Major Pelvic Trauma
Bernard Foley FACEM
Department of Emergency Medicine
Auckland Hospital
Wednesday, 8 April 2015
The Issues
Pelvic trauma doesn’t come in on it’s own
Routine Pelvic x-ray in blunt trauma

Do we always need it?
The unstable patient
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Fracture instability
Haemodynamic instability
Prioritising interventions

No universal algorithm
SI joint and
ligaments
Sacrospinous
ligament
Sacrotuberous
ligament
Pubic symphisis
Anatomy
Pelvic Fracture Types
Lateral Compression
B2 type partially stable
Vertical Shear
C1 type unstable
AP Compression
B1 type partially
stable
Haemodynamic stability is the key
Unstable

Definitive haemostatic procedure
Assisted stability

Investigations to target interventions
Stable

Investigation cascade
Sources of bleeding in pelvic
trauma
Arterial

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Usually laceration/avulsion associated with
ligamentous injuries
Mx therapeutic embolisation
Venous

Mx orthopaedic
Osseous

Mx orthopaedic
Sources of arterial bleeding in
pelvic trauma
Anterior division
branches of internal
iliac most commonly
injured


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Internal pudendal :
between SSL and
STL
Inferior gluteal :
above SSL
Obturator : through
foramen
Posterior division
branches of
internal iliac artery
most commonly
injured

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Superior gluteal :
piriformis fascia or
sacral #
Ilio-lumbar : sacral/
SI joint injuries
Orthopaedic trauma Auckland
Hospital 1995-2000
6040 orthopaedic
trauma admissions
520 Pelvic fractures
45% transfers
Pelvic trauma in Auckland hospital
1 Jan 1995-31 Dec 1998
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364 pelvic fractures
76 Haemodynamically
unstable
Mean ISS 30 (9-66)
39/76 car crash
10/76 motorcycle
8/76 pedestrian
13/76 falls
27/76 deaths
Injury patterns
43.7% Type A
28.5% Type B
27.8% Type C
49 Mechanically
unstable pelvic
injuries / year
Associated injuries
Chest / abdomen
23%
Genitourinary 17%
Head injury 31%
Associated injuries
Sacral nerve injuries
Rectal perforation
Vaginal perforation
Bladder and vesical injuries
Spinal injuries
Femoral fractures
Long-term disability
Mortality
Uncontrolled haemorrhage



Chest
Abdomen
Retroperitoneal
Other unsurvivable injuries

i.e. neurological injury
Multiorgan failure
Sepsis
Multitrauma / Time critical
Structured approach
required

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A,B,C’s
Resuscitation
Trauma radiography
Hx, examination, Ix
Extended trauma team
concept

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Interventional radiology
Orthopaedics
Urology
Prioritising
ABDOMEN
HEAD
PELVIS
CHEST
Pelvic trauma x-ray
Currently recommended as part of trauma series
Gonzalez et al (n=2,176)
 Alert patients (GCS14-15), blunt trauma
 Ethanol levels 16-75mmol/L (n=463)
 97 patients with pelvic fractures
Physical exam sensitivity 93%
 No significant fractures missed
Pelvic x-ray sensitivity 87%
 6 requiring operative intervention
J Am College Surg 194,No2. Feb 2002
CT scanning
Good at assessing haemorrhage in peritoneum and
retro peritoneum

Can aid planning of vascular/orthopaedic procedures
Good at assessing pelvic fractures
Requires stable patient (?assisted stability)
Procedures-pelvic
Sheet wrap
External fixation
Internal fixation
Angiography
Sheet wrap
Quick and easy
Inexpensive
Can do in ED
Good tamponade of
expanding haematoma
Not definitive
stabilisation
May impact on
exposure
External fixation
Good control of
anterior instability
Dependent on bone
quality
Not definitive
Impairs mobilisation
Can burn some
bridges
Open internal fixation
Big exposures
Unavoidable complication rate
Timing problematic in multitrauma
Percutaneous fixation
Exposure not a
problem
Low complication rate
Bio mechanically
ideal
Detailed anatomical
knowledge required
Technically
demanding
Therapeutic embolisation
Selective IIA angiography shows higher
incidence and severity of bleeding than aortic
flush studies

Better pickup of hypo-perfusion and spasm
Method of Embolisation
Anterior Division Embolisation
Proximal embolisation
more effective
Adverse events rare

Buttock claudication
Therapeutic embolisation
Allows ancillary procedures

i.e. percutaneous nephrostomy
Pelvic Fracture: Patient
Haemodynamically unstable
Rule out major peritoneal
or chest bleeding
SHEET WRAP
yes
CXR positive
no
no FAST/DPL grossly positive
yes
INTERCOSTAL DRAIN
yes
LAPAROTOMY
Stable
Stable
yes
no
ANGIOGRAPHY
Consider Ex Fix
PERCUTANEOUS FIXATION
WARD /ICU
Summary 1
A-P pelvis radiograph
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GCS <14
Clear clinical evidence of fracture
Suspicious mechanism
? Validated set of rules
Summary 2
Early involvement of orthopaedic and
Interventional radiology
Prioritisation of interventions
Early haemodynamic instability= arterial
bleeding= interventional radiology
Assisted stability may buy time for
additional investigations
Early percutaneous fixation appears to
produce the best results
It was a pretty bad accident Mrs Griffiths, we did what
we could