1. Methas Arunnart MD.

2. HIGH ENERGY IMPACT
 Falls
 High speed VA
 Crush injury

3. Management strategy of vascular injuries associated with pelvic fractures. J Cardiovasc Surg
33:349, 1992; Prorities in Management. Arch surg 124:422, 1989; Effective classification

4.  1 SACRAL Bone
 2 INNOMINATE bones
 PUBIS
 ILIUM
 ISCHIUM
 Symphysis gap <5 mm

6.  No inherent stability—Ligaments give stability
 Anterior SIL resist external rotation
 Sacrospinous - resists external rotation
 Posterior SIL and ILL - provide posterior
stability by tension band , strongest in body
 Sacrotuberous - resists shear/flexion SI joint

9.  Sacral venous plexus*
 Iliolumbar a.
 Internal iliac a.
 Superior gluteal a.*
 Lateral sacral a.
 Pudendal a.*

11.  Bladder/Urethra
 Rectum
 Prostate
 Vagina

12.  AP pelvis during early phase of resuscitation is
useful to determine presence or absence of
unstable pelvic fracture
 AP pelvis can identify 90% of pelvic injuries

13.  Inlet View – 45 degree caudal tilt
 True AP projection of the pelvic brim
 Evaluates for posterior displacement
 Evaluates for rotation of ilium and sacral impaction
injuries

14.  Outlet View – 45 degree cephalad tilt
 Evaluates for vertical shift of pelvis
 provides a better demonstration of sacral fractures
and injuries to the sacroiliac joints.

15.  CT Scan
 Best visualization for Sacrum and SI joint
 Rotational and posterior displacement can
be easily assessed

17.  Type A: pelvic ring stable
 Type B: rotationally unstable, vertical stable
 Type C: rotationally and vertically unstable
Advantages: Tile classification aids in
the determination of prognosis

18.  Lateral compression (LC)
 Anteroposterior compression (APC)
 Vertical shear (VS)
 Combined mechanism (CM)
Advantages: this classification alerts the surgeon to
potential resuscitation requirements and
associated injury patterns

20.  Airway Maintenance with C-spine protection
 Breathing and Ventilation
 Circulation with hemorrhage control
 Disability: Neurologic status
 Exposure/Environment Control: Undress
patient but prevent hypothermia

21.  Neurologic deficit involving lumbosacral plexus
 Pelvic/flank/perineal
contusions,ecchymoses,abrasions
 Blood at urethral meatus
 Blood in or around rectum
 Open wound of groin,buttock, or preineum
 Leg length inequality or external rotation of one
extremity
 Abnormal pelvic motion on AP or lateral
compression of anterior iliac spines and iliac crests

22.  Rectal exam for tone
 Bulbocavernosus reflex
 Myotomes of lower extremity
 L1-2 : hip flexor
 L3-4 : Quadriceps/knee extension
 L4-5 : Ankle and toe dorsiflexion
 S1 : ankle plantarflexion
 S2-3 : toe plantarflexion

23.  Sheet around pelvis Pelvic binder

24.  Return blood from lower ext. to central vascular system
 Ability to close open-book-type injury, reducing pelvic
volume
 Stabilize pelvic ring permitting clot formation

25.  Advantage
 Useful in assessing and embolization of arterial
injury - Unexplained blood loss after stabilization and aggressive
resuscitation , Pulseless extremity
 Disadvantage:
 Source of arterial bleeding is identified in only 10-
15% of patients with severe pelvic disruption
 Does not address venous bleeding

26. Primary survey
stable unstable
Pelvic Fx No Fx Pelvic Fx
No Fx
CT,FAST,DPL
CT scan
APC LC
CT,FAST,DPL
classify Fx
Reassess Explor lap. Open bookothers
Reassess
- External compression
- Explor lap. +/- packing
- Angiography vs ext. fixation
SI jonit involvement-
consider iliac injury

28.  Lateral compression (LC)
 Anteroposterior compression (APC)
 Vertical shear (VS)
 Combined mechanism (CM)
Advantages: this classification alerts the surgeon to
potential resuscitation requirements and
associated injury patterns

30.  LC type I:
 unilateral rami fx . (transverse)
& ipsilat sacral compression.
 LC type II:
 unilateral rami fx.
& ipsilat post. iliac fx.
 LC type III:
 LC I/II & contralat. APC

32.  APC type I:
 symphysis widened < 2cm;
SI joint intact
 APC type II:
 symphysis widened >2cm or rami fx
& ant. SI lig. Torn
 APC type II:
 symphysis widened >2cm or rami fx
& ant & post SI lig. torn

33.  Vertical shear (VS)
 Vertical displacement
 Combined Mechanical(CM)
 Combination of LC + VS or APC

36.  15-20% of pelvic fractures
 Extraperitoneal vs Intraperitoneal
 clinical
 Scrotal/labial swelling
 Gross hematuria
 Retrograde Urethrogram

37.  Occurs in less than 1%
 Clinical
 Laceration of rectum or perforation of small and/or
large bowel
 Rectal tears accompany perineal wounds
 Requires diverting colostomy in 6-8hr
following injury to reduce incidence of sepsis
and death

38.  Laceration of the vagina
 Results from dislocation or fractures of the
pubic rami
 may require operative intervention