Pelvic fracture

Clinical image

AP pelvic radiograph showing pubic symphysis diastasis. Source: Wikimedia Commons — Nevit Dilmen; CC BY-SA 3.0. Image binary is embedded locally in this package; original source and licence are retained.

Prehospital

• Stop bleeding
• TXA
• Binder
• Hyperfibrinolysis and coagulopathy of a/c trauma

Key points

Talking the talk

• Pelvis X-ray AP view shows an open book APC type III pelvic fracture. My initial concern is the potential
  • life threatening nature of the injury because of the increased incidence of vascular injury, abdominal and urogenital injuries associated
• I will follow the ATLS and BOAST 3 guidelines for the initial management.

Principles

• My principles of initial management after securing the airway , breathing and taking AMPLE history are
• To compensate for the blood loss by giving O neg blood in 1:1:1 ratio by activating MTP (based on the MOI, Physiological status of patient and identified injuries)
• To stop the bleeding by homeostatic resuscitation, permissive hypotension and DCS
• Prevent trauma triad of death (Hypothermia, coagulopathy and metabolic acidosis)
• Rule out open pelvic fracture and urologenetal injury

Prevent resuscitation ass coagulopthy

Trauma death triad

Compenstiong Haemorrhage

• MTP: Transfusion of total blood volume in 24 hours
• Early transfusion of warmed blood along with platelets and fresh frozen plasma in a 1:1:1 ratio
• ROTEM and Thromboelastogram: Helps in targeted blood product resuscitation for ongoing blood therapy, based on viscoelastic behaviour of blood clot.

Key points

Permissive hypotension

• SBP maintained at 90mmHg
• Balance between too much blood loss due to high pressure and tissue hypo perfusion due to low pressure

Haemostatic resuscitation

• Primary clot is the best clot and should be maintained for further consolidation of clot
• Pelvic binder applied at the level of GT with internal rotation of both hips and flexion of knees.
• IV Tranexamic acid 1gm given ideally <1hr at least with in 3 hours of injury as bolus followed by infusion over 8 hours (CRASH 2 trial reduce RR of death to .85)

Tranexamic Acid

• Antifibrinolytic
• Completely inhibits the conversion of plasminogen to plasmin thus preventing degradation of fibrin
• Civilian and military studies (CRASH 1 and 2, MATTERs) has demonstrated significant benefit when given with in 3 hours.

DCS

• Identify the source of bleeding
• Bleeding can be in the floor and 4 more: Chest, abdomen, pelvis and thigh.
• External bleeding controlled by direct compression
• FAST can identify free fluid in abdomen
• CT with IV contrast from head to mid thigh and a he’d to toe scanogram is taken based on patient status
• Selective embolisation of arterial bleed
• Visceral bleed: laparotomy or thoracotomy

3 different responses

• Responders: Pelvic binder protocol
  • Should not be left >24
  • Ex Fix if definitive Sx is delayed (+ reaction if Vertical shear)
  • Post binder xray (masking)
• Transient responders and Non responders:
  • Surgical packing of pelvis
  • Selective embolisation IR

DCO

• CR of dislocations
• Reduce and splint fractures
• Traction
• Ex Fix long bones
• Open fracture : Debride and ex fix

When to do DCO

• Aim is to prevent second hit phenomenon where the condition of patient worsens after a surgery
• Patients are categorised in to Stable, Borderline, Unstable and in extremis after initial resuscitation
• Tests for adequacy of resuscitation and perfusion
  • Stable harm-dynamics
  • No hypoxemia, hypercapnia
  • S.Lactate
    • <2mmol/l: ETC
    • 2-2.5: observe the trend,

    • 2.5:DCS

  • normal coagulation
  • normothermia
  • normal renal function >1ml/kg/hr

Associated injuries

• Potential injury to bladder and urethra: Follow BOAST 14 guideline
• Potential anorectal injury

Open pelvic fracture

• Urgent assessment by the General surgeon to rule out potential anorectal injury
• Such injury require construction of de functioning stoma.

Urological injury

• Urological trauma is rare and the incidence of severe urethral trauma is 1/million population/year.
• The majority of cases are due to blunt high-energy trauma with associated multi-system injuries and 80% of these cases are associated with pelvic fractures.
• Urological injuries are potentially fatal and can result in severe long-term disability.

