Pelvic trauma

Section: Trauma Curriculum: Curriculum, page 80

Surgical Anatomy

• Key Points - Ischium, Ilium, Pubis
  • Pelvic inlet/ring fracture’s - almost always anterior and posterior fracture
  • Divided into true and false pelvis
    • True pelvis - below the pelvis brim/pelvic inlet
      • Internal illiac vessels
      • Most major pelvic bleeding
    • False pelvis - between iliac crest and pelvic brim
      • External iliac vessles
  • Blood supply is rich within cancellous bone
    • Most pelvic bleeding is venous from fractures
  • Can accommodate up to 3L of blood
    • May track up to retroperitoneum or down thigh
  • SIJ crossed by lots of important structures → Debilitating when #
    • Iliac vessels
    • Lumbosacral nerves
    • Sciatic nerve roots
    • Ureters
  • Pelvic organs bear brunt of force too → Rectum, Vagina, Uterus, Bladder
  • Fracture penetration of bladder
  • Acetabulum injury should be recognised as are associated with significant disability

Tile’s Classification

• Based on pelvic ring stability
• Type A - Completely stable with intact Posterior Arch
  • Isolated Iliac Wing or Pubic Rami #’s or Transverse Sacral #
  • Minimally associated with bleeding
  • Conservative mx
• Type B - Rotational instability (vertically stable)
  • B1 - Externally rotated # Unilateral
    • External rotationally unstable, vertically stable, posterior arch incomplete disruption
    • Open Book
    • Anterior lesion (Symphysis, Inf/Sup Pubic Rami) +
    • Posterior disruption (Ant or Post SIJ ligaments)
    • Pelvic organ injury
  • B2 - Internally rotated # Unilateral
    • Lateral compression
    • Internal rotation instability
    • Bladder perf
    • Shock
    • Pelvic organ injury
  • B3 - Bilateral
• Type C - Rotation and vertical instability
  • C1 - Unilateral complete disruption of posterior arch
  • C2 - Unilateral complete disruption of posterior arch with contralateral rotational instability/incomplete posterior arch disruption (B type #)
  • C3 - Bilateral complete disruption of posterior arch with spinopelvic dissociation

Clinical

• Tenderness on pelvic palpation or discrepancy in ASIS heights
• Perineal bruising
• High riding prostate
• Haematuria or meatal blood

Management

• If suspicious for pelvic bleeding or has transiently responded
  • Pelvic binder or draw sheet compression wrapped around level of greater trochanters
  • External fixation - c-clamp applied at level of SIJ
  • If ongoing bleeding
  • EPP +/- IR
• If pt is unstable
  • Consider REBOA/aortic cross clamping dependent on pt situation
    • Pelvic binder may block this and need to be repositioned
  • EPP and or IR
  • If there’s a blush → Arterial → Unlikely to settle with EPP → need IR
  • EPP reduces pelvic potential volume and tamponades venous bleeding
• External Fixation
  • Unable to provide complete stability to a circle with external forces
  • Options - Iliac crest route, supra-acetabular route, pelvic c-clamp route
• Laparotomy
  • Can do EPP if there is a large or expanding pelvic haematoma
  • DCS including post-op IR embolization after EPP
• Extra-peritoneal Packing
  • Pelvic binder or ex fix on
  • 5cm lower midline incision to fascia → Divided to Parietal Peritoneum
  • Protect bladder, develop Retzius space and bluntly develop extraperitoneal plane circumferentially starting from pubic symphysis and following the pelvic brim
  • Pack from deep to superficial with large packs after passing the SIJ (palpable bony prominence
  • Temporary closure
  • NB: EPP should be done prior to DCS laparotomy