Common Adult Fractures - Pelvis

Common Adult Injuries Axial Skeleton Pelvis

Prof. Mamoun Kremli

Outline

• Introduction

  • The pelvic ring
  • What does a pelvic injury indicate?

• Emergency assessment & management

  • Differentiation between stable & unstable injuries
  • Classification and reading x-rays

• Treatment options

Anatomy

The Pelvic Ring

• Integrity and stability of the pelvic ring is essential

High Energy

• It takes high energy to create such damage

Serious Injury

• Bleeding – up to 3L or more
• Damage to other soft tissues
  • Urethra, bladder
  • Bowel
  • Nerves
  • Genitalia
  • Rectal sphincter
• Usually with other major fractures / Injuries

Primary Assessment

• Bone is not of primary importance. Life is ! Assessment in suspected pelvic ring fracture is according to ATLS (advanced trauma life support)

Primary Assessment - ATLS

Unstable – Why??

• Exclude other sources
• Open wound — adds risk of sepsis
• Thoracic/abdominal hemorrhage
  • Hemothorax
  • Hemo-abdomen
• Major fractures
  • Long-shaft bone fractures
  • Pelvic fracture

Bleeding from Pelvis

• If the pelvis is the source of bleeding, massive blood loss is:
  • Mostly venous 80%,
  • Cancellous bone oozing
  • posterior disruption
  • Supported by enlarged compartment
  • Arterial source is rare

Emergency Treatment

• Protect primary blood clot by
  • Early pelvic splintage / sheet/ clamp. External fixator and
  • Prevention of excessive movement
• Resuscitation
  • IV fluids, blood transfusion & fresh frozen plasma, platelets, cryoprecipitate
  • For massive transfusions: Ratio of 1:1:1 (PRBC: FFP: Platelets)
• Prevent hypothermia & acidosis
• Stop other bleeding sites(!!)

Bleeding from Pelvis

• Emergency treatment: Reduce Compartment

  • Pelvic sheet

  • External fixator

  • Pelvic c- clamp

• If the patient still not responding • Think of arterial sources • Either need pelvic packing or embolization by interventional radiologist

Clinical Picture

• Bruising
• Urethral / genital bleeding
  • indicates injury to viscera
  • Rectal and vaginal examination is mandatory to rule out open fracture
  • Do not forget to assess the perineum for wounds

• Tenderness on attempted pressure
• Neurologic exam
  • Rule out lumbosacral plexus injuries (L5 and S1 are common)
  • Rectal exam to evaluate
    • Sphincter tone
    • Perirectal sensation

Primary Assessment

• A standard x-ray reveals up to 90% of fractures

Additional Imaging

• CT scan must be done for pelvis fracture to study condition of posterior ring

Ruptured bladder (urethrogram)

Pelvic Fractures

• Isolated fractures
• Pelvic Ring fractures

Isolated Fractures

• All are Stable
• One bone only
  • Or ring on one side
• Avulsion Fractures
  • Sudden pull of muscles
    • Sartorius: ASIS
    • Rectus Femoris: AIIS
    • Adductor Longus: Pubis
    • Hamstring: Ischium
• Treatment: Rest / analgesics

Fractures of Pelvic Ring

In adults, one break in the ring is accompanied by another break in the ring

Three mechanisms:

AP compression

• Anteroposterior compression

• Frontal collision of car-pedestrian
  • Pubic rami fractured or
  • Disruption of symphysis pubis
  • Open-book (stable if <2cm)

Lateral Compression

• Mechanism:
  • Side-on impact in RTA/ fall from height
• Anteriorly:
  • Fractured pubic rami
• Posteriorly:
  • Sacroiliac strain / fractured ilium & sacrum
  • Unstable if severely displaced - needs surgery

Vertical Shear

• Mechanism:
  • Fall from height on one leg
• Innominate bone displaced superiorly on one side
  • Fracture of pubic bones
  • Disrupted sacroiliac joint on the same side
  • Severe, unstable, soft tissue damage, bleeding

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Operative Treatment Options

• External fixation
  • Temporary Clamp

• Internal fixation

  • Screws & Plates

• Combinations

Conclusions

• Pelvic Fractures – Emergency management
  • More than just a bony injury
  • Suspect high energy trauma
  • First, save patient’s life
  • If unstable: Stabilization of paramount importance
  • Many might be treated nonoperatively