Pelvic Ring Disruptions

8/12/2019 Pelvic Ring Disruptions

1/8

Pelvic Ring Disruptions

Pelvic ring disruptions are a major cause of mortality and morbidity inmultiply injured patients. Whereas fatalities result from uncontrolledretroperitoneal hemorrhage and other associated injuries, disabilitiessuch as low back pain, leg-length discrepancies, dyspareunia,

diculties withchildbearing, and impotence are caused by the anatomic disruption ofthe pelvic ring. Pelvic fractures can be particularly lethal when theyoccur incombination with signicant injuries to other major organ systems.!!"#ecause of the high force necessary to disrupt the pelvic ring in youngpatients, itis not surprising that up to $%& of these patients have additionalmusculoskeletal injuries. 'ortality rates in the patient with high-energypelvic ringinjuries are appro(imately !)& to *)&. +hese deaths are generally a

result of the injuries commonly associated with this injury pattern.'ortalityincreases nearly ! times when the patient presents with hypotension.When combined with either a head or an abdominal injury that reuiressurgicalintervention, the mortality increases to )%&. When both proceduresare necessary, mortality increases to %&.Classifcation

/rthopedic surgeons and traumatologists broadly classify pelvic ringdisruptions into two major groups0 stable and unstable. 1 stable pelvisis denedas one that can withstand normal physiologic forces without displacing.+his stability depends on the integrity of bony and ligamentousstructures 2 3ig.*!4 5. Instability is generally divided into rotational and verticalcomponents 2 3ig. *!4!% 5. +hese displacements can be appreciated onthe initialanteroposterior screening radiograph. 6table injuries includenondisplaced fractures of the pelvic ring and anterior displacements ofless than *.) cm.7otational instability is characteri8ed by widening of the symphysispubis or displacement of pubic rami fractures of greater than *.) cm.6uperiortranslation of a hemipelvis through fractures of the sacrum or ilium anddisruption of the sacroiliac joint by more than ! cm constitute verticalinstability. 6erial sectioning studies reveal that division of thesymphyseal ligaments alone leads to diastasis of *.) cm or less,maintaining stability.!*"


2/8

3urther sectioning of the anterior sacroiliac ligaments and sacrospinousand sacrotuberous ligaments 2pelvic 9oor5 permits rotational instability.:erticalinstability results only after the posterior sacroiliac ligaments are alsosectioned. ;isplaced fractures 2superior and inferior pubic rami

fractures, sacral oriliac wing fracture5 can also result in similar instability patterns.#ecause the pelvis is a true ring structure, a signicant anteriordisplacement must beaccompanied by a corresponding posterior disruption. ;isruptions inthe pelvic ring are usually a combination of fractures and ligamentousinjuries.n %& of cases, this is sucient to assess stability and guide initialtreatment.1nterior injuries are easily identied on this projection. 'ost unstableposterior injuries can also be appreciated. 1vulsion fractures at the =)transverseprocess and the ischial spines indicate ligamentous disruption and areusually identiable. =arge posterior gapping or displacement of the

hemipelvissuperiorly by more than ! cm indicates complete posterior disruptionand instability.!*";etailed classication systems have been developed based on thedirection of force, stability of the pelvis, location of fracture, or whetherit is an openor closed injury. +he ?omprehensive Pelvic ;isruption classication ofthe 1rbeitsgemeinschaft fur /steosynthesefragen 21/5 combines the


3/8

mechanism of injury with the degree of pelvic instability. +ype 1 injuriespreserve the integrity of the posterior ligamentous and bonystructures. +heseinjuries maintain a stable pelvic ring and usually reuire no furthertreatment unless neurologic injury is associated with a sacral fracture.

+ype #injuries represent incomplete disruption of the posterior pelvis. +heseinjuries result in rotational instability of the pelvis. 1 varying degree ofsacroiliacjoint or sacral disruption is characteristic. +hese injuries occur withboth anterior and lateral compression mechanisms. >n type ? pelvicinjuries, thehemipelvis is vertically, rotationally, and posteriorly unstable.=ateral compression as well as vertical shear-type fractures areassociated with intra-abdominal and head injuries. +he most commoncause of death in a

lateral compression injury to the pelvis is associated closed headtrauma."+he anteroposterior compression-type injuries have thegreatest risk forretroperitoneal hemorrhage. >ntrapelvic visceral injuries are also morecommon in the anteroposterior patterns. 'ortality in anteroposteriorcompression-type injuries relates to a combination of retroperitonealbleeding and visceral injuries."547

