1. Major Pelvic Trauma Bernard Foley FACEM Department of Emergency Medicine Auckland Hospital Wednesday, 13 May 2015Wednesday, 13 May 2015Wednesday, 13 May 2015Wednesday, 13 May 2015

2. The Issues Pelvic trauma doesn’t come in on it’s own Routine Pelvic x-ray in blunt trauma Do we always need it? Do we always need it? The unstable patient Fracture instability Fracture instability Haemodynamic instability Haemodynamic instability Prioritising interventions No universal algorithm No universal algorithm

3. Anatomy Sacrospinous ligament Sacrotuberous ligament SI joint and ligaments Pubic symphisis

4. Pelvic Fracture Types AP Compression B1 type partially stable Lateral Compression B2 type partially stable Vertical Shear C1 type unstable

5. Haemodynamic stability is the key Unstable Definitive haemostatic procedure Definitive haemostatic procedure Assisted stability Investigations to target interventions Investigations to target interventionsStable Investigation cascade Investigation cascade

6. Sources of bleeding in pelvic trauma Arterial Usually laceration/avulsion associated with ligamentous injuries Usually laceration/avulsion associated with ligamentous injuries Mx therapeutic embolisation Mx therapeutic embolisationVenous Mx orthopaedic Mx orthopaedicOsseous

7. Sources of arterial bleeding in pelvic trauma Anterior division branches of internal iliac most commonly injured Internal pudendal : between SSL and STL Internal pudendal : between SSL and STL Inferior gluteal : above SSL Inferior gluteal : above SSL Obturator : through foramen Obturator : through foramen Posterior division branches of internal iliac artery most commonly injured Superior gluteal : piriformis fascia or sacral # Ilio-lumbar : sacral/ SI joint injuries

8. Orthopaedic trauma Auckland Hospital 1995-2000 6040 orthopaedic trauma admissions 520 Pelvic fractures 45% transfers

9. Pelvic trauma in Auckland hospital 1 Jan 1995-31 Dec 1998 364 pelvic fractures 364 pelvic fractures 76 Haemodynamically unstable 76 Haemodynamically unstable Mean ISS 30 (9-66) Mean ISS 30 (9-66) 39/76 car crash 39/76 car crash 10/76 motorcycle 10/76 motorcycle 8/76 pedestrian 8/76 pedestrian 13/76 falls 13/76 falls 27/76 deaths 27/76 deaths

10. Injury patterns 43.7% Type A 28.5% Type B 27.8% Type C 49 Mechanically unstable pelvic injuries / year

11. Associated injuries Chest / abdomen 23% Genitourinary 17% Head injury 31%

12. Associated injuries Sacral nerve injuries Rectal perforation Vaginal perforation Bladder and vesical injuries Spinal injuries Femoral fractures Long-term disability

13. Mortality Uncontrolled haemorrhage Chest Chest Abdomen Abdomen Retroperitoneal Retroperitoneal Other unsurvivable injuries i.e. neurological injury i.e. neurological injury Multiorgan failure Sepsis

14. Multitrauma / Time critical Structured approach required A,B,C’s A,B,C’s Resuscitation Resuscitation Trauma radiography Trauma radiography Hx, examination, Ix Hx, examination, Ix Extended trauma team concept Interventional radiology Interventional radiology Orthopaedics Orthopaedics Urology Urology

15. Prioritising HEAD CHESTPELVIS ABDOMEN

16. Pelvic trauma x-ray Currently recommended as part of trauma series Gonzalez et al (n=2,176) Alert patients (GCS14-15), blunt trauma Alert patients (GCS14-15), blunt trauma Ethanol levels 16-75mmol/L (n=463) Ethanol levels 16-75mmol/L (n=463) 97 patients with pelvic fractures 97 patients with pelvic fractures Physical exam sensitivity 93% No significant fractures missed No significant fractures missed Pelvic x-ray sensitivity 87% 6 requiring operative intervention 6 requiring operative intervention J Am College Surg 194,No2. Feb 2002

17. CT scanning Good at assessing haemorrhage in peritoneum and retro peritoneum Can aid planning of vascular/orthopaedic procedures Can aid planning of vascular/orthopaedic procedures Good at assessing pelvic fractures Requires stable patient (?assisted stability)

18. Procedures-pelvic Sheet wrap External fixation Internal fixation Angiography

19. Sheet wrap Quick and easy Inexpensive Can do in ED Good tamponade of expanding haematoma Not definitive stabilisation May impact on exposure

20. External fixation Good control of anterior instability Dependent on bone quality Not definitive Impairs mobilisation Can burn some bridges

21. Open internal fixation Big exposures Unavoidable complication rate Timing problematic in multitrauma

22. Percutaneous fixation Exposure not a problem Low complication rate Bio mechanically ideal Detailed anatomical knowledge required Technically demanding

23. Therapeutic embolisation Selective IIA angiography shows higher incidence and severity of bleeding than aortic flush studies Better pickup of hypo-perfusion and spasm Better pickup of hypo-perfusion and spasm

24. Method of Embolisation Anterior Division Embolisation Proximal embolisation more effective Adverse events rare Buttock claudication Buttock claudication

26. Therapeutic embolisation Allows ancillary procedures i.e. percutaneous nephrostomy i.e. percutaneous nephrostomy

27. Pelvic Fracture: Patient Haemodynamically unstable yes no yes no yes no

28. Summary 1 A-P pelvis radiograph GCS <14 GCS <14 Clear clinical evidence of fracture Clear clinical evidence of fracture Suspicious mechanism Suspicious mechanism ? Validated set of rules ? Validated set of rules

29. Summary 2 Early involvement of orthopaedic and Interventional radiology Prioritisation of interventions Early haemodynamic instability= arterial bleeding= interventional radiology Assisted stability may buy time for additional investigations Early percutaneous fixation appears to produce the best results