdominal
bleeding.

38. MANAGEMENT I
The G suit is used to maintain
blood pressure during the critical
period of investigation of the
bleeding source .
Angiography is most helpful
Angiographic embolization is used
in selected cases .

39.  back

40. MANAGEMENT II
I. Constant reassessment to
avoid late bleeding
II. FAST (Focused Assessment
with Sonography for Trauma)
1.stable with positive finding
non op.

41. MANAGEMENT III
III. Angio or external fixation ???
1.Angio for large blood loss and
hematoma or vessel injury showed by
CT.
Angiographic embolization in
selected cases

42. MANAGEMENT III
III . Angio or external fixation ???
2.external fixation for fast
stabilization of the structure.
IV. OR if patient is unstable with
FAST or DPL positive finding.

44.  Urinary bladder injuries
o Types and clinical
pictures
1. Extra-peritoneal rupture
a- hypovolaemic shock
b- urine collect in the
retro-pubic space giving
intence desire to void, but
few drops of blood stained
urine , or non
COMPLEX PELVIC TRAUMA
Extra-peritoneal rupture of
urinaty bladder

45. COMPLEX PELVIC TRAUMA
Urinary bladder injuries
oTypes and clinical pictures
1.Extra-peritoneal rupture
a- hypovolaemic shock
b- urine collect in the retro-pubic
space giving intence desire to void, but
few drops of blood stained urine , or non .

46. COMPLEX PELVIC TRAUMA
Urinary bladder injuries
1.Extra-peritoneal rupture
c- Supra-pubic boggy swelling of
urine between the peritoneum and fascia
transversalis .
d- Prostate in its normal position by
P-R .

47. Extra-peritoneal rupture bladder

48. Urinary bladder injuries
o Types and clinical
pictures
o 2- Intra-peritoneal
rupture
a)Shock
b)Severe oliguria or anurea
c)Peritonism and later
peritonitis
d)Fullness in rectovesical
pouch by P-R .
COMPLEX PELVIC TRAUMA

49. Intra-peritoneal rupture bladder

50. COMPLEX PELVIC TRAUMA
Urinary bladder injuries
oInvestigations
a.Plain X-ray show fracture pelvis
b.I.V.U to exclude other urinary injuries and
non filling urinary bladder .
c.Ascending cystogram to show the dye leak .
oD D
Intra-pelvic complete rupture posterior urethra
In which the prostate migrate up from the pelvis

51. COMPLEX PELVIC TRAUMA
Urinary bladder injuries
oTreatment
i. Emergency surgery –lower mid line
incision
ii. Expose the bladder tear --- trim the
edges ---close in two layers by vicryl or
catgut .
iii.Antibiotic prophylaxis
iv.Treat the pelvic fracture .

53. Urethral injuries
o Sites
1. Anterior urethra
(bulbous)
2. Posterior urethra
(prostatic and
membranous)
Both may be complete or
incomplete , total or partial .
COMPLEX PELVIC TRAUMA

54. Rupture posterior ( membranous ) urethra

55. COMPLEX PELVIC TRAUMA
oClinical features
a.Hypovolaemic shock
b.Patient feel desire to void , but no
urine
c.Drops of blood at external meatus
d.Floating prostate by P-R
e.Distended urinary bladder
f.No catheter done

56.  Posterior
membranous urethra
o Complications
i. Hypo-volaemic shock
ii. Extra-peritoneal
extravasation of urine
iii. Injury of external sphincter
iv. Injury of the nerve to
corpora cavernosa leading
to impotence
v. Urethral stricture
COMPLEX PELVIC TRAUMA
Rupture membranous
urethra with floating
prostate

57. Rupture
membranous
urethra with
floating prostate

58.  Posterior
membranous
urethra
oTreatment
a.Treat shock
b.Supra –pubic
cystostomy
c.Treat pelvic fracture
d.Treat urethral
stricture later on
COMPLEX PELVIC TRAUMA
Supra-pubic cystostomy

59. Supra-pubic cystostomy

61. Anatomy
Promontary of sacrum
to anus
•intraperitoneal
•extraperitoneal
Length ~12-20 cm.
RECTAL INJURIES

62. Anatomy
Anal canal
Anorectal ring to anal
verge
Sphincter complex
puborectalis muscle
external sphincter
internal sphincter
RECTAL INJURIES

63. RECTAL INJURIES
Treatment
1.Intra-peritoneal rectal injuries;
as colonic injuries
2.Extra-peritoneal rectal injuries ;
a) Diversion
b) Debridement
c) Distal washout
d) Presacral drainage

64. 1- Diversion
1. Loop colostomy
2 .Loop colostomy with
stapling distal lumen
3 .End colostomy with
mucous fistula
4 .Hartmann’s procedure
RECTAL INJURIES

65. RECTAL INJURIES
. 2- Debridement :
remove devitalized tissue
repair defect if possible
severe injury ; resection
3- Distal washout :
decrease septic complication

66. 4- Presacral
drainage
RECTAL INJURIES

68. EXTERNAL FIXATION
1. Advantages
It helps tamponade bleeding from bone
edges .
Stabilizing the clots and the bone.
Could be done in 20 min.
2. Disadvantages
Can’t stop arterial bleeding. Delay the
embolization for ongoing arterial
hemorrhage.
Degrade the quality of CT and angio.
.

69. FRACTURE PELVIS ( CONT.)
EXTERNAL FIXATION
1. Advantages
i- It helps tamponade bleeding
from bone edges .
ii- Stabilizing the clots and the
bone.
iii- Could be done in 20 min.

70. FRACTURE PELVIS ( CONT.)
EXTERNAL FIXATION
2. Disadvantages
i- Can’t stop arterial bleeding.
ii- ii- Delay the embolization for
ongoing arterial hemorrhage.
iii- Degrade the quality of CT and
angiography.

72. ”
Internal fixation

73. Internal fixation

75. ‫هلل‬ ‫الحمد‬