3. Management strategy of vascular injuries associated with pelvic fractures. J Cardiovasc Surg
33:349, 1992; Prorities in Management. Arch surg 124:422, 1989; Effective classification
4. 1 SACRAL Bone
2 INNOMINATE bones
PUBIS
ILIUM
ISCHIUM
Symphysis gap <5 mm
5.
6. No inherent stability—Ligaments give stability
Anterior SIL resist external rotation
Sacrospinous - resists external rotation
Posterior SIL and ILL - provide posterior
stability by tension band , strongest in body
Sacrotuberous - resists shear/flexion SI joint
7.
8.
9. Sacral venous plexus*
Iliolumbar a.
Internal iliac a.
Superior gluteal a.*
Lateral sacral a.
Pudendal a.*
12. AP pelvis during early phase of resuscitation is
useful to determine presence or absence of
unstable pelvic fracture
AP pelvis can identify 90% of pelvic injuries
13. Inlet View – 45 degree caudal tilt
True AP projection of the pelvic brim
Evaluates for posterior displacement
Evaluates for rotation of ilium and sacral impaction
injuries
14. Outlet View – 45 degree cephalad tilt
Evaluates for vertical shift of pelvis
provides a better demonstration of sacral fractures
and injuries to the sacroiliac joints.
15. CT Scan
Best visualization for Sacrum and SI joint
Rotational and posterior displacement can
be easily assessed
16.
17. Type A: pelvic ring stable
Type B: rotationally unstable, vertical stable
Type C: rotationally and vertically unstable
Advantages: Tile classification aids in
the determination of prognosis
18. Lateral compression (LC)
Anteroposterior compression (APC)
Vertical shear (VS)
Combined mechanism (CM)
Advantages: this classification alerts the surgeon to
potential resuscitation requirements and
associated injury patterns
19.
20. Airway Maintenance with C-spine protection
Breathing and Ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/Environment Control: Undress
patient but prevent hypothermia
21. Neurologic deficit involving lumbosacral plexus
Pelvic/flank/perineal
contusions,ecchymoses,abrasions
Blood at urethral meatus
Blood in or around rectum
Open wound of groin,buttock, or preineum
Leg length inequality or external rotation of one
extremity
Abnormal pelvic motion on AP or lateral
compression of anterior iliac spines and iliac crests
22. Rectal exam for tone
Bulbocavernosus reflex
Myotomes of lower extremity
L1-2 : hip flexor
L3-4 : Quadriceps/knee extension
L4-5 : Ankle and toe dorsiflexion
S1 : ankle plantarflexion
S2-3 : toe plantarflexion
24. Return blood from lower ext. to central vascular system
Ability to close open-book-type injury, reducing pelvic
volume
Stabilize pelvic ring permitting clot formation
25. Advantage
Useful in assessing and embolization of arterial
injury - Unexplained blood loss after stabilization and aggressive
resuscitation , Pulseless extremity
Disadvantage:
Source of arterial bleeding is identified in only 10-
15% of patients with severe pelvic disruption
Does not address venous bleeding
26. Primary survey
stable unstable
Pelvic Fx No Fx Pelvic Fx
No Fx
CT,FAST,DPL
CT scan
APC LC
CT,FAST,DPL
classify Fx
Reassess Explor lap. Open bookothers
Reassess
- External compression
- Explor lap. +/- packing
- Angiography vs ext. fixation
SI jonit involvement-
consider iliac injury
27.
28. Lateral compression (LC)
Anteroposterior compression (APC)
Vertical shear (VS)
Combined mechanism (CM)
Advantages: this classification alerts the surgeon to
potential resuscitation requirements and
associated injury patterns
29.
30. LC type I:
unilateral rami fx . (transverse)
& ipsilat sacral compression.
LC type II:
unilateral rami fx.
& ipsilat post. iliac fx.
LC type III:
LC I/II & contralat. APC
31.
32. APC type I:
symphysis widened < 2cm;
SI joint intact
APC type II:
symphysis widened >2cm or rami fx
& ant. SI lig. Torn
APC type II:
symphysis widened >2cm or rami fx
& ant & post SI lig. torn
33. Vertical shear (VS)
Vertical displacement
Combined Mechanical(CM)
Combination of LC + VS or APC
37. Occurs in less than 1%
Clinical
Laceration of rectum or perforation of small and/or
large bowel
Rectal tears accompany perineal wounds
Requires diverting colostomy in 6-8hr
following injury to reduce incidence of sepsis
and death
38. Laceration of the vagina
Results from dislocation or fractures of the
pubic rami
may require operative intervention