4. Epidemiology
~3% of all fractures in ED (Emergency Department)
50-60% secondary to MVA
Motorcycle crashes ~15%
Car vs. pedestrian ~15%
Falls 10-30%
Crush injuries ~5%
( Mortality is about 6 - 50%) :
Mortality 6-10% ; Inc’s to ~50% in unstable pt (prothrombin time)
– 39% due to bleeding (early).
– 30% due to sepsis & multi-organ failure (late).
Complications:
Hemorrhage, neurological injury, deformity, GU injury, GI injury
Mortality quoted tends to be all causes of mortaltiy; less than 1%
will die as a direct consequence of their pelvis fracture.
6. Anatomy of Pelvis
Pelvis contains one pair of fused
bone
Each half contains: ilium, pubis,
and ischium
Joined together in posterior by
sacrum
Joined in anterior by symphysis
pubis
Coalesce at triradiate cartilage.
Ilium, ishium and pubis have three
separate ossification centers that
fuse at sixteen years.
Gap in symphysis < 5 mm
SI joint 2-4 mm
11. Posterior Ligaments
Ant. SI Joint – resist external rotation
Post. SI and Interosseous – posterior stability by tension band
(strongest in body)
Iliolumbar ligaments augments posterior complex
Sacrotuberous (sacrum behind sacro-spinous into ischial
tuberosily vertically)Resists shear and flexion of SI joint
Sacrospinous – (anterior sacral body to ischial spine
horizontally) resists external rotation
12. Normal SI Joint Motion with
Gait
< 6 mm of translation
< 6° rotation
Intact cadaver resist 5,837 N (1,212 lbs)
14. Acetabulum
Divided into 3 columns:
Anterior superior column (= ilium)
Anterior inferior column (= pubis)
Posterior Column (= ischium)
Ant superior column is the
primary weight bearing
structure.
The ant inferior column is thin
and easily fractured.
The post column is thick and
strong but most commonly
fractured.
15. Vascular Anatomy
Vessels lie closely adherent
to posterior pelvic walls
Most common cause of
bleeding is venous
Most commonly injured
arteries are superior gluteal
and internal pudendal aa.
Venous bleeding is most
common because of relative
deficiency in protective
vasospasm, and lack of
valves in pelvis with
extensive collateral
16. Vascular Anatomy
Internal iliac artery
courses medial to the
vein, splits into anterior
and posterior branches.
Posterior branch is
more likely injured (SGA
is largest branch).
Usual bleeding is from
venous plexus.
17. Pelvic Stability
Stability : ability of pelvic
ring to withstand
physiologic forces
without abnormal
deformation.
Physiologic load may be
sitting, side lying, or
standing, as dictated by
patient needs , else
consider as unstable.
Strength of ring: 40%
anterior and 60%
posterior.
Vsphere = 4/3r³.
18. Pelvic Ring Stability
Posterior ring integrity is important in
transferring load from torso to lower
extremities
19. Common Fractures of Pelvis
Pelvic ring fractures
Pelvic ring is likely to separate in more
than one location
Iliac crest fractures
Fractures to upper wing of ilium
Loss of posterior ring integrity leads to
instability
Loss of anterior ring integrity may
contribute to instability, and may be a
marker to posterior ring injury.
