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Guide to Pelvic Fractures
- 1. PELVIC FRACTURES Dr. Raman Ghimire 2018/01/16 Pelvic Fractures
- 2. Overview • Introduction • Epidemiology • Etiology • Relevant anatomy • Classification • Approach to Polytrauma • Complications • Take home messages • MCQs • References 2018/01/16 Pelvic Fractures
- 3. Introduction • Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum and coccyx. • Benign to life threatening • Component of Polytrauma , associated injuries : Chest injuries (63%) Long bone fractures (50%) Head injury (40%) Solid organ injury (40%) Intestinal injuries (14%) 2018/01/16 Pelvic Fractures
- 4. Epidemiology • Incidence : 23 per 100,000 persons per year • Age : 15-28 years • Male <35 years , Female >35 years • 3 percent of skeletal injuries • Open pelvic fractures: 2 – 4% • Mortality:5 -16 % (unstable pelvic fractures:8 %) 2018/01/16 Pelvic Fractures
- 5. Etiology • High energy blunt trauma RTA: 80 - 84% of pelvic fractures Falls from height: 5 -12% Young people Abdominal and pelvic visceral injury • Low energy mechanism Fall from standing height Old people 2018/01/16 Pelvic Fractures
- 6. Relevant Anatomy 2018/01/16 Pelvic Fractures
- 7. Stability of Pelvis • Pelvic ring Strength of ring: 40% anterior 60% posterior • Ligaments 2018/01/16 Pelvic Fractures
- 8. Ligaments Posterior ligaments are stronger than anterior (Sacroiliac strongest) Transverse: resist rotational force Longitudional : resist vertical shear 2018/01/16 Pelvic Fractures
- 9. Vessels Bleeding commonly from venous plexus Blood loss : Pelvic fracture : 1500-2000 ml Femur fracture: 1000-1500ml 2018/01/16 Pelvic Fractures
- 10. Nerves L5 –S1 nerve roots are commonly injured 2018/01/16 Pelvic Fractures
- 11. Visceral Anatomy Bladder injury: 16% urethral 7% Common with APC injury 2018/01/16 Pelvic Fractures
- 12. Classification 1. Young and Burgess Classification 2. Tile Classification 3. Apley ‘s Classification 4. Academy of Orthopedics/Orthopedic Trauma Association classification system (AO/OTA) : Research 5. Denis zone of classification : sacral injury 6. Jones-Powell Classification : open pelvic fractures 2018/01/16 Pelvic Fractures
- 13. Young and Burgess Classification (mechanism of injury) • Lateral compression (LC) • Anteroposterior compression (APC) • Vertical shear (VS) • Combined mechanism (CM) 2018/01/16 Pelvic Fractures
- 15. Tile Classification (stability) TILE A : stable 2018/01/16 Pelvic Fractures
- 16. TILE B: rotationally unstable/vertically stable 2018/01/16 Pelvic Fractures
- 17. TILE C: rotationally and vertically unstable 2018/01/16 Pelvic Fractures
- 18. APPROACH TO POLYTRAUMA 2018/01/16 Pelvic Fractures
- 19. Primary Survey and Resuscitation • Airway Maintenance with C-spine protection • Breathing and ventilation • Circulation with hemorrhage control Start 2 Large Bore IV Lines Infuse Crystalloids 2 to 3 Litres ; Blood transfusion • Disability: Neurologic status ; AVPU • Exposure –undress patient but prevent hypothermia 2018/01/16 Pelvic Fractures
- 21. Diagnostic tools • CXR-AP • X-ray C-spine- Lateral • X-ray Pelvis-AP • FAST scan 2018/01/16 Pelvic Fractures
- 22. Hemorrhage control in pelvic fracture • Pelvic Containment – Sheet – Pelvic Binder – External Fixation • Angiography and embolization • Laparotomy • Pelvic Packing 2018/01/16 Pelvic Fractures
- 23. Circumferential Sheeting Pelvic binder 2018/01/16 Pelvic Fractures
- 24. 2018/01/16 Pelvic Fractures widening of symphysis pubis & sacroiliac joint. displaced fracture of the right femoral shaft . APC injury (open book) S/P pelvic binder application
- 26. Secondary Survey • DOES NOT BEGIN UNTIL Primary Survey( ABCDEs) is completed, Resuscitative efforts are well established Normalisation of vital functions • INCLUDES: Head to toe evaluation History Reassessment of all vital organs 2018/01/16 Pelvic Fractures
- 27. Examination of pelvis (secondary survey) • Open wounds • Limb shortening and rotation • Swelling & hematoma • Bleeding Per urethra , high riding prostate • Pelvic compression test • Roux's sign: decreased distance from greater trochanter to pubic tubercle • Earle's sign: hematoma or bony prominence and tenderness on rectal examination 2018/01/16 Pelvic Fractures
