Emergency Stabilization of Pelvic Fractures
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Transcript Emergency Stabilization of Pelvic Fractures
Yoyos Dias Ismiarto, dr., SpOT(K), M.Kes, FICS., CCD.
Epidemiology
• The overall incidence of pelvic ring
injuries is estimated at about 3% of all
fractures (AO).
– Among the polytrauma patients, the
incidence has risen to 25%.
– Mortality is about 6 - 50%.
– 39% due to bleeding (early).
– 30% due to sepsis & multi-organ failure
(late).
Anatomy of Pelvis
Pelvis contains one pair of fused bone
Each half contains: ilium, pubis, and ischium
Joined together in posterior by sacrum
Joined in anterior by symphysis pubis
Anatomy of Pelvis
Ilium
Male Pelvis
Female Pelvis
Sacrum
Pubis
Ischium
Symphysis Pubis
Anatomy Around Pelvis
Organs near pelvis
Parts of digestive system
Reproductive organs
Bladder and urethra
Blood vessels run through and around
Right and left iliac arteries from off aorta
Right and left iliac veins returning from legs
Blood vessels supplying pelvis and tissues around
pelvis
Function of Pelvis
Pelvis bears weight of upper body
Balances weight for legs when standing
Protect blood vessels and organs
Also serves as connection point for numerous
leg muscles
Common Fractures of Pelvis
Pelvic ring fractures
Pelvic ring is likely to
separate in more than one
location
Iliac crest fractures
Fractures to upper wing of
ilium
Pelvic Fractures
Common mechanisms of pelvic injury result
from high energy
ex. MVC, significant falls, skiing accident
Those at risk for pelvic fractures
Growing teens (especially those involved in
sports)
Elderly patients (osteoporosis)
Risks of Pelvic Factures
Iliac Crest fracture
Typically pelvis still stable
Little blood loss
Pelvic Ring fracture
Internal organ damage
Significant blood loss (up to 4 liters)
•
Hypovolemic shock
Unstable pelvis
Risk of death (Mortality of 3.4%-42%)
Pelvic Ring Stability
Stability defined as patient ability to support
physiologic load
Physiologic load may be sitting, side lying, or
standing, as dictated by patient needs else
consider as unstable
Pelvic Ring Stability
Posterior ring integrity is important in transferring
load from torso to lower extremities
Pelvic Ring Stability
Loss of posterior ring integrity leads to instability
Loss of anterior ring integrity may contribute to
instability, and may be a marker to posterior ring
injury
Young and burgess classification will guide us for
stability issues
Young & Burgess Classification
Pathology
The poor prognosis of pelvic fractures
Fracture and vascular injury can cause the
formation of hematoma in the pelvis and
retroperitoneum 4 liters of blood
90% bleeding venous disruption or cancellous
bone
10% bleeding an arterial injury
Assessment
ATLS Approach
Check Stability :
Mechanic
Haemodynamic
Assessment cont.
Pelvis specific assessment
Check for bruising, deformity, or abrasions
Listen/Feel for crepitus
Check limb length
Assessment cont.
Check stability of pelvis (DON’T REPEAT)
Apply gentle medial pressure with palms by
pressing inward on iliac crests
2) With patient supine, apply gentle posterior
pressure by pressing downward on iliac crests
3) Apply gentle downward pressure on pubis to
check pelvic ring stability
1)
Stability Assessment
1) Medial pressure
2) Posterior iliac pressure
3) Posterior pubis pressure
Diagnosis
1. General: abrasion, contusion, hematoma,
over bony prominence of pelvis, scrotal, vulvar
hematoma.
2. PE
3. X-ray
4. FAST
5. DPL
6. CT
Radiographic Evaluation
• X-Ray AP view:
– Anterior lesions:
pubic rami fractures
– Symphysis
displacement
– Sacroiliac joint and
sacral fractures
– Iliac fractures
– L5 transverse
process fractures
Radiographic Signs of
Instability
• Broken ‘Ring’
• Symphysis gap > 2.5 cm
• Sacroiliac displacement of 5 mm in any
plane.
• Avulsion of the 5th lumbar transverse
process, the lateral border of the sacrum
(sacrotuberous ligament), or the ischial
spine (sacrospinous ligament).
Treatment
Treat for life threatening injuries
Treat for possible shock
Oxygen
Intravenous infusion
Splinting / Wrap
Pain control
RAPID TRANSPORT!!!
Palients with hemorrhagic shock and unstable
pelvic fractures have four potential sources of
bloodloss :
(1) fractured bone surfaces
(2) pelvic venous plexus
(3) pelvic arterial injury, and
(4) extrapelvic sources.
The pelvis should be temporarily stabilized or
"closed" using an available commercial
compression device or sheet to decrease
bleeding.
•
•
In the presence of unstable pelvic ring
disruption and a positive abdominal
study, stabilization of the pelvis
should be undertaken before
laparatomy.
If hemodynamic stability is not
achieved after placement of the
external fixator, arteriography should
then be performed.
Non-Operative Management
(haemodinamically stable )
Lateral impaction type injuries with minimal
(< 1.5 cm) displacement
Pubic rami fractures with no posterior
displacement
Minimal gapping of pubic symphysis
Operative Management
Operative
indications
Pelvic unstable
symphysis diastasis > 2.5 cm
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
Hemodynamically unstable
Operative Management
Hemodynamically unstable
Reduce pelvic volume : promote blood
clot as well as reducing blood volume
from inside bleeding
Technique
First aid : pelvic wrap
Next
: Ex fix/ C clamp
Haemodynamic Status
Options for immediate hemorrhage
control
• Military antishock
trousers (MAST):
Typically applied in
the field.
– No impact on survival
rate.
– Severe complications
reported
(compartment
syndrome, extremity
loss)
Haemodynamic Status
Options for immediate hemorrhage
control
Pelvic binder (pelvic
wrap):
• This is wrapped circumferentially
around the pelvis.
C-Clamp
Operative Management
Posterior ring structure is important
Goal : restoration of anatomy and enough
stability to maintain reduction during healing
Anterior ring fixation may provide structural
protection of posterior fixation
Anterior Fixation of Pelvic
Posterior Fixation of Pelvic
Haemodynamic Status
Options for immediate hemorrhage
control
• Anterior external fixator:
– In the acute phase many
advocate external fixation as a
temporary device to achieve
stabilization of the fracture and
a positive effect on
haemorrhage.
External fixation
1. Advantages
It helps tamponade bleeding from bone
edges .
Stabilizing the clots and the bone.
Could be done in 20 min.
2. Disadvantages
Can’t stop arterial bleeding. Delay the
embolization for ongoing arterial
hemorrhage.
Degrade the quality of CT and angio.
Complications
• Infection
• Thromboembolism
• Non-Union
• Malunion
Summary
Pelvic fracture High morbidity and mortality
Multiple trauma Team work (ATLS Approach)
Check stability (Mechanic and Haemodynamic)
Early immobilization Pelvic Wrap
Diagnostic tools
Definitive treatment