Young and burgess classification will
guide us for stability issues
20. Pelvic Fractures
Common mechanisms of pelvic injury result from
high energy
ex. MVC, significant falls, skiing accident
Those at risk for pelvic fractures
Growing teens (especially those involved in
sports)
Elderly patients (osteoporosis)
21. Classification systems
2 most common are Tile and Young systems
Tile Classification system:
Advantages
Comprehensive
Predicts need for operative intervention
Disadvantages
Does NOT predict morbidity or mortality
Young Classification System:
Advantages
Based on mechanism of injury predicts injury
Estimates mortality
Disadvantages
Excludes more minor injuries
22. Tile
:
Classification System
Type A: Stable
pelvis post
structures intact
A1: avulsion injury
A2: iliac wing or ant
arch
A3: Transverse
sacrococcygeal
24. Tile
:
Classification System
Type C: Unstable
pelvis: complete
disruption of
posterior structures
C1: unilateral
C2: bilateral w/ one
side Type B, one
side Type C
C3: bilateral Type C
26. Classification System: Young
Lateral Compression
(50%) – transverse of
pubic rami, ipsilateral or
contralateral to posterior
injury
LC I – sacral
compression on side of
impact
LC II – iliac wing on side
of impact
LC III – LC-I or LC-II on
side of impact w/
contralateral APC injury
27. Classification System: Young
AP Compression
(25%)
Symphyseal and / or
Longitudinal Rami
Fractures
APC I – slight widening of
the pubic symphysis
and/or anterior SI joint
APC II – disrupted anterior
SI joint, sacrotuberous,
and sacrospinous
ligaments
APC III – complete SI joint
disruption w/ lateral
displacement and
disruption of
28. Classification System: Young
Vertical Shear ( VS) (5%)
Symphyseal diastasis or
vertical displacement
anteriorly and posteriorly
Example : Fall from heights
Combined Mechanism
(CM) combination of injury
patterns
29. Young: Morbidity & Mortality
Fracture
Type
Severe
Bleeding
Bladder
Rupture
Urethral
Injury
Mortalit
y
LC - I 0.5% 4% 2% 6%
LC – II 36% 7% 0% 6%
LC – III 60% 20% 20% 13%
APC – I 1% 8% 12% 7%
APC – II 28% 11% 23% 7%
APC – III 53% 14% 36% 25%
VS 75% 15% 25% 25%
CM 58% 16% 21% 17%
40. Risks of Pelvic Factures
Iliac Crest fracture
Typically pelvis still stable
Little blood loss
Pelvic Ring fracture
Internal organ damage
Significant blood loss (up to 4 liters) : Fracture and vascular
injury can cause the formation of hematoma in the pelvis
and retroperitoneum Hypovolemic shock
90% bleeding venous disruption or cancellous bone
10% bleeding an arterial injury
Unstable pelvis
Risk of death (Mortality of 3.4%-42%)
41. Assessment
ATLS Approach (Advanced
Trauma Life Support)
Check Stability :
Mechanic
Haemodynamic
Pelvis specific assessment
Check for bruising, deformity,
or abrasions
Listen/Feel for crepitus
Check limb length
42. Stability Assessment
Check stability of pelvis (DON’T REPEAT)
1) Apply gentle medial pressure with palms by
pressing inward on iliac crests
2) With patient supine, apply gentle posterior pressure
by pressing downward on iliac crests
3) Apply gentle downward pressure on pubis to check
pelvic ring stability
1) Medial pressure 2) Posterior iliac pressure 3) Posterior pubis pressure
43. Diagnosis
1. General: abrasion, contusion,
hematoma, over bony prominence of
pelvis, scrotal, vulvar hematoma.
2. PE ( Physical Exam )
3. X-ray
4. FAST
5. DPL
6. CT
44. IDENTIFY THE HIGH RISK PELVIC
DISRUPTION
By Physical Exam By Radiography
45. Radiographic Evaluation
• X-Ray AP view:
– Anterior lesions:
pubic rami fractures
– Symphysis
displacement
– Sacroiliac joint and
sacral fractures
– Iliac fractures
– L5 transverse
process fractures
46. Radiographic Signs of Instability
Broken ‘Ring’
Symphysis gap > 2.5 cm
Sacroiliac displacement of 5 mm in any plane.
Avulsion of the 5th lumbar transverse process,
the lateral border of the sacrum (sacrotuberous
ligament), or the ischial spine (sacrospinous
ligament).
47. Treatment
Treat for life threatening injuries
Treat for possible shock
Oxygen
Intravenous infusion
Splinting / Wrap
Pain control
RAPID TRANSPORT!!!
48. Patients with hemorrhagic shock and unstable
pelvic fractures have four potential sources of
blood loss :
(1) fractured bone surfaces
(2) pelvic venous plexus
(3) pelvic arterial injury
(4) extrapelvic sources.
The pelvis should be temporarily stabilized or
"closed" using an available commercial
compression device or sheet to decrease
bleeding.
49. •
In the presence of unstable pelvic ring
disruption and a positive abdominal
study, stabilization of the pelvis
should be undertaken before
laparatomy.
