Management of Pelvic Fractures in Trauma Patients

Management of pelvic fractures in trauma patients

Five potential sites of potentially fatal haemorrhage in trauma

§  External

§  Long bones

§  Chest

§  Abdomen

§  Retroperitoneum

Approach to a patient with suspected pelvic injury

§  Primary survey

o  Airway – assess and stabilise

o  Breathing – O2 therapy and ventilatory parameters

o  Circulation –

§  2 X wide bore >18g IV access

§  Initial crystalloid fluid boluses titrate

·  To cerebral perfusion

·  To maintain systolic BP >90mmhg

·  Consider early call for un-crossmatched blood transfusions

·  Early group hold and screen and pre-empt need for massive transfusion protocol

·  Control external sites of bleeding

·  If obvious limb shortening and evidence of pelvic fractures with hypotension consider placing pelvic binding with mechanical device or bed sheet while log-rolling

o  Disability – assess and record

o  E-exposure – undress and assess, cover up and prevent heat loss

o  Check LIMITS –

§  Lines – ETT/IVC/NGT/SaO2/vitals/ETCO2

§  Investigations – bloods/ABG/ECG/X-rays/FAST

·  Check CXR for hemo-/pneumo-thorax

·  Check Pelvic x-ray for unstable fractures, disruption of ring – apply pelvic binding if obvious fractures and hemodynamically unstable

§  Monitoring – SaO2/ETCO2/ECG/NBP/neuro/BSL

§  Intravenous therapy – IV fluids and analgesia as required

§  Teams – early referral to orthopaedic or radiology teams if persistently unstable with no other obvious cause for hemorrhage

§  Stabilise patient prior to beginning secondary survey

§  Secondary survey

o  Only once primary survey complete and resuscitation complete

o  Complete head to toe exam

o  In 32% of pelvic fracture patients, significant abdominal injury will also be found – so primary goal to rule out abdominal pathology

o  DPA or FAST according to local protocol and availalbility

o  Exclude all other sites of bleeding

§  Angiography facilities available

o  If FAST negative and clinically unstable ® transfer to angiography for embolisation

o  Regular review of abdomen for free fluid

o  If FAST positive and clinically stable ® immediate laparotomy, damage control ® pack pelvis, fix intra-abdominal pathology ® transfer to angiography facility for pelvic bleeding control

o  If clinically very unstable <70mmhg systolic for urgent packing OT to stabilise patient even before angiography

o  If clinically mild instability ® consider theatre before plan for operative or angiographic intervention

§  Angiography services unavailable in hospital:

o  Systolic BP >80 ® non invasive external stabilisation ® 100-200ml boluses to maintain BP® contact retrieval services for transfer to tertiary center

o  Systolic BP<80 ® despite fluid resuscitation ®immediate laparotomy with surgical ligation of bleeders ® pack pelvis with large sponges ® invasive external stabilisation of pelvis

Classification of pelvic fractures – Young and Burgess

Young and Burgess classification is the most commonly used system for classification of pelvic fractures

·  Classifies pelvic fractures by vector of force

o  Anteroposterior compression (APC)

o  Lateral compression (LC) and

o  Vertical shear (VS) types

·  APC and LC further classified into types I, II and III with increasing degrees of severity

·  Type I APC/LC are stable since posterior elements are intact

·  Type II APC/LC varying degress of instability

·  Type III APC/LC and VS all significantly unstable

Bladder rupture

·  Occurs in 9-16% of all pelvic fractures

·  Diagnosed by cystogram ± CT

·  Extraperitoneal or intraperitoneal

o  Extraperitoneal due to shearing forces or laceration by bony spicules anteriorly

o  Intraperitoneal due to severe pressure to a distended bladder

o  Mixed rupture in 12% of case

·  Signs – suprapubic tenderness, low urine output and gross hematuria (>95%)

·  Treatment

o  Intra-peritoneal – surgical repair

o  Extra-peritoneal – conservative with IDC insertion

Urethral rupture

·  Occurs in 4-14% of pelvic fractures

·  Diagnosed by retrograde urethrography

·  May be partial or complete

·  Signs – meatal bleeding (98%), gross hematuria, perineal hematoma, vaginal laceration

·  Treatment

o  Depends on location and severity

o  Suprapubic or aligning urinary catheter

o  Primary repair or

o  Delayed urethroplasty/otomy