Early Management of Pelvic Ring Disruption Flashcards
How can open fractures occur in relation to the rectum and genitourinary systems?
perforation of the rectum and genitourinary systems
What examination is necessary for women with suspected open fractures
A speculum examination
open fractures Tx ?
antibiotics within 1 hour
First-generation cephalosporins
ADD Gram-negative coverage large degloving injuries or wounds that communicate with the bowel
Small lacerations irrigated and closed
larger wounds may require operative exploration
packing open wound performed before applying binder
extremity traction ?
realigning anatomy
decreasing bleeding
reducing pain
beneficial for definitive treatment
skeletal traction pins placed in the distal femur, proximal or distal tibia, or calcaneus.
What alternatives exist if skeletal traction is not possible?
manual traction during binder application, internal rotation of the extremities, and taping the toes together.
risks of continued use of a CPAS or binder beyond 24 hours
obscure femoral access, impede abdominal access, and cause skin necrosis
How should removal of the CPAS or binder be performed
ideally in the ICU, with the binder removed slowly and left in place beneath the patient for rapid reapplication if needed.(Hypotension)
When is pelvic angiography indicated
persistent arterial bleeding
unresponsive to resuscitative efforts
have a binder or external fixation in place
and do not require surgical hemorrhage control.
hen should pelvic packing be considered
when retroperitoneal hemorrhage is suspected
patient is unresponsive to binder
and primary resuscitation with intravenous fluids and blood.
Why is understanding the pathoanatomy of pelvic hemorrhage important for pelvic packing?
because retroperitoneal veins in the space of Retzius and retroperitoneum are responsible for much of the pelvic hemorrhage
How is pelvic packing performed?
Three pads are forcibly packed on each side: along the pelvic brim, into the true pelvis, and posteriorly near the sacroiliac joint.
pelvis must be stabilized with a binder or an external fixator
What are the characteristics of an APC1 injury?
minimal anterior widening at the symphysis or anterior pelvis with insignificant ligamentous or bony disruption
What identifies an APC2 injury, and what structures are disrupted?
> 2.5 cm of anterior symphysial widening
disruption of the sacrospinous
sacrotuberous
anterior sacroiliac ligaments
the posterior sacroiliac ligaments remain intact.
What are the characteristics of an APC3 injury?
rupture of all anterior and posterior pelvic ligaments, gross instability of one or both hemipelves
significant intrapelvic hemorrhage
need for immediate intervention.
What is indicated in the initial resuscitation of all APC injuries?
A binder
What are the characteristics of an LC1 injury?
the sacral foramen or ala
anterior fractures of the superior and inferior rami
internal rotation of one hemipelvis.
common in the elderly after a fall from standing.
What are the characteristics of an LC2 injury?
posterior fractures through the iliac wing
anterior fractures of the rami.
LC3 injury, and why is it known as the “wind-swept” pelvis?
internal rotation of one hemipelvis
external (AP-type) rotation of the opposite hemipelvis, creating the “wind-swept” appearance.
These injuries have the greatest instability.
How common is distal displacement in VS fractures,
very rare but is associated with significant nerve injury
proximal vertical displacement in VS fractures?
vascular injury and soft tissue damage to the iliolumbar ligaments
anterior and posterior sacroiliac ligaments
anterior pelvic ligaments
How is pelvic hemorrhage managed in patients with VS fractures?
Longitudinal traction on the shortened limb and binder application
When does external fixation have a significant role
after 24 hours, typically when the patient can be transported to the operating room
What is the preferred method of external fixation for pelvic fractures?
supra-acetabular two-pin external fixation
When is external fixation preferred over internal fixation
when prior surgery or radiation complicates anterior open approaches
when there is an open fracture or gross contamination
or when other surgical incisions make standard approaches difficult.
