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The Acute
Management
of Pelvic Ring
Injuries
Sean E. Nork, MD
Harborview Medical Center, Seattle, Washington
Original Author: Kyle F. Dickson, MD; Created March 2004
New Author: Sean E. Nork, MD; Revised January 2007
Pelvic Ring Injuries

High energy
Morbidity/Mortality
Hemorrhage
Cylinder: 4/3 rπ 3
???
Best estimated by a hemi-elliptical sphere
(Stover et al, J Trauma, 2006)
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
Consideration for Transfer:
Pelvic & Acetabular Fractures
Posterior pelvis instability/displacement
Initial AP x-ray
Bladder/urethra injury
Open pelvic fractures
Lateral directed force with fractures through iliac wing,
sacral ala or foramina Open book with anterior
displacement > 2.5 cm
Acetabular fractures
> 1 mm articular step off on any view
Lack of parallelism of femoral head and roof
Displacement of wall or column
Physical Exam
Degloving injuries
Limb shortening
Limb rotation
Open wounds
Swelling & hematoma
Defining Pelvic Stability???
Radiographic
Hemodynamic
Biomechanical (Tile & Hearn)
Mechanical
“Able to withstand normal
physiological forces without
abnormal deformation”
Single examiner
Use fluoro if available
Best in experienced hands
Stable or Unstable?
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)
Open Pelvic Injuries
Open wounds extending to the colon, rectum, or
perineum: strongly consider early diverting
colostomy
Soft-tissue wounds should be aggressively debrided
Early repair of vaginal lacerations to minimize
subsequent pelvic abscess
Urologic Injuries
15% incidence
Blood at meatus or high riding prostate
Eventual swelling of scrotum and labia (occasional
arterial bleeder requiring surgery)
Retrograde urethrogram indicated in pelvic injured
patients
Urologic Injuries
Intraperitoneal & extraperitoneal bladder ruptures are
usually repaired
A foley catheter is preferred
If a supra-pubic catheter it used, it should be tunneled to
prevent anterior wound contamination
Urethral injuries are usually repaired on a delayed basis
Sources of Hemorrhage
External (open wounds)
Internal: Chest
Long bones
Abdominal
Retroperitoneal
Sources of Hemorrhage
External (open wounds)
Internal: Chest
Long bones
Abdominal
Retroperitoneal
Chest x-ray
Physical exam, swelling
DPL, ultrasound, FAST
CT scan, direct look
Shock vs Hemodynamic Instability
Definitions Confusing
Potentially based on multiple factors & measures
Lactate
Base Deficit
SBP < 90 mmHg
Ongoing drop in Hct
Response to fluid challenge
Pelvic Fractures & Hemorrhage
Fracture pattern associated with risk of vascular injury
(Young & Burgess)
ER & VS > IR
APC & VS at increased risk
Injury patterns that are tensile to N-V structures
Iliac wing fractures with GSN extension
Dalal et al, JT, 1989
Burgess et al, JT, 1990
Whitbeck et al, JOT, 1997
Switzer et al, JOT, 2000
Eastridge et al, JT, 2002
Pelvic Fractures & Hemorrhage
ER & VS > IR
APC & VS at increased risk
Hemorrhage Control
Pelvic Containment
Sheet
Pelvic Binder
External Fixation
Angiography
Laparotomy
Pelvic Packing
Supine
2 “Wrappers”
Placement
Apply
“Clamper”
30 Seconds
1
2
3
4
Routt et al, JOT, 2002
Circumferential Sheeting
Sheet Application
Sheet Application
Pelvic Binders
External Fixation
Location
AIIS
ASIS
C-clamp
Clinical Application
Resuscitative
Augmentative
Definitive
Biomechanics of External Fixation
Open book injuries with posterior ligaments (hinge)
intact:
All designs work
C-type injury patterns
No designs work
Biomechanics of External Fixation
Pin size
Number of pins
Frame design
Biomechanics: Pin Location
AIIS:
Biomechanically
equivalent
(superior?)
Patients can sit
Kim et al, CORR, 1999
Kim et al, CORR, 1999
ASIS Frames
AIIS:
Biomechanically
equivalent
(superior?)
Patients can sit
Kim et al, CORR, 1999
AIIS Frames
AIIS:
Biomechanically
equivalent
(superior?)
Patients can sit
AIIS Frames
Kim et al, CORR, 1999
AIIS:
Biomechanically
equivalent
(superior?)
Patients can sit
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
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
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
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
Technical Details: ASIS & AIIS Frames
Pin Orientation
Pin Orientation
Pin Orientation
Technical Details: ASIS Frames…
Consider partial closed reduction first!
