Yoyos Dias Ismiarto, dr., SpOT(K), M.Kes, FICS., CCD.
Epidemiology
• The overall incidence of pelvic ring
injuries is estimated at about 3% of all
fractures (AO).
– Among the polytrauma patients, the
incidence has risen to 25%.
– Mortality is about 6 - 50%.
– 39% due to bleeding (early).
– 30% due to sepsis & multi-organ failure
(late).
Anatomy of Pelvis
 Pelvis contains one pair of fused bone
 Each half contains: ilium, pubis, and ischium
 Joined together in posterior by sacrum
 Joined in anterior by symphysis pubis
Anatomy of Pelvis
Ilium
Male Pelvis
Female Pelvis
Sacrum
Pubis
Ischium
Symphysis Pubis
Anatomy Around Pelvis
 Organs near pelvis
 Parts of digestive system
 Reproductive organs
 Bladder and urethra
 Blood vessels run through and around
 Right and left iliac arteries from off aorta
 Right and left iliac veins returning from legs
 Blood vessels supplying pelvis and tissues around
pelvis
Function of Pelvis
 Pelvis bears weight of upper body
 Balances weight for legs when standing
 Protect blood vessels and organs
 Also serves as connection point for numerous
leg muscles
Common Fractures of Pelvis
 Pelvic ring fractures
 Pelvic ring is likely to
separate in more than one
location
 Iliac crest fractures
 Fractures to upper wing of
ilium
Pelvic Fractures
 Common mechanisms of pelvic injury result
from high energy
 ex. MVC, significant falls, skiing accident
 Those at risk for pelvic fractures
 Growing teens (especially those involved in
sports)
 Elderly patients (osteoporosis)
Risks of Pelvic Factures
 Iliac Crest fracture
 Typically pelvis still stable
 Little blood loss
 Pelvic Ring fracture
 Internal organ damage
 Significant blood loss (up to 4 liters)
•
Hypovolemic shock
 Unstable pelvis
 Risk of death (Mortality of 3.4%-42%)
Pelvic Ring Stability
 Stability defined as patient ability to support
physiologic load
 Physiologic load may be sitting, side lying, or
standing, as dictated by patient needs else
consider as unstable
Pelvic Ring Stability
 Posterior ring integrity is important in transferring
load from torso to lower extremities
Pelvic Ring Stability
 Loss of posterior ring integrity leads to instability
 Loss of anterior ring integrity may contribute to
instability, and may be a marker to posterior ring
injury
 Young and burgess classification will guide us for
stability issues
Young & Burgess Classification
Pathology
 The poor prognosis of pelvic fractures
 Fracture and vascular injury can cause the
formation of hematoma in the pelvis and
retroperitoneum  4 liters of blood
 90% bleeding  venous disruption or cancellous
bone
 10% bleeding  an arterial injury
Assessment
 ATLS Approach
 Check Stability :
 Mechanic
 Haemodynamic
Assessment cont.

Pelvis specific assessment
 Check for bruising, deformity, or abrasions
 Listen/Feel for crepitus
 Check limb length
Assessment cont.

Check stability of pelvis (DON’T REPEAT)
Apply gentle medial pressure with palms by
pressing inward on iliac crests
2) With patient supine, apply gentle posterior
pressure by pressing downward on iliac crests
3) Apply gentle downward pressure on pubis to
check pelvic ring stability
1)
Stability Assessment
1) Medial pressure
2) Posterior iliac pressure
3) Posterior pubis pressure
Diagnosis
 1. General: abrasion, contusion, hematoma,
over bony prominence of pelvis, scrotal, vulvar
hematoma.
 2. PE
 3. X-ray
 4. FAST
 5. DPL
 6. CT
Radiographic Evaluation
• X-Ray AP view:
– Anterior lesions:
pubic rami fractures
– Symphysis
displacement
– Sacroiliac joint and
sacral fractures
– Iliac fractures
– L5 transverse
process fractures
Radiographic Signs of
Instability
• Broken ‘Ring’
• Symphysis gap > 2.5 cm
• Sacroiliac displacement of 5 mm in any
plane.
• Avulsion of the 5th lumbar transverse
process, the lateral border of the sacrum
(sacrotuberous ligament), or the ischial
spine (sacrospinous ligament).
Treatment
 Treat for life threatening injuries
 Treat for possible shock
 Oxygen
 Intravenous infusion
 Splinting / Wrap
 Pain control
 RAPID TRANSPORT!!!
 Palients with hemorrhagic shock and unstable
pelvic fractures have four potential sources of
bloodloss :
 (1) fractured bone surfaces
 (2) pelvic venous plexus
 (3) pelvic arterial injury, and
 (4) extrapelvic sources.
The pelvis should be temporarily stabilized or
"closed" using an available commercial
compression device or sheet to decrease
bleeding.
•
•
In the presence of unstable pelvic ring
disruption and a positive abdominal
study, stabilization of the pelvis
should be undertaken before
laparatomy.
If hemodynamic stability is not
achieved after placement of the
external fixator, arteriography should
then be performed.
Non-Operative Management
(haemodinamically stable )
 Lateral impaction type injuries with minimal
(< 1.5 cm) displacement
 Pubic rami fractures with no posterior
displacement
 Minimal gapping of pubic symphysis
Operative Management
 Operative
 indications

Pelvic unstable






symphysis diastasis > 2.5 cm
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
Hemodynamically unstable
Operative Management
 Hemodynamically unstable
 Reduce pelvic volume : promote blood
clot as well as reducing blood volume
from inside bleeding
 Technique
 First aid : pelvic wrap
 Next
: Ex fix/ C clamp
Haemodynamic Status
Options for immediate hemorrhage
control
• Military antishock
trousers (MAST):
Typically applied in
the field.
– No impact on survival
rate.
– Severe complications
reported
(compartment
syndrome, extremity
loss)
Haemodynamic Status
Options for immediate hemorrhage
control
 Pelvic binder (pelvic
wrap):
• This is wrapped circumferentially
around the pelvis.
C-Clamp
Operative Management
 Posterior ring structure is important
 Goal : restoration of anatomy and enough
stability to maintain reduction during healing
 Anterior ring fixation may provide structural
protection of posterior fixation
Anterior Fixation of Pelvic
Posterior Fixation of Pelvic
Haemodynamic Status
Options for immediate hemorrhage
control
• Anterior external fixator:
– In the acute phase many
advocate external fixation as a
temporary device to achieve
stabilization of the fracture and
a positive effect on
haemorrhage.
External fixation
1. Advantages
 It helps tamponade bleeding from bone
edges .
 Stabilizing the clots and the bone.
 Could be done in 20 min.
2. Disadvantages
 Can’t stop arterial bleeding. Delay the
embolization for ongoing arterial
hemorrhage.
 Degrade the quality of CT and angio.
Complications
• Infection
• Thromboembolism
• Non-Union
• Malunion
Summary
 Pelvic fracture  High morbidity and mortality
 Multiple trauma  Team work (ATLS Approach)
 Check stability (Mechanic and Haemodynamic)
 Early immobilization  Pelvic Wrap
 Diagnostic tools
 Definitive treatment