Management of pelvic fractures: the first 24 hours.

Peter Worlock

Newcastle General Hospital

Objectives:

• Review assessment of pelvic injury.• Understand concept of different types of

‘stability’.• Management algorithm.

Diagnosis:

• Made during primary survey.• Airway with c-spine control.• Breathing (oxygen).• Circulation– IV access– Crystalloid– Control external loss– Look for major pelvic injury

Assess pelvis:

• History– Suspect in high energy injury

• Examination– External bruising/wounds (anterior/posterior)– Test for vertical/horizontal instability– Rectal examination– Vaginal examination

Radiographs:

• Every polytrauma patient should have– Lateral c-spine– Chest– AP Pelvis

• AP pelvis is done to detect major (and potentially life-threatening) pelvic injury.

Inlet view:

Patient flat on trolley.XR plate under pelvis.Direct XR beam at 60 degrees to plate.Effectively ‘transverse’ section through sacrum.Will show sacral #.Will show any posterior shift of hemi-pelvis.Will show internal/external rotation of hemi-pelvis.

Outlet view:

Patient flat on trolley.XR plate under pelvis.Direct XR beam at 45 degrees to plate.Effectively true AP view of sacrum.Will show vertical shift of hemi-pelvis.Will reveal any ‘bucket-handle’ injury.Will help in assessing leg length discrepancy.

Pelvic fracture classification: Type A.

Stable.Minimally displaced.Posterior arch intact.

Pelvic fracture classification: Type B.

Can be unstable.Incomplete disruption of posterior arch.Actual or potential horizontal translation.No vertical translation.

Pelvic fracture classification: Type C.

Unstable.Complete disruption of posterior arch.Actual or potential horizontal and vertical displacement.

Type B injuries:

• B1: open book injury (external rotation). Can be mechanically unstable.

• B2: lateral compression injury (internal rotation) - includes ipsilateral and contralateral (“bucket-handle”) types. Usually mechanically stable.

• B3: bilateral Type B injuries (includes “windswept” pelvis). External rotation injury can be mechanically unstable.

Type C injuries:

• C1: unilateral complete disruption of posterior arch.

• C2: unilateral complete disruption of one posterior arch, with incomplete disruption of contralateral posterior arch.

• C3: bilateral complete disruption of posterior arch.

• All are mechanically unstable.

Management of major pelvic fracture:

• You have to be an orthopaedic surgeon, a urologist, a vascular surgeon, a colo-rectal surgeon and (sometimes) a gynaecologist!

Initial management:

• Save life.• Do not do anything to compromise definitive

reconstruction.• Most important piece of equipment to

master?

The telephone!

Open pelvic fracture:

• Wound may be external, into rectum, into vagina or into bladder.

• ALL wounds must be explored, lavaged and debrided.

• Defunctioning colostomy if any large bowel communication with fracture, with washout of distal limb.

Urethral injury:

• Pass urethral catheter only if:– No blood at meatus– No scrotal/perineal haematoma– Normal rectal examination

• Urethrogram will define injury.• Suprapubic catheter will rapidly contaminate

tissues posterior to symphysis.

Urethral injury:

• Consider urgent transfer to pelvic fracture unit for combined pelvic/urethral reconstruction as emergency.

Nerve injury:

• Careful examination as soon as possible to detect any nerve damage.

• Document clearly.• Treat expectantly.• Lumbo-sacral plexus damaged in up to 45% of

Type C injuries.

Assessment of ‘stability’:

• Mechanical:– Based on clinical examination and radiographs.

• Haemodynamic:– Normal.– Stable (maintaining P/BP/urine output by continuous

infusion of fluid = on-going bleeding somewhere).– Unstable (failure to maintain P/BP/urine output

despite continuous infusion of fluid).

Type I injuries:

• Mechanically stable (usually Type B lateral compression).

• Haemodynamically stable.• No emergency treatment for pelvic lesion.• Obtain CT scan.• Liaise with pelvic fracture unit re definitive

management.

Type II injuries:

• Mechanically unstable (open book and Type C injuries).

• Haemodynamically stable.• No emergency treatment for pelvic lesion.• Careful haemodynamic monitoring.• Obtain CT scan.• Liaise with pelvic fracture unit re definitive

management.

Type III injuries:

• Mechanically stable (usually Type B lateral compression).

• Haemodynamically unstable.• Pelvis already closed/stable – no need for

emergency treatment for pelvic lesion.• Look for bleeding elsewhere (chest/abdomen).• If none found, consider:– Angiography/embolisation.– Laparotomy/pack pelvis.

Type IV injuries:

• Mechanically unstable (open book and Type C injuries).

• Haemodynamically unstable.• Look for bleeding elsewhere (chest/abdomen).• Reduce pelvic fracture and stabilise with

anterior external fixator or C-clamp.• If laparotomy indicated, you MUST apply

external fixator BEFORE abdomen opened.

Type IV injuries:

• After external fixation, careful haemodynamic monitoring.

• If continuing haemodynamic instability:– Angiography/embolisation (if skills rapidly

available).– Laparotomy/simple anterior plate

fixation/maintain external fixator/pack pelvis.

Type V injuries:

• Mechanically unstable (open book and Type C injuries).

• Haemodynamically unstable.• Patient in extremis. Dying in front of you

despite aggressive fluid resuscitation.• Immediate operation required to save life.

Type V injuries:

• Apply simple anterior external fixator or C-clamp.

• Laparotomy and deal with any intra-abdominal bleeding.

• If still haemodynamically unstable, perform simple anterior plate fixation/maintain external fixator/pack pelvis.

Pelvic injury with haemodynamic instability:

• Beware of “consumption coagulopathy”.• Secondary haemorrhage can be

uncontrollable.• Start aggressive replacement of clotting

factors/platelets/calcium early (after five units of blood).

• Obsessional monitoring of clotting status.

Definitive care:

• Posterior approach to sacrum may be compromised by de-gloving of skin.

• Anterior approach to SI joint compromised by external fixator pin wounds on iliac crest.

• Anterior approach to symphysis pubis compromised by ruptured viscus and intra-peritoneal contamination.

Definitive care:

• Anterior approach to symphysis pubis compromised by suprapubic catheter for >24 hours.

• When haemodynamically stable, start prophylaxis against DVT/PE.

• Transfer early – best results come if pelvis reconstructed within 5-10 days of injury.

Summary:

• All units receiving trauma must be able to save life in major pelvic injury.

• Haemodynamically stable or unstable?• Define # pattern on XR - mechanically stable

or unstable?• The only injuries that require you to operate

as emergency are those that are mechanically and haemodynamically unstable.

Summary:

• Detect all complications of the pelvic injury.• Definitive care:– Get it right first time.– Speak to your local pelvic fracture unit ASAP.– Do not compromise definitive reconstruction by

inappropriate early care.