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Pelvic fracture


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Published in: Health & Medicine, Technology

Pelvic fracture

  1. 1. Methas Arunnart MD.
  2. 2. HIGH ENERGY IMPACT Falls High speed VA Crush injury
  3. 3. Management strategy of vascular injuries associated with pelvic fractures. J Cardiovasc Surg33:349, 1992; Prorities in Management. Arch surg 124:422, 1989; Effective classification
  4. 4.  1 SACRAL Bone 2 INNOMINATE bones PUBIS ILIUM ISCHIUM Symphysis gap <5 mm
  5. 5.  No inherent stability—Ligaments give stability Anterior SIL resist external rotation Sacrospinous - resists external rotation Posterior SIL and ILL - provide posteriorstability by tension band , strongest in body Sacrotuberous - resists shear/flexion SI joint
  6. 6.  Sacral venous plexus* Iliolumbar a. Internal iliac a. Superior gluteal a.* Lateral sacral a. Pudendal a.*
  7. 7.  Bladder/Urethra Rectum Prostate Vagina
  8. 8.  AP pelvis during early phase of resuscitation isuseful to determine presence or absence ofunstable pelvic fracture AP pelvis can identify 90% of pelvic injuries
  9. 9.  Inlet View – 45 degree caudal tilt True AP projection of the pelvic brim Evaluates for posterior displacement Evaluates for rotation of ilium and sacral impactioninjuries
  10. 10.  Outlet View – 45 degree cephalad tilt Evaluates for vertical shift of pelvis provides a better demonstration of sacral fracturesand injuries to the sacroiliac joints.
  11. 11.  CT Scan Best visualization for Sacrum and SI joint Rotational and posterior displacement canbe easily assessed
  12. 12.  Type A: pelvic ring stable Type B: rotationally unstable, vertical stable Type C: rotationally and vertically unstableAdvantages: Tile classification aids inthe determination of prognosis
  13. 13.  Lateral compression (LC) Anteroposterior compression (APC) Vertical shear (VS) Combined mechanism (CM)Advantages: this classification alerts the surgeon topotential resuscitation requirements andassociated injury patterns
  14. 14.  Airway Maintenance with C-spine protection Breathing and Ventilation Circulation with hemorrhage control Disability: Neurologic status Exposure/Environment Control: Undresspatient but prevent hypothermia
  15. 15.  Neurologic deficit involving lumbosacral plexus Pelvic/flank/perinealcontusions,ecchymoses,abrasions Blood at urethral meatus Blood in or around rectum Open wound of groin,buttock, or preineum Leg length inequality or external rotation of oneextremity Abnormal pelvic motion on AP or lateralcompression of anterior iliac spines and iliac crests
  16. 16.  Rectal exam for tone Bulbocavernosus reflex Myotomes of lower extremity L1-2 : hip flexor L3-4 : Quadriceps/knee extension L4-5 : Ankle and toe dorsiflexion S1 : ankle plantarflexion S2-3 : toe plantarflexion
  17. 17.  Sheet around pelvis Pelvic binder
  18. 18.  Return blood from lower ext. to central vascular system Ability to close open-book-type injury, reducing pelvicvolume Stabilize pelvic ring permitting clot formation
  19. 19.  Advantage Useful in assessing and embolization of arterialinjury - Unexplained blood loss after stabilization and aggressiveresuscitation , Pulseless extremity Disadvantage: Source of arterial bleeding is identified in only 10-15% of patients with severe pelvic disruption Does not address venous bleeding
  20. 20. Primary surveystable unstablePelvic Fx No Fx Pelvic FxNo FxCT,FAST,DPLCT scanAPC LCCT,FAST,DPLclassify FxReassess Explor lap. Open bookothersReassess- External compression- Explor lap. +/- packing- Angiography vs ext. fixationSI jonit involvement-consider iliac injury
  21. 21.  Lateral compression (LC) Anteroposterior compression (APC) Vertical shear (VS) Combined mechanism (CM)Advantages: this classification alerts the surgeon topotential resuscitation requirements andassociated injury patterns
  22. 22.  LC type I: unilateral rami fx . (transverse)& ipsilat sacral compression. LC type II: unilateral rami fx.& ipsilat post. iliac fx. LC type III: LC I/II & contralat. APC
  23. 23.  APC type I: symphysis widened < 2cm;SI joint intact APC type II: symphysis widened >2cm or rami fx& ant. SI lig. Torn APC type II: symphysis widened >2cm or rami fx& ant & post SI lig. torn
  24. 24.  Vertical shear (VS) Vertical displacement Combined Mechanical(CM) Combination of LC + VS or APC
  25. 25.  15-20% of pelvic fractures Extraperitoneal vs Intraperitoneal clinical Scrotal/labial swelling Gross hematuria Retrograde Urethrogram
  26. 26.  Occurs in less than 1% Clinical Laceration of rectum or perforation of small and/orlarge bowel Rectal tears accompany perineal wounds Requires diverting colostomy in 6-8hrfollowing injury to reduce incidence of sepsisand death
  27. 27.  Laceration of the vagina Results from dislocation or fractures of thepubic rami may require operative intervention