Pelvic Trauma

Dr Charles A Simanjuntak, dr, SpoT(K), FICS, MPd

FKIK - Universitas Jambi
Pelvic trauma(1)
• one of the most complex management
in trauma care and occurs in 3% of
skeletal injuries
• usually young and have a high overall
injury severity score (ISS) (25 to 48
ISS)

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Pelvic trauma(2)
• Mortality rates remain high,
particularly in patients with
hemodynamic instability, due to the
rapid exsanguination, the difficulty to
achieve hemostasis and the
associated injuries

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Pelvic trauma(3)
• Multidisciplinary approach is crucial
to manage the resuscitation, to
control the bleeding and to manage
bones injuries particularly in the first
hours from trauma ie trauma
surgeons, orthopedic surgeons,
interventional radiologists,
anesthesiologists, ICU doctors and
urologists
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Pelvic trauma(4)

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Pelvic trauma(5)

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Pelvic trauma(6)

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Pelvic trauma(7)

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Pelvic trauma(8)

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Pelvic trauma(9)

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Pelvic trauma(10)

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Pelvic trauma(11)

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Pelvic trauma(12)

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Pelvic trauma(13)

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Pelvic trauma(14)

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Pelvic trauma(15)

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Pelvic trauma(16)

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Pelvic trauma(17)

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Pelvic trauma(18)

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Pelvic trauma(19)

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 The WSES Classification of
Pelvic ring Injuries
• – Minor (WSES grade I) comprising
hemodynamically and mechanically
stable lesions
• – Moderate (WSES grade II, III)
comprising hemodynamically stable and
mechanically unstable lesions
• – Severe (WSES grade IV) comprising
hemodynamically unstable lesions
independently from mechanical status.
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Tile Classification
– A stable
– B partially stable
– C unstable

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Management

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Pelvic Ring Injuries(1)
High energy

Morbidity/Mortality

Hemorrhage

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Pelvic Ring Injuries(2)
An unstable pelvic injury may allow
hemorrhage to collect in the true
pelvis as there is no longer a
constraint which allows tamponade.
The volume was traditionally assume to
be a cylinder with a volume of 4/3π
r3, However…

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Primary survey: ABC’s
Airway maintenance with cervical
spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/environment control: undress
patient but prevent hypothemia

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 Considerations for Transfer or Care at a
Specialized Center: Pelvic Fractures(1)
• Significant posterior pelvis
instability/displacement on the initial
AP X-ray (indicates potential need
for ORIF)

• Bladder/urethra injury

• Open pelvic fractures

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 Considerations for Transfer or Care at a
Specialized Center: Pelvic Fractures(2)
• Lateral directed force with fractures
through iliac wing, sacral ala or
foramina

• Open book with anterior

displacement > 2.5 cm (value of 2.5
centimeters somewhat arbitrary and
controversial with regards to
reliability)

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Physical Exam

• Degloving injuries

• Limb shortening

• Limb rotation

• Open wounds

• Swelling & hematoma

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Defining Pelvic Stability???
• Radiographic
• Hemodynamic
• Biomechanical (Tile & Hearn)
• Mechanical

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 Operative Indications
• Resuscitation
– See previous lecture on Acute Management
• Assist in mobilization
– Just as stabilizing long bones helps in
mobilization of polytrauma patients
• Prevent long term functional impairment
– Deformity of pelvic ring can impact function

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Non-Operative Treatment(1)
• Tile A (stable) injuries can generally
bear weight as tolerated
• Walker/crutches/cane often helpful in
early mobilization
• Serial radiographs followed during
healing
• Displacement requires reassessment of
stability and consideration given to
operative treatment
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 Non-Operative Treatment(2)
• Tile B (partially stable) injuries can be
treated non-operatively if deformity is
minimal
• Weight bearing should be restricted (toe-
touch only) on side of posterior ring injury
• Serial radiographs followed during
healing
• Displacement requires reassessment of
stability and consideration given to
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operative treatment
Non-Operative Treatment(3)
• Failure of non-operative treatment
may be due to displacement after
mobilization
• Excessive pain which precludes early
mobilization may also be failure of
non-operative treatment

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Principles of Operative Treatment
• Posterior ring structure is important
• Goal is restoration of anatomy and
enough stability to maintain reduction
during healing
• Most injuries involve multiple sites of
injury
– In general, more points of fixation lead to
greater stability
– This does NOT mean that all sites of injury
need fixation
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Principles of Operative Treatment
• Anterior ring fixation may provide
structural protection of posterior
fixation
• If combined open and percutaneus
techniques are used, the open portion
is often done first to aid in reduction
of the percutaneusly treated injury

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Preoperative Planning
• Consider patient related factors
– Surgical clearance, resuscitation
– Coordination of care
• Trauma surgeon, intensivist, neurosurgeon

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Outcomes(1)
• Pain common
• Improvement occurs for at least a
year in most patients
• Neurologic injury most common
predictor of poor outcome
• SI dislocations have poor tolerance
for residual displacement

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Outcomes(1)
• Sacral fractures have more tolerance
for displacement, but parameters
poorly understood
• Injury Severity Score and fracture
type do not correlate with functional
outcome

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