Fluoro dependent
3 to 5 cm posterior to the ASIS
Incisions directed toward the
anticipated final location
1/3 from the medial aspect
(lateral overhang)
Aim: 30 to 45 degrees (from
lateral to medial)
Toward the hip joint
Inner Table
Outer Table
ASIS
Outlet Oblique Image
Inner Table
Outer Table
ASIS
Outlet Oblique Image
Check Pin Placement
Technical Details: AIIS frames…
Consider partial closed reduction first!
Fluoro dependent:
30/30 outlet/obturator oblique
Iliac oblique
Inlet/obturator oblique
Incisions directed toward the
anticipated final location
Blunt dissection
Aim: According to fluoro
Outlet Obturator Oblique Image
Outlet Obturator Oblique Image
5 degrees too much obturator 5 degrees too little obturator
5 degrees too little outlet5 degrees too much outlet
5 degrees too much obturator 5 degrees too little obturator
5 degrees too little outlet5 degrees too much outlet
Iliac Oblique Image
Inlet Obturator Oblique Image
Outlet Obturator Oblique Image
Pin Orientation
Inlet (with obturator oblique)
Pin Orientation
Inlet (with obturator oblique)
Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Apply in fluoro/OR?
Combined with packing?
Ertel, W et al, JOT, 2001
Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Apply in fluoro/OR?
Combined with packing
Ertel, W et al, JOT, 2001
Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Apply in fluoro/OR?
Combined with packing
Ertel, W et al, JOT, 2001
Emergent Application
C-clamp: Anatomical Landmarks
Pohlemann et al, JOT, 2004
Pin Location
Near IS screw entry point
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
Avoid Overcompression in Sacral Fxs!
Caution…
Pelvic Packing
Ertel, W et al, JOT, 2001
Pohlemann et al, Giannoudis et al,
Arterial onlyArterial only
5-15%5-15%
TimingTiming
Institution dependentInstitution dependent
Role of Angiography???
Fracture Pattern!Fracture Pattern!
Contrast CT suggestsContrast CT suggests
Effective in retrospectiveEffective in retrospective
studies!!!studies!!!
Role of Angiography???
Vascular Injuries
Arterial vs Venous vs
Cancellous
Unstable posterior ring
association
Associated fracture extension
into notch
Role of angiography
Cryer et al, JT, 1988
O’Neill et al, CORR, 1996
Goldstein et al, JT, 1994
Acute Hemipelvectomy….
Acute Hemipelvectomy….
Acute Hemipelvectomy….
Retrospective Evidence Suggests…
Hypotensive with stable pelvic pattern…
Laparotomy (85% with abdominal hemorrhage)
Hypotensive with unstable pelvic pattern…
Angio (59% with positive angio)
Eastridge et al, JT, 2002
Contrast enhanced CT very suggestive
(40 fold likelihood ratio)
(PPV and NPV of 80%, 98%)
Stephen et al, JT, 1999
Protocol for Management
Hypovolemic shock and no response to fluids…
(+) DPL: 1. Laparotomy (+/- packing with ex fix)
2. Angio
(-) DPL: 1. Sheet/binder/ex-fix (some still crash lap)
2. Angio
Hypovolemic shock with response to fluids…
(++) DPL: 1. Laparotomy (+/- packing with ex fix)
2. Ex Fix
3. Angio
(+) DPL: 1. Ex Fix
2. Laparotomy
3. Angio
(-) DPL: 1. Sheet/binder
2. Angio
3. Ex Fix
Protocol for Management
Protocol for Management
Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001
5 elements: Immediate trauma surgeon availability (+ Ortho!)
Early simultaneous blood and coagulation products
Prompt diagnosis & treatment of life threatening injuries
Stabilization of the pelvic girdle
Timely pelvic angiography and embolization
Changes: Patients more severely injured (52% vs 35% SBP < 90)
DPL phased out for U/S
Pelvic binders and C-clamps replaced traditional ex fix
Protocol for Management
Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001
Mortality decreased from 31% to 15%
Exsanguination death from 9% to 1%
MOF from 12% to 1%
Death (<24 hours) from 16% to 5%
The evolution of a multidisciplinary clinical pathway, coordinating the resources
of a level 1 trauma center and directed by joint decision making between
trauma surgeons and orthopedic traumatologists, has resulted in improved
patient survival. The primary benefits appear to be in reducing early deaths
from exsanguination and late deaths from multiple organ failure.
