Luchelle Stemmet

• High Energy mechanism:

1. MVA
2. PVA
3. Fall from height
• Major Haemorrhage
• Other major injuries
1. Intra-abdominal organs and aortic
2. Hollow viscus injury
3. Renal injury
• High morbidity and mortality
Young-Burgess
classification

Tile classification
Anteroposterior compression (APC)
-Common feature is diastasis of the pubic symphysis or vertical fracture
of the pubic rami
-Typically from head-on collisions
Lateral compression (LC)
-Common feature is a transverse fracture of the pubic rami
-Typically from side impact collisions
Vertical shear injuries (VS)
-Common feature is a vertical fracture of the pubic rami
-Displaced fractures of the anterior rami and posterior columns,
including SI dislocation
-Typically from a fall from a height
Combined mechanism (CM) fractures
Surfaces of fractures bones
Pelvic venous plexus (90%)
Pelvic arterial injury (10%)
Extra-pelvic sources

*Suspect arterial bleeding in patients with on going bleeding

despite pelvic binding or mechanical stabilisation
 True pelvic volume is about 1.5L this is increased with disruption
of the pelvic ring

 The tamponade effect of the pelvic ring is lost in severe pelvic

fractures with disruption of the parapelvic fascia

 Pelvic fractures cause bleeding into the retroperitoneal space,

even when intact the retroperitoneal space can accumulate 5L
of fluid with a pressure rise of only 30mmHg

 Hemorrhage can escape into the peritoneum and thighs with

disruption of the pelvic floor (e.g. open book fractures)
Assessment for pelvic trauma should be part of a coordinated,
structured assessment for multiple traumatic injuries (e.g. ATLS
approach)

Airway
Breathing
Circulation
Disability
Environment, Exposure
• Inspection
 Look for echymoses, deformity, asymmetry, wounds

• Palpation of skeletal structures

 Pubic symphysis, iliac crests, the posterior sacroiliac joints, ischial tuberosities
as well as the spine extending inferiority of the sacrum and coccyx
• Assess for mobility
 Gently compress the iliac crests to feel for instability
 NB! Gentle technique and cautious approach is important to avoid
aggravating haemorrhage if the pelvis is fractured
 The manoeuvre should only be performed once, ideally by the most senior
trauma doctor present.
 Do not ‘rock’ the pelvis
Bedside:
1. Venous blood gas (Hb, Lactate and acidemia)
2. FAST
3. Diagnostic peritoneal aspirate
Laboratory :
1. Cross match
2. Full blood count and coagulation profile (Hb, Platelets,
Clotting profile)
3. BhCG in women of child bearing age
Imaging
AP pelvis x-ray
Indications: Contraindications:
o Hemodynamically unstable o Normal examination and
the patient is alert and
o Altered mental state
able to ambulate
o Distracting injuries o Abdominopelvic CT will
o Children be performed anyway for
o Abdominopelvic another reason
CT abdomen and pelvis with IV contrast
o Imaging modality of choice for assessing pelvic ring injury
o Performed in stable patients, to rule out intra-abdominal and
retroperitoneal injury, and to characterize the type and
severity of pelvic injury and may identify those suited to
interventional radiology
Angiography
o Used to identify arterial injury and to guide embolisation
• Abdominal and gastrointestinal injuries
• Genitourinary injuries
• Coordinated team-based ATLS approach to address immediate
life threats and identify other potential serious injuries
• Commence haemostatic resuscitation if appropriate
• Pelvic stabilization:
1. Avoid unnecessary movement of patient
2. Apply a pelvic binder early
3. Pelvic binder should be applied before intubation (if required),
as neuromuscular blockade may allow pelvic volume to expand
• Haemodynamically stable
 Apply a pelvic binder
 Perform an abdominopelvic CT with IV
contrast, +/- CT cystography to
identify abdominal and pelvic injuries
and allow prioritisation of
management
 A pelvic ‘blush’ indicates the need for
angiography and selective
emobilisation of the actively bleeding
artery
 Non-emergent surgical fixation as
require
• Haemodynamically unstable
 Commence hemostatic resuscitation
 Apply pelvic binder
 Perform bedside tests: AP pelvis, FAST,
DPA
 If pelvic fracture:
+FAST, or FAST – ,but DPA +
Then the patient requires emergency
laparotomy, during which pelvic
stabilization and/or pre-peritoneal pelvic
packing is performed pending definitive
management of the pelvic injury.
 Patient may be scanned once stable
• Isolated injuries are uncommon, usually associated injuries due to high
energy mechanism
• Approach
1. Commence hemostatic resuscitation
2. Apply a pelvic binder
3. Consult early (general surgery and orthopaedic surgery)
4. 3 Management options:
-Angiography with embolisation
-Packing (Pre-peritoneal vs direct retroperitoneal during laparotomy)
-Mechanical stabilisation by external fixation
-Definitive imaging and treatment of pelvic fractures can be performed
once the patient has stabilized following damage control resuscitation.
• Neurovascular observation
• Seek and treat complications
Acute Late
o Major haemorrhage and o Infection
shock o Fracture complications
o Visceral and soft tissue injury o Disability and immobility
o Nerve injury o Incontinence
o Ileus o Sexual dysfunction
o Fat emobolization o Dystocia following
o Acute respiratory distress subsequent pregnancy
syndrome
o Venous thromboembolism
o Abdominal compartment
syndrome