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Case Discussion

Hemodynamic Unstable
Pelvic Fracture

Yoyos Dias Ismiarto, dr.,


SpOT(K), M.Kes, FICS., CCD.

Department of Orthopedics & Trauma


Hasan Sadikin Hospital
Faculty of Medicine Universitas Padjadjaran
Case
Male, 38 y.o
Chief complain : Pain at abdominal and

pelvic region
Primary Survey
A : clear with C-spine control
B : shape and movement was equal both
hemithorax, vesicular breath around equal both
hemithorax. RR: 24x/minute
C : BP 80/50 mmHg HR 110x/ minute
D : GCS 15 E4V5M6, pupil isocor+/+, light reflex
+/+
E : at pelvic region there was bruising and
swelling at left pelvic region so perform bimanual
compression
Secondary Survey
a/r Abdominal
Inspection : Distension
Palpation : tenderness and muscle rigidity
Auscultation : bowel sound was decrease
a/r Pelvic
Look : pelvic bruising
Feel : tenderness, distal sensibility normal,
pulsation popliteal artery normal
Move : Active ROM hip limited due to pain
Passive ROM hip flexion 0-90 &
extension 0-10
X-Ray
USG
FAST : fluid adhesion at splenorenal space
& vesico retro sp
Laboratory
Haemoglobin : 8.4 gr/dl
Hematrocite : 40 %
WBC : 15.500 gr/dl
RBC : 4, 57
Working Diagnosis

?
Management

?
True or False
2 weeks Later
Introduction
Definition
Pelvic fracture is a disruption of the bony structure of the pelvis

Frequency
In US it represent 3 % of all skeletal fracture with single
fracture of pubic rami and avulsion fracture are the most
Common

Mortality/Morbidity
Overall 10 percent in adult and 5 percent in children,
pelvic hemorrhagic is the direct cause of the death
If hypotension is present the death reach 50%, if open it reach
30%
Anatomy
Pelvic is a ring
Sacrum and 2

innominate bones
(Ilium, Ischium &
Pubic)
Stability : soft

tissue
Anatomy, structural
stability
Main stabilizer posterior
part (loading line)
Posterior stability :
SI joint
Interosseous lig.
Post. Sacroilica lig.
Ant. Sacroiliaca lig.
Connecting ligament
Sacrotuberosus lig.
Sacrospinosus lig.
Iliolumbar lig.
Lateral lumbosacral lig.
Posterior tension band
Anatomy, structural
stability
Anatomy, structural
stability
Anterior stability
Symphysis pubis
hialyn cartilage,
united by layers of
fibrocartilage and
fibrous tissue
Anatomy, interior of pelvic
bone
Anatomy, structures at
risk
Lumbosacral and
coccygeal nerve plexus
Blood vessels
median sacral & superior
rectal A.
Internal iliac A.
Posterior division : sup
gluteus., iliolumbar, lat.
sacral A.
Anterior divisiom
inf gluteus, int. pudendal A.
Veins
Urogenital,
gastrointestinal
Biomechanics
Pelvic is a ring, no disruption on one side without
another side involvement

Load that work : ext. rot. (compression), int. rot.


(lat. compression) and vertical shear

On sit / stand position : tension on symphysis


and compression on posterior complex.

Unilateral stance : vertical shear on same side


and internal rotation
Biomechanics
Biomechanics, open book
Biomechanics, open book
External rotation : labour (physiologies),
posterior crush, direct pressure on ASIS
and ext. rot. through the femur
Diagnosis
History
Trauma mechanism
Age, sex
Diagnosis
Physical examination
ABCs primary survey
Look : wound, contusion, abrasion
bleeding from urethra / vagina
rotation / shortening on lower extremities
Feel & move
Medial and lateral push
Direct pressure in symphysis gap
Shortening traction (+) unstable (vertical shear)
(-) posterior complex impaction
Vaginal and rectal examination
Neurovascular status
Diagnosis, Radiology
AP view
Sufficient on acute situation
Symphysis disruption, pubic rami #
Poor for posterior displacement
Note : avulsion of the tip of transverse process
of L vert, end of sacrospinosus lig.
Diagnosis, Radiology
Inlet view
Show the true pelvic inlet
Best for anterior or posterior displacement
Diagnosis, Radiology
Outlet view
Show posterior & inferior displacement of
anterior part and superior displacement of
posterior part
Classification, Tile
Type A :
Stable
A1 fractures of the pelvis not involving the ring
A2 stable, minimally displaced fractures of the ring
A3 transverse fracture of the sacrum and coccyx
Type B :

