Pelvic Trauma

Why are Pelvic Fractures Important in Major Trauma Involve high energy impact Major Hemorrhage  Difficult to control High morbidity + mortality 10-30% (up to 50% if shocked)

Expose Palpate How to Examine Asymmetry Gentle Compress Iliac Crest Carefully Asymmetry Palpate Gentle Compress Iliac Crest

Careful Examination of Expose Rectum – DRE (Blood, wounds, bony fragments, Sphincter function and a boggy high-riding Prostrate Perineum and Genitalia Lower limb length discrepancy malrotation and neurology Abdomen – tenderness, distention, external signs of trauma

Why examine Rectal Injury Common up to 5% Open fractures, which are more likely to be hemodynamically unstable Risk of death from secondary sepsis

Bedside Inx VBG FAST scan DPL out of date Monitor Hb, Lactate and acidemia in major hemorraghe FAST scan Positive Scan  intra-abdominal haemorrhage false positive may suggest associated bladder rupture DPL out of date

Lab tests Imaging G & H or X-match 4-8 units if severe injury FBC & Coag profile Consider BhCG Imaging AP Pelvis x-ray CT abdo + Pelvis with contrast

Indications for Pelvic X-rays Hemodynamically unstable Altered mental state Distracting injuries Children (physical exam is less reliable) Abdominopelvic CT not being done for another reason

Do not perform pelvis xray if Normal exam and patient is alert and able to ambulate (consider mechanism of injury)

Pelvic Fracture Classification Tile A – rotational and vertical stable Pubic ramus fracture, iliac wing fracture, pubic stasis diastasis <2.5cm Tile B – rotationally unstable, vertically stable B1: PS diastasis >2.5cm and widening of SI joints (open book fracture due to external rotation forces on hemipelvises) B2: pubic symphysis overriding (internal rotation force on hemipelvises) Tile C - rotationally & vertically unstable. Disruption of SI joints due to vertical shear forces C1: unilateral C2: bilateral C3: involves acetabulum

Young-Burgess classification Anteroposterior compression (APC) Diastasis of PS or vertical fracture of pubic rami APC I: PS diastasis <2.5cm, no sig posterior ring injury (stable) APC II: PS diastasis >2.5cm, tearing of anterior sacral ligaments (rotationally unstable, vertically stable) APC II: hemipelvis separation with complete disrution of PS and poterior ligament complexes (completely unstable)

Lateral Compression (LC) Transverse fracture of the pubic rami LC I: posterior compression of SI joint without ligament disruption (Stable) LC II: posterior SI ligament rupture, sacral crush injury or iliac wing fracture (rotationally unstable, vertically stable) LC III: LC II, with open book (APC) injury to contralateral pelvis (completely unstable)

Vertical shear injuries (VS) Vertical fracture of the pubic rami Displaced fractures of anterior rami and posterior columns, including SI dislocation (completely unstable) Combined mechanism (CM) fractures Massive pelvic fractures that do not fit other categories (Completely unstable)

Other injuries associated with Pelvic Fractures Bladder + Urethral injuries (5–20%) Posterior urethra with pelvic fractures Anterior urethra with straddle injuries Intra-abdominal injury Spleen and liver (12%) Bowel (4%) Open Pelvic fractures (5%) involve rectal and vaginal tears Pelvic fractures imply high impact energy and hence head & chest injuries may also be present

Complications of Pelvic fractures ACUTE Major hemorrhage Visceral and soft tissue injury Sacral plexus injury Ileus Fat embolization ARDS Venous thromboembolism Abdominal Compartment syndrome

Complications of Pelvic fractures LATE Infection (second most common cause of death) Fracture complications (OA, malunion) Disability and immobility Incontinence Sexual dysfunction Shoulder Dystocia following subsequent pregnancy

Objectives of Pelvic stabilization Prevent reinjury from pelvic motion Decrease pelvic volume Tamponade bleeding pevic bones and vessels Decrease pain

Methods of Pelvic Stabilisation Pelvic binder (eg. Sheet, SAM sling, T-POD...) Anterior external fixation C clamp Pneumatic antishock garment (PASG) aka Military Anti-Shock Trousers (MAST) - obsolete

How to manage Suspected Pelvic Trauma STABLE CONSIDER TRAUMA CALL BIND pelvis if in doubt. CT with IV Contrast +/- CT cystography

IF UNSTABLE ACTIVATE TRAUMA CALL Resuscitate Apply pelvic binder Fast If Positive FAST  urgent open laparatomy If negative FAST (controversial)  CT with IV contrast +/- CT cystography Some centers have angiography with embolization