1. Pelvic Fractures Presented By: Fadel Naim M.D. Orthopedic Surgeon
Faculty of Medicine
IUG

3. Introduction Only 3-8% of all fractures
Occurs in 25% of multiply injured patient
Associated blunt, soft-tissue injury
Mortality as high as 20%-25%
Open pelvic fracture = 30-50% mortality

4. Classification 1. Vectors of injury Lateral compression AP-direction
Vertical shear
2.Young and Burgess’s classification scheme—prediction of pelvic fracture related hemorrhage .

5. back

6. back

7. back

10. Primary Assessment Primary Survey
Airway Maintenance with cervical spine protection
Breathing and Ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/Environment Control: Undress patient but prevent hypothermia

11. Resuscitation Intravenous lines Crystalloid Solution
Blood Administration
50-69% of unstable pelvic fractures require 4 or more units of blood
30-40% require 10 or more units

12. Physical Examination
Bimanual compression and distraction of the iliac wings
Assess for rotational stability
Manual leg traction
aids in determining vertical stability
Rectal examination
Palpate prostate – urethral injury
Palpate sacrum
assess for fracture

13. Physical Examination Vaginal examination Perineal skin evaluation
Bleeding or laceration indicate open fractures
Perineal skin evaluation
Laceration may indicate open fracture;
laceration may be caused by hyper-abduction of the leg

14. Associated injuries

15. Associated Injuries Vascular Neurologic Visceral Urologic
Rectal/Gastrointestinal
Gynecologic
Degloving - Moral-Lavalle

16. Vascular Hemorrhage occurs in up to 75% of pelvic fractures
Three source of bleeding
Osseous
Vascular
Visceral
Intra-abdominal source is present in 40% of patients with pelvic fractures

17. Possible Bleeders Iliolumbar artery Lateral sacral artery
Internal iliac artery
Internal pudendal
Sacral venous plexus
Superior gluteal artery
the most commonly injured vessel

18. Retroperitoneal Veins

19. Vascular Major source of bleeding is the venous plexus
Retroperitoneal space holds up to 4 L of blood
Arterial source of bleeding is present in only10-15% of patients

20. Neurologic
Fracture of sacrum or dislocation of SI joint can lead to injury to lumbosacral plexus
L5 & S1, most common
L2 to S4 possible
Amount of displacement more important than location

21. Visceral Injury Blunt vs. impaled by bony spike Bladder/urethra Rectum
Vagina
Prostate

22. Urologic 15-17% of pelvic fractures Scrotal/labial swelling
Urethral 15% of men
Urethral injury rare in women
Indicators:
Blood in meatus
High-riding prostate
Straddle-type fracture
Retrograde Urethrogram

23. Ruptured Urethra Classical Triad
Blood on external meatus
Distended bladder
Inability to void

24. Rectal/Gastroinstestinal
Occurs in less than 1%
Laceration of rectum or perforation of small and/or large bowel
Rectal tears accompany perineal wounds
Requires diverting colostomy

25. Gynecologic Laceration of the vagina
Results from dislocation or fractures of the pubic rami
Large laceration may involve perineum and rectum
Inferior rami fracture that causes impingement may require operative intervention

26. Morel–Lavalle’ Lesion
Closed degloving injury
Greater trochanter
pelvic and acetabular fx
Shear injury
Subcutaneus tissue torn
Cavity of hematoma/liquefied fat
Not initially apparent/overlooked
Infected in 1/3 of cases

27. Hemodynamically Unstable Patient
Causes of bleeding/hypovolemia:
Hemothorax
Intrabdominal injury
Intracranial/Spinal injury
Closed/Open fractures
Coagulopathies (hypothermia, low calcium, acidosis)
PELVIC FRACTURE

28. Hemodynamically Unstable Patient
Intra-abdominal Bleeding
Assess:
Abdominal CT Scan
Peritoneal Lavage
Ultrasound
Pelvis
AP Pelvis
Physical exam
Pelvic CT Scan

29. Imaging AP pelvis can identify 90% of pelvic injuries
It can guide the surgeon to additional imaging needs, such as CT scan
AP pelvis during early phase of resuscitation is useful to determine presence or absence of unstable pelvic fracture

