Update on the Early Mana

gement of
the Fractured Pelvis

Nur Rachmat Lubis,

Why this is such a problem
90% will have other injuries
index for intraabdominal injury
(9-11%)
index for bladder injury (4-6%)
index for renal injury (1-2%)
index for urethral injury (2-3%)
other: TBI, chest, aorta
 Introduction
Pelvic fracture account for 3% of all fracture
60% from traffic accident
30% from falls
10% from crush injuries, athletic injuries
 Pelvis Anatomy

Three bones;stabilized by ligamentous network

Symphysis pubis
 Pelvic fx-focus on 4 topics!
Hemorrhage - Life threatening
Genitourinary injury (GU)
Deformity- orthopedics
Neurologic injury
Class 1 fracture: Hemorrhage!!
Meeting Cryers criterion :
-correlation between hemorrhage and
displacement > 5mm
Open-book injury(A)
- pubic symphysis separation
Sprung injury(C)
- pubic symphysis + SI joint
separation
Open pelvic fracture
- penetrating to skin,bowel..
Class 2 fracture: GU complication
Straddle fracture----
-direct force to pubis
-all 4 rami fracture:
bladder rupture, urinary
tear,hematuria..

Malgaignes fractrue
-vertical shearing force
-usually falls
Class 2 fx:GU complication(continue
d)
Bucket Handle Fracture--
-lateral compressive force with an
upward rotation component.
Class 3 fracture: Deformity
Double break in the ring
Such as: Open-book, straddle, Malgaigne, bu
cket handle.
Class 4 fracture:Neurologic disorder
Sacrum fracture direct blow to sacrum
-Cauda equina injuries, radiculopathies, plexopathies.
-Damage to sacral root, obturator nerve, 5th lumbar roots.
-(A)Vertical (90%)
(B)Lower segment sacral fracture(below S2) - less injury
(C)Upper segment sacral fracture(above S2) severe injury
-perianal pain, buttock pain, perineal sensation decrease.
Class4 fx:Neurologic disorder
(continued)
Acetabular fracture
-up to 13% associated with sciatic nerve injury.
-once acetabular fracture in indicated,
immobilization are indicated.
Management of Pelvic Fracture
As with any trauma patient, ATLS and the AB
Cs must be given first priority.
Management :
- Hemodynamically Unstable patient
- Hemodynamically Stable patient
Primary Survey: ABCs

Airway maintenance with cervical spine pr

otection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/environment control: undress p
atient but prevent hypothemia
Hemorrhage Control
Pelvic Containmen
t
Sheet
Pelvic Binder
External Fixation

Angiography

Laparotomy

Pelvic Packing
External circumferential pelvic compression
 Draw Sheet Method cont.

Locate the great

Wrap and twist the running This method can also
trochanter
ends around the pelvis be used while patients
are in the car
 PASG/ MAST Pants

Inflate top
compartment

Apply pants as normal

Then inflate top compartment of
pants
Be sure middle of bubble is over
great trochanters
 Circumferential Sheeting
Supine
2
2 Wrappers
1
Placement

Apply

Clamper

30 Seconds
4 3

Routt et al, JOT, 2002

Sheet Application
Sheet Application
Pelvic Binders
Traumatic Pelvic Orth
otic Device
(T-POD)

Photos courtesy of:

Pyng Medical
 Video
http://www.y
outube.com/w
atch?v=w3AKw
DSdtnU

SAM Pelvic Sling

Photos courtesy of:

SAM Medical Products
Pelvic compression
(sheets, belts)
Very simply & rapidly
applied
Re-conforms displaced
pelvis
May help tamponade
hemorrhage
Much less respiratory or
constrictive problems
Allows arterial access
limited data available
Pelvic Binder
 Hip Hugger/Hip Huggie
Hip Hugger Hip Huggie
Place device over
greater trochanters
and fold velcro
together

Place device over greater trochanters

and fold velcro together Snap buckles
together
Snap buckles
together Then tighten
straps labeled
1 at the
same time,
Then: followed by 2

Photos used with

permission
 Hemodynamic Unstable
Resuscitative fluid (crystalloid, blood)
Management of unstable hemodynamic pelvic fractur
e (The EAST practice Management Guildline, reviewed 459 cita
tions- Level 2 recommendation)
a. External stabilization
b. Angiography and possible embolization c.Laparoto
my
 Anti-shock Clamp (C-clamp)

Better posterior pelvis

stabilization

Allows abdominal
access

Apply in fluoro/OR?

Combined with packing?

Ertel,Wetal,JOT,2001
 Anti-shock Clamp (C-clamp)

Betterposteriorpelvis
stabilization

Allowsabdominalaccess

Applyinfluoro/OR?

Combinedwithpacking

Ertel,Wetal,JOT,2001
 Anti-shock Clamp (C-clamp)

Betterposteriorpelvis
stabilization

Allowsabdominalaccess

Applyinfluoro/OR?

