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OPEN PELVIC TRAUMA
AND
ASSOCIATED INJURY MANAGEMENT
Dr Uday Kumar
MS(Orth) DNB(Orth)
Sagar Hospitals
Sindhi Hospital
Chinm...
High velocity MVA ---Open pelvic fractures
Open pelvic trauma
Open pelvic fractures
--Communication between fracture fragments
and skin or a pelvic visceral cavity.
• 4-5% of pelvic fr...
Team approach
Management
Multidisciplinary
Early
Aggressive
Injury 2005
TEAM
-Immediate trauma team availability
-Early simultaneous blood and coagulation
products
-Prompt diagnosis & treatment of li...
Primary survey--ATLS
• Airway Maintenance
• Breathing and Ventilation
• Circulation with hemorrhage control
• Disability: ...
General examination
--Shock
Local examination
--Open wound of groin,buttock or perineum
--Abnormal pelvic mobility
--Leg l...
INVESTIGATIONS
Blood parameters
Xrays---pelvis
--spine
--chest
CT ----pelvis with 3d recon
---abdomen
Pelvic Fractures & Hemorrhage:
Young and Burgess Classification
ER & VS > IR
APC & VS at increased risk
Lateral
Compressio...
Pelvic Fractures & Hemorrhage
• APC & VS (antero-posterior compression
and vertical shear)
at increased risk of hemorrhage
Hemorrhage
Pre-sacral venous plexus
overlies the SI joint
Fracture disrupts SI joint
Tears the veins
hemorrhage
Pelvis forms a limited
container
Disrupted pelvic ring
opens this container
Haemorrhage leaks into
retroperitoneum
MASSIVE...
--control haemorrhage and shock
fluids/vol expanders/blood
-- External fixator application
for APC and VS injuries
HYPOVOL...
Ability to close open-book-type injury,
reducing pelvic volume
Stabilize pelvic ring permitting clot formation
Soft tissue injury management
-- broadspectrum antibiotics
-- repeated, meticulous
wound debridement
and irrigation
--acti...
CT ABDOMEN and PELVIS
Shows abdominal haemorrhage
General surgeon
Laparotomy
Controls obvious bleeding
If bleeding continu...
Pelvic Packing
• additional damage control procedure in
pelvic bleeding
• directly tamponades sources of bleeding
within t...
Gastrointestinal Injury
• Bowel Injury:
– Perforations in the rectum or anus
– Entrapment of bowel in the fracture site ma...
Genitourinary Injury
• Urethral injury: 10% with
pelvic fractures
• more in males
– blood at the urethral
meatus
– high-ri...
Genitourinary Injury
• Bladder injury:
– gross hematuria in 95%
– Treatment:
•Extraperitoneal bladder-- Foley catheter
dra...
Gynecologic injury
• Laceration of the vagina
• Results from dislocation or fractures of the
pubic rami
--Early repair of ...
Haemodynamic Status
• if hemorrhage continues
inspite of all this
• Then consider
angiography or embolization
– Arterial l...
Possible Bleeders
• Sacral venous plexus*
• Iliolumbar a.
• Internal iliac a.
• Superior gluteal a.*
• Lateral sacral a.
•...
Angiography-embolisation
• Advantage
– Useful in assessing and embolization of arterial
injury
• Disadvantage
– Source of ...
Angiography-complications
• Lead to necrosis of buttock after occlusion of
entire internal iliac artery
• Sciatic or femor...
Definitive treatment
--done at a later date after patient is fit
-external fixator is continued or converted to orif
-uret...
Pelvic infection
soft tissue infection
osteomyelitis
high mortality and morbidity
long-term disability
Open pelvic fractur...
--Sciatic nerve injury
--Urogenital problem like stricture, incontinence
and impotence
--Persistent sacroiliac pain due to...
Open pelvic trauma and associated injury management
Open pelvic trauma and associated injury management
Open pelvic trauma and associated injury management
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Open pelvic trauma and associated injury management

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Open pelvic trauma and associated injury management