- 29. Investigations • X-ray: Standard AP Inlet view, Outlet view Judet view 2018/01/16 Pelvic Fractures
- 32. Radiographic signs of instability • > 5 mm displacement of posterior sacroiliac complex • Avulsion fractures of: ischial spine ischial tuberosity sacrum transverse process of 5th lumbar vertebrae 2018/01/16 Pelvic Fractures
- 33. • CT-scan posterior injury 3D reconstruction CT 3D Reconstruction- APC 3 2018/01/16 Pelvic Fractures
- 34. • Hb/ PCV • Retrograde urethrography • cystography • IV urogram • Angiography 2018/01/16 Pelvic Fractures
- 35. Non Operative Management • Pain management • Protected weight bearing with crutch or walker • Serial x-ray to look for instability 2018/01/16 Pelvic Fractures
- 36. Operative Management • External Fixator • ORIF with screws and plate • Iliosacral screws 2018/01/16 Pelvic Fractures
- 37. Complications • Hemorrhage– shock • Nerve injury • Fat embolism • Infection • DVT • Non Union • Malunion 2018/01/16 Pelvic Fractures
- 38. Take Home Messages • Tile and Burgess & Young Classifications are the most commonly used classifications • Follow ATLS protocol : ABCDE • Systematic well-organized multidisciplinary approach needed for management. • Ilium- Part of hip bone Ileum-Part of small intestines 2018/01/16 Pelvic Fractures
- 39. MCQs 1.All of the following areas are commonly involved sites in pelvic fracture except: A. Pubic rami B. Alae of ilium C. Acetabulum D. Ischial tuberosities 2018/01/16 Pelvic Fractures
- 40. 2. Which of the following is commonly injured with pelvic fracture : A. urethra B. bladder C. prostate D. rectum 2018/01/16 Pelvic Fractures
- 41. 3 .Death 3 days after pelvic fracture is most likely to be due to: A Haemorrhage В Pulmonary embolism С Fat embolism D Respiratory distress E Infection. 2018/01/16 Pelvic Fractures
- 42. REFERENCES • Campbell's operative orthopaedics 13th edition • Apley's System of Orthopaedics and Fractures, 9th Edition • Rockwood and green's fractures in adults 8th edition • Uptodate • Medscape 2018/01/16 Pelvic Fractures
- 43. THANK YOU 2018/01/16 Pelvic Fractures
Editor's Notes
- Transfer of weight from the upper axial skeleton to the lower appendicular components of the skeleton, especially during movement. Provides attachment for a number of muscles and ligaments used in locomotion.= Contains and protects the abdominopelvic and pelvic visera. Gap in symphysis < 5 mm SI joint gap 2-4 mm
- a single break in the ring does not lead to instability, whereas for unstable injuries there are always injuries to at least two areas of the pelvis
- Transverse: lig of pubic symphysis, Ant SI lig,sacrospinous Longitudional :Post SI (long),sacrotuberous
- LS- S1 nerve roots are commonly injured .
- Apley Classification:1. Avulsions 2. Ring fractures 3. Acetabular fractures 4. Sacral / coccygeal fractures
- overall mortality for APC injuries is approximately 20%, whereas LC injuries are about 6.6%. The major cause of death in the LC fracture was head injury. APC deaths were secondary to both the visceral and pelvic injuries Vertical shear injuries have a high risk of hypovolemic shock
- Pelvic# presents as a part of polytauma since high energy trauma is a major cause Appraoch with ATLS protocol
- Consider C-spine injury in every polytrauma patient unless ruled out by invx. Tension pneumothorax diagnose clinically . A Alert • V Responds to vocal stimuli • P Responds to painful stimuli • U Unresponsive • GCS to be done in secondary survey
- Triad of urethral injury; Blood at the urethral meatus. • Inability to void (or distended bladder). • Pelvic fracture with pelvic haematoma
- Destot’s sign: superficial hematoma above inguinal ligament or in scrotum or thigh Morel Lavale lesion;closed internal degloving injury which commonly occurs over greater trochanter
- Inlet view (X-Ray beam tilted 40o caudal) : shows anteroposterior displacement, rotational deformity, and crescent fractures Outlet view (X-Ray beam tilted 40o cranial) : shows vertical displacement and provides face view of the sacrum. Oblique:ilium and acetabulum
- Acetabulum
- D
- С Within first few hours after severe injuries death may occur due to hypovolaemia from haemorrhage and within 3 days from fat embolism. Pulmonary embolism usually occurs at about 3 weeks from injury. Respiratory distress is a part of fat embolism