Methas Arunnart MD.

HIGH ENERGY IMPACT

 Falls
 High speed VA
 Crush injury
Management strategy of vascular injuries associated with pelvic fractures. J Cardiovasc Surg
33:349, 1992; Prorities in Management. Arch surg 124:422, 1989; Effective classification
 1 SACRAL Bone
 2 INNOMINATE bones
 PUBIS
 ILIUM
 ISCHIUM

 Symphysis gap <5 mm

 No inherent stability—Ligaments give stability
 Anterior SIL resist external rotation
 Sacrospinous - resists external rotation
 Posterior SIL and ILL - provide posterior
stability by tension band , strongest in body
 Sacrotuberous - resists shear/flexion SI joint
 Sacral venous plexus*
 Iliolumbar a.
 Internal iliac a.
 Superior gluteal a.*
 Lateral sacral a.
 Pudendal a.*
 Bladder/Urethra
 Rectum
 Prostate
 Vagina
 AP pelvis during early phase of resuscitation is
useful to determine presence or absence of
unstable pelvic fracture
 AP pelvis can identify 90% of pelvic injuries
 Inlet View – 45 degree caudal tilt
 True AP projection of the pelvic brim
 Evaluates for posterior displacement
 Evaluates for rotation of ilium and sacral impaction
injuries
 Outlet View – 45 degree cephalad tilt
 Evaluates for vertical shift of pelvis
 provides a better demonstration of sacral fractures
and injuries to the sacroiliac joints.
 CT Scan
 Best visualization for Sacrum and SI joint
 Rotational and posterior displacement can
be easily assessed
 Type A: pelvic ring stable
 Type B: rotationally unstable, vertical stable
 Type C: rotationally and vertically unstable

Advantages: Tile classification aids in

the determination of prognosis
 Lateral compression (LC)
 Anteroposterior compression (APC)
 Vertical shear (VS)
 Combined mechanism (CM)

Advantages: this classification alerts the surgeon to

potential resuscitation requirements and
associated injury patterns
 Airway Maintenance with C-spine protection
 Breathing and Ventilation
 Circulation with hemorrhage control
 Disability: Neurologic status
 Exposure/Environment Control: Undress
patient but prevent hypothermia
 Neurologic deficit involving lumbosacral plexus
 Pelvic/flank/perineal
contusions,ecchymoses,abrasions
 Blood at urethral meatus
 Blood in or around rectum
 Open wound of groin,buttock, or preineum
 Leg length inequality or external rotation of one
extremity
 Abnormal pelvic motion on AP or lateral
compression of anterior iliac spines and iliac crests
 Rectal exam for tone
 Bulbocavernosus reflex

 Myotomes of lower extremity

 L1-2 : hip flexor
 L3-4 : Quadriceps/knee extension
 L4-5 : Ankle and toe dorsiflexion
 S1 : ankle plantarflexion
 S2-3 : toe plantarflexion
 Sheet around pelvis Pelvic binder
 Return blood from lower ext. to central vascular system
 Ability to close open-book-type injury, reducing pelvic
volume
 Stabilize pelvic ring permitting clot formation
 Advantage
 Useful in assessing and embolization of arterial
injury - Unexplained blood loss after stabilization and aggressive
resuscitation , Pulseless extremity

 Disadvantage:
 Source of arterial bleeding is identified in only 10-
15% of patients with severe pelvic disruption
 Does not address venous bleeding
 Primary survey

stable unstable
No Fx Pelvic Fx
No Fx Pelvic Fx
CT,FAST,DPL CT,FAST,DPL
APC LC classify Fx
CT scan Reassess Explor lap. others Open book

SI jonit involvement- Reassess

consider iliac injury
- External compression
- Explor lap. +/- packing
- Angiography vs ext. fixation
 Lateral compression (LC)
 Anteroposterior compression (APC)
 Vertical shear (VS)
 Combined mechanism (CM)

Advantages: this classification alerts the surgeon to

potential resuscitation requirements and
associated injury patterns
 LC type I:
unilateral rami fx . (transverse)
& ipsilat sacral compression.

 LC type II:
 unilateral rami fx.
& ipsilat post. iliac fx.

 LC type III:
 LC I/II & contralat. APC
 APC type I:
 symphysis widened < 2cm;
SI joint intact

 APC type II:

symphysis widened >2cm or rami fx
& ant. SI lig. Torn

 APC type II:

symphysis widened >2cm or rami fx
& ant & post SI lig. torn
 Vertical shear (VS)
 Vertical displacement

 Combined Mechanical(CM)
 Combination of LC + VS or APC
 15-20% of pelvic fractures
 Extraperitoneal vs Intraperitoneal
 clinical
 Scrotal/labial swelling
 Gross hematuria
 Retrograde Urethrogram
 Occurs in less than 1%
 Clinical
 Laceration of rectum or perforation of small and/or
large bowel
 Rectal tears accompany perineal wounds
 Requires diverting colostomy in 6-8hr
following injury to reduce incidence of sepsis
and death
 Laceration of the vagina
 Results from dislocation or fractures of the
pubic rami
 may require operative intervention