Pelvic Trauma

Pelvic TraumaLecture Outline

ƒ Associated injuriesƒ Resuscitationƒ Classificationƒ Example radiographs

Pelvic Trauma General Considerations

ƒ Pelvis : ? The most important (or perhaps most favorite) area of the body (since it houses the sexual organs)

ƒ Pelvic injuries often represent multi-system injuries

ƒ Definitive management may require a subspecialist orthopedic surgeon

Pelvic Fractures Epidemiology

ƒ Overall mortality 6 to 19 %ƒ If hypotensive, mortality 40 to 50 %ƒ 60 % due to motor vehicle crashes

(MVC's)–Third most common cause of death from MVC's

ƒ 30 % due to fallsƒ 10 % due to direct crush of pelvisƒ 65 % of deaths due to hemorrhage

Immediate Sequelae of Pelvic Trauma

ƒ Massive hemorrhageƒ Bony disruption of pelvisƒ Vascular interruption (major and

minor)ƒ Urologic injuryƒ Bowel and vaginal tears or

perforationsƒ Neurologic injury

Massive Hemorrhage from Pelvic Trauma

ƒ Major cause of death from pelvic fracture (60 to 80 %)

ƒ 50 to 60 % of deaths due primarily to pelvic fracture occur within first nine hours of hospital admission

ƒ Degree of hemorrhage dependent on fracture type; truly massive in large posterior fractures

ƒ Retroperitoneum can accomodate large amount of blood and problem compounded with open fracture

ƒ "Direct open" operative treatment seldom if ever indicated unless major vascular injury uncontrolled after angiography (however, surgical placement of external fixator often indicated & can be done in E.D.)

Pelvic Trauma : Initial Examƒ Local palpation : assess gross instabilityƒ Check both hips ; associated hip Fx commonƒ Blood at meatus (elicit by "milking" along the

urethra first) : mandates urethrogram and cystogram ; Do not pass foley first !

ƒ Careful neuro examƒ Vaginal & rectal exam ; if mucosa violated,

patient must go to O.R. for diverting colostomyƒ Early external fixator may be needed for unstable

Fx ; another option is compressive external clamp

Pelvic Fractures : Radiologyƒ Anteroposterior (AP) view shows most fx'sƒ Inlet view : shows inward fx displacementƒ Outlet view : provides true AP view of sacral

foraminaƒ Tangential view : good for sacral fx & sacroiliac

(SI) separationƒ Judet views (45 degrees oblique on both sides)–Help delineate acetabular fx's

ƒ Computed tomography (CT) : more accurate for posterior arch & acetabular fx's

Standard AP view of pelvis

Standard pelvic inlet view

Standard outlet view of pelvis

Indications for Pelvic Radiography in the Trauma Patient

ƒ AP view can be used as screening study–Other film choices on prior slide can then be ordered based on findings on the AP view

ƒ Should obtain in :–all major truncal trauma cases (especially if pain perception altered by head trauma, intoxication, etc.) with any abdominal pain or findings–patients with hip pain (may actually show pelvic Fx on the other side)

Additional Indications for Pelvic Films for the Trauma Patient

ƒ Ecchymosis or tenderness over any pelvic bone

ƒ Joint pain with internal or external rotation of hips

ƒ Abnormal rectal examƒ Abnormal lower extremity neuro

examƒ Blood at urethral meatus or

hematuria

Pelvic Fractures : Diagnostic Peritoneal Lavage (DPL)

ƒ May be required to quickly R/O intra-abdominal bleeding as cause for shock or hypotension

ƒ False positive rate higher than for isolated intraperitoneal injury

ƒ Should use supraumbilical open approach

ƒ Will miss diagnosis if hemorrhage is all retroperitioneal (so CT is better for Dx if patient stable enough to obtain scan)

M.A.S.T. (P.A.S.G.)

ƒ Inflation may be helpful to control bleeding from pelvic fx (inflate abdominal compartment and leg compartments) if external fixator or large external clamp not available

ƒ If unable to stabilize patient within 2 hours of application & suspected arterial bleeder present, then go to angiography

ƒ If left on too long : risk of compartment syndrome in legs

Angiography for Pelvic Trauma

ƒ Indicated when hypovolemia persists and other sources of bleeding ruled out

ƒ Consider early for posterior arch fx's (associated with greater bleeding)

ƒ Allows Rx by vasopressin infusion or transcatheter embolization (wire coils or autologous clot) of bleeding vessel(s)

Classification of Pelvic Fractures

STABLEFracture of individual bones : no break in the pelvic ring Avulsion fractures anterior superior iliac spine anterior inferior iliac spine ischial tuberosity Fracture of the pubis or ischium (around the obturator foramen) Fracture of the wing of the ilium (Duverney's fracture) Fracture of the sacrum Fracture of the coccyxSingle break in the pelvic ring Fracture of two ipsilateral rami Fracture near or subluxation of symphysis pubis Fracture near or subluxation of sacroiliac joint

Classification of Pelvic Fractures (cont.)

