1. Management of pelvic fracture
By:
Dr. Abdulaziz AlQareer
Supervised:
Dr. Wieslaw Pospula

2. Pelvic injuries are a major cause of mortality and morbidity in multiple injures patients.
The close proximity of osteoligamentous structures to pelvic organs, neurovascular, hollow viscera, and urogenital structures may lead to wide range of severe complications and late sequel if not diagnosed and treated early.

3. Fatalities are due to uncontrolled retroperitoneal hemorrhage.
Disabilities are due to anatomic disruption the pelvic ring. ( low back pain, leg-length discrepancies, dyspareunia, impotence, difficulties with child bearing).
Pelvic fractures can be particularly lethal when occur in combination with significant injuries to other major organ systems.

4. Up to 80% of pelvic fracture patients have additional musculoskeletal injuries (because of the high force necessary to disrupt the pelvic ring in young patients.
Mortality rates in cases of high-energy pelvic ring injuries 15 – 25%. (these deaths usually due to associated injuries).

5. Mortality increase nearly 13 X when the patient presents with hypotension.
Mortality increases to 50% when combined with either a head or an abdominal injury that requires surgical intervention, and to 90% when both procedures are necessary.

6. Pelvic anatomy and structures at risk in pelvic fracture.
Classification of pelvic injury.
Assessment of patients.
Stabilization techniques.
Management of patients.
Complications.
Results and follow up.

7. Pelvic
Anatomy
Pelvic ring formed by connection of the sacrum to innominate bones at sacroiliac joints and symphysis pubis.
Weight bearing lines are transmitted across the sacroiliac joint and into the neck of the femur. (Thus major stabilizing structures are posterior).
The anterior joint (symphysis pubis) prevents pelvis from collapse.

8. The pelvic ring articulations have no inherent stability; therefore, strong ligamentous structures provide the needed stability.
Transversely oriented ligaments resist transverse rotational instability.
These include:
iliolumbar,
short posterior SI,
anterior SI,
sacrospinous ligements.

9. Vertically oriented ligaments resist vertical displacement of the pelvis.
These include:
long posterior SI,
sacrotuberous,
lateral lumbosacral ligaments.
(The strongest of these and the most important with regard to pelvic stability are the short and long posterior SI ligaments).

10. Interosseous SI ligaments provide an added level of support to the SI joints. (these unit the tuberosities of the ilium and sacrum).

11. The obturator foramen:
separating pubis from ischium, is covered by a membrane, deficient only on top to allow the obturator vessels and nerves to escape from the pelvis. At this point they are vulnerable and may be torn in pelvic trauma.

13. Structures at risk in pelvic fracture
Lumbosacral and coccygeal nerve plexus
(T12 – S4):
1- Branches from the roots of
the plexus.
2- Branches that pass through the greater sciatic notch.
3- Anterior coccygeal plexus.

14. Branches from the roots of the plexus: - Muscular branches to the
piriformis, levator ani &
coccygeus.
- Pelvic splanchnic nerve.

15. Branches that pass through the greater sciatic notch:
- Sciatic nerve.
- Pudendal nerve (S2,S3,S4).
- Superior gluteal nerve.
- Inferior gluteal nerve.
- N. to obturator internus.
- N. to quadratus femoris.
- Posterior cutaneous n.
of the thigh.

17. -Has 2 divisions: tibial & peroneal.
The sciatic nerve:
-Forms the largest branch of the sacral plexus.
-Has 2 divisions: tibial
& peroneal.
-It is commonly injured in pelvic trauma, especially in posterior dislocation of the hip with or without acetabular fracture).
-Peroneal branch is most prone to injury and least likely to recover).

18. Blood vessels:
- Massive hemorrhage is the major complication of a pelvic disruption.
- Precise knowledge of the anatomy of pelvic vasculature is essential because embolization of the bleeding vessel has emerged as one of the treatment options.

