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Managementul de

urgenta in
leziunea inelului
pelvin

Sean E. Nork, MD
Harborview Medical Center, Seattle, Washington

Original Author: Kyle F. Dickson, MD; Created March 2004


New Author: Sean E. Nork, MD; Revised January 2007
Rezultatul leziunii inelului pelvin

Energie înaltă

Morbiditate/Mortalitate

Hemoragie

Volumul cilindrului: 4/3π r2 h ???


Cel mai bine estimat de sfera semi-eleptica
(Stover et al, J Trauma, 2006)
Generalitati

Mecanismul - de obicei traumă cu energie mare


• Rata mortalității 15-25 % pentru fracturi inchise ,
si mai mult de 50 % pentru fracturi deschise
Hemoragiea este principala cauza de deces
Cresterea mortalitătii este asociata cu
 presiunea sistolică < 90 la internare
 varsta > 60 de ani
 cres
șterea scorului de severitate a prejudiciului ( ISS )
sau Scor Trauma revizuit ( RTS )
 nevoia de transfuzie > 4 unități
leziuni asociate

o leziuni toracale - în până la 63 %


o fracturi de oase lungi - în 50 %
o cap și leziuni abdominale la 40 %
o coloanei vertebrale fracturi la 25 %
o leziuni urogenitale în 12-20 %
Prognoză

o prevalenta inalta a rezultatelor funcționale slabe și


durere cronica
o rezultatele slabe sunt asociate cu
 incongruenta SI de > 1 cm
 grad ridicat de deplasare inițială
 Calusul vicios sau deplasare rezidual
 discrepanță de lungime > 2 cm
 pseudartroze
 leziuni neurologice
 leziuni uretrale
Fracturi pelviene la copii

Copiii cu cartilaj triradiat deschis vor avea


diferite modele de fractura decat copiii ale caror
cartilaj triradiat a fuzionat
 în cazul în care cartilajul triradiat este deschis
aripa iliacă este mai slab decât ligamentele
pelvine elastice , rezultând în eșec os înainte de
întrerupere inel pelvin
 Din acest motiv, fracturi implica , de obicei, Rami
pubian și aripi iliace și rareori necesita tratament
chirurgical
anatomie

• Osteologie
Structură de inel format din sacrum și două oase
nenumite
Stabilitatea depinde de structurile ligamentare
puternice din jur
Deplasarea poate avea loc doar cu întreruperea
inelului în două locuri
Structurile neurovasculare sunt intim legate cu
ligamentele pelvine posterioare
 indice ridicat de suspiciune de leziune a vaselor
iliace interne sau plexului lumbosacral
Ligamentele

o anterior
 ligamentele symphyseal
 rezista rotație externă
o podea pelvin
 ligamentele sacrospinous
 rezista rotație externă
 ligamentele sacrotuberous
 rezista forfecare și de flexie
o complexă sacroiliace posterior ( banda de tensiune posterior )
 puternice ligamentele din organism
 mai important decât structurile anterioare de stabilitate inel pelvin
 ligamentele sacroiliace anterioare
 rezista rotație externă , ​după eșecul de planseului pelvin și structurile anterioare
 sacroiliace interosoasa
 rezista traducere antero- posterior al pelvisului
 sacroiliace posterior
 rezista deplasare cephalad - caudad de pelvis
 iliolombar
 rezista rotație și spori ligamentele SI posterioare
complexul sacroiliac posterior ( banda de
tensiune posterioara )

 Dintre cele mai puternice ligamentele din organism


 mai important decât structurile anterioare de stabilitate
inel pelvin
 ligamentele sacroiliace anterioare
 rezista rotație externă , ​după eșecul de planseului pelvin și
structurile anterioare
 sacroiliace interosoasa
 rezista traducere antero- posterior al pelvisului
 sacroiliace posterior
 rezista deplasare cephalad - caudad de pelvis
 iliolombar
 rezista rotație și spori ligamentele SI posterioare
Evaluarea primară: ABC

