Professional Documents
Culture Documents
DR.A.PRANEETH
2ND YEAR PG RESIDENT
DEPT OF GENERAL SURGERY
DR PSIMS & RF
Pelvic Trauma : epidemiology
The incidence of this injury that jeopardize not only the function, but the very
life of the patient has increased for past two decades due to high speed
motor vehicle accidents.
Fractures of the pelvis account for less than 5% of all skeletal injuries,
Among the polytrauma patients, the incidence has risen to 25%.
Complex pelvic fractures (higher energy) – younger patients,
M:F = 3:1
Massive haemorrhage.
Bony disruption of pelvis.
Vascular interruption (major and minor).
Urologic injury.
Bowel and vaginal tears of perforations.
Neurologic injury.
ANATOMY
The pelvic ring is composed of the sacrum and 2 innominate bones joined
anteriorly at the symphysis and posteriorly at the paired sacroiliac joints.
stable unstable
rotational vertical
Stable injuries include non displaced fractures of the pelvic ring and
fractures resulting in <2.5cms of displacement of anterior structures ,
anterior pubic rami or symphysis.
Rotational instability is characterized by widening of symphysis pubis or
displacement of pubic ramus fractures by > 2.5 cms.
Vertical disruption of SI joint by > 1cms constitute vertical instability.
LC type – 1 : a posteriorly directed force causing a sacral crushing injury &
ipsilateral horizontal pubic ramus fractures.
LC type – 2 : a more anteriorly directed force causing horizontal pubic
ramus fractures with an anterior crushing injury and either disruption of of
the posterior SI joints or fractures through the wing.
LC type – 3 : an manteriorly directed force that is continued and leads to
a type 1 or 2 ipsilateral fracture with an external rotation component to
the contralateral side; SI joint is opened posteriorly.
APC type 1 : an AP directed force opening the pelvis but with the posterior
ligamentous structures intact.
APC type 2 : continuation of type 1 fracture with disruption of
sacrospinous and potentially the sacrotuberous ligaments & an anterior
SI joint opening.
APC type 3 : a completely unstable or vertical instability pattern with
complete disruption of all ligamentous supporting structures.
Vertical shear fractures : a vertically directed force at right angles to the
supporting structures of the pelvis ,leading to vertical fractures in the rami
and disruption of all the ligamentous structures.
Diagnosis
History:
Mechanism of injury forms the key component in the
diagnosis, classification and management of pelvic injuries.
H\O road traffic accident, fall from a height or crush injury.
Clinical evaluation
Hepatorenal
Splenorenal fossa
fossa
Pelvis or douglas
pouch
The Iliopectineal line should be traced back to its intersection
with lateral margin of ala.
It should be at the same level ( usually at superior margin of
S2 foramen) bilaterally.
best demonstrates ring configuration of
pelvis, & narrowing or widening of diameter
of ring is immediately apparent.
evaluates for posterior displacement of
pelvic ring or opening of pubic symphysis
shows the anterior ring superimposed on the posterior ring.
- evaluates for vertical shift of pelvis (migration of
hemipelvis);
- proximal or distal displacements of anterior or posterior
portion of ring are best appreciated on this view;
- sacrum appears in its longest dimension, w/ neural
foramina
evident.
Judet views
4.Treatment of 2.Management of
fracture Mx severe bleeding
3.Mnagaemnet of
urethra and
bladder , bowel
injuries
Haemodynamic status
Arterial bleeding usually arises from branches of the internal iliac system
with the superior gluteal and pudendal arteries being the most commonly
identified source.
Hypovolemic shock : why it bleeds so much….
pre-sacral venous plexus overlies the joint pelvis forms a limited container
BLEEDS
MASSIVE BLEED
(5-6 LITRES)
Definitive treatment
C-clamp
MAST/PASG
Extra peritoneal pelvic
packing
Non-Operative Management
APC – 2 : ORIF
This does NOT mean that all sites of injury need fixation.
Timing of surgery
Stoppa extension
Exposes symphysis to SI joint along pelvic brim
Posterior pelvic ring :
Anterior approach
Iliac window of the ilioinguinal
Exposure of SI joint
Posterior approach
Exposure of sacrum and posterior ilium
Iliac fracture dislocations of the SI joint
(crescent fracture
Reduction & fixation
Thromboembolism
The urinary bladder is generally protected from external trauma because of its deep
location in the bony pelvis.
Most blunt bladder injuries are the result of rapid-deceleration motor vehicle
Collisions, but many also occur with falls, crush injuries.
Disruption of the bony pelvis tends to tear the bladder at its fascial attachments, but
bone fragments also can directly lacerate the organ.
The most common associated injury is pelvic fracture, which is associated with 83%
to 95% of bladder injuries
Conversely, bladder injury has been reported to occur in only 5% to 10% of pelvic
fractures
Types of bladder injuries
The usual treatment of uncomplicated extraperitoneal bladder ruptures, when conditions are
ideal, is conservative management with urethral catheter drainage alone for 7-14 days,
placement.
Cystography is necessary to verify complete healing before catheter removal 14 days after
injury .
Intra peritoneal injuries are often larger than suggested on cystography and are
unlikely to heal spontaneously, and continued leak of urine causes a chemical
peritonitis.
When concurrent rectal or vaginal injuries exist, the organ walls should be
separated, overlapping suture lines should be avoided.
every attempt should be made to interpose viable tissue in between the repaired
structures.
Fibrin sealant injected over the bladder wall closure may help reduce complications
when intervening tissue is unavailable
Unrecognized bladder neck, vaginal, and rectal injury associated with the
bladder rupture - incontinence, fistula, stricture, and difficult delayed major
reconstruction.
Fracture of the anterior pelvic ring or pubic diastasis are almost always
present when urethral disruption is encountered.
