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ORTHOPAEDIC TRAUMATOLOGY - PELVIC FRACTURES Karl Akke Alberts, M.D.

The Orthopaedic Surgeon is a member of the trauma team and the immediate task is to perform primary assessment of the trauma patient. The pelvic ring, extremities and the entire spine including neuromuscular function and peripheral circulation of the extremities are examined. The objectives of the orthopaedic treatment are to improve the physiological condition by control of internal and external haemorrhage and to decrease the systemic response of the trauma. The incidence of SIRS, ARDS and MOF is reduced by reperfusion of an iscemic extremity, debridement of open wounds and immediate reduction and stabilisation of fractures. A soft collar is used to temporarily stabilise an unstable pelvis and a quick traction device is used for femoral fractures. Secondary assessment is then performed. Further investigations, priorities and order of treatment of different injuries are determined in agreement with the trauma leader. Bleeding from pelvic disruptions or fractures has the first priority among the orthopaedic injuries. Second priority has open fractures and fractures with compartment syndrome or arterial injury. Third priority has femoral shaft fractures. An adequate fixation should be done within 12 hours. A pelvic fracture is the fracture, which is associated with the highest death rate. Death is not caused by the skeletal injury itself but by complications such as bleeding or sepsis from an infected open fracture. The severity of a pelvic fracture can easily be underestimated. It is therefore important to make an early manual examination for pelvic instability and to make a plain film already in the resuscitation room. The pelvic ring can be stabilised by three different methods depending on the situation namely a soft collar, a C-clamp or an anterior external frame. Another bleeding source than a retroperitonal haematoma from an unstable pelvic injury in a patient who is in circulatory shock must be found immediately with the help of a chest film and an ultrasound scan of the abdomen. Four different scenarios can be anticipated in a patient with a mechanically unstable pelvic injury: 1. A dying patient (in extremis): Emergency laparatomy and aortic compression followed by external fixation with a C-clamp or an anterior frame and pacing of the

retroperitoneal bleeding in the pelvis. 2. A circulatory unstable patient not improved by i.v. fluids and with suspected intraabdominal haemorrhage on ultrasound examination: again start with laparatomy, control intraabdominal bleeding and continue with emergency pelvic external fixation. 3. A circulatory unstable patient not improved by i.v. fluids and with no intraabdominal haemorrhage: start with emergency external fixation of the pelvis with a C-clamp or an anterior frame. If the patient does not improve continue with laparatomy and packing or angiographies with embolisation depending on the qualifications. 4. A circulatory stable patient or a patient who improves after i.v. fluids and pelvic stabilisation with a soft collar: precede with a spiral CT scan. If the patient shows signs of continuos bleeding, which often is arterial continue with angiographies.

Classification of pelvic injuries to determine the extent of mechanical instability is usually done according to Tile. In high energy trauma there usually is an anterior and a posterior injury in the pelvic ring. Three injury types according to mechanism are described: an open book injury caused by an anterio-posterior direction of force, a bucket handle injury caused by lateral compression and a vertical shear injury with disruption of the entire hemipelvis. The comprehensive AO classification of fractures in A, B and C injuries with sub-classes is based on these principal fracture patterns. A-injuries are stable and need no fixation. B-injuries including open book injuries with symphysis pubis widening more than 2.5 cm are treated by external fixation or plate fixation. C-injuries which are vertically unstable need reduction and fixation of the anterior as well as the posterior pelvic ring injuries in order to mobilise the patient. For fixation of posterior ring injuries in the SI-joint or sacrum, percutaneousely inserted ileosacral screws to the S1 body are often used.