Airway maintenance with cervical spine protection


Întreţinerea căilor respiratorii cu protecţia coloanei cervicale
Breathing and ventilation
Respiraţie şi ventilaţie
Circulation with hemorrhage control
Hemodinamica cu controlul hemoragie
Disability: Neurologic status
Dizabiliatea: statut neurologic
Exposure/environment control: undress patient but prevent
hypothemia
Control la expunere/mediu: pacientul se dezbracă, dar a preveni
hipotermia
Consideraţie pentru transfer: Fracturi
pelvine şi acetabulare
Instabilitate / deplasare
Iniţial radiografie anteroposterioară
Leziunea vezicii biliare / uretrei
Fracturi pelvine deschise
Forţă laterală dirijată cu fracturi prin aripa iliac, ala sacrală sau
foramina Cartea deschisă cu deplasare anterioară> 2,5 cm
Fracturi acetabulare
> 1 mm articulare trece în orice caz
Lipsa de paralelism a capului femural și acoperiș
Deplasarea de perete sau coloană
Acetabular fractures
> 1 mm articular step off on any view
Lack of parallelism of femoral head and roof
Displacement of wall or column
Physical Exam

Degloving injuries

Limb shortening

Limb rotation

Open wounds

Swelling & hematoma


Cum determinăm stabilitatea pelvină???

Radiografic

Hemodinamic

Biomecanic (Tile & Hearn)

Mecanic

“Able to withstand normal


physiological forces without
abnormal deformation”
Stabil sau instabil?

Un singur examinator
R-TV dacă este posibil
Cele mai experimentate mîini
Semnele radiologice ale instabilităţii

Disjuncţia sacroiliacă de 5 mm în orice plan

Prezenţa diastazei posterioare (mai frecvent decît


impactarea)

Avulsia procesului transvers la L5, mărginii


laterale a sacrului (lig. Sacrotuberal) sau spinei
ischiadice (lig. Sacrospinos)
Fracturile pelvine deschise

Open wounds extending to the colon, rectum, or


perineum: strongly consider early diverting
colostomy

Soft-tissue wounds should be aggressively debrided

Early repair of vaginal lacerations to minimize


subsequent pelvic abscess
Urologic Injuries

15% incidence

Blood at meatus or high riding prostate

Eventual swelling of scrotum and labia (occasional


arterial bleeder requiring surgery)

Retrograde urethrogram indicated in pelvic injured


patients
Urologic Injuries

Intraperitoneal & extraperitoneal bladder ruptures are


usually repaired

A foley catheter is preferred

If a supra-pubic catheter it used, it should be tunneled to


prevent anterior wound contamination

Urethral injuries are usually repaired on a delayed basis


Sursele de hemoragie

Externe (leziunile deschise)

Interne: Torace
Oasele lungi
Abdomenul
Retroperitoneal
Sursele de hemoragie

Externe (leziunile deschise)

Interne: Torace R-grafia toracelui


Oasele lungi Edem, exam fizică
Abdomenul LPD, USG, Lap-Centeză
Retroperitoneal CT scan, Laparoscopie
Shock vs Hemodynamic Instability

Definitions Confusing
Potentially based on multiple factors & measures

Lactate
Base Deficit
SBP < 90 mmHg
Ongoing drop in Hct
Response to fluid challenge
Pelvic Fractures & Hemorrhage
Fracture pattern associated with risk of vascular injury
(Young & Burgess)

ER & VS > IR
APC & VS at increased risk

Injury patterns that are tensile to N-V structures


Iliac wing fractures with GSN extension

Dalal et al, JT, 1989


Burgess et al, JT, 1990
Whitbeck et al, JOT, 1997
Switzer et al, JOT, 2000
Eastridge et al, JT, 2002
Pelvic Fractures & Hemorrhage

ER & VS > IR
APC & VS at increased risk
Controlul hemoragiei
Mneţinerea bazinului
Sheet (cearşaf)
Centură plevină
(Pelvic Binder)
Fixator extern

