1. Yoyos Dias Ismiarto, dr., SpOT(K), M.Kes, FICS., CCD.
PELVIC RING INJURIES
Yoyos Dias Ismiarto, dr., SpOT(K), M.Kes, FICS., CCD.

3. Epidemiology
The overall incidence of pelvic ring injuries is estimated at about 3% of all fractures (AO).
Among the polytrauma patients, the incidence has risen to 25%.
Mortality is about %.
39% due to bleeding (early).
30% due to sepsis & multi-organ failure (late).

4. Anatomy of Pelvis Pelvis contains one pair of fused bone
Each half contains: ilium, pubis, and ischium
Joined together in posterior by sacrum
Joined in anterior by symphysis pubis

5. Anatomy of Pelvis Ilium Male Pelvis Female Pelvis Sacrum Pubis Ischium
Symphysis Pubis

6. Anatomy Around Pelvis Organs near pelvis
Parts of digestive system
Reproductive organs
Bladder and urethra
Blood vessels run through and around
Right and left iliac arteries from off aorta
Right and left iliac veins returning from legs
Blood vessels supplying pelvis and tissues around pelvis

7. Function of Pelvis Pelvis bears weight of upper body
Balances weight for legs when standing
Protect blood vessels and organs
Also serves as connection point for numerous leg muscles

8. Common Fractures of Pelvis
Pelvic ring fractures
Pelvic ring is likely to separate in more than one location
Iliac crest fractures
Fractures to upper wing of ilium

9. Pelvic Fractures
Common mechanisms of pelvic injury result from high energy
ex. MVC, significant falls, skiing accident
Those at risk for pelvic fractures
Growing teens (especially those involved in sports)
Elderly patients (osteoporosis)

10. Risks of Pelvic Factures
Iliac Crest fracture
Typically pelvis still stable
Little blood loss
Pelvic Ring fracture
Internal organ damage
Significant blood loss (up to 4 liters)
Hypovolemic shock
Unstable pelvis
Risk of death (Mortality of 3.4%-42%)
Mortality rate found at:

11. Pelvic Ring Stability
Stability defined as patient ability to support physiologic load
Physiologic load may be sitting, side lying, or standing, as dictated by patient needs else consider as unstable

12. Pelvic Ring Stability
Posterior ring integrity is important in transferring load from torso to lower extremities

13. Pelvic Ring Stability
Loss of posterior ring integrity leads to instability
Loss of anterior ring integrity may contribute to instability, and may be a marker to posterior ring injury
Young and burgess classification will guide us for stability issues

14. Young & Burgess Classification

15. Pathology The poor prognosis of pelvic fractures
Fracture and vascular injury can cause the formation of hematoma in the pelvis and retroperitoneum  4 liters of blood
90% bleeding  venous disruption or cancellous bone
10% bleeding  an arterial injury

16. Assessment
ATLS Approach
Check Stability :
Mechanic
Haemodynamic

17. Assessment cont. Pelvis specific assessment
Check for bruising, deformity, or abrasions
Listen/Feel for crepitus
Check limb length

18. Assessment cont. Check stability of pelvis (DON’T REPEAT)
Apply gentle medial pressure with palms by pressing inward on iliac crests
With patient supine, apply gentle posterior pressure by pressing downward on iliac crests
Apply gentle downward pressure on pubis to check pelvic ring stability

19. Stability Assessment 1) Medial pressure 2) Posterior iliac pressure
3) Posterior pubis pressure

20. Diagnosis
1. General: abrasion, contusion, hematoma, over bony prominence of pelvis, scrotal, vulvar hematoma.
2. PE
3. X-ray
4. FAST
5. DPL
6. CT

21. Radiographic Evaluation
X-Ray AP view:
Anterior lesions: pubic rami fractures
Symphysis displacement
Sacroiliac joint and sacral fractures
Iliac fractures
L5 transverse process fractures

22. Radiographic Signs of Instability
Broken ‘Ring’
Symphysis gap > 2.5 cm
Sacroiliac displacement of 5 mm in any plane.
Avulsion of the 5th lumbar transverse process, the lateral border of the sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous ligament).

23. Treatment Treat for life threatening injuries Treat for possible shock
Oxygen
Intravenous infusion
Splinting / Wrap
Pain control
RAPID TRANSPORT!!!

24. Palients with hemorrhagic shock and unstable pelvic fractures have four potential sources of bloodloss :
(1) fractured bone surfaces
(2) pelvic venous plexus
(3) pelvic arterial injury, and
(4) extrapelvic sources.
The pelvis should be temporarily stabilized or "closed" using an available commercial compression device or sheet to decrease bleeding.

25. 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.

26. Non-Operative Management (haemodinamically stable )
Lateral impaction type injuries with minimal (< 1.5 cm) displacement
Pubic rami fractures with no posterior displacement
Minimal gapping of pubic symphysis

27. Operative Management Operative indications Pelvic unstable
symphysis diastasis > 2.5 cm 
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
Hemodynamically unstable

28. Operative Management Hemodynamically unstable
Reduce pelvic volume : promote blood clot as well as reducing blood volume from inside bleeding
Technique
First aid : pelvic wrap
Next : Ex fix/ C clamp

29. Haemodynamic Status Options for immediate hemorrhage control
Military antishock trousers (MAST): Typically applied in the field.
No impact on survival rate.
Severe complications reported (compartment syndrome, extremity loss)

30. Haemodynamic Status Options for immediate hemorrhage control
Pelvic binder (pelvic wrap):
This is wrapped circumferentially around the pelvis.

31. C-Clamp

32. Operative Management Posterior ring structure is important
Goal : restoration of anatomy and enough stability to maintain reduction during healing
Anterior ring fixation may provide structural protection of posterior fixation

33. Anterior Fixation of Pelvic

34. Posterior Fixation of Pelvic

35. Haemodynamic Status Options for immediate hemorrhage control
Anterior external fixator:
In the acute phase many advocate external fixation as a temporary device to achieve stabilization of the fracture and a positive effect on haemorrhage.

36. External fixation 1. Advantages
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.

37. Complications
Infection
Thromboembolism
Non-Union
Malunion

38. Summary Pelvic fracture  High morbidity and mortality
Multiple trauma  Team work (ATLS Approach)
Check stability (Mechanic and Haemodynamic)
Early immobilization  Pelvic Wrap
Diagnostic tools
Definitive treatment

39. THANK YOU