Pelvic Fractures

Question 0

Can you describe is more detail the APC classification and the way this aids management?

Answer 0

APC 1- symphysis pubis widening 2.5cm anterior SI joint diastatsis. Post intact - ANT symphysis plate/ ex fix
APC 3- DISRUPTION ANT & POST SI LIG ( SI Dislocation)
Assoc VASCULAR injury
-> symphysis pubis plate/ex fix & POST SI SCREWS

Question 1

Describe the classification of pelvic fractures ?

Answer 1

YOUNG and BURGESS
ANTERIOR POSTERIOR COMPRESSION 1-3
LATERAL COMPRESSION 1-3
VERTICAL SHEAR

Question 2

Can you describe is more detail the LC type classification and the way this aids management?

Answer 2

LC 1- oblique ramus # & IPSILAT ANT SACRAL ALA compression # -> non op. Protected WB
LC2- rami fractures and IPSILATERAL POST ilium # dislocation
-> ORIF of ilium
LC 3- IPISILAT LC & CONTROLAT APC- WINDSWEPT PELVIS
RTA- rollover person vs vehicle
-> Post stabilisation plate / SI SCREW: Percutaneous vs open

Question 3

Can you describe is more detail the vertical shear classification and the way this aids management?

Answer 3

Only one described
POST and SUPERIOR DIRECT FORCE
-> POST STABILISATION w PLATE/SI SCREWS- Percutaneous s open

Question 4

What are vertical shear injuries assoc with ?

Answer 4

Highest risk of hypovolaemic shock -63% and MORTALITY RATE. 25%

Question 5

Ina pt with a pelvis fracture where could the sources of bleeding be?

Answer 5

Intraabdominal
Intrathoracic
Retroperitoneal
Extremity- thigh compartments
Pelvic- common source -
VENOUOS INJURY 80%- shearing injury of POST THIN WALLED VENOUS PLEXUS
Bleeding cancellous bone
ARTERIAL-uncommon but SUP GLUTEAL common, APC
INT PUDENAL- LC
OBTURATOR- LC

Question 6

How would you tx a pt with a pelvic fracture?

Answer 6

Resuscitation -rbc,ffp, platelets 1:1:1
Pelvic binder- initial for unstable ring
Centred over Greater troch to effect indirect reduction
Do not place over iliac crest / abdomen
May augment with INT ROTATION of legs
Transition to alternative fixation ASAP

Question 7

What are the indications for an angiogram/ embolisation?

Answer 7

Ct useful in determining presence of absence of ongoing arterial haemorrhage

Question 8

When would conservative tx be given for a pelvic fracture?

Answer 8

APC 1, LC 1- we as tolerated

Question 9

When would you operate on a pelvic fracture?

Answer 9

Symphysis pubis > 2.5cm
SI joint displacment > 1cm
Sacral fracture w displacment >1 cm
Displacement and rotation of the hemi pelvis 
Open fracture

Question 10

When would a diverting colostomy be considered?

Answer 10

Open fracture especially w extensive PERONEAL injury or RECTAL involvement

Question 11

What approach would be used to stabilise the anterior ring/ symphysis pubis?

Answer 11

Pfannensteil approach- rectus splitting- can combine with laparotomy and gu procedure

Question 12

What are the risks in plating the anterior SI joint?

Answer 12

Risk of L4/L5 injury w placement of anterior sacral retractors

Question 13

What is the safe zone in placement of sacroiliac screws?

Answer 13

In vertebral body of S1
Outlet view- best guide for superior- inferior placement
Inlet view- best guide for ant-post placement

Question 14

What are the complications of SI screws ?

Answer 14

L5 root injury complications

Question 15

In ipsilateral acetabular and pelvic ring fractures what shoulde. E fixed first?

Answer 15

Pelvic ring

Question 16

What are the complications of pelvic ring fractures ?

Answer 16

Acute- neurological- L5 ( runs over sacral ala joint )
DVT/PE -60% DVT. 27% PE prophylaxis essential
Urogenital 12-20% ( greater in men )
Bladder rupture-? Extravasation: mortality 22-34%
POST URETHRAL TEAR-most common injury
Dx w Retrograde urethrocystogram
Indications - blood at meatus, high riding prostate, haematuria
Tx- supra public catheter, surgical repair
Complx- urethral stricture, impotence, ant ring infection, incontinence
Chronic - instability- subjective instability and mechanical symptoms, dx w alternating single- leg stance pelvic X-rays

Question 17

What is the mechanism for pelvic fractures ?

Answer 17

High energy blunt trauma

Question 18

What is mortality rate?

Answer 18

Closed fracture- 15-25%

Open fracture 50%

Question 19

What is the leading use of death?

Answer 19

Haemorrhage

Question 20

What are the other injuries associated with a pelvic fracture?

Answer 20

Chest injury- 63%
Long bone fracture -50%
Head and abdomen- 40%
Spine -25%
UROGENTIAL 12-20%

Question 21

What is the prognosis Of pelvic fractures ?

Answer 21

High prevalence of poor functional outcome and chronic pain

Question 22

Name the ligaments around the pelvis?

Answer 22

Anterior - SYMPHYSEAL

Pelvic floor-SACROSPINOUS
SACROTUBEROUS

Post- POSTERIOR SACROILAC COMPLEX- more important than ANT SACROILIAC structures for pelvic stability
STRONGEST LIGAMENTS IN THE BODY
POST Iinclude- INTEROSSOEUS SACROILIAC. ILIOLUMBAR and post sarcoiliac