Pelvic Fractures

2nd Northern Trauma Network Conference

P FearonConsultant Orthopaedic Trauma Surgeon - RVI

Overview

• Identify the priorities of life saving, limb saving, and disability-limiting surgery

• Outline the general and local factors affecting decision-making

• Importance of teamwork

• Orthopedic and trauma surgeons naturally concentrate on the fracture

• It is vital to realise that there are other factors that may dominate decision making in the management of a particular fracture

Injury Patient

Care team Resources

Injury• Fracture• Vascular injury• Compartment syndrome• Open wound• Crush injury• Nerves

Patient• Previous Condition

• Age (physiologic)• Diagnoses• Medications!

• Other injuries• Physiologic response• Expectations/needs

Care Team• Surgeon• Assistants• Anesthesia• Other specialties• OR nurses• Postoperative• Rehabilitation• Social supports

Resources• OR • Instruments• Implants• Imaging• ICU• (Other Patients)

Classification systemsSurvivors Non-survivors

Non-survivorsEarly Death Late Death

HaemorrhageBrain injury

SepsisMOF

Bleeding# bones, venous plexus, arterial injury, extra-pelvic sources

Survivors• Mental health problems• Chronic pain• Pelvic obliquity• Leg length discrepancy• Gait abnormalities• Sexual & urological dysfunction• Long term unemployment

Pre-Hospital• Goals:-

– Early suspicion

– Identification – no need to spring/log roll

– Management

Pelvic immobilisation should be routine

MOISymptomsClinical findings– deformity, bruising or swelling over the bony prominences, pubis, perineum or

scrotum. – Leg length discrepancy or rotational deformity of a lower limb (without fracture

in that extremity) may be evident.– Wounds over the pelvis or bleeding from the patient's rectum, vagina or urethra

may indicate an open pelvic fracture. – Neurological abnormalities may also rarely be present in the lower limbs after a

pelvic fracture.

Ease of applicationAccess for interventionShown just as good as external fixators

• Prevent re-injury from pelvic motion (clot disruption)

• Tamponade bleeding pelvic bones & vessels

• Decrease pain

• Decrease pelvic volume (lesser)

ED• Resuscitation / Management

• MHP

• WBCT – trauma series

– TEAM – TEAM TEAM TEAM

Illustrated case• 29 yr female• Motor cyclist• GCS 14/15• BP 90/40• Hr 110• PV bleeding• Binder applied

Pathway• Resuscitation on going

via CT scanner

All bets off!

Team Huddle – Senior Decision making

Modify Plan

• Aorta stented• Evaluation of coeliac

– Common hepatic– Left hepatic

• Both internal iliac– Left pudendal branch

embolised (anterior division of internal iliac)

• Prehospital• ED• ITU & anaesthetics• Ortho• Gen Surg• HBP• CT/radiology• Interventional radiology• Urology• Rehab• Pain team• Sexual dysfunction clinic• Clinical psychology

Holistic Approach

Improve disability

How much blood loss from pelvic #?• WBV

– (true pelvic vol 1.5L, but ↑ with disruption)– Retroperitoneal space 5L– Loose tamponade effect/disruption parapelvic

fascia– Escape into peritoneum & thighs

? Arterial Bleeding• MOI

• Open fractures• Elderly patients (gluteal injuries)• Sacrum/SIJ, symphyseal separation–gluteal, pudendal• CT scan – vascular blush/large haematoma≡sig bleed

Head on collisions

Jumpers

Binder

MHP

Trauma CT

Urology

Surgery

Pelvic fixation

Holistic Rehab

Coordinated Team Approach

• Isolated haemodynamically unstable pelvic trauma uncommon– Associated injuries due to high MOI

• Resuscitation/intervention team based with better understanding & cooperative team working

– surgeons included

Thank you