Management principles

• Initial
• Theatre
• post operative

Initial

• All high energy injury patients mush have exam of perineum , genitalia and rectum
• Single gentle attempt at catheterisation with 16F soft silicon catheter by an experienced doctor
• Blood stain urine, do retrograde cystogram
• Catheter does not pass/ drains only blood: do not inflate, withdraw and do Retrograde urethrogram
• Inform urologist/paediatric urologist
• Percut, suprapubic catheter by seldinger technique with skin incision in midline 3-4 fingers above symphysis
• Pelvic fracture is treated as open if urine leaks (IV ABx and early surgery)

Retrograde Urethrogram:

- Usually in Resuscitation room.
- X-ray plate under pelvis.
- 20 ml dilute IV contrast medium (10 ml contrast + 10 ml saline).
- Balloon of small Foley catheter into penile meatus and gently inflated.
- Hold catheter in place and inject contrast.
- AP Pelvis x-ray taken. Additional lateral if possible.

Catheter Cystogram:

  - • Usually in Resuscitation room.
- X-ray plate under pelvis.
- 300ml dilute IV contrast medium (150 ml contrast + 150 ml saline).
- Push catheter in a further 2-3 cm so balloon not blocking bladder neck.
- nject contrast down catheter with bladder syringe and clamp catheter.
- AP Pelvis x-ray taken. Additional lateral if possible.
- Evacuate contrast and repeat AP Pelvis x-ray.

Theatre

• Intraperitoneal bladder rupture: emergency laparotomy and direct repair
• Extraperetoneal bladder
  • Stable pelvis: catheter only
  • unstable: fix fracture and repair bladder
  • Identified during pelvic sx: repair
• Urethras injury
  • Children and female: supra regional urologist discussion
  • Primary repair: with anorectal inj, perennial devolving, bladder neck inj, massive bladder displacement, penetration of anterior urethra
  • Male: delayed repair 3 months

Post operative

• Communicate high incidence of urinary and sexual dysfunction
• Linked andrological service
• TRAN and audit

Definitive treatment Pelvis

• Referred to specialist centre with in 24 hours
• Reconstruction with in 72 hours
• Thrombo prophylaxis
• Follow up for Functional recovery
• Written advice on sexual disfunction

Definitive treatment

• Investigations:
  • inlet and outlet view
  • CT
  • Classification: Young and burgess
    • A: LC Rami #
      • • sacral ala #
      • • post ilium #
      • 11 with C/L posterior injury
    • B: APC
      • APC1: <2.5 cm pubic widening
      • APC 11: >2.5 cm (post lig intact)
      • APC111: anterior and post big gone. High vascular injury
    • C: VS

Treatment

• Non surgical: Undisplaced #/Patient too ill for surgery
• Operative :
  • Plate fixation of Pubic diasthesis va a pfannensteil incision. Use ilioinguinal/stoppa approach if associated rami # present
  • If soft tissues are precluding / anterior comminution is present anterior internal fixation (INFIX) using supraacetabular pedicle screws connected by subcut connecting rods.
  • Sacroiliac disruption: ORIF/Posterior trans iliac rods/ percuta screw fixation

Complications

• Chronic pain
• Mental health issue
• pelvic obliquity
• LLD
• Abnormal gait
• Urogenital and sexual dysfunction
• Nerve injury(VS #)
• Morel Lavalle
• DVT, Non and Man unions

Ilioinguinal Approach

• Patient is fully prepared, marked and consented for the surgery, case notes and relevant imaging are made available in the theatre. WHO check list is done.
• I will seek the help of a general surgeon as dissection involve isolating femoral vessels/nerves and spermatic cord.

Ilioinguinal

• Position: Supine on arms abducted on a radiolucent table
• Landmarks: ASIS, Pubic tubercle
• Incision: Line starting over I crest, 5cms above ASIS to around 1cm above pubic tubercle
• Internervous plane: NONE
• Superficial dissection: involve aponeurosis of EO and rectus sheath. Spermatic cord/round log to be isolate
• Deep: Divide RA, IO, and TA. Sling is passed around femoral vessels and Psoas, creating 3 windows

# windows

• Medial b/w Vessels and Sy Pubis
• Middle b/w vessels and iliopsoas
• Lateral: Lateral to iliopsoas
• Can be extended proximally and posteriorly to expose SIJ

Structures at risk

• LCNT
• Sp cord
• Obturator vessels and nerves
• inf epigastric vessels
• Urinary bladder
• Sacral nerve roots

Stoppa

• Position: Supine with hip and knee slightly flexed
• Landmark: Pubic sy and ASIS
• IN plane: NONE
• Superficial: RA split vertically
• Deep:Sub periosteal dissection in to quadrilateral plate
• Corona mortis: b/w O.a and F.a is ligated

ISS

• 6 predefined areas
• score in each areas range from 1 to 6
• 3 highest scoring areas selected, squared and added
• Max score is 75
• Any 6 score automatically make the total score 75
• predicts survival