Pelvic Fractures
and
Associated Injuries
Dr Huw Williams MB BCh MCEM
Pelvic Injuries in Trauma
1o Survey
A
B
C
D
E
2o Survey
3o Survey
Pelvic Injuries in Trauma
1o Survey
A
B
C
D
E
2o Survey
3o Survey
Pelvic Anatomy
Pelvic Anatomy
1. Sacrum
2. Innominate bones
3. Ligamentous complex
Pelvic Fractures in Trauma
Pelvic # in approx. 9% of all major traumas
All age mortality rate = 5-to-16%
Age > 65 years mortality rate = 20%
Some mortality quotes up to 45% ?
Pelvic Fractures in Trauma
Pelvic # in approx. 9% of all major traumas
All age mortality rate = 5-to-16%
Age > 65 years mortality rate = 20%
Some mortality quotes up to 45% ?
What does this mean?
? isolated pelvic injury (without an abdominal injury)
Pelvic #s = increased risk of death
Where can we
bleed from?
Where can we
bleed from?
1. Pelvic venous plexus
2. Pelvic arterial injury
3. Fracture bone surfaces
4. Any visceral injury
Remember: extra-pelvic injuries
Where can we
bleed from?
1. Pelvic venous plexus
2. Pelvic arterial injury
3. Fracture bone surfaces
4. Any visceral injury
Remember: extra-pelvic injuries
How much blood can we
lose into our pelvis ?
1 litre ?
2 litres ?
3 litres ?
4 litres ?
5 litres ?
How much blood can we
lose into our pelvis ?
‘Haemorrhage from pelvic fracture is essentially bleeding
into a free space, potentially capable of accommodating
the patient’s entire blood volume without gaining
sufficient pressure-dependent tamponade’
(Suzuki et al., 2008)
Mechanism of Injury
and Classification
Three mechanisms 
i.
AP Compression Injury
ii. Lateral Compression Injury
iii. A Shear Force Injury
Mechanism of Injury
and Classification
Three mechanisms  four patterns
i.
AP Compression Injury
ii. Lateral Compression Injury
iii. A Shear Force Injury
iv. A Combination
i.
AP Compression Injury
How:
RTC (car vs. peadestrian / motor-cycle crash)
direct crush injury
fall (>12ft)
i.
AP Compression Injury
How:
RTC (car vs. peadestrian / motor-cycle crash)
direct crush injury
fall (>12ft)
What Happens:
symphysis pubis brakes 
tearing of posterior ligamentous complex
AP Compression (‘open book pelvis’)
Frequency = 15 to 20 %
(may rupture venous plexus / internal iliac artery)
ii.
Lateral Compression Injury
How:
RTC (motor-cycle crash)
Direct compression / crush
ii.
Lateral Compression Injury
How:
RTC (motor-cycle crash)
Direct compression / crush
What Happens:
internal rotation of hemi-pelvis 
fractures around pubis 
Lateral Compression (‘closed pelvis’)
Frequency = 60 to 70 %
genitourinary system injury
(life threatening haemorrhage is less common)
iii.
Shear Force Injury
How:
falling from a height onto one limb
RTC
iii.
Shear Force Injury
How:
falling from a height onto one limb
RTC
What Happens:
high-energy applied in a vertical plane 
major instability of pelvis
Vertical Shear
Frequency = 5 to 15%
iv.
Combination
Tile Classification
Young Classification
Ross Classification
iv.
Combination
i.
AP Compression Injury 
? major haemorrhage of the venous plexus / internal iliac artery
ii.
Lateral Compression 
injury to bladder/urethra/other / ↓ pelvic volume therefore ? ↓ haemorrhage
iii. A Shear Force 
high-energy / major instability
Assessing the Pelvis
‘Springing the Pelvis’
Assessing the Pelvis
‘Springing the Pelvis’
Assessing the Pelvis
Direct Peritoneal Lavage
Assessing the Pelvis
Direct Peritoneal Lavage
Assessing the Pelvis
PR for ? high-riding prostate
Assessing the Pelvis
PR for ? high-riding prostate
Assessing the Pelvis
Signs
Inspect flanks, scrotum, peri-anal area
?blood at meatus / ?swelling / ?bruising / ?deep laceration
Major disruption
Leg length discrepancy
Distending Abdomen
Assessing the Pelvis
Symptoms
Tachycardia
Hypotension
Abdominal Pain
Pelvic Pain
Assessing the Pelvis
Imaging
Plain film PXR
BONE
eFAST
BLOOD
CT
BONE / BLOOD
Angiography / CT angiography
BLOOD
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
PELVIC X-RAY PLAIN FILM
AP Compression Injury
Lat. Compression Injury
A Shear Force Injury
A Combination
Normal
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
-VE FAST
FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA
+VE FAST
CT
Plain film
CT Scan
CT
CT Scan
CT 3D reconstruction
CT
Angiography /
CT Angiography
Managing the Pelvis in the ED
Sheet
Pelvic binders / splints
? Bend knees & tie ankles (internal rotation)
Scoops (not boards)
Large IV lines / ?permissive hypotensive
resuscitation / ? haemorrhage protocol
Definitive Management of the Pelvis
Surgery  stem bleeding / fix pelvis / pack pelvis
Angiography plus iatrogenic embolization
Conclusion
Assume there is not a isolated pelvic injury
Assume the worst
Early intervention / minimal pelvis movement once splinted
Thankyou
Any Questions?
References
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