19. Arteries: - Internal iliac. (The most surgically significant).
- Median sacral.
- Superior rectal.

20. Internal iliac artery:
- Severe trauma to the pelvis can disrupt the internal iliac artery, survival is unlikely in such cases.
1- Posterior divisions.
2- Anterior divisions.

21. Internal iliac artery: 1- Posterior divisions:
- Most prone to damage (Because severe trauma to pelvic ring usually causes posterior displacement).
*Divisions:
- Superior gluteal artery.
(largest branch, and can be ass. With massive hemorrhage in pelvic trauma).
- Iliolumbar artery.
- Lateral sacral artery.

22. Internal iliac artery: 2- Anterior divisions:
- Visceral branches
supplying bladder, genitalia, portion of rectum ( superior and inferior vesical and middle rectal arteries).
- Limb & perineal branches
(internal pudendal and inferior gluteal arteries).
- Obturator artery (to obturator foramen).

23. Pelvic veins:
- Pelvic viscera lie upon a massive thin walled venous plexus.
- Massive bleeding can occur following pelvic trauma.
* Drainage into:
- Internal iliac veins (most).
- Superior rectal >> inferior mesenteric >> Portal v.

24. Hemorrhage in pelvic fracture:
- Mostly from posterior pelvic venous plexus and bleeding cancellous bone surfaces.
- < 10% cases due to arterial bleeding. (Bleeding from a large artery is even less frequent).

25. The floor of the pelvis comprises the coccygeal and levator ani muscles.
The urethra, rectum and vagina transverse the floor of the pelvis & can be traumatized significantly during pelvic ring disruption.

26. Classification of pelvic injury
Disruptions in the pelvic ring are usually a combination of fractures and ligamentous injuries.
Many classification systems have been developed based on the direction of force, stability of the pelvis, location of fracture, or whether it is open or closed injury.

27. The AO Muller classification:
-Pelvic ring disruptions usually classified into 2 major groups according to AO Muller system:
1- Stable.
2- Unstable.
-Disruptions in the pelvic ring are usually a combination of fractures and ligamentous injuries.

28. Stable:
- It can withstand normal physiologic forces without displacing.
- It depends on the integrity of bony and ligamentous structures.

29. Stable:
- Stable injuries include non-displaced fractures of the pelvic ring and anterior displacements of
< 2.5 cm.
- These considered
type A (50-70% of patients).
- Surgical stabilization is only exceptionally indicated.

30. Stable:
- Stable fracture can result also from division of the symphyseal ligaments alone leading to diastasis of 2.5 cm or less.

31. Unstable:
- Generally divided into rotational and vertical components.
- These displacements can be appreciated on the initial AP radiographs.

32. Unstable:
1 - Rotational instability (partial posterior stability):
- Rotational instability is characterized by widening of the symphysis pubis or displacement of pubic rami fractures of >2.5 cm.
- These considered type B injuries (20-30%).
- Stabilization of the anterior pelvic ring alone is sufficient.

33. Unstable:
1 - Rotational instability
- Rotational instability can also result from division of the anterior sacroiliac, sacrospinous and sacrotuberous ligaments.

34. Unstable:
2- Vertical/translational instability
- Superior translation of a hemipelvis through fractures of the sacrum or ilium and disruption of the sacroiliac joint by > 1cm.
- These constitutes type C
fractures ( 10-20% patients).

35. Unstable:
2- Vertical/translational instability (combined anterior and posterior instability):
- Adequate stabilization of the ring required to minimize risk of secondary displacement as well as fatal hemorrhage.

36. Unstable:
2- Vertical/ translational instability :
- Vertical instability can also results from division of the posterior tension band ligaments (posterior sacroliliac and iliolumbar ligaments)

37. Anterior – posterior compression injury:
- Caused by motorcycle crashes, pedestrian – vehicle collisions, direct crushing injury to the pelvis, and falls from heights > 3.6 meters.
- Can cause an open book type pelvic injury.
- This type of injury carries the greatest risk for retroperitoneal hemorrhage as well as Intrapelvic visceral injuries. Both account for increased mortality rates in this type of fracture.

