this is a talk about the ongoing debate of what to do in the management of pelvic fractures with haemodynamic instability a revision of literature to see the best sequence of events ..

1. Mubarak M Abdelkerim
MBBS MCh Orth FRCSI FRCSEd FRSM(UK)FICS (USA)
Hemodynamic Instability in Patients
with Pelvic Fractures

3. Objectives:
 Epidemiology & Relevance
 Anatomical Review
 Classification Systems
 Hemorrhage Control
 Management

4. Pelvic Fractures: Epidemiology
 ~3% of all fractures in ED
 50-60% secondary to MVA
 Motorcycle crashes ~15%
 Car vs. pedestrian ~15%
 Falls 10-30%
 Crush injuries ~5%
 Mortality 6-10%; Inc’s to ~50% in unstable pt
 Tends to occur in setting of multi-system injury
therefore often other serious injuries
 Complications:
 Hemorrhage, neurological injury, deformity, GU
injury, GI injury

6. Mechanism of Injury

7. Patient demographics

8. Associated Injuries

9. Predictors of mortality

10. Pelvic Anatomy
 Anterior Support:
 ~40% of strength
 Symphysis pubis
 Fibrocartilaginous joint covered by ant & post symphyseal
ligaments
 Pubic rami
 Posterior Support:
 ~60% of strength
 Sacroiliac complex
 Sacroiliac ligaments
 Iliolumbar ligaments
 Pelvic floor
 Sacrospinous ligament
 Sacrotuberous ligament
 Pelvic diaphragm

11. 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

12. History & Physical
 ABC’s & initial stabilization
 AMPLE Hx
 Most important feature is mechanism
 Destot’s sign:
 Hematoma above inguinal ligament or scrotum
 Grey-Turner’s sign
 Earle’s sign:
 Presence of bony prominence, palpable hematoma, or tender #
line on DRE
 Blood at urethral meatus / vaginal introitus
 Examine pelvis only once
 Sensitivity of exam 93% vs. 87% for AP pelvis
 Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5

13. 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

14. FAST/CT/Total Body CT
• Initial clinical experience with a 64-MDCT
whole-body scanner in an emergency department:
better time management and diagnostic quality
• Rieger, Michael MD; Czermak, Benedikt MD; El Attal, Rene MD; Sumann, Günther MD; Jaschke, Werner MD;
Freund, Martin MD
• Journal of Trauma volume 66-3 march 2007 648-657

18. Classification Systems:
 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 associated injury
 Estimates mortality
 Disadvantages
 Excludes more minor injuries

19. Classifications and the Risk of Bleeding
• Young-Burgess classification has less inter and inter-
observer reliability
• It is well correlated with the mechanism, the amount
of energy, the concomitant injuries and transfusion
requirements

20. Tile Classification System
 Type A: Stable pelvis: post
structures intact
 A1: avulsion injury
 A2: iliac wing or ant arch #
 A3: transverse sacrococcygeal #

21. Tile Classification System
 Type B: Partially
stable pelvis:
incomplete posterior
structure disruption
 B1: open-book injury
 B2: lateral
compression injury
 B3: contralateral /
bucket handle injuries

22. 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

23. Young Classification System:
 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

24. Young Classification System:
 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 sacrotuberous
and sacrospinous ligaments

25. Young Classification System:
 Vertical Shear (5%)
 Symphyseal diastasis or
vertical displacement
anteriorly and posteriorly
 Combined Mechanism
Combination of injury
patterns

26. Tile &Burgess

27. Young: Morbidity & Mortality
Fracture
Type
Severe
Bleeding
Bladder
Rupture
Urethral
Injury
Urethral
Injury
LC - I 0.5% 4% 2% 2%
LC – II 36% 7% 0% 0%
LC – III 60% 20% 20% 20%
APC – I 1% 8% 12% 12%
APC – II 28% 11% 23% 23%
APC – III 53% 14% 36% 36%
VS 75% 15% 25% 25%
CM 58% 16% 21% 21%

28. Comparing The Predictive Value Of The Pelvic Ring Injury By Young And Burgess
And Tile
Georg Osterhoff Max J.Scheyerer et al Injury, 2013

29. Immediate Action
• During primary survey pelvic binders should be used despite the fact there is no
conclusive evidence from the literature to support these binders decrease the
need for transfusion, embolization and improve mortality rates but they decrease
the pelvic volume.
• Prolonged use can cause trochanteric ulcers, also the secondary survey is
difficult while the binder is on.
Chesser T.J,Cross AM,(the use of pelvic binders in the emergent management of potential pelvic trauma
Injury2012,43:667-9
Ghaemmaghami V,Sperry J.Friese R,et al .effects of early use of external pelvic compression on transfusion
requirements and mortality in pelvic fractures.American Journal of surgery 2007:204:935-9.

