Vascular injury in pelvic trauma

Vascular Injury in
Pelvic trauma
Peter Giarso
Page 1

Introduction

Pelvic Trauma:
• Excellent knowledge of the anatomy
• Complex anatomic relation, pathway of nerves and vessels networks
• Substantial force.
• There are many organs in it.
• Connects to abdominal and retroperitoneal space.
• Rapid transportation to a trauma center, early recognition of the injuries.
• Early surgical intervention, good surgical judgment

Demetriades D, Inaba K. Capther 154 – Vascular Trauma : Abdominal . Cronenwett: Rutherford's Vascular Surgery, 7th ed. Page 2

Anatomy

Thompson JC. Netter’s Concise Atlas of Orthopaedic
Anatomy
Page 3

Anatomy

Thompson JC. Netter’s Concise Atlas of Orthopaedic
Anatomy
Page 4

Surgical
anatomy
For vascular trauma purposes:
•Zone 1
The midline retroperitoneum,from the
aortic hiatus to the sacral promontory.
The supramesocolic area and The
inframesocolic area.
•Zone 2 (left and right),
Which includes the kidneys, paracolic
gutter, and renal vessels.
•Zone 3,
Which includes the pelvic
retroperitoneum and contains the iliac
vessels.


Surgical
anatomy


Mechanism of injury

Penetrating trauma :

1. Low-velocity missiles cause direct injury to the vessel.
2. High-velocity missiles and blasts can also cause vascular trauma by
means of the shock wave and transient cavitation.

Blunt trauma (abdomen pelvis):

1. Rapid deceleration, (accidents or falls from heights)
2. Direct anteroposterior crushing, (seat belts)
3. Direct laceration of a major vessel by a bone fragment, as occurs in
severe pelvic fractures.

Incidence

• Insiden antara arteri dan vena sama(1)
• Rutherford: Arterial injuries (49%) dan venous injuries (51%).
• Vascular trauma book(2)
•Arteri common iliaka (40%), a. iliaka internal (30%) a.iliaka eksternal
(30%).
•Vena: common iliaka (48%), v. iliaka eksternal (32%), v. iliaka internal
(22%)
•Blunt trauma : Paling sering vena iliaka internal (strectching atau laserasi)

1. Demetriades D, Inaba K. Capther 154 – Vascular Trauma : Abdominal . Cronenwett: Rutherford's Vascular Surgery, 7th ed.
2. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed.
Page 8

Clinical Presentation

•Multiple severe trauma, jejas/ VL daerah pelvis
•Tanda-tanda perdarahan: s/d syok, distensi abdomen, pulsasi a. femoralis
•Rectal bleeding, OUE bleeding, high riding prostate
•Secondary thrombosis (intimali tear): leg ischemia
•Fraktur pelvis: one examiner

2. Rich NM, Mattox KL, Hirshberg A. Vasular Trauma. 2ed.
Page 9

Clinical Presentation

•Radiologis: pada hemodinamik stabil(2)
•Proyektil
•Blunt trauma: increased risk vascular trauma:
•Presence of symphysis pubis diastisis >2.5 cm
•Sacroiliac joint disruption
• Superior and inferior rami fractures bilaterally (Butterfly fracture)
(demetradee et al: undergo angiographic embolization dan massive transfusion)

•CT Scan: (1)
•USG : late abdominal vascular complication
•Angiography: site and severity, control bleeding

2. Rich NM, Mattox KL, Hirshberg A. Vasular Trauma. 2ed.
Page 10

Classification

•Radiology:
•Anatomy (leutornel, Dennis, Tile, OTA)
•Mechanism: (Young and Burgess)
•Vector of force
•Degree of bony displacement
•predict risk of blood loss and types of associated injuries

Stein DM, O’Toole R, Scalea TM. Multidisciplinary Approach for Patients withPelvic Fractures and Hemodinamic Instability.
Journal of Surgery. 96: 272-80, 2007 Page 11
Stephen D. Management of high-energy pelvic fractures.

Classification

•Anterior-posterior compression (APC 1F3)
•APC1Fstable
•APC 2Fpartial instability
•APC 3Fcomplete instability
•Lateral compression (LC 1F3)
•LC lFstable impacted
•LC2Fposterior ring fracture without pelvic floor disruption
•LC3Fdirect rollover
•Vertical shear (VS)
•Combined mechanism injury (CMI)
•Not classifiable


Classification

•Anterior-posterior compression (APC 1F3)
•High speed crashes
•Open book fracture
•Substantial blood loss


Classification

•Lateral compression (APC 1F3)
•T-bone vehicular crashes
•Fall where lands on side
•Vascular injury may occur
•Generally not substantial blood loss
(concomitant injury)


Management

•Prehospital:
•Scoop and run
•Bleeding control
•Fluid resuscitation (controversy, crystalloid fluid)
•Increase rate and volume of blood loss
•Hypotension control
•Hypothermia

.
2. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed.
Page 15

Management

•Treating Pelvic Hemorrhage:
•Principle: reducing fracture
•Bed sheet:
•Greater trochanter: the compressive device is centered over the greater
trochanters of the hip, not over the iliiac crest
•Crisscrossed
•Mannually reduces the pelvis, post reduction x-ray
•MAST (military anti-shock trouser), PASG (pneumatic anti-shock garments)
•C-Clamp

1. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed
.
2. Stein DM, O’Toole R, Scalea TM. Multidisciplinary Approach for Patients withPelvic Fractures and Hemodinamic Instability. Page 16
Journal of Surgery. 96: 272-80, 2007

Management

.

Management

•Treating Pelvic Hemorrhage:
•Angiographic embolization
•Time, place, and personnel required
•A flush pelvic aortogram, then selected pelvic angiography
•Embolization
•Direct operative exploration

.

Management

.

Management

•Operating management:
•Arterial injuries:
•Compression and control(proximal and distal)
•Iliac vessels: approach : dissection paracolic peritoneum and medial rotation
the colon.
•Proximal control: clamp> vessel tape
•Distal vessel: can be difficult, extending midline incision
•Primary repair
•Ligation the common and external iliaca should be aviod (50% limb loss)

.

Management

•Operating management:
•Venous injuries:
•More challenging: difficult exposure and air embolism
•Lateral venorraphy
•Ligation
•SE: stenosis (possb 50%), edema and compartment syndrome (from ligation)
•Individual choice

.

Conclusion

•Hemodinamically unstable patient with pelvic fracture present a unique challenge.

•Diagnosing the sources and resuscitation

•Close coordination

•Algorithm and tools to manage

.

Vascular injury in pelvic trauma

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