Angiografia

Laparotomia

Pelvic Packing
(Tamponaj)
Circumferential Sheeting

Decubit dorsal 2

2 “cearşăfari” 1

Trohanter=Gîtul mîinii

Aplicarea şi tensionarea

“Fixarea”

(30 secunde) 4 3

Routt et al, JOT, 2002


Aplicarea cearşafului
Aplicarea cearşafului
Pelvic Binders
Fixarea externă

Localizare Aplicarea clinică

SIAI Resuscitative

SIAS Augmentative

C-clamp Definitive
Biomecanica fixării externe

Open book injuries with posterior ligaments (hinge)


intact:

All designs work

C-type injury patterns

No designs work
Biomechanics of External Fixation

Pin size
Number of pins
Frame design
Biomechanics: Pin Location

AIIS:
Biomechanically
equivalent
(superior?)

Patients can sit

Kim et al, CORR, 1999


ASIS Frames

AIIS:
Biomechanically
equivalent
(superior?)

Patients can sit

Kim et al, CORR, 1999


AIIS Frames

AIIS:
Biomechanically
equivalent
(superior?)

Patients can sit

Kim et al, CORR, 1999


AIIS Frames

AIIS:
Biomechanically
equivalent
(superior?)

Patients can sit

Kim et al, CORR, 1999


Indications for External Fixation

Resuscitative (hemorrhage control,


stability)

To decrease pain in
polytraumatized patients?

As an adjunct to ORIF

Definitive treatment (Rare!)


Distraction frame
Can’t ORIF the pelvis
Indications for External Fixation

Resuscitative (hemorrhage control,


stability)

To decrease pain in
polytraumatized patients?

As an adjunct to ORIF

Definitive treatment (Rare!)


Distraction frame
Can’t ORIF the pelvis
Indications for External Fixation

Resuscitative (hemorrhage control,


stability)

To decrease pain in
polytraumatized patients?

As an adjunct to ORIF

Definitive treatment (Rare!)


Distraction frame
Can’t ORIF the pelvis
Indications for External Fixation

Resuscitative (hemorrhage control,


stability)

To decrease pain in
polytraumatized patients?

As an adjunct to ORIF

Definitive treatment (Rare!)


Distraction frame
Can’t ORIF the pelvis
Technical Details: ASIS & AIIS Frames
Pin Orientation
Pin Orientation
Pin Orientation
Technical Details: ASIS Frames…

Fluoro dependent
3 to 5 cm posterior to the ASIS
Incisions directed toward the
anticipated final location
1/3 from the medial aspect
(lateral overhang)

Aim: 30 to 45 degrees (from


lateral to medial)
Toward the hip joint

Consider partial closed reduction first!


Outlet Oblique Image

Inner Table

Outer Table

ASIS
Outlet Oblique Image

Inner Table

Outer Table

ASIS
Check Pin Placement
Technical Details: AIIS frames…

Fluoro dependent:
30/30 outlet/obturator oblique
Iliac oblique
Inlet/obturator oblique
Incisions directed toward the
anticipated final location
Blunt dissection

Aim: According to fluoro

Consider partial closed reduction first!


Outlet Obturator Oblique Image

Outlet Obturator Oblique Image


5 degrees too much obturator 5 degrees too little obturator

5 degrees too much outlet 5 degrees too little outlet


5 degrees too much obturator 5 degrees too little obturator

5 degrees too much outlet 5 degrees too little outlet


Iliac Oblique Image
Inlet Obturator Oblique Image
Outlet Obturator Oblique Image
Pin Orientation

Inlet (with obturator oblique)


Pin Orientation

Inlet (with obturator oblique)


Anti-shock Clamp (C-clamp)

Better posterior pelvis


stabilization

Allows abdominal access

Apply in fluoro/OR?

Combined with packing?

Ertel, W et al, JOT, 2001


Anti-shock Clamp (C-clamp)

Better posterior pelvis


stabilization

Allows abdominal access

Apply in fluoro/OR?

