A case based approach on the management of a pelvic fracture. it is based on ATLS guideline. A brief account on anaesthetic and orthopedic point of view also included.

1. Pelvic fractures
Dr KTD Priyadarshani
Registrar in Emergency Medicine
National Hospital-Kandy
2024/01/17

2. Objectives
• Initial assessment and management
• Epidemiology
• Anatomy
• Classifications
• Management
• Complications

3. Case
• Age - 39 Years old male
• Timing - at 5 pm
• Mechanism – MB rider collided with a lorry
• Injury
• Perineal laceration, unstable pelvis, externally rotated LL
• Blood at the meatus
• Signs – SPO2 100% on oxygen 10L/min, BP 80/50 mmHg, HR 130/min,
GCS 15/15, Agitated
• Treatment received – Fluid resuscitation up-to 6L of NS at LH

4. Epidemiology
• Men in 40s
• Diversity in associated visceral and soft-tissue injuries
• Mortality –
• All type of pelvic fractures – 5-30%
• Closed pelvic fracture and hypotension - 10-42%
• Open pelvic fracture – 50%

5. Important considerations
• High energy mechanisms, such as:
• Motor vehicle crashes
• Collisions with pedestrians
• Falls from height
• Major hemorrhage, which can be difficult to control
• Other associated injuries
• Intra-abdominal organs (28%), including aortic injury
• Hollow viscus injury (13%)
• Genitourinary injury
• Rectal injury (up to 5%)

6. Initial assessment
• ATLS approach
• Receive the patient
• AT MIST
• Triage
• Activate trauma call
• Trauma surgeons,
• Orthopedic surgeons,
• interventional radiologists or vascular surgeons,
• anesthetist,
• Blood bank,
• theatre staff.

7. Primary survey
• Airway with C-spine immobilization
• Jaw thrust
• Manual in-line stabilization
• Breathing
• Assess RR, auscultate, SPO2
• NRBM oxygen with 10-15 l/min
• Circulation
• PR, BP, CRFT
• Supra diaphragmatic intravenous (IV) access.
• Blood for FBC, Gr & DT – 4-8 Units, PT/INR, APTT, VBG, S.Ca, fibrinogen and
ROTEM
• Activate massive transfusion protocol+ IV tranexemic
• Hemostatic resuscitation
• Permissive hypotension – Target SBP 90mmHg, MAP 50 mmHg
• Analgesia

9. Rapid hemorrhage control
• Look for obvious bleeding
• The floor (external hemorrhage), and four more, chest, abdomen,
pelvis, and long bones.
• Mechanical stabilization of the pelvic ring and external counter
pressure.
• Internal rotation of the lower limbs
• Pelvic binder
• REBOA with real-time fluoroscopy or under USS guidance
• HD unstable - zone III of the aorta, or just above the aortic
bifurcation

10. Major site of hemorrhage
•Surfaces of fractured bones
•Pelvic venous plexus – 90%
•Pelvic arterial injury – 10%
•Extra-pelvic sources (present in 30% of pelvic fractures)
•Bleeding into the retroperitonal space upto 5L.

11. Pelvic binder
•Apply at the level of the greater trochanters of the femur.
•Tie the patient’s ankles together.
• Pelvic splints
• Improvise - Bed sheet, Kocher clamps, towel clips
• Sam splint
• T-pod
•Caution
• Should be applied before intubation
• Exclude lateral compression pattern
• Skin breakdown and ulceration in 24 hour

12. Following resuscitation
• A- talking, rational
• B- RR 36, SPO2 100% on RA
• C- PR 127, BP 124/80
• D – GCS 15/15

13. • Primary survey adjuncts
• AP pelvis XR
• EFAST
• Disability
• GCS / AVPU
• Pupils
• Exposure
• Skin and soft tissue injury - open injury, Ecchymosis
• Palpate on bony fragments, echchymisis, tenderness
• Urethral injury- ecchymosis or hematoma of the scrotum or
perineum, blood at urethral meatus, gross hematuria
• Log roll – DRE, spine tenderness
• DRE- sphincter tone, prostrate, palpable fracture, blood
• VE- fractures, mucosal integrity, blood

14. Secondary Survey
• Head to toe secondary survey & adjuncts
• Head injury – NCCT brain with C-spine
• Abdomen – Distention, tenderness
• LL – length discrepancy, Malrotation
• Distal neuro vascular status

15. AP Pelvis

16. Injuries
• Open book pelvic fracture
• APC III - Anterior symphyseal widening ≥ 25 mm,
disruption of anterior and posterior SI,
sacrospinous, and sacrotuberous ligaments &
vertical fracture of pubic rami
• R/ Neck of the femur fracture
• R/ Acetabular fracture
• Open wound - Perineal laceration

17. Anatomy
• Pelvic ring – No inherent stability
• Anterior stability - Symphysis pubis
• Posterior stability - anterior and
posterior sacroiliac ligaments
• Pelvic Floor - sacrospinous and
sacrotuberous ligaments
The pelvis is a ring structure; thus, the identification of a single fracture should
raise suspicions for a second fracture.

