Pelvic Trauma Flashcards
Mortality in pelvic fracture:
30-50%
Injuries associated with pelvic fractures:
Bladder rupture
Urethral injury
Vaginal laceration
Rectal
Low cord, cauda equina (sacral #)
Always examine:
Genitals:
- Blood at meatus**
- PV bleed
Perineum
- Bruising**
Rectal:
- Blood
- High-riding prostate
- Tone**
Free fluid
- Blood or urine
** urethral rupture
APPROACH to suspected unstable pelvic fracture:
- Apply binder (unless HD STABLE with VS/LC)
- Non-aggressive BP goals- incompressible major bleed
- Gently examine for tenderness. DO NOT SPRING
- Look for associated injury:
—> Urethral (meatal blood, high prostate, perineal bruise)
NO IDC IF SUSPECTED URETHRAL INJURY
—> Rectal (blood)
—> PV
—> Neurol: cauda stuff and L5/S1: big toe up and down -
FAST
—> Fluid in pelvis could be haemorrhage, or could be URINE from bladder rupture. - Pelvic XR or CT/angio
- Definitive:
—> OT: packing / fixation
—> Embolisation (doesn’t address VENOUS bleeding- may still need packing)
—> HDU/ ICU
Indications for embolisation in pelvic trauma:
CT angio showing arterial bleed with active blush
Not already requiring emergent laparotomy/packing
(Eg. Venous plexus bleed, associated injury)
Alternatives to pelvic binder:
Sheet
—> Wrap and tie
—> Sandbags on sides
—> Internally rotate hips
External fixation
- Doesnt stabilise posterior
- Limits laparotomy access
Removal of a pelvic binder:
Never off prior to reasurring imaging
Even if imaging okay, proceed with caution
After removal, monitor closely ++ for deterioration. If any, straight back on.
LATERAL COMPRESSION
- Most common
- The injury reduces pelvic volume = less haemorrhage
Grade I:
- Impaction # to sacrum and pubic ramis (often horizontal)
- Major ligaments fine
- Stable
Grade II:
- PLUS ileum # (Crescent #)
- Unstable (in rotation)
Grade III:
- PLUS ‘open book’ to other side
- Unstable completely
AP COMPRESSION
- BAD: expands pelvic volume, major haemorrhage, associated injuries ++
Grade I
- Symphysis widened <2.5cm (normal 3mm)
- Stable
Grade II
- Symphysis >2.5cm
- Ligaments disrupted but SIJ intact
- Unstable
Grade III
- PLUS, SIJ gone
VERTICAL SHEAR
BAD: as per AP.
May disrupt at symphysis, OR through rami
Grossly unstable.
Pelvic anatomy
PELVIC RING
- Doesn’t include acetabulum or coccyx
- It is the STRONG LIGAMENTS that keep the ring stable
- Anterior + posterior sacroiliac
- Sacrotuberous
- Sacrospinous
- Pubic symphysis
Usually disrupted in two places at a time
ANTERIOR ARCH and POSTERIOR ARCH, demarcated by acetabulum.
Management of ileac wing fracture (Duverney)?
Stable
Conservative
Protected WB
Denis Classification (sacrum):
Sacral fractures
Zone 1
- Lateral to foramina
- Stable and benign
- Sometimes L5 injury
Zone 2
- Through foramina
- Sometimes unstable
- Risk of injury to sacral nerves
Zone 3
- Medial to foramina
–> Transverse
–> ‘U’ type
- Involves spinal canal
- High risk neurology (60%)
Which neurological structures can be injured in sacral #, and how would you check?
Cauda equina
Nerve roots L5 - S4
Sacral plexus
- Full bladder
- Saddle anaesthesia (2-point, sharp)
- Reduced perineal sensation
- PR tone/ wink
- Lower limb tone/strength/reflexes
- Sacral dermatomes
- Bulbocavernosis reflex
- Cremasteric reflex
XR will miss sacral fractures a lot of the time
CT or MRI (if neuro).
How is this fracture classified? What are the complications?
Scaphoid #
Classified:
- Prox third
- Waist (80%)
- Distal third
- Tubercle
Displaced = >1mm
Risks:
Associated trans-scaphoid perilunate dislocation
Non union
Avascular necrosis proximal segment (blood supply distal)
Post traumatic arthritis
How often is a scaphoid # NOT visible on XR?
30% will not be seen initially.
Triquetral fracture
Almost all (95%) are small dorsal avulsions (flake)
Can be associated with perilunate dislocation - LOOK.