  1. 1. OPEN PELVIC TRAUMA AND ASSOCIATED INJURY MANAGEMENT Dr Uday Kumar MS(Orth) DNB(Orth) Sagar Hospitals Sindhi Hospital Chinmaya Hospital Bangalore 30th July 2015 MSR
  2. 2. High velocity MVA ---Open pelvic fractures
  3. 3. Open pelvic trauma
  4. 4. Open pelvic fractures --Communication between fracture fragments and skin or a pelvic visceral cavity. • 4-5% of pelvic fractures • Mortality is ~30%--50% in open fractures
  5. 5. Team approach Management Multidisciplinary Early Aggressive Injury 2005
  6. 6. TEAM
  7. 7. -Immediate trauma team availability -Early simultaneous blood and coagulation products -Prompt diagnosis & treatment of life threatening injuries -Stabilization of the pelvic girdle -Timely pelvic angiography and embolization -Treatment of associated visceral injuries JOT, 2001
  8. 8. Primary survey--ATLS • Airway Maintenance • Breathing and Ventilation • Circulation with hemorrhage control • Disability: Neurologic status • Exposure/Environment Control: Undress patient but prevent hypothermia
  9. 9. General examination --Shock Local examination --Open wound of groin,buttock or perineum --Abnormal pelvic mobility --Leg length inequality --Blood at urethral meatus --Bleeding per anum/rectum/vagina --Neurological deficit
  10. 10. INVESTIGATIONS Blood parameters Xrays---pelvis --spine --chest CT ----pelvis with 3d recon ---abdomen
  11. 11. Pelvic Fractures & Hemorrhage: Young and Burgess Classification ER & VS > IR APC & VS at increased risk Lateral Compression (LC) Anteroposterior Compression (APC) Vertical Shear (VS)
  12. 12. Pelvic Fractures & Hemorrhage • APC & VS (antero-posterior compression and vertical shear) at increased risk of hemorrhage
  13. 13. Hemorrhage Pre-sacral venous plexus overlies the SI joint Fracture disrupts SI joint Tears the veins hemorrhage
  14. 14. Pelvis forms a limited container Disrupted pelvic ring opens this container Haemorrhage leaks into retroperitoneum MASSIVE BLEED (5- 6 LITRES)
  15. 15. --control haemorrhage and shock fluids/vol expanders/blood -- External fixator application for APC and VS injuries HYPOVOLEMIC SHOCK
  16. 16. Ability to close open-book-type injury, reducing pelvic volume Stabilize pelvic ring permitting clot formation
  17. 17. Soft tissue injury management -- broadspectrum antibiotics -- repeated, meticulous wound debridement and irrigation --active tetanus prophylaxis
  18. 18. CT ABDOMEN and PELVIS Shows abdominal haemorrhage General surgeon Laparotomy Controls obvious bleeding If bleeding continues---Pelvic packing
  19. 19. Pelvic Packing • additional damage control procedure in pelvic bleeding • directly tamponades sources of bleeding within the pelvis. • Packs can be placed in the preperitoneal and retroperitoneal spaces. • packs must be removed 48 hours after insertion.
  20. 20. Gastrointestinal Injury • Bowel Injury: – Perforations in the rectum or anus – Entrapment of bowel in the fracture site may occur – If either is present, the patient should undergo diverting colostomy.
  21. 21. Genitourinary Injury • Urethral injury: 10% with pelvic fractures • more in males – blood at the urethral meatus – high-riding prostate on rectal exam – retrograde urethrogram
  22. 22. Genitourinary Injury • Bladder injury: – gross hematuria in 95% – Treatment: •Extraperitoneal bladder-- Foley catheter drainage. •Intraperitoneal bladder rupture: exploration and suture closure or If a supra-pubic catheter is used, it should be tunnelled to prevent anterior wound contamination
  23. 23. Gynecologic injury • Laceration of the vagina • Results from dislocation or fractures of the pubic rami --Early repair of vaginal lacerations to minimize pelvic abscess
  24. 24. Haemodynamic Status • if hemorrhage continues inspite of all this • Then consider angiography or embolization – Arterial lesions only represent 10-20% of cases.
  25. 25. Possible Bleeders • Sacral venous plexus* • Iliolumbar a. • Internal iliac a. • Superior gluteal a.* • Lateral sacral a. • Pudendal a.*
  26. 26. Angiography-embolisation • Advantage – Useful in assessing and embolization of arterial injury • Disadvantage – Source of arterial bleeding is identified in only 10- 15% of patients with severe pelvic disruption – Does not address venous bleeding
  27. 27. Angiography-complications • Lead to necrosis of buttock after occlusion of entire internal iliac artery • Sciatic or femoral paresis • Bladder wall necrosis • Emboli to normal vessels
  28. 28. Definitive treatment --done at a later date after patient is fit -external fixator is continued or converted to orif -urethral injuries are repaired -colostomy closure -bladder closure if SPC was used -plastic surgery reconstructive procedures
  29. 29. Pelvic infection soft tissue infection osteomyelitis high mortality and morbidity long-term disability Open pelvic fractures---complications
  30. 30. --Sciatic nerve injury --Urogenital problem like stricture, incontinence and impotence --Persistent sacroiliac pain due to unstable pelvis

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