Pelvic Trauma
Epidemiology
Complications
Classification
Others
Assessment
Ix
Mng
Account for 3% of #’s; present in 30% multitrauma; 50% require blood transfusion; mostly MVA / falls; 5-20% mortality; 50%
mortality if decr BP OA; 30% mortality if open
Vascular: common iliac artery  divides at SIJ  int iliac (intrapelvic); if post ring involvement  2-3x blood requirement; can
lose up to 4-6L blood; 15iu for APC, 9iu for VS, 3.5iu for LC; major cause of death; trt with pelvic sling (may decr pelvic vol by up to
10%) or mechanical fixation; bleeding from multiple sources in 60%, bilateral in 50%; most bleeding is low p venous bleeding and
bleeding from bone edges; 10-15% are arterial (usually from int iliac; esp sup gluteal and obturator); shock and death usually due
to arterial; if bleeding is refractory to resus, likely arterial and hence angiography should be persued
Neural: lumbar and sacral plexus; S1-2 nerve roots commonly involved in post element #’s, assoc with sacral inj; impotence in
1/6th sacral #’s; lumbar root assoc with SIJ dislocation or #
GU: bladder or urethral in 16%; urethral in 5%; usually in ant bulbous urethra; vaginal lac in 4% (techinically open if present); high
fetal death rate; possible obstetric probs; if suspect, do retrograde urethrography before placing IDC
GI: rectal inj uncommon (usually assoc with urinary inj and ischial #)
Other: ruptured diaphragm
See below; usually pubic symphysis breaks 1st  sacrospinous lig and sacrotuberous lig  ant SI lig
Single break = stable inj; 2 breaks = unstable with risk of displacement
Suggestive of LC: Horizontal #’s; SIJ diastasis and crush # of sacrum; central hip dislocation
Suggestive of AP: vertical #’s; posterior hip dislocation
Suggestive of VS: vertical #’s with vertical displacement
Avulsion #: ASIS (sartorius; pain on flexion + abduction)
Ischial tuberosity (hamstrings; non-union common; OT needed)
AIIS (rectus femoris; can’t flex hip)
Post spine (erector spinae)
Iliac crest (direct violence)
Acetabular #: 20%; transmission of force through femoral head via post / central / ant dislocation; usually due to MVA
CT better than XR
Usually treated with traction, but may need OT esp if displaced
assoc with sciatic and femoral nerve inj, femoral #, knee inj
Pelvic ring #: post # have higher incidence of vascular and neuro complications
History: bladder, bowels
Haematuria (blood at meatus, high riding prostate, boggy mass on PR), rectal, PV bleeding; abnormal bony prominence on PR;
altered tone on PR
Destot’s sign: haematoma above inguinal lig or in scrotum
Roux’s sign: distance betweem gt trochanter and pubic symphysis unequal
Earle’s sign: tender # line palpable on PR exam
Grey-Turner’s sign: flank bruise due to retroperitoneal blood
XR: 65-90% sens; pelvic inlet view for ant SIJ inj and AP displacement of ring #’s; pelvic outlet view for vertical displacement /
transverse # through sacrum and arcuate lines; judet view for acetabular #;
CT: needed for acetabular inj, pelvic ring disruption, post element #, single rami #, complex #; extravasation of contrast 80-90%
sens, 98% spec for need for vessel embolisation
Retrograde urethrogram: inject 200-300ml contrast
Bladder poorly filled with extravasation to side: extraperitoneal rupture; conservative trt if small, OT if large
Bladder doesn’t fill, extravasation to pelvic floor: membranous urethra rupture; needs cystoscopy
Bladder doesn’t fill, extravasation beneath pelvic floor: bulbar urethra rupture
Catheter: dry tap: intraperitoneal rupture
Blood stained tap: extraperitoneal rupture
ABC
Stabilisation: doesn’t prevent arterial bleeding; may prevent dislodgement of existing clot; doesn’t support post pelvis; difficult if
obese; assess for other causes of blood loss
Pelvic sling: best if major disruption and opening of pelvic ring; CI IF LC / VS inj, isolated pubic rami #; don’t use >24hrs
External fixation: quick and can be done in ED; use if pubic diastasis >2.5cm / involvement of post elements
Pneumatic anti-shock garment: can be used pre-hospital; works in APC; may incr bleeding in LC; decr BP if sudden removal,
