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+ Pelvic Ring Fractures Christy Johnson Slide 2 + Outline Background Anatomy and Function Assessment Radiology Classification Treatment Slide 3 + Background Mechanism: high energy blunt trauma Mortality rate: 15-25% for closed fractures Up to 50% for open fractures Hemorrhage is the leading cause of death overall Venous (80%) > arterial Have a high index of suspicion for injury of internal iliac vessels or lumbosacral plexus Slide 4 + Background Associated injuries: Chest injury (63%) Long bone fracture (50%) Head and abdominal injury (40%) Spine fractures (25%) Urogenital injuries in 12-20% Survivors: 1.89 additional injuries Non-survivors: 2.95 additional injuries Only 2 in 14 deaths (14%) are directly attributable to pelvic injury Slide 5 + Anatomy: Osteology Ilium Sacrum Femur Pubis Ischium Slide 6 + Osteology Ring structure made up of the sacrum and two innominate bones No inherent osseous stability Slide 7 + Anatomy: Muscles Sartorius Rectus femoris Iliacus Piriformis Adductor magnus Pectineus Adductor longus Adductor brevis Slide 8 + Ligaments Anterior structures: provide 40% of stability Posterior structures: provide 60% of stability Slide 9 + Pelvic Stabilizers Posterior interosseous sacroiliac ligaments are the strongest in the body Iliolumbar: Augment posterior stability Sacrotuberous Ligament: Resist ER and Vertical shear Sacrospinous Ligament: Resist ER Slide 10 + Assessment Primary Survey Airway Breathing Circulation Disability Exposure Secondary Survey Pelvis assessed by compression/distraction Skin evaluation Smith/Johnson/Cothren et al Journal of Trauma 2007 Slide 11 + Resuscitation/ Hemorrhage 2 large-bore IVs 2L crystalloid on arrival Hct/Hgb does NOT correspond to EBL Hypotension = 30- 40% EBL Patients presenting in shock (SBP + Anteroposterior Compression TypeDefinition APC1Symphysis widening < 2.5cm APC2Symphysis widening > 2.5 cm. Sacrotuberous, sacrospinous and anterior SI joint ligaments are disrupted. Posterior SI ligaments intact. APC3Disruption of anterior and posterior SI ligaments. Disruption of sacrospinous and sacrotuberous ligaments Slide 19 + Lateral Compression Slide 20 + TypeDefinition LC1Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture LC2Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture) LC3Ipsilateral lateral compression and contralateral APC (windswept pelvis). Common mechanism: rollover vehicle or peds struck Slide 21 + Vertical Shear Slide 22 + Associated with the highest risk of hypovolemic shock, mortality Usually result from falls from height Posterior and superior directed force APCIII + vertical displacement Slide 23 + Mortality from Pelvic Injuries Hemodynamic instability + pelvic fracture = 40% mortality Major cause of death: Hemorrhage (15%) Major cause of death LC injuries: closed head injuries Major cause of death APC: combined pelvic and visceral injuries Hemorrhage in pelvic injuries Venous bleeding more common than arterial bleeding Superior gluteal artery (most common arterial injury in APC) Internal pudendal artery (most common in LC) Metz et al Orthop Clin N Am 2004 Smith et al J Trauma 2007 Slide 24 + Circumferential Pelvic Antishock Sheeting Rapid, inexpensive, temporary means of decreasing pelvic volume Indications: initial management of an unstable ring injury Risk of bladder injury in pelvic fractures with internal rotation component (i.e. LC injuries) Technique: center over greater trochanters (NOT iliac crest/abdomen) Slide 25 + External Fixation Advantages: Decreases pelvic volume Stabilization of pelvis Indications: Pelvic ring injuries with an external rotation component (APC, VS) Unstable ring injury w/ ongoing blood loss Contraindications Ilium fracture that precludes safe application Acetabular fracture Technique: Iliac wing or supra- acetabular pins Egbers Orthopade 1992 Slide 26 + Angiography/ Embolism Small percentage of pelvic fractures have significant arterial injuries amendable to angio (10%) Must have stabilized pelvis (pattern or ex-fix) because most bleeding is venous which will tamponade Eliminate other sources of bleeding Successful in 70-90% of cases but takes 3-4hrs Slide 27 + Treatment Overview Nonoperative Indicated for mechanically stable pelvic ring injuries LC1: anterior impaction fracture of sacrum and oblique ramus fx with