Edinburgh Trauma Instructional Course by mikesanye


     Acute Management of Pelvic Fractures

                                                                  • What’s so special about
                                                                    pelvic fractures

                                                                  • Principles of early
                  P V Giannoudis                                    management

               Professor & Chairman
                                                                  • Conclusion
  Academic Department of Orthopaedic & Trauma Surgery
                 University of Leeds, UK

                   Objectives                                     What is so special about pelvic fractures?
                                                                             1. High Energy Trauma
• What’s so special about
                                                                   RTA, Falls, Crush Injuries
  pelvic fractures

• Principles of early                                              Usually seen in the spectrum of
  management                                                       polytrauma

• Conclusion

                                                                  What is so special about pelvic fractures?
What is so special about pelvic fractures?
                                                                            3. Close proximity big major vessels
           2. Associated injuries                                                 Increased risk of bleeding
    Pelvic Fractures – Associated injuries
       Chest trauma                     21.2%
       Head Injury                      14.1%
       Liver / spleen lacerations       8%
       Two or more long bone #s         7.6%
       Urethra/ bladder injury          3.9%                                  -Arterial             SGA, OA, IPA
                                                                              -Low Pressure of venus plexus
       Spinal Fractures                 2.7%
                            Giannoudis et al. J Trauma 2007                  -Cancellous bone edges, fracture site

              Pelvic Fracture Bleeding            What is so special about pelvic fractures?
                 Where does it go ?
                                                          4. Increased mortality rates
 1.Pelvic volume
   minimal in true pelvis

 2.It goes up the chimney !
    retroperitonieum open

 3.Into the thighs
   the pelvic floor is ripped

                                                             Danger from hemodynamic
                                                            instability and injury severity

                                                  What is so special about pelvic fractures?
                                                            5. Think of injuries to other
                                                            intrapelvic/abdominal / organs

                                                        Bowel                    Urinary Bladder

What is so special about pelvic fractures?        What is so special about pelvic fractures?
            6. Require emergency management                        Summary
                                                  • High Energy Trauma
                                                  • Associated injuries
                                                  • Close proximity big major vessels- Increased
                                                    risk of bleeding
                                                  • Increased mortality rates
                                                  • Think of injuries to other
                                                    intrapelvic/abdominal / organs
                                                  • Require emergency management

                                                  Principles of Early Management

• What’s so special about                            - Part of the resuscitation process
  pelvic fractures                                   - Restoration of haemodynamic stability

• Principles of early

                                             Increased Risk of Mortality !
• Conclusion

Initial Assessment of Pelvic Fractures       Initial Assessment of Pelvic Fractures

        ATLS® principles                           ATLS® principles
     A irway + Cervical Spine
                                              C irculation: volume therapy
             B reathing

Initial Assessment of Pelvic Fractures                       Critical Decision Making:
              Source of Bleeding ?                                  Is the Blood?
        ATLS® principles
                                             In the chest?      In the belly?   On the floor?   Around pelvis?
    C irculation: search for the

   Management of Pelvic Fractures                Haemorrhage control

                                                 Pelvic fracture
          “Stop the Bleeding”
                                                 “the first clot is the best clot”

Haemorrhage control

Pelvic fracture

        Immobilise patient
                  - protect spine & pelvis

        Do not log roll
                  - until pelvis “cleared”

    Haemorrhage control

    Pelvic fracture

            Shock - do not test for stability
                      - protect the clot

            Early xray

Haemorrhage control                             Haemorrhage control

Pelvic fracture                                  Pelvic fracture

         Immediate blood transfusion                        Prevent hypothermia

         FFP, cryo & platelets early                        Prevent acidosis
          - protect the clot
         Factor VIIa

Haemorrhage control                             Pelvic Fracture Bleeding Control

Pelvic fracture                                 A. Indirect
                                                    -Volume replacement
         Immediate Orthopaedic referral
                                                       -tie legs together/ sheeting
                                                       -belts & bean bags
         Splint pelvis                                 -avoid all unnecessary movement
          - protect the clot
                                                    -External fixation

  Bleeding Control – C-Clamp                     Pelvic Fracture Bleeding Control
   exclusion fracture os ilium (X-ray AP)
                                                B. Direct
   point of insertion like SI-screws
   direct compression posterior ring
                                                  -Laparotomy + packing
                                                    (stabilised skeleton)

                                                  -Ligation of vessels


     Role of Pelvic Packing in Severe                                 Pelvic Fracture Bleeding Control
                   Pelvic Ring Injury ?
                                                                               Pelvic Sling
                                                                               External Fixation
                                                 Extremis                      Pelvic C clamp
                                                                               Internal Fixation
                                                                               Pelvic packing
                                                                               Direct Bleeding control
                                                                               Ligation of hypogastric artery
                                                                               Temporary aortic occlusion

          Indications of Angiography                                                          Objectives
   Patients who have been stabilized with volume
replacement but ongoing haemorrhage is suspected;                     • What’s so special about
(1-2 units PRBC transfusion per hour)                                   pelvic fractures

   Patients where intraoperative hemorrhage can not                   • Principles of early
be controlled (Packing–Resuscitation–Angiography)                       management

   Patients who have developed pseudoaneurysms
                                                                      • Conclusion

                                                                                 Management of Pelvic Fractures
 Acute Treatment: Shock Management                                                     Clinical Condition of Patient

                                                                      Stable       Borderline                Unstable         In extremis
                     Pelvic bleeding                                                                                    OR
    Endorotation legs (open book)                                               Cause of haemorrhage              Ex-fix/C-clamp
    Pelvic sling                    fracture bleeding                            (chest abdomen)?                       Packing
    C-clamp (complete unstable)

    external fixation (open book)   fracture bleeding   85-90%       OR          Re-evaluation                          DCO
    ORIF anterior ring                                                          2nd FAST
    peripelvic packing              venous bleeding                                                              If continuously unstable:
                                                                                 Stable OR Uncertain/OR Extrapelvic bleeding sources ?
    selective embolisation                                                                 Ex –Fix C-clamp
                                    arterial bleeding
    surgical haemostasis                                                                                          Pelvic haemorrhage
                                                                      ORIF         ORIF         DCO            Yes                 No
                                        10-15%                                                                Angiography Repacking /ITU


Mortality secondary to associated injuries and bleeding

Initial assessment as per ATLS protocol
                                                              THANK YOU
Exclude other sources of bleeding

Do not let anyone die as a result of haemorrhage


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