Pelvic Trauma Pikula R., Ira D. Department of Trauma Suregry University Hospital Brno logo PELVIS: TRAUMA nFractures n nHemodynamic consequences n nAssociated injuries nconnected with pelvis fracture npolytrauma n ANATOMY nRami nSymphysis pubis nSacrum nSacroiliac joints nIlium nIschium nHip & Femur nLumbar spine nSoft tissues npo0003e3 nClosed head injury — 51% nLong bone fracture — 48% nPeripheral nerve injury — 26% nThoracic injury — 20% nUrethra (male) — 15% nBladder — 10% nSpleen — 10% nLiver — 7% nGI tract — 7% nKidney — 7% nUrethra (female) — 6% nMesentery — 4% nDiaphragm — 2% n n pelvic%2520girdleb coxal%2520bonesd n PelvisLigamentsRearFemale n PelvisLigamentsFrontAboveMale n pelvis_female1 Pelvic Ring Injuries •High energy • •Morbidity/Mortality • •Hemorrhage Cylinder: 4/3π r3 ??? Best estimated by a hemi-elliptical sphere (Stover et al, J Trauma, 2006) X - ray n n CT nMore sensitive, more specific, more accurate nPelvis is part of CT trauma protocol nMore detailed CT examination can be performed if needed for orthopedic planning npo0003eb npo0003ed Primary Survey: ABC’s lAirway maintenance with cervical spine protection lBreathing and ventilation lCirculation with hemorrhage control lDisability: Neurologic status lExposure/environment control: undress patient but prevent hypothemia Physical Exam nDegloving injuries nLimb shortening nLimb rotation nOpen wounds nSwelling & hematoma open pelvis_belly_distractor Pelvic Stability x Instability nRadiographic n nHemodynamic n nBiomechanical (Tile & Hearn) n nMechanical •“Able to withstand normal physiological forces without abnormal deformation” nSingle examiner nUse fluoro if available nBest in experienced hands Stable or Unstable? Radiographic Signs of Instability nSacroiliac displacement of 5 mm in any plane n nPosterior fracture gap (rather than impaction) n nAvulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament) Shock vs Hemodynamic Instability nDefinitions Confusing nPotentially based on multiple factors & measures n nLactate nBase Deficit nSBP < 90 mmHg nOngoing drop in Hct nResponse to fluid challenge Open Pelvic Injuries nOpen wounds extending to the colon, rectum, or perineum: strongly consider early diverting colostomy n nSoft-tissue wounds should be aggressively debrided n nEarly repair of vaginal lacerations to minimize subsequent pelvic abscess Urologic Injuries n15% incidence n nBlood at meatus or high riding prostate n nEventual swelling of scrotum and labia (occasional arterial bleeder requiring surgery) n nRetrograde urethrogram indicated in pelvic injured patients Urologic Injuries nIntraperitoneal & extraperitoneal bladder ruptures are usually repaired n nA foley catheter is preferred n nIf a supra-pubic catheter it used, it should be tunneled to prevent anterior wound contamination n nUrethral injuries are usually repaired on a delayed basis Sources of Hemorrhage nExternal (open wounds) nInternal: nChest nLong bones nAbdominal nRetroperitoneal Sources of Hemorrhage nExternal (open wounds) nInternal: nChest nLong bones nAbdominal nRetroperitoneal •Chest x-ray •Physical exam, swelling •DPL, ultrasound, FAST •CT scan, direct look Pelvic Fractures & Hemorrhage n •ER & VS > IR •APC & VS at increased risk Hemorrhage Control nPelvic Containment n Sheet n Pelvic Binder n ExternalFixation n nAngiography nLaparotomy nPelvic Packing nSupine n2 “Wrappers” nPlacement nApply “Clamper” n30 Seconds CPAS 1 CPAS 2 CPAS 3 CPAS 4 1 2 3 4 HMC_logo Routt et al, JOT, 2002 Circumferential Sheeting Sheet Application n Pelvic Binders SAM_Pelvic_Sling_II SAM_Pelvic_Sling_II_steps External Fixation nLocation •AIIS • •ASIS • •C-clamp •Clinical Application •Resuscitative • •Augmentative • •Definitive n Pelvis Packing extraperitonealpack angioembolization pelvicangio01 TRAUMA nMinor force injuries n nMajor force injuries Minor Injuries nGround level falls n nAvulsions Minor Injuries: Ground Level Falls nRami fractures n nSacrum and coccyx fractures Rami Fractures n nOsteoporosis is the most common predisposing condition. nStable, if isolated. nTreatment is symptomatic npo0003ef