Ageng Budiananti Noviana Sie

Pelvic fracture is a disruption of the bony structures of the pelvis. In elderly persons, the most common cause is a fall from a standing position. However, fractures associated with the greatest morbidity and mortality involve significant forces such as from a motor vehicle crash or fall from a height.


1. 2. 3.

4.

Four groups Isolated fractures with an intact ring. Fractures with broken ring (stable or unstable). Fracture of the acetabulum; although it is ring fracture but involvement of the joint raise a special problem. Sacrococcygeal fractures.

1. Avulsion fractures. A piece of bone is pulled off by violent muscle contraction usually seen in athletes.
a. The anterior superior iliac spine pulled off by sartorius muscle. b. The anterior inferior iliac spine by rectus femoris. c. The pubis by adductor longus. d. Part of ischium by the hamstrings All need only resting for few days and reassurance.

2. Direct fractures. A direct blow to the pelvis like fall from a height may lead to fracture of the iliac blade or the ischium. Rest until pain subsides is usually all that is needed.

3. Stress fractures. Fractures of the pubic rami and around the sacro-iliac joint in severely osteoporotic and osteomalacic patients; it is usually painless and discovered accidentally.

Lateral Compression
Types I-III Horizontally oriented pubic fractures force is from side

Anteroposterior Compression
Types I-III Sagittal disruptive force (MVAs) Anterior pelvic disruption

Vertical Shear

Horizontally oriented pubic fractures (force is from side)

Type I

Sacral compression fx on side of impact Iliac wing fracture on side of impact LC type I or II fracture + contralateral Anteroposterior Compression Fracture

Type II Type III

Type I
pubic rami or ligament disruption Slight widening of symphysis

Type II
Iliac wings rotated externally hinging at SI joint posterior aspect Open Book

Type III
Complete disruption of sacroiliac ligaments unstable

 Fall

from heights Anterior: both pubic ramis fractured Posterior: SI complex or sacral fracture

1. Fracture

of the pelvis should be suspected in every patient with serious abdominal injury or lower limb injury. 2. H\O road traffic accident, fall from a height or crush injury. 3. Severe pain, swelling and bruises in the lower abdomen, perineum, thighs, scrotum or valva. 4. Extravasations of urine. 5. Symptoms and signs of bleeding and hemorrhagic shock.

6.

7. 8.

Tenderness all over the especially when attempt to distract the pelvis. Tender abdomen due to intrapelvic structure injuries. Rectal examination should every case.

pelvic bone compress or

bleeding or

be done in

Bleeding in external meatus indicates urethral injury. If no bleeding ask the patient to void and give direct look to the urine, if the patient able to void this indicates either no urethral injury or there is only minimal damage to the urethra. Note no attempt should be made to pass a catheter, as this could convert the partial injury to complete injury. 10. Neurological examination should be done to exclude sacral and lumber plexus injury.
9.

1. Early management Treatment should not await full and detailed diagnosis. Doctor should move according to the priority of life saving measures with the already available information.Six questions must be asked and the answers acting upon as they emerge:

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2. 3. 4. 5. 6.

Is there a clear airway? Are the lungs adequately ventilated? Is the patient losing blood? Is there an intra abdominal injury? Is there a bladder or urethral injury? Is the pelvic fracture stable or not? After exclusion of the above, the doctor now has a good idea about the patient general condition and the associated injuries so further investigation can be done

2. Management of severe bleeding

1.

Treatment of shock.

3. 4.

Laprotomy. 3. External fixation to close the book. Management of urethral and bladder injury. Treatment of the fracture
2.

 During

acute resuscitation, management of patients with pelvic fractures should follow one of the existing trauma protocols The MAST suit (military antishock trousers) has proved beneficial during patient transport but is not used routinely in the evaluation/resuscitation phase A deflatable bean bag has been suggested to stabilize the pelvis temporarily in the initial resuscitation phase.

 In

patients with an unstable pelvic fracture who demonstrate hemodynamic instability after an initial fluid bolus, emergency external fixation should be performed early in the resuscitation effort. Reported benefits are: (1) a tamponade effect on the retroperitoneal hematoma, effected by reducing the retroperitoneal volume; (2) less motion of the fracture surfaces, which allows more effective clot formation; and

(3) greater patient mobility during transport and for CT scanning and other evaluations Moreno et al., Burgess et al., and others noted a reduction in the transfusion requirements of patients with unstable pelvic fractures who were treated with immediate external fixation compared with those who did not undergo immediate fixation.

 Stable,

nondisplaced pelvic fractures (Tile type A) do not require operative stabilization and can be adequately managed with early mobilization and analgesics. Operative reduction and stabilization have been advocated for rotationally unstable but vertically stable (Tile type B) fractures with a pubic symphysis diastasis of more than 2.5 cm, pubic rami fractures with more than 2 cm displacement, or

 other

rotationally unstable pelvic injuries with significant limb-length discrepancy of more than 1.5 cm or unacceptable pelvic rotational deformity.

 Goal:

reduce pelvic volume to decrease hemorrhage (earlier tamponade) External Pelvic Fixation (EPF)

Standard Invasive

Temporary

stabilization

Quickly applied (5-60min) Lower transfusion volumes at 24h & 48h

C-clamp T-pod

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2. 3.

Sciatic nerve injury. Urogenital problem like stricture, incontinence and impotence. Persistent sacroiliac pain due to unstable pelvis.