UNSTABLE : DOUBLE BREAKS IN THE PELVIC RINGDouble vertical fracture or dislocation of the pubis (straddle fx)Double vertical fracture or dislocation of the pelvis(Malgaigne's fx)Severe multiple fractures (including sacral fracture)

FRACTURES OF THE ACETABULUMUndisplacedDisplaced

Types of pelvic fractures

Classification of Pelvic Fractures by Causative Mechanismƒ Lateral compression

–Most common cause ( > 50 %)–Associated with high incidence of brain injury

ƒ Anteroposterior compression–30 % of cases–High incidence of associated thorax and abdominal injuries

ƒ Vertical shear–Less common–Usually from fall from height

Pelvic Avulsion Fractures

ƒ Anterior superior iliac spine avulsion (from pull from sartorius)

ƒ Anterior inferior iliac spine avulsion (from pull from rectus femoris)

ƒ Ischial tuberosity avulsion (from pull from hamstrings)

ƒ Rx : Analgesics, rest, may need temporary use of crutches ; ORIF rarely only for professional athletes

Ischial avulsion fracture due to hamstring or adductor muscle pull

16 year old sprinter with pain in groin and buttocks from bilateral ischial apophyses avulsion fractures

Coccygeal Fractures

ƒ Usually caused by fall in sitting position

ƒ May be caused by childbirthƒ No need to reduce transrectally

since reduction usually not maintained due to muscle pull

ƒ Rx : Analgesics, stool softeners, sacral dough-nut ; consider coccygectomy if severe persistent pain (usually if > 1 month)

Sacral Fractures

ƒ Isolated sacral fx's usually transverse (vertical fx's always associated with Malgaigne fx)

ƒ Do not do bimanual reduction via rectum (may cause enlargement of presacral hematoma or conversion to contaminated open fx)

ƒ If neurologic Sx, Rx by surgeryƒ If no neuro Sx : bed rest, analgesics,

sacral corset

Type II Pelvic Fractures

ƒ Single break in pelvic ring–Fracture of 2 ipsilateral rami–Subluxation of symphysis or SI joint

ƒ Usually mechanically stableƒ Rx : analgesics, initial bed rest,

then gradual ambulation advanced as tolerated

Lateral compression injury with overriding pubic symphysis

“Open-book” or anteroposterior compression injury

Type III Fractures

ƒ Double breaks in pelvic ringƒ Unstableƒ Almost all require surgeryƒ Are one of criteria for referral to

a trauma center

Straddle Fracture

ƒ Fractures of both pubic rami on both sides or Fx of both rami on one side & a symphysis separation

ƒ 1/3 have lower GU tract injuryƒ 1/3 have abdominal visceral

injury

Straddle fracture with bladder rupture

Inlet view showing inward displacement of fracture fragments from a straddle fracture

Straddle fracture with “teardrop” bladder compressed by lateral hematomas

Malgaigne Fracture

ƒ Anterior and posterior pelvic ring fracture

ƒ Anterior : both pubic ramiƒ Posterior : fx ilium, SI joint

separation or sacral fx (vertical)

Malgaigne Fracture Associated Injuries

ƒ 50 % have intra-abdominal injury

ƒ 50 % have GU tract injuryƒ > 25 % have head injuryƒ > 25 % have chest injury

Malgaigne fracture with diastasis of pubic symphysis and left S-I joint and left posterior hip dislocation

Vertical shear injury with superior migration of right hemipelvis

Acetabular Fractures

ƒ Posterior lip fx –Most common –Associated with posterior hip dislocation

ƒ Central or transverse fxƒ Fracture of anterior (iliopubic)

columnƒ Fracture of posterior (ilioischial)

column (Walther fx)

Transverse acetabular fracture (note cystogram shows intact bladder)

Pelvic ring fracture and right acetabular fracture

Displaced posterior wall acetabular fracture

External pelvic fixator frame

Pelvic Fractures : Summary

ƒ Assess pelvis as part of secondary survey

ƒ Treat associated injuriesƒ Consider sequence of fluid

support : angiography : M.A.S.T. inflation : surgery (laparotomy or external fixator +/- plating) for continued bleeding from pelvic fractures

ƒ Assess for associated injuries to GU tract, rectum, and femurs