Sacrum Fractures nFall directly on the buttocks or repetitive microtrauma nCommon in osteoporosis nAcute and stress types n npo0003f1 Sacrum Fractures: Acute nCan be subtle on plain films. nStable. nTreatment is symptomatic. nMay occasionally damage sacral plexus nerve roots. npo0003f3 Coccyx Fractures nFall on buttocks. nRadiologic diagnosis is difficult due to marked normal variation. nClinical diagnosis is more accurate: local tenderness. nStable. nSymptomatic treatment. npo0003f9 Avulsion fractures nApophyseal avulsions from abnormal tension by tendons: physis injuries. nAnterior-superior and anterior-inferior iliac spines, and ischial tuberosity are most common sites. nAthletic older adolescents and young adults. nNonoperative injuries. Anterior-inferior Iliac Spine nRectus femoris muscle attaches to and avulses the spine when marked tension is applied to the tendon. npo0003fb Major Force Injuries Mechanically challenging Hemodynamically threatening Major Pelvis Injuries: Classification Classification of Burgess-Young nBased on THREE distinct mechanisms of injury, and TWO combined mechanisms. n nEach of the three has its own anterior ring signature key, which is the clue to the mechanism and to the important posterior ring injury. Mechanisms nLateral Compression (LC) nAnterior-Posterior Compression (APC) nVertical Shear (VS) nCombined Mechanical: LC + APC or LC+VS F:\prezentace\páteř prednáška\obr. páteř\P1030601.JPG F:\prezentace\páteř prednáška\obr. páteř\P1030602.JPG F:\prezentace\páteř prednáška\obr. páteř\P1030603.JPG n Table Mechanism and Type Characteristics Hemipelvis Displacement Stability AP compression, type I Pubic diastasis <2.5 cm External rotation Stable AP compression, type II Pubic diastasis >2.5 cm, anterior SI joint disruption External rotation Rotationally unstable, vertically stable AP compression, type III Type II plus posterior SI joint disruption External rotation Rotationally unstable, vertically unstable Lateral compression, type I Ipsilateral sacral buckle fractures, ipsilateral horizontal pubic rami fractures (or disruption of symphysis with overlapping pubic bones) Internal rotation Stable Lateral compression, type II Type I plus ipsilateral iliac wing fracture or posterior SI joint disruption Internal rotation Rotationally unstable, vertically stable Vertical shear Vertical pubic rami fractures, SI joint disruption +/- adjacent fractures Vertical (cranial) Rotationally unstable, vertically unstable n n n Lateral Compression nTypes I, II, III nForce applied to side of pelvis: fall from a height, pedestrian vs auto nAll types have horizontal or oblique fracture of a ramus: the anterior key n Lateral Compression: posterior injuries nType I: Sacrum arcade fracture(s), ipsilateral nType II: Crescent fracture of ilium, ipislateral nType III: Anterior disruption of contralateral sacroiliac joint (“open book”) LATERAL COMPRESSION n n nAnterior ring key, common to all LC’s: Horizontal or oblique ramus fracture. npo0003fd LC Type I nMost common major force pelvis fracture: 70% of total nSacral arcade fracture nHemodynamic instability: Low nTreatment: Nonoperative, bed rest npo0003ff LC Type I n nArcade fractures can be subtle: look for any asymmetry, irregularity, overlap, discontinuity, or angulation. npo000401 LC Type II nCrescent fracture of ipsilateral ilium nHemodynamic instability: moderate nTreatment: ORIF npo000403 LC Type III nContralateral disruption of anterior sacroiliac joint, “open book”. nHemodynamic instability: high nTreatment: ORIF npo000405 Anterior-Posterior Compression: APC n nA large force applied to the anterior pelvis: pedestrian vs auto, n fall from a height npo000407 Anterior-Posterior Compression: APC n nAnterior ring key: vertical rami fractures or diastasis of symphysis pubis npo000409 APC Type II n(There is no Type I) nDisruption of anterior sacroiliac joint(s) (“open book”) or vertical sacrum fractures nHemodynamic instability: high nTreatment: ORIF n npo00040b APC Type III n nDisruption of anterior and posterior sacroiliac ligaments: SI joint dissociation. nHemodynamic instability: very high nTreatment: ORIF npo00040d Vertical Shear: VS nForce up one leg, by fall from a height or MVA nAnterior ring key: fractured rami or diastasis symphysis pubis, but with cephalad displacement of hemipelvis npo00040f Vertical Shear: VS nPosterior injury is vertical sacrum/iliac fracture or diastasis of sacroiliac joint, with cephalad displacement. nHemodynamic instability: variable nTreatment: ORIF npo000411 Ilium Fracture nIsolated iliac wing fractures occur with direct force nA major force fracture, but not part of previous classification nHigh incidence of intra-abdominal injuries, so always get CT Abdomen npo000413 Hemodynamic Instability in Blunt Trauma nDetermine source: chest, peritoneal cavity, “on the floor”, retro- or extraperitoneum. nChest film, FAST/ DPL, pelvis film. nIf pelvis fractures are the source, the bleeding is into the extraperitoneum, and surgery is usually not effective. Management of Hemodynamic Instability nAll causes: Fluid/blood replacement n“Floor”: Rapid suture hemostasis nChest: Chest tube, OR nPeritoneal cavity: OR, observation, (angiography and embolization) nExtraperitoneum: External fixation, angiography and embolization, (OR) Angiography and Embolization nLocalize the bleeding vessel, usually a branch of Internal Iliac Artery. nOcclude it with Gelfoam, coil, etc. nComplications: ischemia, incontinence, impotence. npo000415 Complications nImmediate complications nPelvic hemorrhage. nBladder injury nurethral injury nNerve injury n nEarly complications nBlood loss nInfection nDVT, tromboembolism n nLate complications. nPain nMalunion. nNonunion n Injuries of the Urinary Tract nPosterior urethra and, rarely, anterior urethra in males. Female urethra injuries rare. nBladder. nUreters: very rare in blunt trauma. Evaluation: Retrograde Urethrogram nUse 30% I.V. type contrast (e.g. Conray 30) nFlush the Foley to remove air nUse sterile saline not KY as lubricant nInsert Foley until balloon disappears nInflate balloon nDrip in 15-20cc contrast from bottle 2 ft above table top RUG: Normal nSmooth urethra nNormal caliber nNo extravasation nContrast reaches internal sphincter or bladder npo000417 Urethra Injury nNarrowing or false channel, but no extravasation n nNote the air bubbles: always clear the Foley catheter of air before insertion! npo000419 •Extravasation: Base of bladder, scrotum, upper medial thigh npo00041b Bladder Injuries Extraperitoneal Intraperitoneal Combined Conventional Cystogram: Normal npo00041d CT Cystogram nCan do CT cystogram, which is more sensitive. Technique is similar to conventional cystogram. nBoth conventional and CT cystograms must be done retrograde. nAntegrade filling by I.V. contrast is not sensitive enough for small leaks. CT Cystogram: Normal npo00041f Bladder Injuries: Minor n nPerivesical hematoma nMucosa and mural injuries without rupture npo000421 Extraperitoneal Rupture n2-3 X more common than intraperitoneal injury nAnterior pelvis fractures nInjury is at bladder base nExtravasation around base of bladder nManagement: Divert with suprapubic catheter and debride n npo000423 Intraperitoneal Rupture nOften no pelvis fractures, usually blow to full bladder nDome is injury site nContrast in paracolic gutters and around bowel nManagement: emergency laparotomy to repair tear and prevent peritonitis npo000425 Acetabular fractures nCommonly associated with high energy trauma, and frequently associated with (especially posterior) hip dislocation nAlthough they can also occur with lower energy injuries in the osteoporotic elderly after a fall nFractured acetabulum is by definition an intra-articular fracture and as such is a joint threatening fracture that frequently nneeds anatomic reduction and fixation, especially in the young DSCN6984 nLetournel Classification nElementary types nPosterior wall nPosterior column nAnterior wall nAnterior column nTransverse n nAssociated types nT-type nTransverse and posterior wall nPosterior column and posterior wall nAnterior and posterior hemitransverse nBoth columns n DSCN6984 DSCN6985 nPriority is to exclude any associated