30. Inlet and Outlet Views Inlet View 45 degree caudal tilt
True AP projection of the pelvic brim
Evaluates for posterior displacement
Evaluates for rotation of ilium and sacral impaction injuries

31. Inlet and Outlet Views Outlet View 45 degree cephalad tilt
Evaluates for vertical shift of pelvis
Visualizes Sacral foramen

32. CT Scan Best visualization for Sacrum and SI joint
Rotational and posterior displacement can be easily assessed
3-D reconstruction may be helpful in determining overall displacement of the pelvic fracture

33. Angiography Useful in assessing and embolization of arterial injury
Can determine patency of superior gluteal artery for viability of large surgical exposures
Disadvantage:
Source of arterial bleeding is identified in only 10-15% of patients with severe pelvic disruption
Does not address venous bleeding

34. Open Pelvic Fractures High mortality rate (30% - 50%)
Potential for major vascular injury with hemorrhage
High incidence of associated gastrointestinal and genitourinary injuries
Diverting colostomy may be required
Requires aggressive multidisciplinary treatment

35. Assessment of ‘stability’:
Mechanical:
Based on clinical examination and radiographs.
Haemodynamic:
Normal.
Stable (maintaining P/BP/urine output by continuous infusion of fluid = on-going bleeding somewhere).
Unstable (failure to maintain P/BP/urine output despite continuous infusion of fluid).

36. Type I injuries: Mechanically stable (usually lateral compression).
Haemodynamically stable.
No emergency treatment for pelvic lesion.
Obtain CT scan.

37. Type II injuries: Mechanically unstable Haemodynamically stable.
No emergency treatment for pelvic lesion.
Careful haemodynamic monitoring.
Obtain CT scan.

38. Type III injuries: Mechanically stable Haemodynamically unstable.
Pelvis already closed/stable – no need for emergency treatment for pelvic lesion.
Look for bleeding elsewhere (chest/abdomen).
If none found, consider:
Angiography/embolisation.
Laparotomy/pack pelvis.

39. Type IV injuries: Mechanically unstable Haemodynamically unstable.
Look for bleeding elsewhere (chest/abdomen).
Reduce pelvic fracture and stabilise with anterior external fixator or C-clamp.
If laparotomy indicated, apply external fixator BEFORE abdomen opened.

40. Type IV injuries:
After external fixation, careful haemodynamic monitoring.
If continuing haemodynamic instability:
Angiography/embolisation
Laparotomy/simple anterior plate fixation/maintain external fixator/pack pelvis.

41. Type V injuries: Mechanically unstable Haemodynamically unstable.
Patient in extremis.
Dying despite aggressive fluid resuscitation.
Immediate operation required to save life.

42. Type V injuries: Apply simple anterior external fixator or C-clamp.
Laparotomy and deal with any intra-abdominal bleeding.
If still haemodynamically unstable, simple anterior plate fixation/maintain external fixator/pack pelvis.

43. Acute Intervention Stabilization of Pelvic Hemorrhage Traction
Sheet/Pelvic Binder
Anti-shock Garment
Pelvic clamp/External fixator
Angiographic embolization

44. Sheet
Sheet can be wrapped around iliac wings and held with towel-clamp or knot
Hips slightly flexed and internally rotated

45. Pelvic Binder

46. Anti-shock Garment MAST (Military antishock trousers) Uncommon
Limits access for examination
Decreases lung function
Can contribute to lower extremity compartment syndrome

47. External Fixator
Indicated in the unstable patient who does not respond to initial fluid resuscitation
Stabilizes pelvis, preventing redisruption of Clot
? May decrease pelvic volume
Not adequate for posterior pelvic disruption

48. External fixation 1. Advantages 2. Disadvantages
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.

49. Pelvic C-clamp Applied to the posterior ilium in line with sacrum
Requires fluoroscopy and expertise
Higher risk of iatrogenic injury
Not available in many institutions
Good for stabilizing posterior disruption

52. Definitive Fixation Anterior External fixator Plate fixation (ORIF)
Posterior Iliosacral screw
Plate fixation
Combined

53. Non-Operative Management
bed to chair mobilization
WBAT with support
serial xray after mobilization
monitor for subsequent displacement
posterior ring displacement > 1cm: STOP WBAT
Very unstable patients: require prolonged immobility (poor results)