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Kyle F. Dickson, MD
Chief of Orthopaedics, Charity Hospital Director of Orthopaedic Trauma Tulane University
Created March 2004
Primary survey
A. B.
C. D. E.
Circulation with hemorrhage control Disability: Neurologic status Exposure/environment control: undress patient but prevent hypothemia
Posterior instability/displacement
Initial AP x-ray
Bladder/urethra injury Open pelvic fractures Lateral directed force with fractures through iliac wing, sacral ala or foramina
Transfer (cont.)
High ISS
Tile, 1980 McMurty, 1980
Associated injuries
Head & abdominal, 50% mortality
Age
Looser, 1976
Extremely High Energy Injuries with a Large Number and Variety of Associated Injuries
Associated Injuries
Long bone injuries Knee injuries Foot injuries
Colon, rectum, or perineum Early diverting colostomy Soft-tissue wounds aggressively debrided Early repair of vaginal lacerations minimize subsequent pelvic abscess
Team Approach
Direct the general surgeon for a transverse colostomy vs. descending colostomy to prevent possible wound contamination of an anterior approach
Colostomy is Indicated for Any Open Injury Where the Fecal Stream Will Contact the Open Area
Urologic Injuries
15% incidence Blood at meatus or high riding prostate Eventual swelling of scrotum and labia (occasional arterial bleeder requiring surgery)
Urologic (cont.)
Retrograde urethrogram indicated in pelvic injured patients but insure hemodynamic stability or embolization may be difficult due to dye extravasation
Urologic (cont.)
Intra & extra peritoneal bladder ruptures are repaired Foley preferred supra-pubic catheter tunneled to prevent ant. wound contamination
Urologic (cont.)
Neurologic Damage
L5 & S1, most common L2 to S4 possible Dependent on location of fracture and amount of displacement
Neurologic Injury
Careful exam may need decompression of sacral foramen if progressive loss of neural function May take up to 3 years for recovery
Hemodynamically unstable Patient Fluid resuscitation (causes of hypovolemia) Other causes: external bleeding (i.e. open fractures -- sterile dressing) Hemothorax --- (chest tube) closed fractures (i.e. femur ---- traction eventual early reduction and fixation) coagulopathies (hypothermia, low calcium, acidosis) Intra-abdominal Bleeding Assess: ultrasound CT supraumbilical peritoneal lavage negative AP Pelvis & physical exam Emergency Mechanically stable pelvis Mechanically unstable pelvis External fixator Small Other causes of hypotension: cardiac quadriplegia or spinal injury terminal brain injury hypothermia Patient unstabl e Patien t stable look for other causes laparotomy
(should not delay emergency laparotomy)
positive
External fixator
Assess retroperitoneal hemorrhage Large and expanding hematom a Surgical ligation & packing Patient unstable Patient stable
Patient unstabl e
Angiographic embolization
Patien t stable
Other causes:
external bleeding (i.e. open fractures -- sterile dressing) Hemothorax --- (chest tube) closed fractures (i.e. femur ---- traction eventual early reduction and fixation) coagulopathies (hypothermia, low calcium, acidosis)
Negative
Positive
Negative
External fixator
Patient stable
Positive
Emergency laparotomy
Angiography on standby
Positive
Assess retroperitoneal hemorrhage
Small
look for other causes
Large and expanding hematoma Surgical ligation & packing Patient unstable Patient stable Patient stable
Patient unstable
Angiographic embolization
Retroperitoneal bleeding
Shock (cont.)
Mortality 8.6% 2/210 pelvic injury patients where pelvic injury was primary cause of death Contributed 10/210
Hemorrhage Control
Mortality
3% hemodynamically stable patients 38% unstable patients
Burgess (cont.)
LC head injury major cause of death APC pelvic and visceral injury major cause of death
LC1 and LC2 50% brain injury LC3 (windswept pelvis rollover/crush)
60% retroperitoneal hematoma 40% lower extremity fracture 20% bowel injury 0% brain injury
Force (cont.)
Force (cont.)
Vertical shear
63% shock 56% brain injury 25% splenic injury 25% death 23% lung injury
Coagulopathy
Prolonged Hypovolemia
Aggravate pulmonary contusion Head and visceral injuries Increased sepsis Adult respiratory distress syndrome (ARDS) Multiple organ failure
Only patients with mechanical instability can have hemodynamic instability related to the pelvic injury
Force Vectors
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)
Hemorrhage (cont.)
Skeletal traction External fixation Mast suit Embolization Surgical stabilization with packing Towel clamp with sheet
Hemorrhage (cont.)
Iliolumbar artery Superior gluteal artery Lateral sacral artery Internal iliac artery Internal pudendal (active bleeding most commonly found)
Anterior Frame
Safer and easier to apply May not give the necessary posterior support Indication acutely for a mechanically and hemodynamically unstable pelvis injury
Posterior Clamp
Same indications Advantages, posterior stabilization Contraindications: Iliac wing fracture or comminution of sacrum (over compression)
External fixation is a resuscitative fixation and cannot be used as the definitive fixation in completely unstable pelvic injuries.
Patient NJ
VS initially attempted to be treated with anterior plate and ex-fix with hardware failure 3 stage pelvic reconstruction ( ant. post ant. 2 yr follow-up Auburn football player)
Must understand the 3-D deformity Reduce the posterior complex (do not just squeeze anterior symphysis together)
Retroperitoneal space is massive (30L with only 3 mmHg) Stabilization is from holding hemipelvis stable not reducing pelvic volume
Glut. Medius tubercle Follow contour of iliac wing 2 - 2.5 cm post. To ASIS
Anterior (cont.)
K-wires helpful for inner and outer cortex Starting drill hole than let pin find direction Traction and close pelvis posteriorly
16/151 unstable pelvic injuries referred with external fixator as initial treatment Review AP, inlet, outlet, and CT before and after external fixator
Reduction
67% (8/12) worsening of posterior complex 30% (3/10) loss of reduction Average maximum displacement 3 cm (range 1.5 cm 5.4 cm)
Unexplained blood loss after stabilization and aggressive resuscitation Pulselessness extremity
Surgical
Stabilization with internal fixation of pelvis Stabilization of hemodynamic instability with surgical packing of retroperitoneal space rare
Acknowledgement
Joel Matta, Jim Pohlemann, Mark Vrahas