1. Management of pelvic fractures: the first 24 hours. Peter Worlock Newcastle General Hospital

2. Objectives: Review assessment of pelvic injury. Understand concept of different types of ‘stability’. Management algorithm.

3. Diagnosis: Made during primary survey. Airway with c-spine control. Breathing (oxygen). Circulation – IV access – Crystalloid – Control external loss – Look for major pelvic injury

4. Assess pelvis: History – Suspect in high energy injury Examination – External bruising/wounds (anterior/posterior) – Test for vertical/horizontal instability – Rectal examination – Vaginal examination

5. Radiographs: Every polytrauma patient should have – Lateral c-spine – Chest – AP Pelvis AP pelvis is done to detect major (and potentially life-threatening) pelvic injury.

6. Inlet view: Patient flat on trolley. XR plate under pelvis. Direct XR beam at 60 degrees to plate. Effectively ‘transverse’ section through sacrum. Will show sacral #. Will show any posterior shift of hemi-pelvis. Will show internal/external rotation of hemi-pelvis.

7. Outlet view: Patient flat on trolley. XR plate under pelvis. Direct XR beam at 45 degrees to plate. Effectively true AP view of sacrum. Will show vertical shift of hemi- pelvis. Will reveal any ‘bucket-handle’ injury. Will help in assessing leg length discrepancy.

8. Pelvic fracture classification: Type A. Stable. Minimally displaced. Posterior arch intact.

9. Pelvic fracture classification: Type B. Can be unstable. Incomplete disruption of posterior arch. Actual or potential horizontal translation. No vertical translation.

10. Pelvic fracture classification: Type C. Unstable. Complete disruption of posterior arch. Actual or potential horizontal and vertical displacement.

11. Type B injuries: B1: open book injury (external rotation). Can be mechanically unstable. B2: lateral compression injury (internal rotation) - includes ipsilateral and contralateral (“bucket- handle”) types. Usually mechanically stable. B3: bilateral Type B injuries (includes “windswept” pelvis). External rotation injury can be mechanically unstable.

12. Type C injuries: C1: unilateral complete disruption of posterior arch. C2: unilateral complete disruption of one posterior arch, with incomplete disruption of contralateral posterior arch. C3: bilateral complete disruption of posterior arch. All are mechanically unstable.

13. Management of major pelvic fracture: You have to be an orthopaedic surgeon, a urologist, a vascular surgeon, a colo-rectal surgeon and (sometimes) a gynaecologist!

14. Initial management: Save life. Do not do anything to compromise definitive reconstruction. Most important piece of equipment to master?

15. The telephone!

16. Open pelvic fracture: Wound may be external, into rectum, into vagina or into bladder. ALL wounds must be explored, lavaged and debrided. Defunctioning colostomy if any large bowel communication with fracture, with washout of distal limb.

17. Urethral injury: Pass urethral catheter only if: – No blood at meatus – No scrotal/perineal haematoma – Normal rectal examination Urethrogram will define injury. Suprapubic catheter will rapidly contaminate tissues posterior to symphysis.

18. Urethral injury: Consider urgent transfer to pelvic fracture unit for combined pelvic/urethral reconstruction as emergency.

19. Nerve injury: Careful examination as soon as possible to detect any nerve damage. Document clearly. Treat expectantly. Lumbo-sacral plexus damaged in up to 45% of Type C injuries.

20. 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).

21. Type I injuries: Mechanically stable (usually Type B lateral compression). Haemodynamically stable. No emergency treatment for pelvic lesion. Obtain CT scan. Liaise with pelvic fracture unit re definitive management.

22. Type II injuries: Mechanically unstable (open book and Type C injuries). Haemodynamically stable. No emergency treatment for pelvic lesion. Careful haemodynamic monitoring. Obtain CT scan. Liaise with pelvic fracture unit re definitive management.

23. Type III injuries: Mechanically stable (usually Type B lateral compression). 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.

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

25. Type IV injuries: After external fixation, careful haemodynamic monitoring. If continuing haemodynamic instability: – Angiography/embolisation (if skills rapidly available). – Laparotomy/simple anterior plate fixation/maintain external fixator/pack pelvis.

26. Type V injuries: Mechanically unstable (open book and Type C injuries). Haemodynamically unstable. Patient in extremis. Dying in front of you despite aggressive fluid resuscitation. Immediate operation required to save life.

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

28. Pelvic injury with haemodynamic instability: Beware of “consumption coagulopathy”. Secondary haemorrhage can be uncontrollable. Start aggressive replacement of clotting factors/platelets/calcium early (after five units of blood). Obsessional monitoring of clotting status.

29. Definitive care: Posterior approach to sacrum may be compromised by de-gloving of skin. Anterior approach to SI joint compromised by external fixator pin wounds on iliac crest. Anterior approach to symphysis pubis compromised by ruptured viscus and intra- peritoneal contamination.

30. Definitive care: Anterior approach to symphysis pubis compromised by suprapubic catheter for >24 hours. When haemodynamically stable, start prophylaxis against DVT/PE. Transfer early – best results come if pelvis reconstructed within 5-10 days of injury.

31. Summary: All units receiving trauma must be able to save life in major pelvic injury. Haemodynamically stable or unstable? Define # pattern on XR - mechanically stable or unstable? The only injuries that require you to operate as emergency are those that are mechanically and haemodynamically unstable.

32. Summary: Detect all complications of the pelvic injury. Definitive care: – Get it right first time. – Speak to your local pelvic fracture unit ASAP. – Do not compromise definitive reconstruction by inappropriate early care.