Pelvic Injury

See algorithm

How are pelvic fractures classified

Tile classification

· A: antero-posterior compression. Usually isolated ilaic wing or pubic ramus. Stable. Conseravative Mx.

· B1: Lateral compression. Usually stable with mostly fracture of pubic arch

· B2: Horizontal instability due to anterior and posterior (sacroiliac joint ligaments) lesions – open book type fracture

· C: Shear – prodeuces complete horizontal and vertical instability. Verticle instability is associated with a fracture of the transverse process of L5.

Injuries are either stable or unstable – the difference can be appreciated on an AP X-ray

Rotationaly unstable injuries are have widening of the pubic symphysis or displacement of pubic rami more than 2.5cm

Vertically stable fractures have superior translation of a hemipelvis more than  1cm due to fractures through the sacrum or ilium plus disruption of the sacroiliac joint.


What are the causes of haemorrhage in pelvic fractures

· Bleeding from the pelvic venous plexus and cancellous bone in 90% of cases.

· Reduction and stabilization usually control this bleeding

 

Reduction and stabilization can be achieved in a number of ways

· Pelvic binding:

· The patient is placed on a linen sheet. The sheet is wrapped around the pelvic ring from posterior to anterior.

· The sheet is then clamped in position using two Kocher clamps (two at the top and two at the bottom).

· The clamps are applied as high and lateral as possible to avoid obscuring any X-rays.

Re-aligment is checked with X-rays.

· It applies pressure over both iliac wings and trochanteric areas

The alternative is the pneumatic anti-shock garment

· This is an inflatable device that is applied in the field and are use in transportation and initial resuscitation.

· Whilst they are easy to use and reduce displacement is AP compression fractures, they may increase displacement in lateral compression fractures.

· They also restrict access to the patient, compromise pulmonary reserve and may cause gluteal compartment syndrome if applied for prolonged period.

Pelvic external fixators:

· Pins placed into the iliac wings and conneceted to an external fixating frame. Whilst these devices can be applied in ED, they are more often applied in the OR and so venous bleeding controlled.

Pelvic C-clamp:

· Pins are placed into the bone just superior to the acetabulum and connected to a C shaped clamp. These can be applied in ED and can be replaced by definitive stabilization when appropriate.

· If the pelvis is completely disrupted these devices do not prevent posterior pelvic displacement. 


When is pelvic stabilization required

· When there is an open book or vertical shear fracture where the displacement is considerable stabilization may decrease pelvic volume and promote clot formation by a tamponade effect.


What if bleeding does not stop after stabilization of the pelvis

· Bleeding then likely arterial and best addressed by angio-embolization.

· The arteries most commonly involved are the superior gluteal, internal pudendal, obturator, lateral sacral arteries.

· If a large vessel is involved surgical ligation may be required, if a smaller vessel then embolization may be possible.


What is the incidence of associated injuries

· Urological injuries in 16%

· 80% have other musclo-skeletal injuries

· Overall mortality 25%


How do you evaluate the pelvic fracture patient


Primary survey:
ABCDE. Wide bore IV access. X-match blood. Apply temporary pelvic stabilizer. C-spine protected. Resuscitation with Crystalliod and blood. CXR. AP pelvis x-ray and C-spine X-rays.


Secondary survey:
Log roll. Search for other injuries. Search for signs of pelvic fracture – gross rotational deformity, leg length descrepency, open fractures (lacerations of perineum, rectum, buttocks, iliac wings, external genitalia), PR and VE in women to exclude open fracture into rectum, vagina or high riding prostate. Search for perineal bruising indicating urethral injury and blood at meatus. Gently feel pelvis for rotational disturbance.


Patients fall into four groups

  1. Haemodynamically stable with a stable pelvis – continue assessment. CT scan is best modality for assessing pelvis.
  2. Haemodynamically stable with an unstable pelvis – continue assessment. CT scan best modality. May apply external fixator in OT if required before definitive Management using ORIF.

The CT may show evidence of active haemorrhage (large haematoma of blush). A pelvic wrap should be performed and external fixation considered. If this does not control haemorrhage then angio-embolization may be required. Monitor in ICU.

  1. Haemodynamically unstable with a stable pelvis: Rule out other sites of haemorrhage – chest (CXR, Pericardial tamponade FAST scan) or peritoneal cavity (Do a DPL [supra-umbilical] or FAST scan).

a.     If FAST/DPL positive – laparotomty

b.     If FAST/DPL negative – transfer to angio for embolization

  1. Haemodynamically unstable with a unstable pelvis: Temporary stabilization in ED (pelvic binder, PASG). Transfer to theatre and apply external fixating device. Then do DPL or FAST.

a.     If FAST/DPL positive – laparotomy and management of bleeding from other sources. If patient remains unstable then consider extra-peritoneal packing. If patient remains unstable then transfer for angiography.

b.     If FAST/DPL negative – transfer to angio for embolization if patient remains unstable.


What if there is blood at the meatus or a high riding prostate

· A retrograde urethrogram is performed.

A foley is placed in urthra and 2ml of water is used to fill the balloon in the fossa navicularis. Water soluable urograffin is gently injected.

· If there is extravasation the injury is diagnosed. A suprapuic cytotomy is performed

If there is no extravasation, the catheter is advanced into the bladder and cytography is performed.


What if a stable patient has a laparotomy for other injury (Bladder perforation).

Consider applying an external fixator before laparotomy.

All intra-peritoneal, penetrating and selected extra-peritoneal bladder injuries must be repaired at the laparotomy and a supra-pubic catheter placed.


What is the role of pelvic packing

· In pelvic fractures the packs are placed in the retroperitoneal spaced during the urgent laparotomy.

· A midline suprapubic incision is performed and the fascia anterior to rectus is exposed before.

· The endopelvic fascia is divided in the midline to enter the retrorectus palne without entering the peritoneal cavity.

· The fascia is dissected away from the pelvic brim with the bladder held to one side.

· Three sponges are placed: one just posterior to SI joint, one in the retropubic space and one in between.

· The procedure is repeated on the other side.

· The outer fascia is closed and then the skin.

· Packs are removed after 24-48 hours.


When are pelvic fractures considered open

· If there is a communication of fracture haematoma with a skin laceration, injury to vagina or rectum.

· When this is suspected a sigmoidoscopy and speculum examination of vagina are required.

· If there is a rectal or perirectal injury, a diverting colostomy is required on the same day

· If there is a posterior or perineal laceration (but no rectal injury) then a colostomy can be performed in the next 24-48 hours.\