PELVIC TRAUMA

1. PELVIC TRAUMA

2. SURVIVAL STUDIES Mortality rate ? 10% Mortality ? ISS ORIF of unstable pelvic fractures ? mortality rate

3. NATURAL HISTORY 1 Stable fractures � few major long-term problems usually mild or moderate pain

4. NATURAL HISTORY 2 Unstable fractures � Persistent pain � 60% Nonunion � 3.5% Malunion � 4% Permanent nerve injury � 5.5% Permanent urethral injury � 2.5%

5. Prognostic Factors Degree of initial force Type of injury (stable or unstable) Treatment modalities Associated injuries

6. Anatomic considerations Bony ring structure � pelvic ring Ligaments structures � static & dynamic stabilizers

7. Biomechanical considerations Pelvic stability Forces acting on the pelvis Forces transmission to the viscera, vessels, and nerves

12. Management Polytraumatized patient Rapid general assessment and resuscitation (esp. type C)

13. Resuscitation Massive fluid replacement Hemorrhage control

14. Hemorrhage control Pneumatic antishock garment (PASG) Stabilization of the unstable pelvic disruption Embolization of the pelvic vessels Open surgery

15. Hemorrhage control Early, provisional stabilization of the unstable pelvic fracture Use safe, simple and quick methods

16. Indications for Open Surgery Open (compound) fracture. Major vessel injury. Patient in extremis from hypovolemic shock. BP < 60 mmHg secondary to hypovolemic shock, with little or no response to fluid replacement.

17. Clinical Assessment History Patient profile Injury profile Physical Examination Look Wounds, contussions, bleeding genitalia, displacement of pelvis or lower extremities. Feel and Move Palpation, traction, rectal and vaginal examination, neurological examination.

19. Radiographic Assessment Plain Radiography A-P, inlet, outlet, oblique views. Tomography Nuclear Scanning CT

23. Signs of Instability- clinical factors Severe displacement, including rotation of the pelvis and/or shortening of the extremity. Marked posterior disruption characterized by bruising and swelling. Gross instability of the hemipelvis on manual palpation. Associated injuries to viscera, blood vessels, or nerves. Associated open wound.

24. Signs of Instability- radiographic factors Displacement of the posterior SI complex >1 cm, either by a fracture, a dislocation, or a combination of both. The presence of a gap rather than impaction posteriorly. The presence of avulsion fractures of the sacral or ischial end of the sacrospinous ligament. Avulsion fractures of the transverse process of the L5, if associated with a posterior gap. * Indicating a posterior lesion

26. Classification Type A � stable Type B � vertically stable, rotationally unstable Type C � unstable (rotationally + vertically)

37. TYPE B2: LATERAL COMPRESSION INJURIES B2-1 Ipsilateral Anterior and posterior injury B2-2 Contralateral Anterior and posterior injury

45. Pelvic Ring DisruptionManagement

46. Management Protocol for Pelvic Ring Disruption

47. Management Protocol for Pelvic ring Disruption

48. Management Protocol for Pelvic Ring Disruption

49. Management Protocol for Pelvic Ring Disruption

51. Provisional stabilization External frame Pelvic clamp Skeletal traction (30-40 lb)

56. Early Provisional stabilization Type B1 (open book fracture) Type C Both result in an increased pelvic volume

57. Early provisional stabilization Reduce the volume of the pelvis Restore the tamponade effect of the bony pelvis Hemorrhage control

58. Early provisional stabilization Maintaining an upright position for proper ventilation

59. Early provisional stabilization Biomechanically, not strong enough to allow ambulation Redisplacement usually occurs

60. Definitive stabilization Stability of the fracture Risks and benefits of stabilization

61. Definitive stabilization Type A Symptomatic treatment No need for stabilization

62. Definitive stabilization- type B1 (open book) If symphysis is open < 2.5 cm => No specific stabilization If symphysis is open > 2.5 cm => ESF or plate

63. Anterior internal fixation of disrupted symphysis Plating is suggested if : Laparotomy No fecal contamination No need for suprapubic drain

64. Definitive stabilization- type B2-1 No specific stabilization

65. Definitive stabilization- type B2-2 (bucket handle) If LLD < 1.5 cm => No specific stabilization If LLD > 1.5 cm => ESF If tilt fracture => ORIF

66. Definitive stabilization- type C Simple external frame c traction Complex external frame c or � traction ORIF

67. Definitive stabilization Advantages of ORIF : Biomechanically, strong enough to allow early ambulation Reduces the malunion or nonunion rates

68. Definitive stabilization Disadvantages of ORIF : Increased bleeding Wound problems Nerve injury

69. Type C injury Indication for anterior internal fixation Indication for posterior internal fixation

70. Indications for anterior internal fixation Fracture types State of the patient Laparotomy No fecal contamination No need for suprapubic drain

71. Indications for posterior internal fixation State of the patient Unstable, unreduced posterior SI complex (esp. an unreduced SI dislocation c a gap of > 1 cm) Posterior open wound (cf. - contraindicated if the wound is in the perineum) Associated acetabular fracture requiring ORIF

72. Timing of open surgery (ORIF) Wait until general condition is stable, usually between 5th and 7th post-op day

73. Prophylactic antibiotics Routinely given for a minimum of 48 h Cefazolin 2g/day, IV Tobramycin 160mg/day, IV

74. SURGERY- anterior internal fixation Type B1, a 2- to 4-hole reconstruction plate on the superior surface Type C, two plates at 90� to each other, if no posterior fixation is planned

75. SURGERY- posterior internal fixation Sacral fractures, two transiliac bars SI dislocations, anterior plating or posterior screw fixation Iliac fractures, interfragmental screws or plates (3.5-mm reconstruction plates)

76. Early complications Hypovolemia Thromboembolism Fat embolism

77. Late complications Infection Multiple organ failure