38. Lateral compression injury:
- It is the most common mechanism caused by motor vehicle collisions.
- Occurs when a high energy force strikes the lat. Aspect of the trochanter.
- This injury is often associated with thoracic and closed head injuries as well as bladder and or urethra injuries.
- The most common cause of death in this pattern is associated closed head trauma.

39. - It is also called bucket- handle type injury.
External rotation/ abduction force injury:
- It is also called bucket- handle type injury.
- Can cause disruption of the hemipelvis.

40. Vertical shear injury:
- Occurs when an axial load shears the pelvis in a vertical direction, causing severe disruption of the hemipelvis.
- Is associated with intra abdominal and head injuries.

41. Assessment
Primary evaluation and decision making:
- The primary goals in the assessment of pelvic injuries are:
1- In case of severe internal hemorrhage, is this caused by a pelvic fracture?
2- The clinical & radiological assessment of the degree of mechanical stability of the pelvic ring.
3- The diagnosis of peripelvic soft tissue & organ injuries.

42. In case of severe internal hemorrhage, is this caused by a pelvic fracture?
- In the vast majority of pelvic injury cases, hemodynamics are affected only minimally or not at all, however, the diagnosis of hemodynamic instability of pelvic origin must result in immediate surgical resuscitation procedures.
- Major pelvic hemorrhage occurs rapidly and the diagnosis must be made quickly to initiate appropriate resuscitative treatment.

43. The clinical & radiological assessment of the degree of mechanical stability of the pelvic ring:
(Determination of the stability of the injured hemipelvis must be established through a combination of physical examination and a review of AP radiographs).

44. 4- Associated injuries:
Clinical assessment:
History:
1- Age:
(Age affects bone structure)
(Pelvic fracture occurs in elderly with less violent force, and associated with less soft tissue disruptions than young patients).
2- Gender:
( Males: more associated injuries to the urethra compared to females).
( Females: vaginal tear).
3- Mechanism of injury:
4- Associated injuries:
( Is important to determine the amount of trauma on the pelvis).
5- Medical history.
Physical examination:
* Unexplained hypotension may be the only initial indication of major pelvic disruption with instability in the posterior ligamentous complex.

45. Inspection:
( The patient must be completely undressed).
1- Wounds:
(Open wounds in the vicinity of the pelvic disruption must be regarded as communicating with the fracture until proven otherwise).
2- Contusions:
( Position of contusions and abrasions may indicate direction of the injurious force).

46. Inspection:
3- Bleeding genitalia:
(In men, blood from urethra suggests a urethral rupture; in women, blood from urethra or vagina suggests an occult open fracture of the pelvis).

47. Inspection:
4- Displacement of pelvis or lower extremities:
(If there is no other fracture in the leg, its degree of rotation and shortening suggest what type of pelvic fracture is present).
( Shortening appreciated as leg length discrepancy happens as a result of muscular pull on the unstable hemipelvis).

48. Inspection:
4- Displacement of pelvis or lower extremities:
Examples:
- If the extremity is obviously shortened, internally rotated, and displaced at the posterior iliac spine, it is mostly a lateral compression injury with posterior impaction.
- If the extremity is externally rotated and shortened, it indicates mostly a severe unstable vertical shear type.

49. Physical examination:
Palpation:
( Careful manual palpation of the pelvis may reveal crepitus or abnormal motion in the hemipelvis, either one indicative of instability).
( Repeated examination for pelvic instability should be avoided in unstable situations to prevent further induction of blood loss).

50. Palpation:- Palpation also reveals the presence or absence of further injury to lower extremities, because injuries to the hip, femur, and knee are not infrequently associated with pelvic injuries.
Maneuvers:
1- Test for anterior defects:
Direct palpation of symphysis pubis may reveal a gap or ecchymosis, indicating a symphysis disruption.
2- Test for rotational instability:
Grasping the iliac crests and pushing the unstable hemipelvis inward and outward (compression – distraction maneuver).