Figure 21-9 Pelvic stability. A,+he intact ligamentous bony structures of the pelvismaintain its integrity with regard to stability. +he posterior hinge, consisting of theposteriorsacroiliac ligaments and the iliolumbar ligaments, is imperative to maintain vertical

stability. +he sacrospinous prevents rotation, and the sacrotuberous prevents verticalmigration. 1slong as these, the anterior sacroiliac, and the symphysis are intact, the pelvis willremain stable. >f, however, the anterior symphysis is separated or the sacrum iscrushed posteriorly,as seen in B and C, the posterior hinge remains intact and the pelvis is usually stablevertically. +he sacrospinous ligaments are intact, and rotatory abnormalities are thusprevented.(A to C, From Kellam JF, Mayo K: Pelvic ring disruptions. In Browner B, Jupiter !B,"evine #M, !ra$ton P% &eds': )eletal !rauma, *rd ed. P+iladelp+ia, B aunders,-*./e!orr"age in Pelvic Fracture

+he usual cause of hemorrhage in pelvic fractures is from the posterior

pelvic venous ple(us and bleeding cancellous bone surfaces. 7arely, inless than!%& of cases, it may be caused by bleeding from a named artery 2 3ig.*!4!! 5.!" !@" !)" #leeding from a larger artery is even less freuent. +wolargeseries!A" demonstrated rates of bleeding from femoral or iliac vessels in!& and %& of patients. >n light of these studies, initial treatmentshould focus on


4/8

the control of venous bleeding. 7eduction and stabili8ation of thedisplaced pelvic ring help achieve this. 7eduction leads to a decreasein pelvic volumeand tamponade of the bleeding vessels through compression of theviscera and pelvic hematoma. 6tabili8ation maintains the reduction

and avoidsmovement of the hemipelvis, reducing pain and limiting the disruptionof organi8ing clots. 6ince reduction and stabili8ation alone usuallycontrolvenous bleeding, patients who do not respond to these maneuvers aremore likely to have arterial bleeding.#ta$ili%ation

7eduction and stabili8ation of the pelvis can be achieved by a varietyof mechanical means 2 3ig. *!4!* 5. When eld personnel detectunstable pelvicring disruptions on physical e(amination, they can begin treatment bybinding the pelvis with a rolled sheet or applying pneumatic antishockgarments2P16Bs5. =ike the air splints applied to the e(tremities, the garmentfunctions by compressing the pelvis. >f applied in the eld, P16Bsshould not bede9ated until the patient is actively being resuscitated in the traumaroom. +he P16B has as its advantages ease of use, application in theeld, andreusability. Cowever, it blocks access to the patient and restrictse(cursion of the diaphragm, and there have been reports of glutealand thighcompartment syndromes developing after its e(tended use inhypotensive patients.+he standard method for controlling pelvic hemorrhage has been theapplication of an anterior e(ternal (ation frame. Proper application ofan anteriorpelvic54&

Figure 21-1' A, ;ivision of the symphysis pubis will allow the pelvis to open toappro(imately *.) cm with no damage to any posterior ligamentous structures. B,;ivision of theanterior sacroiliac and sacrospinous ligaments, either by direct division of their bers2rig+t5 or by avulsion of the tip of the ischial spine 2le$t5, allows the pelvis to rotatee(ternally

until the posterior superior iliac spines abut the sacrum. Dote, however, that theposterior ligamentous structures 2e.g., the posterior sacroiliac and iliolumbarligaments5 remain intact.

+herefore, no displacement in the vertical plane is possible. C, ;ivision of theposterior tension band ligaments, that is, the posterior sacroiliac, as well as theiliolumbar, depicted hereon the left side, plus an avulsion of the transverse process of =) causes completeinstability of the hemipelvis. Dote that posterior displacement is now possible. (A toC, From Kellam


5/8

JF, Mayo K: Pelvic ring disruptions. In Browner B, Jupiter !B, "evine #M, !ra$ton P%&eds': )eletal !rauma, *rd ed. P+iladelp+ia, B aunders, -*./Figure 21-11 >nternal aspect of the pelvis shows the great vessels in thelumbosacral ple(us as well as the pelvic 9oor and the pelvic contents, bladder, andrectum. (From Kellam JF,Mayo K. Pelvic ring disruptions. In Browner B, Jupiter !B, "evine #M, !ra$ton P%

