PELVIC TRAUMA

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PELVIC TRAUMA
Lee Yong Eng, MD Department of Orthopedic
Surgery SKH
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SURVIVAL STUDIES

• Mortality rate ? 10
• Mortality ? ISS
• ORIF of unstable pelvic fractures ? mortality rate

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NATURAL HISTORY 1

• Stable fractures
• few major long-term problems
• usually mild or moderate pain

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NATURAL HISTORY 2

• Unstable fractures
• Persistent pain 60
• Nonunion 3.5
• Malunion 4
• Permanent nerve injury 5.5
• Permanent urethral injury 2.5

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Prognostic Factors

• Degree of initial force
• Type of injury (stable or unstable)
• Treatment modalities
• Associated injuries

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Anatomic considerations

• Bony ring structure pelvic ring
• Ligamentous structures static and dynamic
  stabilizers

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Biomechanical considerations

• Pelvic stability
• Forces acting on the pelvis
• Forces transmission to the viscera, vessels, and
  nerves

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Classification

• Type A stable
• Type B vertically stable, rotationally unstable
• Type C unstable (rotationally vertically)

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Management

• Polytraumatized patient
• Rapid general assessment and resuscitation (esp.
  type C)

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Resuscitation

• Massive fluid replacement
• Hemorrhage control

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Hemorrhage control

• Pneumatic antishock garment
• Stabilization of the unstable pelvic disruption
• Embolization of the pelvic vessels
• Surgical intervention

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Hemorrhage control

• Early, provisional stabilization of the unstable
  pelvic fracture
• Use safe, simple and quick methods

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Clinical evidence of instability

• Palpation, manipulation, traction
• Severe displacement of the pelvis
• Marked bruising posteriorly
• Severe associated injuries to nerves or vessels
• Presence of an open wound

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Radiographic evidence of instability

• Posterior or superior displacement of the
  posterior complex by gt 1 cm
• Large posterior gap

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Provisional stabilization

• External frame
• Pelvic clamp
• Skeletal traction (30-40 lb)

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Provisional stabilization

• Type B1 (open book fracture)
• Type C
• Both result in an increased pelvic volume

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Early provisional stabilization

• Reduce the volume of the pelvis
• Restore the tamponade effect of the bony pelvis
• Hemorrhage control

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Early provisional stabilization

• Maintaining an upright position for proper
  ventilation

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Early provisional stabilization

• Biomechanically, not strong enough to allow
  ambulation
• Redisplacement usually occurs

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Definitive stabilization

• Stability of the fracture
• Risks and benefits of stabilization

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Definitive stabilization

• Type A
• Symptomatic treatment
• No need for stabilization

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Definitive stabilization- type B1 (open book)

• If symphysis is open lt 2.5 cm
• gt No specific stabilization
• If symphysis is open gt 2.5 cm
• gt ESF or plate

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Anterior internal fixation of disrupted symphysis

• Plating is suggested if
• Laparotomy
• No fecal contamination
• No need for suprapubic drain

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Definitive stabilization- type B2-1

• No specific stabilization

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Definitive stabilization- type B2-2 (bucket
handle)

• If LLD lt 1.5 cm
• gt No specific stabilization
• If LLD gt 1.5 cm
• gt ESF
• If tilt fracture
• gt ORIF

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Definitive stabilization- type C

• Simple external frame c traction
• Complex external frame c or traction
• ORIF

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Definitive stabilization

• Advantages of ORIF
• Biomechanically, strong enough to allow early
  ambulation
• Reduces the malunion or nonunion rates

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Definitive stabilization

• Disadvantages of ORIF
• Increased bleeding
• Wound problems
• Nerve injury

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Type C injury

• Indication for anterior internal fixation
• Indication for posterior internal fixation

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Indications for anterior internal fixation

• Fracture types
• State of the patient
• Laparotomy
• No fecal contamination
• No need for suprapubic drain

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Indications for posterior internal fixation

• State of the patient
• Unstable, unreduced posterior SI complex (esp. an
  unreduced SI dislocation c a gap of gt 1 cm)
• Posterior open wound (cf. - contraindicated if
  the wound is in the perineum)
• Associated acetabular fracture requiring ORIF

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Timing of surgery (ORIF)

• Wait until general condition is stable, usually
  between 5th and 7th post-op day

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Prophylactic antibiotics

• Routinely given for a minimum of 48 h
• Cefazolin 2g/day, IV
• Tobramycin 160mg/day, IV

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SURGERY- anterior internal fixation

• Type B1, a 2- to 4-hole reconstruction plate on
  the superior surface
• Type C, two plates at 90 to each other, if no
  posterior fixation is planned

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SURGERY- posterior internal fixation

• Sacral fractures, two transiliac bars
• SI dislocations, anterior plating or posterior
  screw fixation
• Iliac fractures, interfragmental screws or plates
  (3.5-mm reconstruction plates)

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Early complications

• Hypovolemia
• Thromboembolism
• Fat embolism

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Late complications

• Infection
• Multiple organ failure