30. Sources Of Bleeding
• Arteries,veins,cancellous bone
• Retroperitoneal haematoma - up to 4 liters mostly from venous
plexus and cancellous fractured bone
• Damage control resuscitation is to keep the patient hypotensive
and prevent (coagulopathy,acidosis and hypothermia)
• Permissive resuscitation is to keep SBP at 90 mmhg and thus
preventing excessive exsanguination and at the same time
organs are perfused
• Several questions need to be answered since there is no evidence
supporting this strategy

31. Resuscitation
• Packed RBCS,FFP and platelets
• The optimal ratio of these components is still under research
• Supporting the fibrinolytic system is achieved by giving
tranexamic acid
• Military application of TXA in trauma emergency,Archives
Of Surgery 2012:147:113-9

32. Physical Exam
• Degloving injuries
• Limb shortening
• Limb rotation
• Open wounds
• Swelling & hematoma

33. Clinical Tips
• Presence of blood in the urethra
• Bleeding per vagina
• Edema of the labia
• Leak of urine from the rectum

34. Management
 Stable vs Unstable patient
 Stable pt:
 Conservative Tx (bed rest  slow wt bearing)
 Tile: A1, A2, A3 (coccyx #’s only)
 Young: APC – I, LC – I, some LC – II
 Unstable pt:
 Tile B & C / Young APC & VS = high energy injuries
 Require surgical management
 Timing & methods for stabilization controversial

35. Management: Unstable Patient
 ABC’s, resuscitation
 Evaluate for site(s) of blood loss
 FAST, CT
 Laparotomy if indicated
 Options for patients not requiring laparotomy:
 Sheet around pelvis.
 External fixator.
 Early ORIF
 Angiographic embolization
 Early antibiotics for open # (cefazolin & gent)

36. The Risk of Bleeding
• Metz et al demonstrated that APC are associated with posterior
bleeding and LC with anterior bleeding.
• ISS and the associated injuries and not the fracture type have been
found to represent a better mortality predictor
• the extravasation of iv contrast and the size of pelvic haematoma
have been correlated to bleeding and the need for angiography
• Associated Injuries and Not Fracture Instability Predict Mortality
in Pelvic Fractures: A Prospective Study of 100 Patients
• Lunsjo, Karl MD, PhD; Tadros, Ayman FRCS; Hauggaard, Anders
MD; Blomgren, Rolf MD; Kopke, John MD; Abu-Zidan, Fikri M.
MD, FRCS, PhD,-Journal of TraumaVol62(3)March 2007-pages
687-691.

37. Imaging
• Plain pelvis and chest radiographs ,FAST, selective CT(ATLS)
• Total body CT with split-dose IV contrast
• The effects of this approach comported to the conventional ATLS protocol has
not been established
• Several studies have shown that time spent in CT is not a prohibiting factor in
patient management in modern trauma centers and have emphasized the
efficiency of total body CT
• Wumbte,Quaisser C,Balling et al.(Whole-body CT- improves trauma care in
patients requiring surgery after multiple trauma )Emergency Medicine
Journal: 2009:66:648-57.

38. Pelvic Ring Injuries
An unstable pelvic injury may
allow hemorrhage to collect in
the true pelvis as there is no
longer a constraint which
allows tamponade.
The volume was traditionally
assume to be a cylinder with a
volume of 4/3π
r3, However…
Best estimated by a
hemi-elliptical sphere
(Stover et al, J Trauma, 2006)

39. Defining Pelvic Stability?
• Radiographic
• Hemodynamic
• Mechanical
“Able to withstand
normal physiological
forces without
abnormal deformation”

40. Radiographic Signs of Instability
•Sacroiliac displacement of 5 mm in any
plane
•Posterior fracture gap (rather than
impaction)
•Avulsion of fifth lumbar transverse
process, lateral border of sacrum
(sacrotuberous ligament), or ischial spine
(sacrospinous ligament)

