PELVIC FRACTURE ppt by dr.bharti pawar.ppt

includes pelvic fractures

1. PELVIC FRACTURES
DR.BHARTI PAWAR (PT)

2. PELVIC FRACTURES
Fractures of the pelvis account for less than
5% of all skeletal injuries, but it is important
because it associated with:-
1.Soft tissue injuries and blood loss.
2.Shock.
3.Sepsis.
4.ARDS.
Because of those mortality rate exceeds 10%.

5. PELVIC FRACTURES
Fractures of the adult pelvis, exclusive of the acetabulum,
generally are either stable fractures resulting from low-
energy trauma, such as falls in elderly patients, or
fractures caused by high-energy trauma that result in
significant morbidity and mortality.

6. Mechanisms of injury
 The basic mechanisms of pelvic ring injury are:
1.Anteroposterior compression (APC).
2.Lateral compression (LC).
3.Vertical shear (VS).
4.Combinations of these.

7. Anteroposterior compression
(APC)
Usually caused by a frontal collision between
pedestrian and a car. This injury may lead to:
1.Fracture of the rami.
2.The innominate bones are sprung apart and
externally rotated with disruption of the
symphysis.
3.The anterior sacroiliac joint is partially torn.
4.Fracture of the posterior part of the ilium.
This is called open book injury.

9. Lateral compression (LC)
Side to side compression of the pelvis
causes the ring to buckle and break. This
is due to a side –on impact in a road
accident or a fall from a height.
This injury may lead to
1.Anteriorly the pubic rami on one side or
both sides are fractured.
2.Posteriorly there is severe sacroiliac strain
or fracture of the sacrum or ilium, either
on the same side of the pubic fracture or
on the opposite side.

11. Vertical shear (VS)
The innominate bone on one side is displaced vertically,
fracturing the pubic rami and disrupting the sacroiliac
region on the same side. This is typically occurs when
falls from a height on one leg. These are severe unstable
injuries with gross tearing of the soft tissues and
associated with retroperitoneal hemorrhage.

13. Combination injuries
In severe pelvic injuries there may be a combination of
the above.

14. CLASSIFICATIONS

15. TILES CLASSIFICATION

16. YOUNG AND
BURGRESS
CLASSIFICATION

19. Clinical features and
clinical assessment
1.Fracture of the pelvis should be suspected
in every patient with serious abdominal
injury or lower limb injury.
2.H\O road traffic accident, fall from a height
or crush injury.
3.Severe pain, swelling and bruises in the
lower abdomen, perineum, thighs, scrotum
or valva.
4.Extravasations of urine.
5.Symptoms and signs of bleeding and
hemorrhagic shock.

21. Clinical features and clinical
assessment
6.Tenderness all over the pelvic bone especially when
attempt to compress or distract the pelvis.
7.Tender abdomen due to bleeding or intrapelvic
structure injuries.
8.Rectal examination should be done in every case.

23. Clinical features and clinical
assessment
9.Bleeding in external meatus indicates
urethral injury. If no bleeding ask the
patient to void and give direct look to
the urine, if the patient able to void this
indicates either no urethral injury or
there is only minimal damage to the
urethra.
Note no attempt should be made to pass a
catheter, as this could convert the partial
injury to complete injury.
10.Neurological examination should be
done to exclude sacral and lumber
plexus injury.

24. Radiography
1. plain radiography: 5 views are necessary
1.Anteroposterior view.
2.Pelvic inlet view in which the tube is cephalad
to the pelvis and tilted 45°downwards.
3.Pelvic outlet view in which the tube is caudad
to the pelvis and tilted 45°upwards.
4.Right oblique view.
5.Left oblique view.

25. RADIOGRAPH POSITIONING : AP VIEW
Patient lies supine with the x ray beam centered over the pelvis

26. RADIOGRAPH POSITIONING : INLET
VIEW
X Ray beam is directed 45 degrees caudally.
Simulates a direct view of pelvis from above along its longitudinal axis.

27. RADIOGRAPH POSITIONING :
OUTLET VIEW
X Ray beam is directed 45 degrees cephalad.
Simulates looking at sacrum and SI joint en face.

28. X RAY PELVIS : AP VIEW

29. X RAY PELVIS : AP VIEW
PUBIC SYMPHYSIS SHOULD BE COLINEAR WITH THE SACRAL
SPINOUS PROCESS

30. X RAY PELVIS : AP VIEW
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.

31. X RAY PELVIS : AP VIEW
Asymmetry of SI
joint or foramina :
possibility of SI joint
dislocation or sacral
fracture.

32. X ray Pelvis : AP view
Fracture of L5 transverse
process : Vertical shear
injury due to avulsion of
the processes via
Iliolumbar ligament.

33. Symphyseal
diastasis or pubic
rami fracture :
may have
additional
injuries in the
posterior ring.

34. X RAY PELVIS : INLET VIEW
•AP translation of
hemi pelvis.
•External/ Internal
rotation of hemi
pelvis.
•Opening of SI joint.
•Impaction # of sacral
ala.

35. X RAY PELVIS : OUTLET VIEW
•Vertical shift of hemi
pelvis.
•Sacral fractures relative
to foramina.
•Flexion or Extension
deformity of pelvic ring

36. CT SCAN
CT scan gives accurate details and much information
about the injury.
CT scanning is imperative in any suspected pelvic injury
or in suspected sacral fractures.
2mm to 3mm axial sections are recommended.

37. CT SCAN
LATERAL X RAY OF SACRUM and CT SCAN of the same patient showing
SACRAL FRACTURE DISLOCATION WITH SPINAL PELVIC
DISASSOCIATION.

38. Urethrographyfor diagnosis of urethral
injury

40. Management
1. Early management
Treatment should not await full and detailed diagnosis.
Doctor should move according to the priority of life
saving measures with the already available
information.Six questions must be asked and the answers
acting upon as they emerge:

41. Management
1.Is there a clear airway?
2.Are the lungs adequately ventilated?
3.Is the patient losing blood?
4.Is there an intra abdominal injury?
5.Is there a bladder or urethral injury?
6.Is the pelvic fracture stable or not?

42. Management
After exclusion of the above, the doctor now has a good
idea about the patient general condition and the
associated injuries so further investigation can be done.

43. Management
2. Management of severe bleeding
 Treatment of shock –Rapid fluid
resuscitation,blood transfusion.
Wrapping of pelvis with sheets with internal
rotation & slight flexion of the knees.
Anterior external fixation,pelvic C-
clamp,pneumatic antishock garments.
Pelvic packing & angiographic embolisation if
required.
3. Management of urethral and bladder injury.

44. Management
4.Control of contamination
Repair of genitourinary and rectal injuries.
Debridement of necrotic tissue in case of
open injury.
5.Laparotomy if required

45. Management
5. Treatment of the fracture
1.Isolated fractures and minimally displaced fractures(LC
1 & APC 1): need only bed rest with lower limb
traction.

46. Management
2. More severe pelvic fractures (LC 2 & APC2) with pubic
symphysis diastasis of more than 2.5 cm,pubic rami
fractures with more than 2 cm displacement or other
rotationally unstable fractures with limb length
discrepancy of more than 1.5 cm require surgical
intervention either by external fixation or by closed
reduction and internal fixation.

51. Management
4.AP-III and VC are the most dangerous and the most
difficult to treat. These are unstable fractures and
needs reduction and fixation by either external fixation
or plate and screws.

53. Secondary complications
1.Sciatic nerve injury.
2.Urogenital problem like stricture, incontinence and
impotence.
3.Persistent sacroiliac pain due to unstable pelvis.

54. ACKNOWLEDGEMENT