pelvic injury in brief

1. A Presentation on Injuries of Pelvis
Presentor : Pritam Pandey
Mentor : Dr. Sanjeeb Rijal

2. Surgical Anatomy

6. Pelvic support and stability
• Osseoligamentous structure
1. Posterior / anterior sacroiliac ligament
2. Iliolumbar ligament
3. Sacrospinous ligament
4. Sacrotuberous ligaments

8. Structures inside pelvis
• Major branches of common iiac arteries
• Sacral and lumbar plexus
• Urinary bladder
• Uretha
• Prostate
• pelvic colon

9. Introduction to Pelvic Trauma
Pelvic fractures represents
• 3% of all skeletal injuries annually in the United States
• 9% of trauma patients admitted to the hospital.
• An overall mortality of 10–16%
• Open pelvic fractures (2–4%) , have the highest mortality
rate at nearly 45%.
source :
http://www.jems.com/articles/print/volume-39/issue-
12/features/critical-management-deadly-pelvic-injuri.html

10. Mode of injuries
• motor vehicle accidents (60% of cases)
• falls from a height (30% of cases)
• crush injuries (10% of cases) .
Thus, displaced pelvic ring injuries are a marker for high-
energy trauma
source :
http://pubs.rsna.org/doi/full/10.1148/rg.345135113

11. Types of pelvis injuries
• Isolated Fracture with intact pelvic ring
• Fracture with broken pelvic ring ( Stable
• /unstable )
• Fracture of acetabulum
• Sacrococcygeal fracture

12. Classification of pelvic injuries

18. Tile’s classification
Type A, Stable
• A1, Without involvement of pelvic ring
• A2, With involvement of pelvic ring
Type B, Rotationally unstable
• B1, Open book
• B2, Ipsilateral lateral compression
• B3, Contralateral lateral compression

20. Type C, Rotationally and vertically unstable
• C1, Rotationally and vertically unstable
• C2, Bilateral
• C3, With associated acetabular fracture

21. The risk for mortality in pelvic
fractures
•
• Hemorrhagic Shock caused by rapid and
uncontrolled hemorrhage into the
retroperitoneal space
• ARDS
(Vascular bleed , 90 % being venous by osseous
fragments, disruption of vessels by shear
forces )

22. Approach to pelvic injuries
• Multidisciplinary Approach (head chest and
abdominal Injuries )
• Recognition of pelvic ring disruption and
determination of pelvic stability
• Suspect pelvic fracture in any case of RTA , Fall
in any patients with abdominal or lower limb
abnormalities

23. • Assess the vitals ( tachycardia , hypotension ,
increased respiratory rate may suggest
hypovolemia )
• Look for pallor , cold extremities, bleeding
from meatus , lacerated labia
• Rectal examination must be done (high
prostate)
• Bladder and bowel dysfunction may be
indication of nerve compression

24. • Blood at the urethral meatus is a classic sign
of urethral injury secondary to severe pelvic
trauma

25. • Bruising over the perineum or scrotum is highly
suggestive for the presence of a significant
pelvic injury

27. • Resuscitation
Circulation
1. IV line accessed (2 large gause )
2. Collect blood sample ( Hb%, hematocrit , PCV, Platelets ,
blood grouping ad cross matching )
3. IV fluid and blood transfusion
• Airways and breathing
• Urinary Catherization

28. • Adequate pain management (morphine )

29. Mechanically unstable injuries
• Fractures and dislocation with displacements
more than 1 cm
• injuries that compromise the posterior SI
ligaments

30. signs of instability is indicated by avulsion
fractures of
1. the sacrospinous or iliolumbar ligaments
2. L5 transverse process avulsion fractures

31. Methods of controlling bleeding
1. Rapping the pelvis with bedsheet tightly
2. Pneumatic antishock garments
3. commercial external pelvic compression devices (e.g.,
TPOD, SAM Pelvic Sling)
4. Early stabilization with external fixator (anterior/ C
clamp )in hypotensive patient with unstable fracture
5. Angiography and embolization

32. 1. Laparotomy
2. Retroperitonal pelvic packing
3. ligate the internal iliac artery,
4. clamp the aorta

33. • Suspected Pelvic injuries ( AP radiograph)
Mechanically
stable
Mechanically
Unstable
Stable
hemodynamic
ally
Unstable
hemodynamic
ally
Stable
hemodynami
cally
Unstable
hemodynamicall
y
Pelvic CT inlet
and oulet view
And
observation
CT
angiograph
y
And
observation
Circumferential
pelvic rapping and
traction
Pelvic ct ,
observation ,
surgical fixation
when able
Circumferential
wrapping
Ct Angiography
Urgent surgical
fixation and pelvic
wrapping

34. Definitive Pelvic Stabilization
• Percutaneous Posterior fixation after
reduction using sacroiliac screws and
lumbopelvic fixation for comminuted
posterior injuries
• Iliac wing fractures can be fixed with plates
and screws

35. • rotationally unstable (APCII,LC-II) and/or
vertically unstable pelvic ring disruptions
(APC-III, LC-III, VS, CM )

36. • Selected lateral compression patterns with
rotational instability (LC-II, L-III)
• (external fixation + posterior pelvic ring
fixation)

37. • Pubic symphysis plating represents the
modality of choice for anterior fixation of
“open book” injuries with a pubic symphysis
diastasis > 2.5 cm (APC-II, APC-III)

38. • Spinopelvic fixation has the benefit of
immediate weight bearing in patients with
vertically unstable sacral fractures

40. Complication
• Deep vein Thrombosis
• ARDS
• Pulmonary embolisation
• Pressure sore
• Pulmonary infection

41. Reference
•
https://wjes.biomedcentral.com/articles/10.1186/s130
17-017-0117-6
• http://www.jems.com/articles/print/volume-39/issue-
12/features/critical-management-deadly-pelvic-
injuri.html
• http://medschool2.ucsf.edu/sfgh_surgery/education/sc
hecter-section/Publications/pelvic-fractures.pdf
• http://pubs.rsna.org/doi/full/10.1148/rg.345135113
• http://ccn.aacnjournals.org/
• Appleys system of orthopedics and fracture , 9th edition

42. Thank you