They are also commonly associated with pelvic fractures (up to 10 %) as the
posterior urethra is adherent to the pubic symphysis.
“Straddle fractures” involving all four pubic rami and fractures resulting in vertical
and rotational pelvic instability are associated with the highest risk of urologic injury.
Because the posterior urethra is densely adherent to the pubis via the urogenital
diaphragm and the puboprostatic ligaments, the bulbo-membranous junction is
more vulnerable to injury during pelvic fracture than the prostate-membranous
junction.
In children, injuries are less common but are more likely to extend proximally to the
bladder neck because of the rudimentary nature of the prostate.
Diagnosis
Urethral disruption is heralded by the triad of blood at the meatus, inability to urinate, and
palpably full bladder.
female patients also may develop proximal urethral avulsion injuries. They present with vulvar
edema and blood at the vaginal introitus.
A small-bore (16-Fr) urethral catheter is placed unlubricated 1 cm into the fossa navicularis
the balloon is filled with 1 ml of water to achieve a snug fit 25 mL of contrast medium is
injected gently by a 60-mL catheter-tip Syringe, and the film is taken during injection.
In cases of female urethral disruption related to pelvic fracture, suggest immediate primary
repair, or at least urethral realignment over a catheter, to avoid subsequent urethrovaginal
fistulae or urethral obliteration .
Delayed reconstruction is problematic because the female urethra is too short (about 4 cm) to
be amenable for mobilization.
a large-bore (24-Fr) Foley catheter placed high in the bladder and tunneled through the skin as
high as possible on the lower abdominal midline to keep the tube away from the plated
symphysis.
When the urethral catheter is removed after 4 to 6 weeks, it is imperative to retain a
suprapubic catheter because many patients, despite realignment, will develop
posterior urethral stenosis.
If the patient voids satisfactorily through the urethra, the suprapubic catheter can be
removed 7 to 14 days later.
Incomplete urethral tears are best treated by stenting with a urethral catheter.
Anterior urethral injuries generally occur during a straddle injury and involve the
bulbar urethra.
Penile urethral injury is rare and may result from penetrating injuries to the penis.
Clinical signs of anterior urethral injuries include blood at the meatus, perineal
hematoma, gross hematuria, and urinary retention.
The primary morbidity of straddle injury is urethral stricture, which may become
symptomatic years later.
Management
Initial suprapubic cystostomy is the standard of care for major straddle injuries involving the
urethra
Debridement can be minimized as the robust blood supply to the sponge often results in
spontaneous healing.
Scrotal rotation flaps can be used for more proximal defects if skin loss is limited,
but the hair-bearing nature of scrotal skin risks an unacceptable cosmetic result.
care must be taken to remove any subcoronal skin remaining after debridement.
Lymphatic obstruction of this distal foreskin, if it is not excised, results in
circumferential Lymphedema.
Although only 1.5% of blunt testis injury involves both gonads, about 30% of
penetrating scrotal trauma results in bilateral injury.
Ultrasonography can be helpful to assess the integrity and vascularity of the testis
in equivocal cases.
• Grade 1: Contusion/Hematoma
• Grade 2: Subclinical laceration of tunica albuginea
• Grade 3: Laceration of TA with <50% parenchymal loss
• Grade 4: Major laceration of TA with ³50% parenchymal loss
• Grade 5: Total testicular destruction or avulsion
The tunica albuginea should be closed with small absorbable sutures after removal of
necrotic and extruded seminiferous tubule.
Testicular salvage rates exceed 90% with exploration and repair within 3 days versus
orchidectomy rates threefold to eightfold higher with conservative management and
delayed surgery
For extensive injuries, the testes may be placed in thigh pouches, treated with wet
dressings, or placed under vacuum pressure dressings until reconstruction.
Thigh pouches are not recommended initially, until the infection is stabilized, because
transmission of the infectious process into uninvolved tissues may occur
Rectal injuries
Most commonly, injuries to the rectum occur with penetrating rather than blunt pelvic
trauma.
Although less common with blunt bony pelvic injury, 25 % of patients with an open pelvic
fracture have an associated rectal laceration.
Extraperitoneal space for the rectum is divided into retroperitoneal high up in the abdomen
and subperitoneal low in presacral space.
Suspicion of Injury :
- proper inspection of perineal region
- per rectal examination
- rigid proctoscopy or flexible sigmoidoscopy
- CT of the rectum with rectal contrast should be used with caution as immediate
imaging may not accurately assess high energy wounds to the rectum that are only a partial
injury to the wall that subsequently convert into a full thickness wound.
Investigations
Traditionally, rectal trauma had been managed with the principle of the four Ds: divert,
anastomosis are difficult in the elective setting and even more so in trauma.
Therefore, diversion of the fecal stream with a proximal colostomy with or without presacral
Primary diversion regardless of the size of the rectal injury is the most prudent and
Two to 3 months following the injury, the rectum and distal colon can be evaluated
for healing and patency with a barium enema and, if adequate, the colostomy may
be reversed with high rates of success.
Currently, injuries to the rectum should be managed with proximal diversion with
additional consideration for tissue debridement and omental flap placement when
there is concomitant GU injury.
In perineal and anal canal injuries, no attempt should be done for primary
sphincteric or tissue repair, only debridement and hemostasis are done.
It is however, mandatory to divert the fecal stream totally from the wound in
the perineum if the lesion is even moderately extensive and specially if
involving the sphincteric complex of the anal canal.
The skin is better left open and dressed twice daily, Secondary sutures are
done after 4 to 5 days.
Pre sacral drainage
CONCLUSION
Multidisciplinary approach(general
surgery,urology,neurosurgery,interventional radiology).
Close coordination.
REFERENCES