life threatening or limb-threatening injuries first nMost fractures of the acetabulum can be seen on AP X-ray of the pelvis during screening in the acute setting nWhen patient is stabilised, obtain standard Judet views ± pelvic inlet/outlet view nDocument any associated soft tissue and neural injury nArrange for urgent/early reduction of any hip dislocation nCentral hip dislocation, say, in transverse fractures, may need to apply leg traction to diminish chance of impingement of the femoral head cartilage nFive Standard X-ray Views nAP view nJudet views – sometimes hip subluxation only seen in these oblique views nPelvic inlet nPelvic outlet n nCT Assessment nHip congruency nIntra-articular fragments n3D reconstruction in complex fracture patterns DSCN6982 DSCN6982 DSCN6982 nThe Case for Early/Urgent Operation nOpen fracture nVascular injury nAssociated irreducible hip (e.g. loose body) nHip instability after reduction nProgressive nerve palsy n nIndications for Operative Intervention nMost displaced (> 2 mm) acetabular fractures nHip joint incongruent nEspecially if involve weight-bearing dome n nGoal of Surgery nRestoration of joint congruity nAnatomical reduction of weight-bearing dome nRn of associated injury nApproaches nKocher-Langenbeck n DSCN6986 DSCN6986 nIlioinguinal n n n n nStoppa n DSCN6988 DSCN6988 DSCN6987 DSCN6989 DSCN6989 nExtended iliofemoral DSCN6991 DSCN6991 n Posterior Wall nCommon nAssociation with posterior hip dislocation nthe joint congruency, any subluxation, or loose fragment nFix any sizable fragment with Kocher-Langenbeck approach nFixation involves the use of screws or buttress plate n n Posterior Column nEnsure ruling out of injury/bleeding from superior gluteal artery in nthose fractures that exit at the greater sciatic notch nFixation may consider the use of a buttress plate. Kocher-Langenbeck approach recommended n n Anterior Wall nSignificantly rarer than posterior wall fractures nIlio-inguinal approach nFix with reconstruction plate DSCN6993 DSCN6993 DSCN6994 DSCN6995 n Anterior Column nIlio-inguinal approach nFix with reconstruction plate n n Transverse Fractures nPosterior approach if displacement mainly nposterior or anterior fracture that is relatively undisplaced nAnterior approach if displacement mainly anterior nor posterior fracture that is relatively undisplaced nComplex cases or delayed presentation: combined or extensile approach n n T-fractures nCan be thought of as a transverse fracture with a vertical limb nDifficult to reduce and fix, may sometimes use cerclage as temporary nfixation or as adjunctive definitive fixation nMost need extended iliofemoral approach or triradiate approach n nHook plate DSCN6996 n Posterior Column and Posterior Wall nKocher-Langenbeck approach nIn cases of combined posterior column and posterior wall fractures, nfix the posterior column first n n Transverse and Posterior Wall nKocher-Langenbeck approach nFix the transverse component first n n Anterior Column and Posterior Hemi-transverse nMostly use ilio-inguinal approach nAnterior column fixation by buttress plate and screw nSometimes posterior column lag screw can be inserted via the ilioinguinal Approach n nDouble Column Fractures nIn the occasional case the ilio-inguinal approach alone may suffice nif posterior wall intact and posterior column is a big piece whereby napplication of lag screw ± cerclage (Fig. 11.10) from the anterior approach nis feasible after fixation of the anterior column has been performed nComplications of Fractured Acetabulum n nGeneral: nDVT/PE, unstable haemodynamics from associated injuries like fractured pelvis n nLocal complications: n nNeurologic Deficits n Example: sciatic nerve palsy n Most common present as foot drop n nCartilage Defects ± Later OA n nHeterotopic Ossification n Higher association with surgical approaches that involve extensive surgical dissection n AVN Hip Can occur after hip dislocation/subluxation Although immediate reduction of the hip decreases AVN risk, the patient is at risk for up to 5 years after the injury Effect of AVN – depends on site and size