Pelvic ring fractures
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Pelvic Ring Fractures. Christy Johnson. Outline. Background Anatomy and Function Assessment Radiology Classification Treatment. Background. Mechanism: high energy blunt trauma Mortality rate: 15-25% for closed fractures Up to 50% for open fractures

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Pelvic Ring Fractures

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Pelvic ring fractures

Pelvic Ring Fractures

Christy Johnson


Outline

Outline

  • Background

  • Anatomy and Function

  • Assessment

  • Radiology

  • Classification

  • Treatment


Background

Background

  • Mechanism: high energy blunt trauma

  • Mortality rate:

    • 15-25% for closed fractures

    • Up to 50% for open fractures

  • Hemorrhage is the leading cause of death overall

    • Venous (80%) > arterial

    • Have a high index of suspicion for injury of internal iliac vessels or lumbosacral plexus


Background1

Background

  • Associated injuries:

    • Chest injury (63%)

    • Long bone fracture (50%)

    • Head and abdominal injury (40%)

    • Spine fractures (25%)

    • Urogenital injuries in 12-20%

  • Survivors: 1.89 additional injuries

  • Non-survivors: 2.95 additional injuries

  • Only 2 in 14 deaths (14%) are directly attributable to pelvic injury


Anatomy osteology

Ilium

Sacrum

Pubis

Femur

Ischium

Anatomy: Osteology


Osteology

Osteology

  • Ring structure made up of the sacrum and two innominate bones

    • No inherent osseous stability


Anatomy muscles

Iliacus

Piriformis

Pectineus

Sartorius

Rectus

femoris

Adductor longus

Adductor brevis

Adductor magnus

Anatomy: Muscles


Ligaments

Ligaments

  • Anterior structures: provide 40% of stability

  • Posterior structures: provide 60% of stability


Pelvic stabilizers

Sacrospinous

Ligament:

Resist ER

Pelvic Stabilizers

Iliolumbar:

Augment

posterior

stability

  • Posterior interosseous sacroiliac ligaments are the strongest in the body

Sacrotuberous

Ligament:

Resist ER and

Vertical shear


Assessment

Assessment

  • Primary Survey

    • Airway

    • Breathing

    • Circulation

    • Disability

    • Exposure

  • Secondary Survey

    • Pelvis assessed by compression/distraction

    • Skin evaluation

  • Smith/Johnson/Cothren et al Journal of Trauma 2007


Resuscitation hemorrhage

Resuscitation/ Hemorrhage

  • 2 large-bore IVs

  • 2L crystalloid on arrival

  • Hct/Hgb does NOT correspond to EBL

  • Hypotension = 30-40% EBL

  • Patients presenting in shock (SBP<90) have mortality rates up to 10 times that of normotensive patients

  • Starr et al JOT 2002


Sites of hemorrhage

Sites of Hemorrhage

  • External bleeding controlled by direct pressure

  • Thoracic cavity evaluated by CXR for hemothorax: chest tube if necessary

  • Abdominal cavity evaluated by a FAST or CT scan in stable patients or ex-lapin unstable patients

  • If other causes eliminated, then EBL likely from pelvis

  • Blood replacement as indicated by response to fluid resuscitation

  • Ratio of FFP: PRBC/ 1:1.5 associated with decreased mortality and transfusion requirements

  • Injury 2010


Physical exam

Physical Exam

  • Test stability by placing gentle rotational force on each iliac crest

    • Perform ONCE

  • Look for external rotation of lower extremity +/- limb-length discrepancy


Physical exam continued

Physical Exam (continued)

  • Neurologic exam

    • L5 and S1 injuries most common

    • Rectal exam to evaluate sphincter tone and perirectal sensation

  • Urogenital exam

    • Concomitant urologic injury 12% of the time

    • Catheter placement should be preceded by rectal exam, evaluation of meatus, vaginal exam