•
If hemodynamic stability is not
achieved after placement of the
external fixator, arteriography should
then be performed.
50. Non-Operative Management
( haemodinamically stable )
Lateral impaction type injuries with minimal
(< 1.5 cm) displacement
Pubic rami fractures with no posterior
displacement
Minimal gapping of pubic symphysis
51.
52. Operative Management
Operative
indications
Pelvic unstable
symphysis diastasis > 2.5 cm
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
Hemodynamically unstable
53. Operative Management
Hemodynamically unstable
Reduce pelvic volume : promote blood
clot as well as reducing blood volume
from inside bleeding
Technique
First aid : pelvic wrap
(This is wrapped circumferentially around the pelvis)
Next : Ex fix/ C clamp
54. • Haemodynamic Status
Options for immediate
hemorrhage control
• Military antishock
trousers (MAST):
Typically applied in the
field.
– No impact on survival
rate.
– Severe complications
reported (compartment
syndrome, extremity
55. Posterior ring structure is important
Goal : restoration of anatomy and enough
stability to maintain reduction during healing
Anterior ring fixation may provide structural
protection of posterior fixation
Operative Management
58. • Anterior external fixator:
– In the acute phase many
advocate external fixation as a
temporary device to achieve
stabilization of the fracture and a
positive effect on haemorrhage.
59. 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.
62. Imaging
Plain films
AP
Inlet view / Outlet view
Judet view (oblique)
AP alone ~90% sensitive; combined w/ inlet / outlet views ~94%
sensitive
Limited in ability to clearly delineate posterior injuries
Pelvic films are NOT necessary in pts with normal physical exam
+ GCS >13
At least one study shows clinical exam reliable in EtOH
Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5
CT scans
Evaluates extent of posterior injury better
Superior imaging of sacrum and acetabulum
More detailed info about associated injuries
63. EtOh levels up to 104 mmol/l, most were >
21.7
Prospective study of 2176 consecutive blunt
trauma pts of which 4.5% had pelvic #’s
AP plevis alone missed more injuries than
clinical exam even in intoxicated pts
On the other hand, plain films can help to
predict bleeding complications and should be
done if pelvis is suspected to be busted as the
first step in the work up
64. Inlet & Outlet Views
Inlet view
X-ray beam at 60o to plate
directed towards feet
Used to look for vertical &
horizontal fracture
displacement, and SI
widening
Outlet view
Beam aimed 30o towards
head
Used to look at sacral
fractures & SI disruption
65. Imaging
What you really want to know is if there has
been damage to the posterior structures
Clues on X-rays:
L5 transverse process avulsion (iliolumbar ligament)
Ischial spine avulsion (sacrospinous ligament)
Unable to clearly make out sacral foramina
Assymmetry of sacral foramina
Significant displacement of anterior arch fracture
Sacral avulsion (sacrotuberous ligament)
Ist 2 always denote mechanical instability
66.
67. 6 lines of the pelvis:
1. Iliopubic (arcuate) line – disruption
indicates ant column injury
2. Ilioischial line which defines the
posterior column
3. Teardrop or Roentgenographic U
formed by roof of acetabaulum and
ilioischial spine defines quadrangular
plate – disruption means intraplevic
penetration
4. Roof of acetabulum
5. Post rim of acetabulum
6. Ant rim of acetabulum
7. Shenton’s line = medial femoral shaft
obturator foramen: disruption in hip
dislocation or femoral neck #’s
70. Hemorrhage
The most dangerous &
life threatening
condition
( hypovolemic shock )
Sources :
Retroperitoneal
(Bone-Small & Large
vessels )
Multiple trauma
(Chest-Abdomen- Long
bone fractures)
71. • Evaluating Pelvic Hemorrhage (EPH) Study
– 724 consecutive pelvic fractures at
Harborview
• 62 % male
• Average age = 34
• Mechanism
– Motor vehicle crash 57%
– Car versus pedestrian 21%
– Fall (>3.3 meters) 11%
– Crush 5%
72. • Hemodynamic shock in Emergency Dept.
– Blood pressure<90 27%
– Pulse>130 30%
– Transfuse in ED 29%
• Blood requirement
– Any 80%
– 6 or more units 41%
– Range (0 to 171
units)
• Death 13%