41. Stable or Unstable?
• Single examiner
• Use fluoro if available
• Best in experienced hands

42. • External fixator device to the iliac crest easy to apply, but there is
a risk of infection
• Pelvic c-clamp on the posterior ilium in the SIJ creates a
tamponade effect (?Iliac fractures)
• Injuries to the superior gluteal neuromuscular bundle
• Internal fixation superior but time consuming (extremis)
• Direct surgical control theoretically easy - uncontrolled
circumferential stitching and clip application with inadequate
visualization may lead to iatrogenic nerve injuries
• Pelvic angiography and embolization

43. Shock VS Hemodynamic
Instability
• Definitions Confusing
• Potentially based on multiple factors & measures
• Lactate
• Base Deficit
• SBP < 90 mmHg
• Ongoing drop in Hematocrit
• Response to fluid challenge

44. Sheet Application

45. Sheet Application
Before

46. After

48. Pelvic Binders
Commercially available.
Placed over the trochanters
and not over the abdomen.

49. Circumferential Sheeting
• Supine
• 2 “Wrappers”
• Placement
• Apply
• “Clamper”
• 30 Seconds
1
2
3
4
Routt et
al, JOT, 2002

50. Indications for External Fixation
• Resuscitative (hemorrhage
control, stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvis
Theoretical
and a marginal
indication, bu
t there is
literature
support
Barei, D. P.;
Shafer, B. L.;
Beingessner, D. M.;
Gardner, M. J.;
Nork, S. E.; and
Routt, M. L.: The impact of open
reduction internal fixation on acute pain
management in unstable pelvic ring injuries. J

51. External Fixation
Location
AIIS
ASIS
C-clamp
Clinical Application
Resuscitative
Augmentative
Definitive

54. Anti-shock Clamp (C-clamp)
Better posterior
pelvis
stabilization
Allows abdominal
access
Consider
application with
fluoro or in the
OR to prevent
poor pin
placement

60. Emergent Application

61. C-clamp: Anatomical Landmarks
• Same (similar location) as the starting point
for an iliosacral screw
• “Groove” located on the lateral ilium as the
wing becomes the posterior pelvis
• Allows for maximum compression
• Can be identified without fluoro in
experienced hands
Pohlemann et
al, JOT, 2004
Pin Location
Near IS screw entry
point

62. Avoid Over-
compression in
Sacral
Caution…

63. Control Of Bleeding
•The use of a sacroiliac screw has been reported by Gardner
as having a resuscitation role (the anti-shock iliosacral
screw-Journal Of Orthopaedic Trauma 2010-24:e86-9)
•The best means to control haemorrhage after skeletal
stabilization is a subject of a vivid debate!!!!!
•According to Gullinane DC, and co-workers in their
systemic review (Journal Of Trauma 2011:71:1850-68)
arterial embolization should be strongly recommended:

64. Role of Angio
•Valuable for arterial only
•Estimated at 5-15%
•Timing (early vs late?)
•Institution dependent

65. Role of Angiography???
• Fracture pattern may predict
effectiveness
• Contrast CT suggests
• Effective in retrospective
studies!!!

66. Complications of AE
 Gluteal claudication
 Pelvic Necrosis
 Renal failure
 Although effective in controlling bleeding (arterial)but
published series didn’t show decrease in necessity for blood
product resuscitation
 Clay C Burley 2011 American College of Surgeons

67. Preperitoneal Pelvic Packing
 In Europe (PPP/EF),
 2011,Clay C Burlew et al (75 out of 1,245) concluded
that this method eliminates the question of OR and IR.
 Concurrent operations can be done fixed
 Less than 15% require angio-embolization
 AE should be complementary procedure for life
threatening haemorrhage control following PPP/EF

68. PPP

69. Pelvic Packing
• Ertel, W et al, JOT, 2001
• Pohlemann et al, Giannoudis et al,

70. Summary
• Play well with others (general surgery, urology, interventional
radiology, neurosurgery)
• Understand the fracture pattern
• Do something (sheet, binder, ex fix, c-clamp) call OR/IR .
• Combine knowledge of the fracture, the patients condition, and the
physical exam to decide next steps