Major Pelvic Trauma

Bernard Foley FACEM Department of Emergency Medicine Auckland Hospital Tuesday, 28 April 2020

The Issues

Pelvic trauma doesn’t come in on it’s own Routine Pelvic x-ray in blunt trauma  Do we always need it?

The unstable patient  Fracture instability  Haemodynamic instability Prioritising interventions  No universal algorithm

SI joint and ligaments Sacrospinous ligament Sacrotuberous ligament Pubic symphisis

Anatomy

Pelvic Fracture Types

Lateral Compression B2 type partially stable Vertical Shear C1 type unstable AP Compression B1 type partially stable

Haemodynamic stability is the key Unstable  Definitive haemostatic procedure Assisted stability  Investigations to target interventions Stable  Investigation cascade

Sources of bleeding in pelvic trauma Arterial  Usually laceration/avulsion associated with ligamentous injuries  Mx therapeutic embolisation Venous  Mx orthopaedic Osseous  Mx orthopaedic

Sources of arterial bleeding in pelvic trauma Anterior division branches of internal iliac most commonly injured    Internal pudendal : between SSL and STL Inferior gluteal : above SSL Obturator : through foramen Posterior division branches of internal iliac artery most commonly injured  Superior gluteal : piriformis fascia or sacral #  Ilio-lumbar : sacral/ SI joint injuries

Orthopaedic trauma Auckland Hospital 1995-2000 6040 orthopaedic trauma admissions 520 Pelvic fractures 45% transfers

Pelvic trauma in Auckland hospital 1 Jan 1995-31 Dec 1998         364 pelvic fractures 76 Haemodynamically unstable Mean ISS 30 (9-66) 39/76 car crash 10/76 motorcycle 8/76 pedestrian 13/76 falls 27/76 deaths

Injury patterns

43.7% Type A 28.5% Type B 27.8% Type C 49 Mechanically unstable pelvic injuries / year

Associated injuries

Chest / abdomen 23% Genitourinary 17% Head injury 31%

Associated injuries

Sacral nerve injuries Rectal perforation Vaginal perforation Bladder and vesical injuries Spinal injuries Femoral fractures Long-term disability

Mortality

Uncontrolled haemorrhage  Chest  Abdomen  Retroperitoneal Other unsurvivable injuries  i.e. neurological injury Multiorgan failure Sepsis

Multitrauma / Time critical

Structured approach required  A,B,C’s    Resuscitation Trauma radiography Hx, examination, Ix Extended trauma team concept    Interventional radiology Orthopaedics Urology

Prioritising

ABDOMEN HEAD PELVIS CHEST

Pelvic trauma x-ray

Currently recommended as part of trauma series Gonzalez et al (n=2,176)  Alert patients (GCS14-15), blunt trauma   Ethanol levels 16-75mmol/L (n=463) 97 patients with pelvic fractures Physical exam sensitivity 93%  No significant fractures missed Pelvic x-ray sensitivity 87%  6 requiring operative intervention J Am College Surg 194,No2. Feb 2002

CT scanning

Good at assessing haemorrhage in peritoneum and retro peritoneum  Can aid planning of vascular/orthopaedic procedures Good at assessing pelvic fractures Requires stable patient (?assisted stability)

Procedures-pelvic

Sheet wrap External fixation Internal fixation Angiography

Sheet wrap

Quick and easy Inexpensive Can do in ED Good tamponade of expanding haematoma Not definitive stabilisation May impact on exposure

External fixation

Good control of anterior instability Dependent on bone quality Not definitive Impairs mobilisation Can burn some bridges

Open internal fixation

Big exposures Unavoidable complication rate Timing problematic in multitrauma

Percutaneous fixation

Exposure not a problem Low complication rate Bio mechanically ideal Detailed anatomical knowledge required Technically demanding

Therapeutic embolisation

Selective IIA angiography shows higher incidence and severity of bleeding than aortic flush studies  Better pickup of hypo-perfusion and spasm

Method of Embolisation Anterior Division Embolisation

Proximal embolisation more effective Adverse events rare  Buttock claudication

Therapeutic embolisation

Allows ancillary procedures  i.e. percutaneous nephrostomy

Pelvic Fracture: Patient Haemodynamically unstable Rule out major peritoneal or chest bleeding SHEET WRAP no no FAST/DPL grossly positive yes yes INTERCOSTAL DRAIN CXR positive yes Stable no Stable ANGIOGRAPHY Consider Ex Fix PERCUTANEOUS FIXATION WARD /ICU LAPAROTOMY yes

Summary 1

A-P pelvis radiograph  GCS <14  Clear clinical evidence of fracture  Suspicious mechanism  ? Validated set of rules

Summary 2

Early involvement of orthopaedic and Interventional radiology Prioritisation of interventions Early haemodynamic instability= arterial bleeding= interventional radiology Assisted stability may buy time for additional investigations Early percutaneous fixation appears to produce the best results

It was a pretty bad accident Mrs Griffiths, we did what we could