51. Palpation:
Maneuvers:
3- Test for vertical instability:
Can be appreciated when movement of the hemipelvis is detected as manual compression and traction are applied through an extended uninjured lower extremity.
(Palpating the posterior iliac spine & tubercle while pushing and pulling the unstable pelvis)

52. Palpation:
Traction Maneuver:
- Traction to the extremity is an important maneuver:
1- To R/O an injury to the
extremity.
2- To determine the degree
of pelvic instability.
( If the hemipelvis reduces
with traction, this
indicates gross instability
of that hemipelvis).

53. Physical examination:
Rectal & Vaginal examination:
( Both are essential for complete patient assessment).
- Very often the fracture can be palpated by either of these routes to further assess the stability of the pelvic ring.
- Presence or absence of vaginal or rectal lacerations.
- High riding prostate gland.

54. Physical examination:
Neurological examination
- Injury to lumbosacral plexus, especially L5 root is common, therefore, a careful neurological examination is mandatory.
- Nerve injuries of all types are much more common in shear type fractures.

55. Radiological examination:
- AP pelvic view is mandatory and can provide a reliable working diagnosis in about 90% of the cases.
- For 3 dimensional analysis, oblique views (inlet and outlet films) are included to evaluate anterior, posterior, cranicaudal and rotational displacement).
- The inlet view is the best view for disclosing posterior displacement.

56. Radiological examination:
- Ct examination is performed in all cases to further define the posterior pelvic injury and any possible associated acetabular fracture.
- CT is not a method of emergency evaluation and can in most cases be delayed until the general condition is stabilized.

57. Stabilization
Reduction and stabilization of the pelvis can be achieved by a variety of mechanical means:
- Bind the pelvis by
a rolled sheet.
- Apply pneumatic
antishock garments
(PASGs).
- Pelvic c – clamps.
- External fixator.

58. Pneumatic antishock garments (PASGs).
(It functions by compressing the pelvis, and if applied it should not be deflated until the patient is actively being resuscitated in the trauma room).
Advantages:
- Easy to use, applicable in the field, & reusable.
Disadvantage:
- It blocks access to the patient and restricts excursion of the diaphragm.
- Gluteal & thigh compartment syndromes after its extended use in hypotensive patients.

59. Pelvic C- clamps:
(recently developed devices that can be rapidly applied to reduce and provisionally stabilize the pelvis in the emergency department).
- The design allows for compression of the pelvis through percutaneously inserted pins applied to the outer surface of the ilium. Care must be taken because serious complications can result from misplacement of the pins.

60. Pelvic C- clamps:
- These devices are utilized only in rotationally & vertically unstable pelvic fractures (not in stable Fractures).
- Contraindicated in comminuted iliac fractures.

61. Pelvic C- clamps:
Advantages:
-These devices provide adequate stabilization and easy access to the abdomen or extremities without removal of the device.
-They can remain in place throughout the resuscitation phase and then be replaced by definitive stabilization methods when the patient is able to undergo these procedures.

62. Anterior external fixator:
( The standard method for controlling pelvic hemorrhage).
- Proper application should provide stability to the pelvis and hematoma, while allowing access to the abdomen for surgical procedures.
- Although it can be applied in the emergency department, it is frequently deferred until O.T.

63. Angiography:
- The role of angiography in the diagnosis and management of pelvic hemorrhage is controversial.
Reasons:
- Incidence of arterial hemorrhage amenable to embolization is only 10%.
- It is less common for the bleeding to be the result of an injury to a large or named artery (in these cases arteriography with embolization can be life – saving).
- Catheterization & embolization of pelvic vessels are technically difficult & time consuming.

64. Angiography:
- The use of these techniques should be reserved if all other methods of hemorrhage control have been exhausted.