Immediate Percutaneous Fixation
From Chip Routt, MD
Summary: Acute Management
Play well with others (general surgery, urology,
interventional radiology, neurosurgery)
Understand the fracture pattern
Do something (sheet, binder, ex fix, c-clamp)
Combine knowledge of the fracture, the patients
condition, and the physical exam to decide on the
next step
Sean E. Nork, MD
Harborview Medical Center, University of Washington
Thank You
HMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar, Hanel,
Hanson, Henley, Mirza, Routt, Sangeorzan, Smith, Taitsman
Return to
Pelvis
Index
E-mail OTA
about
Questions/Comments
If you would like to volunteer as an author for
the Resident Slide Project or recommend updates
to any of the following slides, please send an e-
mail to ota@aaos.org

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V02 pelvis acute_mgmt

  • 1. The Acute Management of Pelvic Ring Injuries Sean E. Nork, MD Harborview Medical Center, Seattle, Washington Original Author: Kyle F. Dickson, MD; Created March 2004 New Author: Sean E. Nork, MD; Revised January 2007
  • 2. Pelvic Ring Injuries High energy Morbidity/Mortality Hemorrhage Cylinder: 4/3 rπ 3 ??? Best estimated by a hemi-elliptical sphere (Stover et al, J Trauma, 2006)
  • 3. 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
  • 4. Consideration for Transfer: Pelvic & Acetabular Fractures Posterior pelvis instability/displacement Initial AP x-ray Bladder/urethra injury Open pelvic fractures Lateral directed force with fractures through iliac wing, sacral ala or foramina Open book with anterior displacement > 2.5 cm Acetabular fractures > 1 mm articular step off on any view Lack of parallelism of femoral head and roof Displacement of wall or column
  • 5. Physical Exam Degloving injuries Limb shortening Limb rotation Open wounds Swelling & hematoma
  • 6. Defining Pelvic Stability??? Radiographic Hemodynamic Biomechanical (Tile & Hearn) Mechanical “Able to withstand normal physiological forces without abnormal deformation”
  • 7. Single examiner Use fluoro if available Best in experienced hands Stable or Unstable?
  • 8. 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)
  • 9. Open Pelvic Injuries Open wounds extending to the colon, rectum, or perineum: strongly consider early diverting colostomy Soft-tissue wounds should be aggressively debrided Early repair of vaginal lacerations to minimize subsequent pelvic abscess
  • 10. Urologic Injuries 15% incidence Blood at meatus or high riding prostate Eventual swelling of scrotum and labia (occasional arterial bleeder requiring surgery) Retrograde urethrogram indicated in pelvic injured patients
  • 11. Urologic Injuries Intraperitoneal & extraperitoneal bladder ruptures are usually repaired A foley catheter is preferred If a supra-pubic catheter it used, it should be tunneled to prevent anterior wound contamination Urethral injuries are usually repaired on a delayed basis
  • 12. Sources of Hemorrhage External (open wounds) Internal: Chest Long bones Abdominal Retroperitoneal
  • 13. Sources of Hemorrhage External (open wounds) Internal: Chest Long bones Abdominal Retroperitoneal Chest x-ray Physical exam, swelling DPL, ultrasound, FAST CT scan, direct look
  • 14. Shock vs Hemodynamic Instability Definitions Confusing Potentially based on multiple factors & measures Lactate Base Deficit SBP < 90 mmHg Ongoing drop in Hct Response to fluid challenge
  • 15. Pelvic Fractures & Hemorrhage Fracture pattern associated with risk of vascular injury (Young & Burgess) ER & VS > IR APC & VS at increased risk Injury patterns that are tensile to N-V structures Iliac wing fractures with GSN extension Dalal et al, JT, 1989 Burgess et al, JT, 1990 Whitbeck et al, JOT, 1997 Switzer et al, JOT, 2000 Eastridge et al, JT, 2002
  • 16. Pelvic Fractures & Hemorrhage ER & VS > IR APC & VS at increased risk
  • 17. Hemorrhage Control Pelvic Containment Sheet Pelvic Binder External Fixation Angiography Laparotomy Pelvic Packing
  • 21.
  • 22.
  • 25. Biomechanics of External Fixation Open book injuries with posterior ligaments (hinge) intact: All designs work C-type injury patterns No designs work
  • 26. Biomechanics of External Fixation Pin size Number of pins Frame design
  • 28. Kim et al, CORR, 1999 ASIS Frames AIIS: Biomechanically equivalent (superior?) Patients can sit
  • 29. Kim et al, CORR, 1999 AIIS Frames AIIS: Biomechanically equivalent (superior?) Patients can sit
  • 30. AIIS Frames Kim et al, CORR, 1999 AIIS: Biomechanically equivalent (superior?) Patients can sit
  • 31. 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
  • 32. 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
  • 33.
  • 34.
  • 35.
  • 36.
  • 37. 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
  • 38.
  • 39.
  • 40.
  • 41. 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
  • 42. Technical Details: ASIS & AIIS Frames
  • 46. Technical Details: ASIS Frames… Consider partial closed reduction first! Fluoro dependent 3 to 5 cm posterior to the ASIS Incisions directed toward the anticipated final location 1/3 from the medial aspect (lateral overhang) Aim: 30 to 45 degrees (from lateral to medial) Toward the hip joint
  • 49.
  • 51.
  • 52. Technical Details: AIIS frames… Consider partial closed reduction first! Fluoro dependent: 30/30 outlet/obturator oblique Iliac oblique Inlet/obturator oblique Incisions directed toward the anticipated final location Blunt dissection Aim: According to fluoro
  • 53. Outlet Obturator Oblique Image Outlet Obturator Oblique Image
  • 54.
  • 55. 5 degrees too much obturator 5 degrees too little obturator 5 degrees too little outlet5 degrees too much outlet
  • 56. 5 degrees too much obturator 5 degrees too little obturator 5 degrees too little outlet5 degrees too much outlet
  • 57.
  • 61. Pin Orientation Inlet (with obturator oblique)
  • 62. Pin Orientation Inlet (with obturator oblique)
  • 63.
  • 64.
  • 65.
  • 66. Anti-shock Clamp (C-clamp) Better posterior pelvis stabilization Allows abdominal access Apply in fluoro/OR? Combined with packing? Ertel, W et al, JOT, 2001
  • 67. Anti-shock Clamp (C-clamp) Better posterior pelvis stabilization Allows abdominal access Apply in fluoro/OR? Combined with packing Ertel, W et al, JOT, 2001
  • 68. Anti-shock Clamp (C-clamp) Better posterior pelvis stabilization Allows abdominal access Apply in fluoro/OR? Combined with packing Ertel, W et al, JOT, 2001
  • 70. C-clamp: Anatomical Landmarks Pohlemann et al, JOT, 2004 Pin Location Near IS screw entry point 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
  • 71. Avoid Overcompression in Sacral Fxs! Caution…
  • 72. Pelvic Packing Ertel, W et al, JOT, 2001 Pohlemann et al, Giannoudis et al,
  • 73. Arterial onlyArterial only 5-15%5-15% TimingTiming Institution dependentInstitution dependent Role of Angiography???
  • 74. Fracture Pattern!Fracture Pattern! Contrast CT suggestsContrast CT suggests Effective in retrospectiveEffective in retrospective studies!!!studies!!! Role of Angiography???
  • 75. Vascular Injuries Arterial vs Venous vs Cancellous Unstable posterior ring association Associated fracture extension into notch Role of angiography Cryer et al, JT, 1988 O’Neill et al, CORR, 1996 Goldstein et al, JT, 1994
  • 76.
  • 80. Retrospective Evidence Suggests… Hypotensive with stable pelvic pattern… Laparotomy (85% with abdominal hemorrhage) Hypotensive with unstable pelvic pattern… Angio (59% with positive angio) Eastridge et al, JT, 2002 Contrast enhanced CT very suggestive (40 fold likelihood ratio) (PPV and NPV of 80%, 98%) Stephen et al, JT, 1999
  • 82. Hypovolemic shock and no response to fluids… (+) DPL: 1. Laparotomy (+/- packing with ex fix) 2. Angio (-) DPL: 1. Sheet/binder/ex-fix (some still crash lap) 2. Angio Hypovolemic shock with response to fluids… (++) DPL: 1. Laparotomy (+/- packing with ex fix) 2. Ex Fix 3. Angio (+) DPL: 1. Ex Fix 2. Laparotomy 3. Angio (-) DPL: 1. Sheet/binder 2. Angio 3. Ex Fix
  • 84. Protocol for Management Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. JOT, 2001 5 elements: Immediate trauma surgeon availability (+ Ortho!) Early simultaneous blood and coagulation products Prompt diagnosis & treatment of life threatening injuries Stabilization of the pelvic girdle Timely pelvic angiography and embolization Changes: Patients more severely injured (52% vs 35% SBP < 90) DPL phased out for U/S Pelvic binders and C-clamps replaced traditional ex fix
  • 85. Protocol for Management Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. JOT, 2001 Mortality decreased from 31% to 15% Exsanguination death from 9% to 1% MOF from 12% to 1% Death (<24 hours) from 16% to 5% The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and orthopedic traumatologists, has resulted in improved patient survival. The primary benefits appear to be in reducing early deaths from exsanguination and late deaths from multiple organ failure.
  • 87. Summary: Acute Management Play well with others (general surgery, urology, interventional radiology, neurosurgery) Understand the fracture pattern Do something (sheet, binder, ex fix, c-clamp) Combine knowledge of the fracture, the patients condition, and the physical exam to decide on the next step
  • 88. Sean E. Nork, MD Harborview Medical Center, University of Washington Thank You HMC Faculty Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar, Hanel, Hanson, Henley, Mirza, Routt, Sangeorzan, Smith, Taitsman Return to Pelvis Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e- mail to ota@aaos.org