This document summarizes the clinical presentation of major pelvic injuries. It discusses the assessment of an injured pelvic patient including history taking focusing on mechanism of injury, physical examination of the pelvis and associated injuries, and principles of ATLS management. Major pelvic injuries represent 3% of skeletal injuries and have high mortality, especially in the elderly or those with head, chest, or abdominal trauma. Physical exam evaluates pelvic stability, genitourinary and gastrointestinal injuries, and neurological function. Associated injuries are common, including thoracic aorta injuries with an anterior-posterior compression mechanism.

1. CLINICAL PRESENTATIONS OF
MAJOR PELVIC INJURIES.
PRESENTER: DR.ABDULMAJID HUSSEIN SAID (RESIDENT)
FACILITATOR: PROF HAONGA (Senior Lecturer & Consultant)

2. Raod map
• Background
• Assessment of pelvic injury patient
• Physical examination

3. Background
• Represent 3% of all skeletal injuries
• About 25% in the polytrauma patients
• About 42% of traffic related fatalities
• Increasing mortality up to 50% with:
Hemodynamically unstable patients
Concomitant head, chest and major
abdominal injuries.
Open pelvic fractures
Age > 65
• Pelvic injury must, therefore, be looked as
an indicator of a major trauma

4. Assessment of Pelvic Injury Patient
• Assess the patient haemodynamic stability (ATLS)
• History i.e mechanism of injury
• Patient Presentation (Signs and Symptoms)
• Physical examination;Assess pelvic organs and associated injuries
• Assess the fracture

5. Principle of ATLS

6. Primary survey: ABC’s
Airway maintenance with cervical spine
protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/environment control: undress patient
but prevent hypothemia

7. History
• Mechanism of injury (classification scheme and associated injuries)
High energy
Motorcycle accidents and motor vehicle pedestrian accidents are the
most common mechanisms
 although falls, motor vehicle collisions, equestrian accidents, and
crush injuries also result in pelvic ring injuries.
A fall from standing height- elderly.

8. Importance of Mechanisms of Injury
• APC
Increased incidence in thoracic aorta injuries when compared to
patients with blunt trauma without pelvic ring fracture.
APC III injuries are associated with a high rate of circulatory shock
(67%) and greater blood loss and transfusion requirements than other
injury patterns.
In patients who are hemodynamically unstable there is a higher
incidence of acute respiratory distress syndrome (ARDS) (18.5%),
sepsis (59%), and death (37%).

9. • LC
 Associated with a high incidence of head injury (50%).
The most severe, LC III, which can occur from a rollover mechanism,
is associated with a 20% risk of bowel injury, 40% incidence of
concomitant lower extremity fracture, and 60% presence of a
retroperitoneal hematoma.

10. • VS
 injuries have a high risk of hypovolemic shock (63%), mortality
(25%), head injury (56.2%), lung injury (23%), and splenic injury
(25%).
• Multidisciplinary approach to effectively and efficiently manage the
multiple injuries.

11. Associated Pelvic Injuries
• chest injuries (63%),
• long bone fractures (50%),
• head injury (40%),
• solid organ injury (40%), and spinal fracture (25%).
• Intestinal injuries are also encountered in up to 14% .

12. Physical Examination
• Inspection
• Assess pelvic stability manually (once)
• Genitourinary system
• Open fractures and GIT
• Lower extremity neurologic deficits
• Other associated injuries

13. Inspection
• Scrotal swelling,labial or perineal hematoma
• Ecchymosis
• Flank hematoma
• Lacerations of perineum.
• Leg length inequality
• External rotation of one or both extremities
• Degloving injuries (Morel-lavallee lesion).
• Rectal and vagina lacerations (overlooked but indicative of severe
injury)

15. • VS Injuries
Lower extremity shortening and external rotation of the affected side
• Unstable LC injuries
Internal rotation deformity of the lower extremity
• APC injuries
Scrotal edema

16. Manual Palpation
• Manual compression along iliac crests provides a tactile assessment
of pelvic stability.
• Can reveal crepitus from fractures and can assist with determination
of pelvic stability.

17. Genitourinary Tract
• Bladder and Urethral injuries occur in 6% to 15%
• Male patients have a higher incidence of urethral injury compared to
female patients.
• Anterior portion is common compared posterior portion in male.
• Posterior portion 10 to 20% associated with bladder rupture.
• Vaginal injuries: has a remarkably low incidence of injury, ranging
from 0% to 5%.

18. • Blood at the external urethral meatus
• Perineal and genital swelling
• DRE-high-riding prostate for male-urethral disruption.
• Vaginal exam

19. Bladder injury
• Extraperitoneal bladder rupture (EPBR)
common.
 urine may communicate with the pelvis.
Suprapubic catheter or direct repair.
 An intraperitoneal bladder rupture (IPBR), which is often caused by
compression on the distended bladder resulting in rupture of the
dome, communicates with the peritoneal cavity but will not
contaminate the pelvis.
Ex-lap and repair

20. • Bladder injuries occur in up to 10% of pelvic ring injuries, with
approximately 60% EPBR, 30% IPBR, and 10% both.
• Because the amount of force required to rupture hollow structures,
such as the bladder, is so high, the associated mortality has been
reported anywhere from 22% to 34%.
• Gross hematuria common clinical findings.

21. Open Pelvic injuries and GIT
• Fragments can penetrate soft tissues and resulting in direct
communication with external environment to open fracture 5%.
• In addition, the bony fragments may cause direct damage when in
contact with the visceral cavity.
• These open pelvic ring injuries are often contiguous with the vagina
or rectum resulting in contamination
• This can significantly increase the number of complications including
osteomyelitis, deep pelvic infection, long-term disability, and
mortality

22. • A digital rectal examination and a vaginal examination should be
performed in female patients.
• Open wounds may occur anywhere along the course of the iliac crest
or through the perineum.
• Open pelvic ring injuries with fecal contamination have been
associated with a high mortality rate of up to 50%; therefore, early
recognition and appropriate therapeutic interventions are required.

23. Neurological Exam
• Rectal examination
• Rectal tone and bulboarvenous reflex
• Peripheral nerve examination i.e L5 & S1 nerve roots (sacral
fractures)
• Foot drop

24. Neurovascular injury
• Lacertions of venous plexus
• Arterial injury

27. • Thank you

28. References:
• Purnendu Saxena, Harshal Sakale1 , Alok C. Agrawal2 Consultant
Orthopaedic Surgeon, Visharad Hospital, 1 Assistant Professor Pt.
Jawahar Lal Nehru Memorial Medical College, 2 Professor and Head
of the Department, All India Institute of Medical Sciences, Raipur,
Chhattisgarh, India.
• Ebookmedicin_2020_Rockwood