65. Unstable hemodynamics
Management
Unstable pelvic ring
Unstable hemodynamics VS

66. Instability of the pelvis combined with hemodynamic instability:
- Pelvic fracture patients with systolic BP < 90 mmHg have a 38% mortality rate compared to 3% in normotensive pelvic injury patients.
-In this situation primary therapy has to concentrate on immediate control of pelvic hemorrhage.
- Follow ATLS guidelines for resuscitation (Airway, breathing, circulation).
-Continued evaluation of resuscitation algorithms is necessary to evaluate their efficiency in saving lives.

67. Algorithms for management of the hypotensive patient with a pelvic fracture all should begin with a search for the cause of the shock.
1-All possible causes of bleeding must be explored and controlled (in the following order):
(Hemothorax, intra abdominal source of bleeding, pelvic).
2- Examination of the pelvis (as described previously).

68. Summery of the most
important physical signs:
- Unexplained hypotension.
- Progressive flank, scrotal, or perianal swelling & bruising (associated with failure to respond to initial fluid resuscitation).
- Open fracture wounds about the pelvis (perineum, rectum, buttocks).
- High riding prostate gland.
- Blood at urethral meatus.
- Demonstrable mechanics instability.

69. 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.

70. 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.

71. Management of open pelvic fractures:
- Isolated iliac wing fractures are managed like open fractures in other areas of the body with aggressive debridement & stabilization of fractured components.
- Aggressive debridement and packing of the wound to prevent continual bleeding and possible sepsis.

72. Management of open pelvic fractures:
- Perineal lacerations and wounds that communicate with the rectum or colon require early diverting colostomy (preferably at transverse colon to provide uncontaminated skin around the pelvis).
- Early detection and repair of vaginal lacerations to minimize subsequent pelvic abscesses.
Other advisable damage control procedures at an early stage include suprapubic urine catheter drainage, insertion of a transurethral catheter, and suture of the bladder after urological injuries.

73. Unstable pelvic ring stable hemodynamicsVS

74. Unstable pelvic ring in a hemodynamically stable patient
- This is the most frequently encountered situation.
- In these cases, detailed evaluation of the nature of pelvic ring injury is required before selecting appropriate stabilization techniques.
- A complete diagnostic workup must be completed before making definitive decisions.

75. Pelvic surgery is specialist surgery and a transfer of a stable patient has to be considered.
The following precautions and preparations are mandatory for more extensive surgery:
- Availability of post op. ICU.
- Availability of sufficient blood replacement.
- Strategies to minimize blood loss.
- Experienced operative team.
- Standard and pelvic instruments.

76. Timing of surgery depends on patient’s general condition.
In general, unstable pelvic fracture should be stabilized as early as possible. (After 14 days of injury the difficulty of anatomical reduction increases).
- Type A: Surgical stabilization is not normally required.
- Type B: Stabilization of the anterior ring is usually sufficient.
- Type C: The pelvic ring requires combined posterior and anterior stabilization.

77. Anteriorly, the symphysis is often secured with a plate and screws.
Posteriorly more options exist: sacroiliac joint or sacral fractures can be secured with plates, bars, or percutaneously inserted cannulated screws.

78. Post op. treatment:
- The goal of pelvic stabilization is the early mobilization of the patient.
- Radiological controls should be made after mobilization to check for late displacement due to errors in classification or technique.
- Implant removal is often recommended 6 – 12 months after operation when pelvic joints have been surgically transgressed.

79. complications Complications:
- Surgical complications after pelvic injuries can include the entire range of possibilities:
1- Thromboembolism.
2- Sepsis.
3- Iatrogenic neurological and vascular injuries.

80. Results and long term assessment
- Pelvic fracture, especially unstable types, lead to a high rate of late sequel.
- Frequently long term neurological and urological defects are responsible for patients’ complaints, but a non specific pain in the posterior pelvic ring is also commonly reported.
- Patients after pelvic trauma should be seen in specific follow-up program.