    • 57% of men with urethral injury show no signs

    • Vaginal injuries missed in up to 50% of cases

  • Vaginal and rectal exams

    • Mandatory to rule out occult open fracture


Radiographs

Radiographs

  • Inlet

  • Outlet

  • AP Pelvis

Oblique/Judet

  • Obturator oblique

  • Iliac oblique


Mechanisms of pelvic injury

Mechanisms of Pelvic Injury

  • Anterior Compression

  • Lateral Compression

  • Vertical Shear

  • Combined mechanism

  • Young and Burgess, Rad 1986

  • Young and Burgess J Trauma 1989


Ap compression

AP Compression


Anteroposterior compression

Anteroposterior Compression


Lateral compression

Lateral Compression


Lateral compression1

Lateral Compression


Vertical shear

Vertical Shear


Vertical shear1

Vertical Shear

  • Associated with the highest risk of hypovolemic shock, mortality

  • Usually result from falls from height

  • Posterior and superior directed force

  • APCIII + vertical displacement


Mortality from pelvic injuries

Mortality from Pelvic Injuries

  • Hemodynamic instability + pelvic fracture = 40% mortality

  • Major cause of death: Hemorrhage (15%)

  • Major cause of death LC injuries: closed head injuries

  • Major cause of death APC: combined pelvic and visceral injuries

  • Hemorrhage in pelvic injuries

    • Venous bleeding more common than arterial bleeding

    • Superior gluteal artery (most common arterial injury in APC)

    • Internal pudendal artery (most common in LC)

  • Metz et al OrthopClin N Am 2004

  • Smith et al J Trauma 2007


Circumferential pelvic antishock sheeting

Circumferential Pelvic Antishock Sheeting

  • Rapid, inexpensive, temporary means of decreasing pelvic volume

  • Indications: initial management of an unstable ring injury

  • Risk of bladder injury in pelvic fractures with internal rotation component (i.e. LC injuries)

  • Technique: center over greater trochanters (NOT iliac crest/abdomen)


External fixation

External Fixation

  • Advantages:

    • Decreases pelvic volume

    • Stabilization of pelvis

  • Indications:

    • Pelvic ring injuries with an external rotation component (APC, VS)

    • Unstable ring injury w/ ongoing blood loss

  • Contraindications

    • Ilium fracture that precludes safe application

    • Acetabular fracture

  • Technique: Iliac wing or supra-acetabular pins

  • EgbersOrthopade 1992


Angiography embolism

Angiography/ Embolism

  • Small percentage of pelvic fractures have significant arterial injuries amendable to angio (10%)

  • Must have stabilized pelvis (pattern or ex-fix) because most bleeding is venous which will tamponade

  • Eliminate other sources of bleeding

  • Successful in 70-90% of cases but takes 3-4hrs


Treatment overview

Treatment Overview

  • Nonoperative

    • Indicated for mechanically stable pelvic ring injuries

      • LC1: anterior impaction fracture of sacrum and oblique ramus fx with <1cm of posterior ring displacement

      • APC1: widening of symphysis <2.5 cm with intact posterior pelvic ring

      • Isolated pubic ramus fx

  • Operative

    • Anterior ring stabilization: Symphyseal fixation

    • Posterior ring stabilization

      • Anterior or posterior SI joint fixation

      • Sacral bar

      • Iliac wing fixation


Treatment comparison

Treatment Comparison


Tenets of fixation

Tenets of Fixation

  • Complete instability of posterior ring:

    • Anterior fixation alone is inadequate for maintaining reduction

  • Complete instability of posterior ring with vertical (cephalad) displacement

    • Posterior fixation should be supplemented with anterior stabilization

  • Posterior injury is regarded as the more critical and in need of accurate reduction with stable fixation

    • Reduction generally proceeds from back to front


Summary

Summary

  • Pelvic ring injuries are highly associated with other injuries

  • Evaluation of pelvic stability is critical and requires an understanding of mechanism of injury, a careful examination, and scrutiny of radiographic imaging

  • Management requires an interdisciplinary approach and may be life saving


Questions

Questions?

  • Thanks to:

    • Dr. Helfet

    • Matt Griffith

    • Chris Mattem

    • Milton Little


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