The pelvis has no inherent stability due to its ring-like bone structure connected by ligaments. Pelvic trauma can cause life-threatening bleeding due to proximity to major blood vessels in the highly vascularized bone. Classification systems categorize fractures by stability and force. For unstable fractures with hemorrhage, initial management includes aggressive resuscitation, provisional stabilization techniques like pelvic binding or C-clamps, and potential angiography or surgery to control bleeding. Early recognition and stabilization are crucial for survival in hemodynamically unstable patients with pelvic fractures.

1. PELVIC TRAUMA
Ihsan Oesman
Orthopaedic Department
Cipto Mangunkusumo Hospital

2. Anatomy of the Pelvis
• Pelvic Ring
Bone Structure
• Ring like
structure
• Two innominate
bones and the
sacrum
• No inherent
stability

3. No inherent stability

4. Pelvic Ligaments

5. Important Structures in Pelvis
• Urogenital system
• Digestive system
• Nerve system
• Vascular system

6. Pelvic Trauma
• High association with other injuries
• Major external forces required
• Proximity to major vessels
• Highly vascularized cancellous bone

7. Pelvic Trauma
• Greatest mortality rate of skeletal injury
• Retroperitoneal bleeding
• Overall pelvic fracture mortality : 16%
• Closed pelvic fracture & instability
mortality : 27%
• Open pelvic fracture & instability
mortality : 55%

8. Pelvic Fractures
• Integrity and stability of pelvic ring
are essential
• Pelvic fracture : disruption of pelvic
ring
• Mechanical instability vs
hemodynamic instability
• With / without visceral, vascular or
neurological injuries
• Pelvic fractures with hemodynamic
instability can be life threatening

9. Mechanism of injuries
• Motor vehicle accidents
• Falls
• Crushing injuries
• Working forces :
– Lateral compression
– AP compression
– Vertical shears
– Combined

10. Minor Pelvic Fractures
• Pelvic ring is still stable
• No damage to the major intrapelvic
structures

11. Major Pelvic Fractures
• Displacement of part of the pelvis
• Diastasis of the pelvis, disruption of
sacro-iliac joints, severe bleeding and
upward displacement of the pelvis

12. Complication of pelvic
fracture
• Rupture of the bladder
• Rupture of the urethra
• Sciatic nerve lesion
• Lumbosacral plexus damage
• Major vessel damage
• Massive retroperitoneal haemorrhage
• Paralytic ileus
• Intestinal and rectal damage

13. Pelvic Fracture Classification
• Many classifications
• AO/OTA, Tile, Young & Burgess
• Based on the concept of stability, force
direction and pathoanatomy
• Guide to treatment and allow centres to
compare results of similar cases

14. A type
Stable Pelvic
Ring Injuries

15. B type
Partially Stable
Pelvic Injuries
(Rotationally
Unstable)

16. C type
Completely
Unstable Pelvic
Ring Injuries
(Rotationally and
Vertically
Unstable)

17. Management of pelvic
injuries
• Assessment
• Resuscitation
• Provisional stabilisation

18. Assessment
• General assessment : ATLS (Primary &
Secondary Survey)
• Clinical assessment : important,
determine pelvic stability
• Radiographic assessment

19. Assessment
• General assessment : ATLS (Primary
& Secondary Survey)
• Clinical assessment
• Radiographic assessment

20. Clinical Assessment
• Important
• Determine stability
• Possible
complication :
urethra, bladder,
rectum

21. Assessment
• General assessment : ATLS (Primary
& Secondary Survey)
• Clinical assessment
• Radiographic assessment

22. Radiographic Assessment
• Plain X-ray :
– AP : in acute/resuscitation phase
– Inlet view : posterior displacement
– Outlet view : superior/inferior migration
• CT scan

23. Radiographic Assessment - AP view

24. Radiographic Assessment
Inlet view Outlet view

25. Radiographic Assessment
CT Scan

26. Resuscitation
• Hemorrhage in pelvic trauma : life
threatening
• Site of bleeding : FAST, DPL, CT scan
• Rapid and aggressive resuscitation
• Massive fluid replacement

27. Source of bleeding
• Vein and fracture surface (85-90%)
• Arterial (10-15%)

28. Resuscitation
• Early management : PASG
may be needed
• Pelvic binder, pelvic belt
• Fracture stabilization : ext.fix,
C-clamp
• Angiograpgy / Embolization
• Urgent laparotomy & packing

29. Provisional Stabilization
• Pelvic C-Clamp
• Anterior external
fixation
• Should be applied
quickly

30. Pelvic C-Clamp
Indication & Contra indication
• Direct posterior compression & stabilization
• Decreasing pelvic volume, enhance self-tamponade
and support for pelvic packing
• Unobstructed access to the abdomen
• Indication : posteriorly unstable pelvic injury &
hemodynamically unstable px
• Contraindication : hemodynamically stable px and
posterior iliac wing fractures

31. Pelvic C-Clamp
Insertion Technique
Placement of a stab incision

32. Pelvic C-Clamp
Insertion Technique
The assembled clamp

33. Pelvic C-Clamp
Insertion Technique
Hammered into the bone

34. Pelvic C-Clamp
Insertion Technique
Tightened the threaded tubes

35. Pelvic C-Clamp
Insertion Technique
The clamp can be swiveled

36. Emergency Treatment
Algorithms
• Many different algorithms
• Depend on the facilities and capabilities
• Goal : to simplify the decision making

38. • Internal fixation of major pelvic
fractures in haemodynamic
unstable patient is contra
indicated

39. Summary
• Disruption of the pelvic ring integrity
may cause mechanical instability of the
pelvis
• Gross mechanical instability may be
associated with hemodynamic
instability
• Be aware of associated injuries
• Aggressive resuscitation and early
stabilization are mandatory in
haemodynamically unstable patient

40. Terima Kasih