TRAUMA PELVIC

DARMADJI ISMONO

DEFINITIVE SURGICAL TRAUMA CARE

(DSTC)

Bandung, 21-23 April 2006

Introduction
Usually combination with other
serious or life-threatening
injuries
Musculoskeletal
Respiratory
Central nervous
Gastrointestinal
Urologic
Cardiovascular systems
The management requires
concomitant diagnosis and
treatment of the other
systemic and musculoskeletal
injuries

Osteoligamentous
Anatomy

Assessment
M.I.S.T

An accurate history
Fractures due to highenergy trauma

motor-vehicle accidents,
falls from height,
crushing injuries;

Fractures due to lowenergy trauma

simple falls at home

Mechanisms of Injury
High-energy fractures:
motor vehicle, 57%; pedestrian, 18%;
motorcycle, 9%; falls from heights, 9%; and
crush, 4%
often result in two or more fractures of the pelvic
ring
AP force, lateral impacts, vertical shear
Penetrating mechanisms: associated visceral
and neurovascular injuries

Mechanisms of Injury
Low-energy fractures isolated fractures
do not damage the true integrity of the ring
structure
domestic falls: "straddle" injury from a fall in the
bathtub elderly population
avulsion injuries of the muscle apophyses in
skeletally immature patients.

Schematic view of the principal pelvis injury patterns as

determined by the vector of the provocative blow

ASSOCIATED HEMORRHAGE AND

IMPLICATIONS FOR THERAPEUTIC
INTERVENTION

The general physical

examination
ATLS guide according to
American College of Surgeons
on polytrauma

Secondary survey

Any deformity of pelvic and inferior extremity

Grey tuner sign: bruises at the flank area that indicate the
retroperitoneal bleeding

Leg length discrepancy > 1 cm suspect # pelvic

Morel-Lavalle lesion

-Tenderness or instability

-Earles sign : Palpating the swelling or

hematoma on the pelvic
Maneuver pelvic springing
Gentle Compression/distraction on SIAS
-Femoral artery pulsation + distal part
-Sensory and motoric test suspect sciatic
nerve injury
-Rectal examination suspect urethra injury

Abdominal evaluation

DPL
CT Scan
Focused Abdominal
Sonogram for trauma
Experienced hands
DPL or CT

Diagnosis of Instability

The completely unstable type

C pelvic fracture:

Translates abnormally both

vertically and posteriorly with
no firm end point when a pushpull force is applied to the
limb.

Prevent repeated
manipulation
displace clot, greater
blood loss, neurologic
injury !!!!

Radiologic Assessment
Plain Radiography
AP
Inlet

Outlet

This view shows posterior displacement

entire sacrum, including both
of the sacroiliac complex
sacroiliac joints, and will also sh
superior migration of the iliac cr

Computed Tomography
Further define the posterior
pelvic injury
Possible associated
acetabular
fracture
CT is not emergency
evaluation

Degree of stability/ instability

Classification

Type A (Stable posterior arch intact)

Surgical stabilization
is not
normally required

Type B (Incomplete disruption of posterior arch)

Stabilization
of anterior pelvic ring
B1 (Opensufficient
Book)
usually

B2 (Lateral Compression)

B3 (Bilateral bucket handle)

Type C (Complete disruption of posterior arch)

The pelvic ring

requires combined
posterior and anterior

Young-Burgess
APC Type

Lateral Compression

Transverse fracture of pubic rami, ipsilateral or

contralateral to posterior injury

I: sacral compression on side of impact

II: crescent (iliac wing) fracture on side of impact

III: LC-I or LC-II injury on side of impact; contralateral open-

book (APC) injury

Vertical & Combined

VS: Symphyseal diastasis or vertical

displacement anteriorly and posteriorly,
usually through the SI joint, occasionally
through the iliac wing or sacrum

CM:

Combination of other injury

patterns, LC/VS being the most
common

Pelvic Stability

Stable Can withstand normal physiologic force

Unstable Cannot withstand normal physiologic
force
Common Radiologic instability

Displacement Posterior Scaroiliac Complex > 1 cm

any plane
Presence posterior fracture gap rather inpaction
Avulsion L5 transverse process, sacrum, or ischial
spine (disrupt SS ligament)

Emergent treatment

ATLS principles
Applied Military antishock trousers (MAST)
Resuscitation in shock patients

IV Lines
Crystalloid solution
Blood administration
Prevent hypothermia
Fluid monitoring

Treatment

Methods
Reduction
put the patient on lateral side
Internal rotation with the femur as a
fulcrum

Fixation
Pelvic sling
Hip spica
Operative
External fixation
Internalfixation

Application

Pelvic clamp
External frame plus supracondylar femoral traction
- reduces the pelvic volume,
- partially stabilizes the bones and soft tissues,
- reduces the amount of bleeding and pain
- easier nursing care.

Emerging embolization if indicated

External Fixation
1. Pelvic Clamp

2. Pin External Fixator

3. Skeletal traction

skeletal-traction pin in the distal femur is

recommended as a temporary measure

Timing of External Fixation

Controversy
Whether they should be applied before or after
laparotomy.
The conventional wisdom there is to apply the
frame first and then proceed to laparotomy and
pelvic packing when possible (Europe)
Discusses among all trauma team

Pelvic fracture devastating injuries

Number of complications
Often require extensive rehabilitation
0.3% to 6% of all fractures
Occur in 20% of all polytrauma cases.
Bimodal distribution 15 to 30 and 50 to 70 years
Men : women 57% to 75%
mortality rates range from 6.4% to 30%,5

Complications

Uncontrolled Hemorrhage
Complications of External or Internal Fixation
Infection
Neurologic Complications
Thromboembolism
Persistent Pelvic Pain
Malunion
Nonunion
Urologic and Gynecologic Problems

Question

Conclusion

A major, life threatening pelvic injury should be treated

comprehensively, with priority to manage the dangerous
associated injuries and to achieve pelvic stability that provide
tamponade mechanism to stop the bleeding so haemorrhagic shock
can be prevented.

Choose the methods and instruments to treat the pelvic injury

based on proper evaluation and diagnosis.

The procedure to treat the pelvic injuries should be done correctly

to achieve a good result and to prevent complications.