Combined with packing

Ertel, W et al, JOT, 2001


Anti-shock Clamp (C-clamp)

Better posterior pelvis


stabilization

Allows abdominal access

Apply in fluoro/OR?

Combined with packing

Ertel, W et al, JOT, 2001


Emergent Application
C-clamp: Anatomical Landmarks

Same (similar location) as the starting


point for an iliosacral screw
Pin Location

“Groove” located on the lateral ilium as


the wing becomes the posterior pelvis

Allows for maximum compression

Near IS screw entry point


Can be identified without fluoro in
experienced hands

Pohlemann et al, JOT, 2004


Caution…

Avoid Overcompression in Sacral Fxs!


Pelvic Packing

Ertel, W et al, JOT, 2001


Pohlemann et al, Giannoudis et al,
Role of Angiography???

Arterial only

5-15%

Timing

Institution dependent
Role of Angiography???

Fracture Pattern!

Contrast CT suggests

Effective in retrospective
studies!!!
Vascular Injuries
Arterial vs Venous vs
Cancellous

Unstable posterior ring


association

Associated fracture extension


into notch

Role of angiography
Cryer et al, JT, 1988
O’Neill et al, CORR, 1996
Goldstein et al, JT, 1994
Acute Hemipelvectomy….
Acute Hemipelvectomy….
Acute Hemipelvectomy….
Retrospective Evidence Suggests…
Hypotensive with stable pelvic pattern…
Laparotomy (85% with abdominal hemorrhage)

Hypotensive with unstable pelvic pattern…


Angio (59% with positive angio)
Eastridge et al, JT, 2002

Contrast enhanced CT very suggestive


(40 fold likelihood ratio)
(PPV and NPV of 80%, 98%)
Stephen et al, JT, 1999
Protocol for Management
Hypovolemic shock and no response to fluids…
(+) DPL: 1. Laparotomy (+/- packing with ex fix)
2. Angio
(-) DPL: 1. Sheet/binder/ex-fix (some still crash lap)
2. Angio

Hypovolemic shock with response to fluids…


(++) DPL: 1. Laparotomy (+/- packing with ex fix)
2. Ex Fix
3. Angio
(+) DPL: 1. Ex Fix
2. Laparotomy
3. Angio
(-) DPL: 1. Sheet/binder
2. Angio
3. Ex Fix
Protocol for Management
Protocol for Management
Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001

5 elements: Immediate trauma surgeon availability (+ Ortho!)


Immediate trauma surgeon availability (+ Ortho!)
Early simultaneous blood and coagulation products
Prompt diagnosis & treatment of life threatening injuries
Stabilization of the pelvic girdle
Timely pelvic angiography and embolization

Changes: Patients more severely injured (52% vs 35% SBP < 90)
DPL phased out for U/S
Pelvic binders and C-clamps replaced traditional ex fix
Protocol for Management
Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001

Mortality decreased from 31% to 15%


Exsanguination death from 9% to 1%
MOF from 12% to 1%
Death (<24 hours) from 16% to 5%

The evolution of a multidisciplinary clinical pathway, coordinating the resources


of a level 1 trauma center and directed by joint decision making between
trauma surgeons and orthopedic traumatologists, has resulted in improved
patient survival. The primary benefits appear to be in reducing early deaths
from exsanguination and late deaths from multiple organ failure.
Immediate Percutaneous Fixation

From Chip Routt, MD


Summary: Acute Management

Play well with others (general surgery, urology,


interventional radiology, neurosurgery)

Understand the fracture pattern

Do something (sheet, binder, ex fix, c-clamp)

Combine knowledge of the fracture, the patients condition,


and the physical exam to decide on the next step
Thank You
Sean E. Nork, MD
Harborview Medical Center, University of Washington

HMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar, Hanel,
Hanson, Henley, Mirza, Routt, Sangeorzan, Smith, Taitsman

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