1. Pelvic Trauma

2. 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)

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

4. 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

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

6. Bedside Inx VBG FAST scan DPL out of date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DPL out of date

7. 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

8. 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

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

10. 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

11. 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)

12. 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)

13. 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)

14. 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

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

16. 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

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

18. 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

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

20. 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