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Bleeding Primary

Treatment of Patients
with Pelvic Fracture
dr. Nadia Nastassia Ifran, SpOT

Pelvis
Pelvic ring : sacrum and 2
innominates
Innominate formed by the
fusion of ilium, ischium and
pubis

Function of Pelvis
Protection for visceral organs and traversing
neurovascular structures
The site for load transfer between axial skeleton and
lower extremities

Pelvic Fracture
Low energy injuries:
low energy fall, straddle type injury
Result in fractures of individual bones

High energy injuries


Motor vehicle accident, pedestrian-struck mechanism, fall
from heights, crush mechanism
Result in pelvic ring disruption

Trauma patients
Primary survey (ABCDE)
Address life-threatening injuries

Evaluate injuries to head, chest, abdomen, spine


Identify injuries to pelvis and extremities
Determine mechanism of injury!!

Young and Burgess Classification


Based on direction of forces causing fracture,
associated instability of pelvis, mechanism of injury
LC Lateral Compression

APC - Anterior Posterior Compression


VS Vertical Shear
CM Combined Mechanism

Young and Burgess

Young and Burgess LC


I Sacral crush injury on
ipsilateral side
II Sacral crush injury with
disruption of posterior SI
ligament; iliac wing
fracture (rotationally
unstable)

III LC-I or LC-II on


ipsilateral, contralateral
side external rotation/open
book injury (rotationally
unstable)

Young and Burgess APC


I Slight widening of pubic
symphisis (<2.5cm) and/or
anterior SI joint; intact
posterior SI ligaments
II Symphysys diastasis
(>2.5cm), sacrospinous,
sacrotuberous and anterior
SI ligament disruption;
intact posterior SI
ligaments (rotationally
unstable)

III Symphysis diastasis


>2.5cm, complete
disruption of anterior and
posterior SI ligament
(rotationally and vertically
unstable)

Young and Burgess VS CM


VS

Symphyseal diastasis or
vertical displacament
anteriorly and posteriorly;
usually through SI joint, less
commonly through iliac wing
and/or sacrum

CM
Combination of other injury
pattern (LC/VS)

Pre Hospital
Address other life threatening conditions (pelvic
fracture is a result of major force other significant
injuries??)
Oxygen
Large bore I.V. access fluids and analgesic
External compression

Internal rotate the lower extremities and taping


Avoid unnecessary pelvic movement

Close monitor of vital signs

Suspect pelvic fracture


Massive flank or buttock contusions
Perineal ecchymoses, scrotal or labial hematomes
Leg-length discrepancy,
Rotated lower extremity

Open wounds
Degloving injuries
Swelling in pelvic area
Hemorrhagic shock

Check stability of pelvis


Apply gentle medial pressure with
palms by pressing inward on iliac
crests
With patient supine, apply gentle
posterior pressure by pressing
downward on iliac crests

Apply gentle downward pressure


on pubis to check pelvic ring
stability

External compression
It gives less space for blood to accumulate
Tamponade bleeding sources (fractured bony surface,
ruptured vessels)
Reduce instability of the injured pelvis prevent
further damage to soft tissue and visceral organs
Reduces pain by limiting pelvic movement

Methods
Sheet method
PASG or MAST pants

Commercial/prefabricated devices
Pelvic binder

Hip hugger
Traumatic pelvic orthotic device (T-POD)

Sheet Method
Fold sheet smoothly 12 inch (do not roll)
Place under the patient and centered over greater
trochanter
Wrap and twist ends around pelvis

Tightened, cross the ends and tie or clamp

PASG or MAST pants

Inflate top compartments


Make sure the mid part sit over greater trochanter

Pelvic Binder

Hip hugger & T-POD

Emergency Department

HD unstable patients
Leading cause of death in patients with pelvic fracture
Posterior pelvic venous plexus accounts for majority of
bleeding (up to 80%)
Internal arterial injury <20%

Associated thoracal, abdominal , extremity and external


hemorrhage may be present

HD unstable patients
Damage Control Orthopaedics
Temporary stabilization of pelvis
Fluids resuscitation

External Fixation: AEF, C-clamp

Conversion to ORIF in stabilized patients

Resuscitation in Shock
2 large bore I.V. line (16G or larger)
Administer crystalloid and coloid solution determine
response
Platelets and FFP will be required with massive
transfusions to correct dilutional coagulopathy
Avoid hypothermia! It leads to coagulation problems,
ventricular fibrillation and acid-base disturbance

Anterior External Fixator


ASIS pin and AIIS pin

Emergently placed in HD
unstable patient
Allowing other procedure to be
performed (laparotomy, etc)
Confirmed under fluoroscopy
Indications:

Pelvic ring injury external


rotation component
Unstable ring injury with ongoing
blood loss

Contraindications:

Ilium fracture around insertion


point

Pelvic clamps
Developed to control
posterior pelvis
Large percutaneously placed
pins over the SI joint
posteriorly
Ganz C-clamps

Original designs points of


clamp applied to posterior
ilium in line with sacrum
Confirmed with fluoroscopy
Higher risk og istrogenic
injury than AEF

Pelvic packing
May aid in tamponade the
beeding
Pelvis should be stabilized
before packing
Packs can be placed pre
peritoneal and
retroperitoneal

Angiography Embolization
Indications:
HD unstable patients following
resuscitation
After external fixation
application

Rule out other source of


bleeding

Max. 30 minutes after arrival

Summary
Pelvic fracture that disturb the pelvic ring integrity is
one of the emergency concern
If the mechanism of injury is severe enough to cause
unstable pelvis then it is also severe enough to cause
other life threatening injury asses other areas!

ATLS protocol ABCDE


Splinting before transport