18. Classification
• Young-Burgess classification
• More useful in the ED as it is based on mechanism of injury.
• Mechanisms
• Lateral compression
• Anterior-posterior compression
• Vertical shear
• Combined mechanical injury

20. Classification
• Tile classification
• Based on pelvic stability and useful for guiding pelvic
reconstruction.
• Type A, Rotationally and vertically stable
• Type B, rotationally unstable, vertically stable
• Type C, rotationally and vertically unstable

22. eFAST
• Free fluid
• Hepato renal pouch
• Perisplenic space
• Pelvis
• Liver and kidney normal

23. Rule of DPA
• Rule out a false negative FAST scan in a
hemodynamically unstable patient
• Performed above the umbilicus in patients with
suspected pelvic fractures to avoid aspirating a
pelvic hematoma
• A positive result is the aspiration of 10 mL of frank
blood or GI contents

24. Further management
• Damage control surgery
• External fixation
• Anterior EF approach – APC & LC
• C-Clamp - VS
• Extra-peritoneal packing - Adjunct
• Direct pre-peritoneal approach to pelvis – Allows access to the
retroperitoneal space
• Angiographic embolization – adjunct
• Transcatheter arterial embolization

25. • If patient hemodynamically stable
• Arrange CT abdomen and pelvis with IV contrast
• 30% of posterior injuries can be missed on plain radiographs.
• Soft tissue may be evaluated to detect hematoma formation,
active arterial bleeding
• Rule out intra-abdominal and retroperitoneal injury
• Characterize the type and severity of pelvic injury
• Angiography
• Identify arterial injury and to guide embolization

26. CT

27. Findings
• Evidence of bowel perforation
• Retroperitoneal hematoma
• Linear splenic laceration
• Extra-peritoneal bladder rupture
• Unstable pelvic fracture
• No evidence of pelvic vessel injury with
active bleeding

28. Supportive care
• Analgesia
• Broad spectrum antibiotics
• IV Cefuroxime
• IV Metronidazole
• Tetanus prophylaxis
• Skin traction – 3Kg

29. Associated Injuries & management
• Should evaluated under anaesthesia in OR
• Rectal injury – 5%
• Intestinal injury - up to 5%
• Require faecal Diversion colostomy
• Pre-sacral drainage and perineal debridement
• Bladder and urethral injury (5-20%)
• Bladder: intra- and/or extraperitoneal
• Cystoscopy
• Extra – Catheter drainage
• Urethral injury – Posterior urethra
• Retrograde urethrogram

30. Neurologic injury 10-15%
•Lumbosacral plexus L1-S4
• lateral femoral cutaneous nerve (L2-3)
•Obturator nerve (L2-4)
•Femoral nerve (L2-4)
•Sciaticnerve(L4-S3) – decompression of nerve roots

31. Complications
Acute Late
• Major hemorrhage and shock
• Visceral and soft tissue injury
• Nerve injury
• Fat embolization
• Acute respiratory distress
syndrome
• Venous thromboembolism
• Abdominal compartment
syndrome
• Fracture complications
• Incontinence
• sexual dysfunction

32. Disposition
• Operating theatre
• Interventional radiology suite
• Intensive care unit

33. Definitive Management
• Surgical fixation
• Stabilise disrupted ring
• Early mobilisation
• Prevent deformity
• Minimize long term disability
• Gold standard- open method
• Percutaneous methods are evolving

34. Anaesthetic considerations
• Pre op assessment- multidisciplinary team
• IV access, positioning is affected by other injuries
• Urological injuries- catheterisation, chest drains, EVD
• Blood- 4-6U DT, intraoperative cell salvage
• Metabolic derangements- coagulopathy, electrolyte imbalance
• Critical care after surgery
• Multimodal analgsia
• Thromboprophylaxis- mechanical- ASAP, Chemical- HD stable and clotting parameters
stabilised

35. References
1. AAOS3.pdf
2. ATLS 10th Edition Student Manual.pdf
3. RCEM-Trauma-ibook.pdf
4. https://litfl.com/pelvic-trauma/
5. https://www.bjaed.org/article/S2058-5349(18)30050-
7/fulltext

36. Thank you