Pelvic Fractures

Pelvic fractures

Introduction :

Fractures of the pelvis account for less than 5% of all skeletal injuries, but it is important because it associated with:-
blood loss and shock.
Soft tissue injuries ( esp urogenital )
Sepsis.
ARDS.
Because of those mortality rate exceeds 10%.

Relevant anatomy :

BONES :
Pelvis formed of tow innominate bones
Attached to the sacrum posteriorly .
Each innominate bone formed from fusion of 3 bones ( pubis , ischium and ileum )

Pelvic ring :

Ligaments :

Anterior ligaments - Symphyseal ligaments (resist external rotation)
posterior sacroiliac complex (posterior tension band)
strongest ligaments in the body , more important than anterior structures for pelvic ring stability
– anterior sacroiliac ligaments
– interosseous sacroiliac lig
– posterior sacroiliac lig

Clinical assessment

History/mechanism of injury

• pelvic injuries usually caused by high energy mechanisms (Most commely MVA)

Anterior posterior compression – secondary force in an AP direction leading to diastasis of the symphysis pubis, with or without diastasis of the sacroiliac joint.
Lateral compression – lateral compression force, which cause rotation of the pelvis inwards, leading to fractures in the sacroiliac region and pubic rami.

Vertical shear – an axial shear force with disruption sacroiliac junction, combined with cephalic displacement of the fracture.
Combined mechanism – a combination of two of the above mechanisms , which leads to a pattern of pelvic fracture that is a combination of one or more of the above fracture types

Physical Examination ( ATLS )

Primary survey :-
Begins with the ABCs (airway, breathing, and circulation)
hemorrhagic shock is common with pelvic injuries
Secondary survey :-
PELVIC COMPRESSION/DISTRACTION test
Examination of perineum ( for hematoma or bleeding )
Rectal and vaginal examination.
Examination of lower limbs.


imaging
Plain radiography :
AP ,
inlet and outlet views
iliac oblique and obturator oblique views for acetabulum fracture assessment

CT SCAN :

CT is the modality of choice for accurately showing acetabular or pelvic ring fractures










Other investigations :
• BLOOD GROUPING AND CROSSMATCHING
• FAST ( for associated visceral injuries )• DIAGNOSTIC PERITONEAL LAVAGE ( for intraperitoneal bleeding )• CT ANGIO ( for persistant shock )
• RETROGRADE URETHROGRAM ( fro associated urethral injuries )

CLASSIFICATION of pelvic fractures

Young and Burgess Classification is the Most common classification used and Based on the mechanism of injury

Management

EARLY MANAGEMENt
should follow the ATLS protocol
primary survey ,
secondary survey
and definitive management


Definitive management :
non operative treatment :
Isolated non pelvic ring fractures
minimally displaced fractures
pubic diastasis of less than 2 cm

Treatment by bed rest, and may be combined with lower limb traction for 4–6 weeks

Operative :
Plevic binder can be used initially to control the intrapelvic hemorrhage .
External fixation : with pins in both iliac blades connected by an anterior bar.

Internal fixation by attaching a plate across the symphysis or for post sacroiliac fixation.

Complications :

Thromboembolism : deep vein thrombosis or pulmonary embolism. Prophylactic anticoagulants .
Neurological injury
Urogenital injuries
Persistent sacroiliac pain