compartment syndrome, decr access to legs
Conservative: # bilateral pubic ramus with min displacement
LC I / AP I
non-displaced # ilium
Traction: acetabular and VS #, using femoral pins
LC I + II – bed rest and delayed ORIF
External fixation within 4hrs if: APC II, III + VS, ?LC III, esp if opened >2.5cm anteriorly; effective for controlling venous bleeding
(maybe pre-angio)
OT vs angio: controversy exists about best practice; depends on facilities available but most unstable pelvic trauma should have
angio over OT if there is no abdo injury causing bleeding
OT: Internal fixation if: major visceral / vascular inj, ongoing blood loss, open
Open surgery if: haemodynamically unstable + positive FAST; may need extraperitoneal packing as part of damage contro; can
used as bridge for patients too unstable to survive angiography
Angiography and embolisation if: continuing blood loss and other sources excluded (ie. Intra abdominal exlcuded; need for
ongoing blood transfusion, haemodynamic status, certain amount of iu blood needed, positive helical CT) even if
haemodynamically unstable; only CI’ed if needs laparotomy; takes 1-2hrs; bleeding successfully control in >90%; 7-10% #’s require
embolisation; only useful if branches of int and ex iliac system involved (more likely if VS / APC injury as 20% have arterial haem;
only 2% lat compression #’s have arterial haem)
Pros: avoids retroperitoneal probs assoc with OT, preserves tamponade effect, avoids entering haematoma, more effective
than OT for major arterial bleeding
Cons: source of arterial bleeding only identified in 20-30% pts with severe pelvic disruption; when failure occurs, usually assoc
with severe 2Y coagulopathy; complications = impotence, bladder / gluteal necrosis, sciatic / femoral nerve paralysis, emboli to
normal vessels; not available in some hospitals; operator dependent; time consuming; doesn’t address venous blood loss;
diagnostic and therapeutic; must not perform cystourethrography pre-angiography
Usually assoc with pelvic ring #; can cause sacral nerve damage (weak legs, saddle anaesthesia, incontinence); CT more sens than
XR
Sacral #
Key+Cornwell / Kane
0
I
II
III
IV
30%
1x # (eg. Avulsion ASIS, # ramus, iliac wing)
No break in pelvic ring
Stable
1x break in pelvic ring (eg. 2x rami, SIJ #, pubic symphysis #)
Stable
25% have major STI / visceral inj
2x break in pelvic ring
Unstable
Often STI / visceral inj
Acetabular #
Young
LC #’s (Lat
compression
and int
rotation)
50%
I
II
MVA
III
APC #
(antpost
compression)
25%
I
MVA
III
II
Bucholz
1x # pubic ramus
Mortality 10%
Pubic rami # + SI #
No SI widening
Mortality 25%
Pubic symphysis diastasis with SI hinging
Mortality 35%
SIJ displacement
Mortality 40% (if open)
Most common (50%)
Stable (4% bladder rupture)
# sacrum on side of impact + pubic rami #
7%
Unstable to int rotation (stability depends on degree of involvement of SIJ; 36% severe haem, 7% bladder rupture))
# iliac wing near SIJ (may enter SIJ) + pubic rami #
10%
Unstable (60% severe haem, 20% bladder rupture, 20% urethral inj)
Contralat AP compression inj (open book # ie. Ex rotation), ipsilat lat compression inj (ie. LC I/II)
Symphysis diastasis  slight widening of SIJ; ligs stretched but intact
8% bladder rupture, 12% urethral inj
10%
Disruption of sacrotuberous and sacrospinous and ant SI ligs, intact post SI ligs  widening of ant SIJ’s  open book inj
Lumbosacral plexus and vessels often injured (28% severe haem, 10% bladder rupture, 23% urethral inj)
4%
VS # (vertical
shear)
5%
Axial load
Mixed
Complete disruption of hemipelvis with lateral displacement but without vertical displacement; all ligs disrupted
Significant blood loss (53% severe haem, 15% bladder rupture, 36% urethral rupture)
5%
Hemipelvis displacement superiorly (usually through SIJ)
Need ant and post SI lig disruption for vertical instability: usually SIJ, vertical sacral # or ilial wing #, or complete lig disruption
through PS/PR, interosseous + post SI ligs; may have L5 transverse process #
Significant blood loss (75% severe haem, 15% bladder rupture, 25% urethral rupture)
20-25%
Notes from: