for 5th year medical student

1. UKRIS GUNADHAM, MD FRCOST
Medical Education Center Trang Hospital
Lecture for 5th year medical student
Orthopedic Emergency

2. Orthopaedic Emergency
What are life-threatening conditions?
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3. Orthopaedic Emergency
What are life-threatening conditions in
orthopedics?
 Unstable C-spine fracture
 Unstable Pelvic fracture
 Multiple fractures / Crush injuries

5. Unstable Pelvic Fracture

6. Anatomy

7. Internal iliac artery
Superior gluteal artery
Ventral rami of L5 nerve root

10. Mortality in Pelvic Fractures
 haemorrhage in 42% cause of mortality
 62% is due to pelvic bleeding
 38% is due to other bleeding sources, chest,
abdomen, external
 head injury: 32% cause of mortality
 sepsis & MOF: 14% cause of mortality

11. Time is a Critical Factor
 Delayed access to definitive trauma care
 Injury: discovery, access, EMT, transportation,
ER, trauma team activation, trauma surgeon,
ATLS, consultation, OR, ICU

12. High Index of Suspicion
 Pelvic tenderness
 Pelvic instability - gentle compression; Once
 Haematuria/blood at urinary meatus
 Abdominal/pelvic bruising
 Flank bruising
 Perineal/scrotal haematoma

15. Initial Investigation

16. Pelvic Inlet

17. Pelvic Outlet

18. Tile Classification
Type A: Pelvic Ring Stable
A1: fractures not involving the ring (i.e., avulsions, iliac wing,
or crest fractures)
A2: stable minimally displaced fractures of the pelvic ring
Type B: Pelvic Ring Rotationally Unstable, Vertically Stable
B1: open book
B2: lateral compression, ipsilateral
B3: lateral compression, contralateral, or bucket-handle-type
injury
Type C: Pelvic Ring Rotationally and Vertically Unstable:
C1: unilateral
C2: bilateral
C3: associated with acetabular fracture

19. Tile Classification

20. Young and Burgess Classification
LC: anterior injury = rami fractures
LC I: sacral fracture on side of impact
LC II: crescent fracture on side of impact
LC III: type I or II injury on side of impact with contralateral open
book injury
AP compression (APC): anterior injury = symphysis
diastasis/rami fractures
APC I: minor opening of symphysis and SI joint anteriorly
APC II: opening of anterior SI, intact posterior SI ligaments
APC III: complete disruption of SI joint
Vertical shear (VS) type:
Vertical displacement of hemipelvis with symphysis diastasis
or rami fractures anteriorly, iliac wing, sacral facture, or SI
dislocation posteriorly
Combined mechanism (CM) type: any combination of above
injuries

21. LC - I LC - II
LC - III

22. APC -
I
APC - II
APC-III

23. Vertical shear direction

24. Unstable Pelvis
 Loss of posterior S-I complex
 Loss of impaction (SI dislocation)
 Crush pelvis
 Vertical fracture
 APC III, LC III, VS, Combined

25. Associated Injuries
 Hemorrhage (75%)
 Urologic Injury (12%)
 Neurologic Injury (8%)
 Gynecologic Injury
 Thoracic Aorta Injury
 Rupture of Diaphragm
 Rectal Injury

26. Hemorrhage
 Lack muscular wall for post-traumatic constriction
 Rely on intact peritoneum to contain and
tamponade
 Primary cause of death
 Retroperitoneum space can accommodate 6 liters
of blood

27. Hemorrhage
 Most dangerous complication of pelvic
fracture
 Source  fracture surface ,venous plexus,
torn small a. or v. , disrupt major vessels
 Other source should be considered
 APC + VS  Ext. rotate and tensile load 
tear vascular
 LC  Int. rotate  less risk
 Major arterial bleeding ~ 10%
Hemorrhage can occur in both stable and unstable type !

28. Genitourinary injuries
Approximately 16%
Male > Female ( longer urethra)
Sign / Symptom
- Blood at distal meatus
- High - riding prostate
- Perineal hematoma
Contusion , bladder rupture ,
urethral injuries
Microscopic or gross hematuria
Retrograde cystography (Post
normal retrograde
urethrogram

29. Neurologic injury
 Cause disability : motor , sensory function , bowel
bladder control , sexual function
 Range 10-15%
if posterior pelvic ring involve high as 40-50%
 Neurologic exam , perianal sensation

30. Gastrointestinal injuries
1) laceration cause by fracture fragment
2) tearing or avulsion of surrounding soft tissue
Ex: APC type fracture
- Classified as open pelvic fracture

31. Open pelvic fracture
 Mortality ~ 50%
 Sepsis from fecal
contamination
 Aggressive Rx
Debridement
Diversion of fecal
Broad spectrum ATB

32. Initial Treatments
 Military Anti-Shock Trousers
 Pelvic Binders and Sheets
 External Fixation
 Angiography
 Pelvic Packing
 Fluid Resuscitation
 Blood Products and Recombinant Factor VIIa

48. Evaluation of Resuscitation
 Hb / Hct
 inaccurate during the acute phase of resuscitation
 Normal blood pressure
 Decreased heart rate
 Adequate urine output (≥30 ml/hr)
 Normal central venous pressure

49. Algorithm for the treatment of
patients with pelvic fracture who
present with
hemodynamic instability