Pelvic Fractures AOCP National Course Belfast City Hospital 11 th June 2010
Who s this bloke? Consultant orthopaedic surgeon RVH Trained in Belfast, England and Toronto Interests - pelvic and acetabular trauma - hand surgery
Acute Pelvic Fracture?
High Energy Pelvic Fractures Occur in 10-20% of polytrauma victims Mortality varies with associated injuries Age, ISS and severe haemorrhage are best predictors of mortality
Polytrauma Mortality Pelvic-related mortality ~ 7-18% Pelvic # + intracranial mass (a) ~ 50% + intra-peritoneal injury (b) ~ 50% + (a) + (b) > 90% Pelvic # + thoracic / urological / musculoskeletal ~ 20%
Pelvic - related Mortality Mostly due to bleeding Bleeding may occur from venous or arterial injury or from the cancellous bone surfaces Different sources of bleeding require different interventions
If at first you don t succeed. 16 year old male, scooter vs. lorry Transient response to : - resuscitation - external fixation - embolisation - Novo 7 No response to laparotomy
Pelvic related mortality The key is to differentiate transient and non-responders Clinical - unstable fractures - open fractures X-ray - unstable fractures - evidence of pelvic floor disruption - fractures extending into sciatic notch? Physiological response to resuscitation
A pelvic fracture: Assessment should be suspected from the history may not be clinically obvious confirmed by plain radiographs of the pelvis. In addition to plain anteroposterior films two 45-degree oblique films should be obtained, the pelvic inlet and the pelvic outlet view.
Examination Instability can be assessed by compressing the ASIS, pulling on the leg and looking for evidence of damage to posterior structures (bruising or localised tenderness).
Radiographs Trauma series c-spine chest pelvis (if there is an injury to one part of the pelvis x-ray the whole pelvis)? spine
A.P. pelvis
Inlet view
Outlet view
CT Not necessary in acute situation- unless surgeons want one Useful to assess posterior damage Useful to assess reduction
Contrast studies N.B. Signs of urethral damage Urethrogram If in doubt suprapubic catheter
Angiography / embolisation Has been used for > 20 years Indications and / or timing controversial Availability may be an issue
Young and Burgess LATERAL COMPRESSION AP COMPRESSION VERTICALLY UNSTABLE
Lateral compression I - sacral impaction, stable II - disruption of posterior structures, vertically stable III - injury to contralateral hemipelvis
A.P. compression I - less than 2.5cm diastasis, no posterior injury II - greater than 2.5cm, opening of sacroiliac joint, vertically stable III - complete disruption, unstable
Vertical shear
Pelvic - related Haemorrhage Options to try and control haemorrhage include: Mechanical stabilization Angiography / embolisation Pelvic packing
Pelvic binding Rapid and easily applied Effective Can produce skin necrosis
External fixation Many variations Poor control of posterior pelvic injuries
Inlet view Outlet view
Pelvic clamps Attempt to address posterior pelvic displacement High rate of complications
Open pelvic fractures Pelvic volume is now unlimited
Open pelvic fractures
Outlet view Inlet view AP pelvis
Future developments Identify the fracture patterns likely to continue to bleed Identify features which guide treatment choice Pharmacological manipulation