Initial Management of Pelvic Fractures

Courtesy: Prof Joseph Queally, MD, FRCS Tr and Orth, M Ed
Dublin, Ireland

PELVIC FRACTURES – MANAGEMENT

AIMS

PREVENT MORTALITY
– hemorrhage control
PREVENT MORBIDITY
– early recognition/management of soft tissue, urological, neurological injuries

Mortality

5% mortality rate in pelvic fractures

Predictors of Mortality:

Older patient-Age > 60
SBP < 90mmHg on arrival
Severely displaced fractures (posterior displacement, APC III)
4 unit RCC transfusion
50% of severe pelvic fractures have bleeding source than pelvic Fracture

CLOSE –FILL- FIND

Provide Initial Pelvic Stability using a BINDER (Immediate when pelvic injury Suspected)
Fill with Blood (Tranexamic Acid, Transfusion)

EXTERNAL FIXATOR

(rarely required… open book Or post laparotomy/packing)

TRACTION

very rarely required… Vertical shear injury

C Clamp
(almost never required..
Unstable posterior injury)

BINDER

LIFE SAVING DEVICE
Stabilises pelvis via Circumferential Compression and Tamponade effect
Reduces pelvic volume
Apply at level of GT NOT ILIAC WING
Use Binder or simple sheet
Consider internal rotating lower limbs and tie sheet around Knees

BINDER CARE

LEAVE IN PLACE UNTIL PATIENT STABLE (haemodynamically)
TRY TO REMOVE AFTER 6 HOURS, monitor BP/HR, if still unstable replace
OK TO LEAVE ON IF STILL HEMODYNAMICALLY UNSTABLE BUT MUST CARRY OUT SKIN CARE
Do not over-compress
Check (loosen slightly to access pressure areas)
Every 6 hours pad pressure points

EXTERNAL FIXATION (RARELY REQUIRED, as pelvic binder achieves same function)

Indications :

Unstable pelvis (some open books.. unstable with binder)
Post laparotomy/packing
Open fractures

How to apply :

Iliac wing or Supracetabular Pins

Iliac Wing

Easier/quicker
Less Control

Supra-acetabular(through the SupraAcetabular Corridor: AIIS to Sciatic Buttress)

Need imaging
Better control (posterior pelvis) and stability
technically demanding, with higher rater of complications
ENSURE POSITION ALLOWS PATIENT TO BE NURSED/SIT

C Clamp

WHEN: NEVER/ALMOST NEVER

Severe posterior injuries
Dislocated Sl joint/vertical shear that remains unstable despite binder and Resuscitation

Advantages :

Good posterior stability

Disadvantages : Not easy

Need imaging
Complication risk

Pelvic Haemorrhage

80% presacral venous plexus
20% arterial (internal iliac SGA, obturator artery, obturator)

EMBOLISATION

85- 90 % effective in controlling pelvic fracture related Haemorrhage
Works well for arterial bleeding, not so well for venous bleeding
10% of all pelvic fractures require embolization
Rapid embolization… Within 3 hours of arrival (36.4% v 75% mortality)

PELVIC PACKING

Last resort…. Very rarely required

WHEN:

Patients with arterial bleeding who are unstable despite binder, and embolization
Unstable venous bleeding not amenable to angiography
Exsanguinating bleeding/non responders who have damage control laparotomy

HOW:

Stoppa approach
Laparotomy

SKIN

Always check for OPEN FRACTUREs
MUST INSPECT SKIN AREA CIRCUMFERENTIALLY INCLUDING PERINEUM
Check for Rectal injury (PR bleeding), Vaginal injury (PV bleeding), Scrotal injury
DO NOT MISS OPEN FRACTURE….. mortality up to 50%
Give IV antibiotics, tetanus etc, early debridement

MOREL LAVELLE LESION

Degloving injury where skin + subcutaneous tissue separates from fascia
easy to miss as often closed injury
significant morbidity + infection risk if missed
bruising + fluctuance
Smaller lesions can be managed conservatively
larger need debridement, vac dressing + drain, OrthoPlastic Approach

UROLOGICAL INJURY

Any suspicion of urological injury (blood at meatus, high riding Prostate, haematuria) call urology and arrange imaging

ATTEMPT SINGLE PASS OF CATHETER (16Fr)…

If successful and suspicious of injury, imaging required :
Retrograde cystogram
CT cystogram (gold standard)
If unsuccessful, perform retrograde urethrogram using catheter tip
With balloon and call urology team to place suprapubic catheter
(out of zone of Stoppa incision) via US technique

Retrograde urethrogram/