Rotationally unstable, vertically stable


B1 open book (external rotation)
B2 : lateral compression injury (internal rotation)
B2-1 ipsilateral anteior & posterior injury
B2-2 contralateral (bucket-handle)
B3 : bilateral
Type C

Rotationally and vertically unstable


C1: unilateral
C1-1 : iliac fracture
C1-2 : sacroiliac fracture-dislocation
C1-3 : sacral fracture
C2 bilatera, one side tipe B, one side tipe Cl
C3 associated with acetabular fracture
Classification, Young &
Burgess
LC 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

APC Symphyseal diastasis or longitudinal rami fractures
I : Slight widening of pubic symphysis or anterior SI joint; strecth but
intact anterior SI, sacrotuberosus, and sacrospinosus ligaments; intact
posterior SI ligaments.
II : Widened anterios SI joint; disrupted anterior SI, sacrotuberosus, and
sacrospinosus ligaments; intact posterior SI ligaments.
III: Complete SI joint disruption with lateral displacement; disrupted
anterior SI, sacrotuberosus, and sacrospinosus ligaments; disrupted
posterior SI ligaments.

Classification, Young &
Burgess
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.
Complication
Bleeding
lateral, vertical and posterior displacement
soft tissue under tension
Methods of treating :
Laparotomy and direct vascular ligation
Laparotomy, clot evacuation, extraperitoneal
packing, ORIF
PSAG
Angiography and embolization
ORIF
Closed reduction, percutaneous fixation
External fixation
Complication
Urogenital injury (16%)
Bladder (7%), urethra (6%) and both (2,5%).
Mostly man. Calpinto : urethra pars bulbosa
(sub diafragma)
Gastrointestinal injury
Blunt trauma as well as the pelvic
Due to fractures fragments
Thromboembolism
Treatment
Treatment objectives in pelvic ring injury :
Restoring bony anatomy
Preventing deformity
Minimizing discomfort
Facilitating return to mobility and function
Divided into :
Diastases less than 2,5 cm
Diastases more than 2,5 cm
Treatment
Diastases < 2,5 cm
Intact pelvic floor (APC I)
Symptomatic
Early mobilization
Diastases > 2,5 cm
APC II reduction, fixation
APC III life threatening EF
posterior fixation
Treatment
Methods
Reduction
put the patient on lateral side
Internal rotation with the femur as a fulcrum
Use the pins
Fixation
Pelvic sling
Hip spica
Operative
External fixation
internalfixation
Treatment
External fixation
Safe and effective method
Biomechanically fit, permits early mobilization
Contra fractures line across through the ileum
to the crest
Retained for 6-8 weeks reassess 4-6 weeks
more
Alternative : C-clamps
Treatment
Open book ? just close the book
Treatment
Internal fixation
First choice if laparatomy and urologic
procedure performed at the same time
Contra : feces contamination
open ?
urine contamination vs suprapubic
tube
Short reconstruction or DCP plate
Patient can move, postponed FWB for 4-6 weeks
Treatment
Anterior approach to the pubic symphysis
Treatment
Take Home Message
Play well with others (general surgery, urology,
interventional radiology, neurosurgery)

Understand the fracture pattern

Do something (sheet, binder, ex fix, c-clamp)

Combine knowledge of the fracture, the patients


condition, and the physical exam to decide on the
next step
THANK YOU