case conference

1. Case discussion
อชิรญา มานะธุระ

2. Case
• ผู้ป่วยชายไทยอายุ 56 ปี unknown U/D
• ภูมิลาเนา อาเภอ ขามสะแกแสง จังหวัด นครราชสีมา
• อาชีพ รับจ้างทาสวน
• สัญชาติ ไทย นับถือศาสนา พุทธ
• รับไว้ในโรงพยาบาลครั้งที่ 1

3. Chief complaint
• ปวดสะโพกซ้าย 1 ชั่วโมง ก่อนมาโรงพยาบาล

4. Primary survey
• A: can speak ,can move neck, not tender along C
spine
• B: no accessory muscle use, thechae in midline,
clear and equal breath sound,CCT -Neg
• C: BP 111/73 mmHg, PR 82 /min ,not seen
external bleeding, no gross hematuria
• D:E4V5M5, pupil 3mm RTLBES
• E: seen skin contusion at left hip, tender around
left hip

5. Adjuncts to primary survey
• Obsevre vital sign
• Retain folay catheter
• CXR
• FAST : Neg
• Film pelvis AP : pending

6. Secondary survey
• Allergies: no history of drug or food allergy
• Medications: no current medication
• Past illnesses: no U/D
• Last meal: 15.00 27/06/2560
• Event: ตกจากต้นไม้สูงประมาณ 4 เมตร สะโพกซ้ายกระแทกพื้น
หลังจากนั้นลุกนั่งไม่ได้ปวดสะโพก ขยับขาซ้ายแล้วปวดมากขึ้น

7. Physical examination
• Head: no fracture, no external wound
• Maxillofacial: no deformity ,no bony crepitus
• Cervical spine/Neck : C spine not tender, no sign of airway
obstruction
• Chest: no accessory muscle use, trachea in midline, clear and equal
breath sound
• Abdomen:normoactive bowel sound ,soft, not tender
• Musculo skeletal: skin contusion at left hip, no deformity, tender
around left hip, hip joint limit ROM due to pain,no numbness
• Neurological:grossly intact
• Perineum:
– Perinium: no urethral bleeding
– Rectum: normal sphincter tone, no high riding prostate

8. Pelvis AP

10. Pelvis inlet view Pelvis outlet view
Investigation

11. Investigation
CT 3D pelvic

12. • Official report finding
– Vertical fracture of sacrum
– Fracture left superior and inferior pubic rami
– Bilateral SI joint and pubic sysphysis are intact.

13. Diagnosis
• Cfx left pelvic

14. Management at ER
• Lab pre operative
• Admit bed rest
• Plan: EF pelvis

15. Post operative

16. Post operative

18. PELVIC FRACTURE

19. Anatomy

20. Radiological evaluation
• Systemic review
– Three ring
– Joint space
– Acetabulum
– Sacral foramina
– Proximal femur

21. I. Tree ring

22. II. Joint space

23. III. Acetabulum

24. IV. Sacral foramina

25. V. Proximal femur

26. Classification
• Tile classification
• Young-Burgess Classification

27. • Tile classification

28. • Anterior Posterior Compression (APC)
• APC I : Symphysis widening < 2.5 cm
• APC II :Symphysis widening > 2.5 cm. Anterior SI joint diastasis .
Posterior SI ligaments intact. Disruption of sacrospinous and
sacrotuberous ligaments.
• APC III : Disruption of anterior and posterior SI ligaments (SI
dislocation).
• Lateral Compression (LC)
• LC Type I : Oblique or transverse ramus fracture and ipsilateral anterior
sacral ala compression fracture.
• LC Type II :Rami fracture and ipsilateral posterior ilium fracture dislocation
• LC Type III : Ipsilateral lateral compression and contralateral APC
• Vertical Shear (VS)
• Posterior and superior directed force.
• Young-Burgess Classification

31. Management

32. Management
• Definitive Treatment
– Non operative
mechanically stable pelvic ring injuries including
– LC1
– APC1
– isolated pubic ramus fractures
– Operative
unstable

33. Complications
• Neurologic injury
• DVT and PE
• Urogenital Injuries
– posterior urethral tear
– bladder rupture
– long-term complications
urethral stricture
impotence
 incontinence