Combinedwithpacking

Ertel,Wetal,JOT,2001
Emergent Application
 C-clamp: Anatomical Landmark
s
Same (similar location) as the starting poi
nt for an iliosacral screw
PinLocation
Groove located on the lateral ilium as t
he wing becomes the posterior pelvis

Allows for maximum compression

Can be identified without fluoro in experi NearISscrewentrypoint

enced hands

Pohlemannetal,JOT,2004
Caution

AvoidOvercompressioninSacralFxs!
Pelvic Packing

Ertel, W et al, JOT, 2001

Pohlemann et al, Giannoudis et al,
Pelvic EP packing
technique
Hemodynamic Unstable(continued)
About external fixation! - must be done once fx has been identifi
ed and is determined to be the cause the hemodynamically unst
able- For temponade and fixation.
When to warrant early external stabilization?
-unstable pelvic fracture with hypotension(unstable hemo-)
-patient with unstable pelvic fracture, should received external pel
vic stabilization prior to lapa-incision.
 Will NOT definitively
control major arterial
hemorrhage!
No good controlled
reports of comparative
efficacy
Takes time not good
with severe injuries
May displace posterior
injuries & worsen bleed
Giving way to formal
pelvic ORIF
Hemodynamic Unstable(continued)
About angiography! - identified the source of
bleeder, and embolization if possible.(wire coil
s, sponges...)
When to warrant angiography and possible e
mbolization?(Level 2 recommandation)
- pelvic major fracture with ongoing bleeding,
r/o pelvic bleeder.
- bleeding cannot be adequately controlled at
laparotomy.
Hemodynamic Unstable(continued)
About emergent laparotomy! - massive bleeding
, or angiographic embolization is unsuccessful.
When to warrant urgent laparotomy?(Level 2)
- Hypotension and gross blood in abdomen;
continuous intra-abdominal bleeding
- Diagnostic Peritoneal Lavage(+) aspiration of
gross blood.
- evidence of intestinal perforation
SFGH alg
orithm
On-line.
management of the haemodynamically unstable
patient with pelvic fracture
Hemodynamic Stable
Class 1 fx(hemorrhage)
- CT and admission for observation.
Class 2 fx(GU complications)
- Foley must be delayed until urethral injury is ruled
out.
- Retrograde cystography should be performed.
Hemodynamic Stable(continued)
Class 3 fx(Deformity)
- stability of the pelvic ring
Class 4 fx(Neurologic disorder)
- Sacrum fracture below S2:
symptolytic Rx with bedrest for 4~5 weeks
- Sacrum fracture above S2:
Consult Neurosurgeon or Orthopedics.
- Acetabular fracture:
May consult if Sciatic nerve injury sign(+)
 Conclusion
Pelvic fracture may be categorized into Class
1~4 fracture, including:
- Hemorrhagic fracture
- GU complications
- Orthopedics complications
- Neurologic complications
Rx may be divided into hemodynamic stable
and unstable.
 Conclusion(continued)
If hemodynamic unstable, external stabi
lization, laparotomy, or angiography sho
uld be considered to stop bleeding.
If hemodynamic stable, we may give sy
mptolytic Rx, or consult specialist.
 The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 4, April 2010,
935-941

Acute Definitive Internal Fixation of Pelvic Ring Fractures in

Polytrauma Patients: A Feasible Option

Natalie Enninghorst, MD, Laszlo Toth, MD, Kate L. King, RN, MN, Debra
McDougall, RN,Stuart Mackenzie, MD, and Zsolt J. Balogh, MD, PhD, FRACS

Background: Staged surgery is recommended for the management of

multiple injuries-associated high-energy pelvic ring fractures (acute temporary
skeletal stabilization is followed by definitive internal fixation [ORIF]).
Acute definitive internal fixation is a controversial topic. The purpose of this
study was to evaluate the safety and efficiency of acute pelvic ORIF by
comparing its short-term outcomes with those who had staged surgery.
Methods: A 43-month retrospective review of the prospective pelvic fracture
database of a level-1 trauma center was performed
Conclusion: Acute ORIF of unstable pelvic ring fractures within 6 hours
could be safely performed even in severely shocked patients with multiple
injuries. The procedure did not lead to increased rates of transfusion,
mortality, intensive care unit LOS, or overall LOS. Furthermore, all these
parameters showed a trend toward benefit compared with a staged approach
 (J Trauma. 2010;68: 949953)

The Impact of Open Reduction Internal Fixation on Acute Pain

Management in Unstable Pelvic Ring Injuries

David P. Barei, MD, FRCSC, Brian L. Shafer, MD, Daphne M. Beingessner, MD,
FRCSC,Michael J. Gardner, MD, Sean E. Nork, MD, and M. L. Chip Routt, MD

Background: The management of unstable pelvic ring injuries is complex.

Displacement is a clear indication for surgical intervention. However, reduction
of acute pain after stabilization may have substantial clinical benefits and
affect management decisions. The purpose of this study was to determine the
impact of operative fixation of unstable pelvic ring injuries in diminishing
acute pain.
Conclusions: Operative reduction and fixation of unstable pelvic ring injuries
significantly decreases acute pain. This has substantial physiologic
benefits, particularly by improving mobilization, and should be an additional
factor when determining surgical indication and timing.
Key Words: Pelvis, Pelvic ring, Injury, Fracture, Pain.
Questions?
THANK YOU