&eds': )eletal !rauma, *rd ed. P+iladelp+ia, B aunders, -*./549Figure 21-12 1lgorithm of pelvic fracture management. ?+, computed tomographyE.3., open reduction and internal (ationE6l,sacroiliac. (From Kellam JF, Mayo K: Pelvic ring disruptions. In Browner B, Jupiter !B,"evine #M, !ra$ton P% &eds': )eletal !rauma, *rd ed. P+iladelp+ia, B aunders,-*./

e(ternal (ator should provide stability to the pelvis and hematoma,while allowing access to the abdomen for surgical procedures. 'ultiplestudieshave shown that outcomes can improve with their routine use.!@" !)" !G"1lthough this device can be applied in the emergency department, it is

freuentlydeferred until the patient is brought to the operating suite. >n thesecircumstances, the pelvis can remain displaced for many hours withvenous bleedingcontinuing uncontrolled. >f an e(ternal (ator cannot be appliede(peditiously, another method of provisional stabili8ation must beemployed. 7ecently,devices called pelvic ?-clamps have been developed that can berapidly applied to reduce and provisionally stabili8e the pelvis in theemergencydepartment. +he design allows for compression of the pelvis throughpercutaneously inserted pins applied to the outer surface of the ilium.+hey provideadeuate stabili8ation and easy access to the abdomen or e(tremitieswithout removal of the device 2 3ig. *!4! 5. +he ?-clamps can remainin placethroughout the resuscitation phase and then be replaced by denitivestabili8ation methods when the patient is able to undergo theseprocedures. ?aremust be taken in the55'

Figure 21-1( Pelvic ring disruption with massive hemorrhage. A, 1nteroposterior

21P5 radiograph of the pelvis shows disruption of the symphysis pubis and thesacroiliac joint. B,1P view of the pelvis following reduction by application of the pelvic stabili8er. C andD, Patient with the pelvic stabili8er in the standard position and elevated to allowaccess to theperineum or the hips to be 9e(ed into the lithotomy position.

application of these clamps because serious complications can resultfrom misplacement of the pins. 1ccordingly, these devices are utili8edonly in


6/8

rotationally and vertically unstable pelvic ring disruptions and not instable injury patterns.+he role of angiography in the diagnosis and management of pelvichemorrhage is controversial. =arge series have demonstrated theincidence of

arterial hemorrhage amenable to emboli8ation to be appro(imately!%&.!" !@" 3urthermore, it is even less common for the bleeding to bethe result of aninjury to a large or named artery. >n these cases, arteriography withemboli8ation can be lifesaving. Cowever, catheteri8ation andemboli8ation ofvessels in the pelvis are technically dicult and time consuming. +heuse of these techniues should be reserved for those cases when allother methodsof control of hemorrhage have been e(hausted.!")anage!ent Algorit"!s

1lgorithms for management of the hypotensive patient with a pelvicfracture all should begin with a search for the cause of the shock 2 3ig.*!4!@ 5. 1llpossible causes of bleeding are e(plored. 1uscultation of the chest andreview of the chest radiograph determine the presence of hemothora(and theneed for thoracostomy. /nce the hemothora( is either ruled out as acause of shock or is controlled by chest tubes, a diagnostic peritoneallavage orultrasound of the abdomen is performed.


7/8

=ong-term, denitive care of pelvic ring disruption is dependent on theseverity and the pattern of injury. 6table fractures or injury patternsusuallyreuire no more than restricted weight bearing. 3or the reasonsdescribed previously, unstable injuries often need to be denitively

(ed. 3reuently,the e(ternal (ator can provide denitive stabili8ation, if appliedeIectively and reduction has been maintained. >n cases when the(ator may beobstructing access to the abdomen or an interim ?-clamp has beenapplied, /7>3 or closed reduction and percutaneous (ation may beindicated. Whenrotational or vertical instability is present, both the anterior and theposterior pelvis must be stabili8ed. 1nteriorly, the symphysis is oftensecured with aplate and screws. Posteriorly, more options e(ist. +he sacroiliac joint or

sacral fractures can be secured with plates, bars, or percutaneouslyinsertedcannulated screws 2 3ig. *!4!) 5.

Pelvic 3ractures>njuries to the pelvic ring should be diIerentiated between the low-energy,stable fractures and the high-energy, life-threatening injuries. +he former arecommonly seen in older adult osteoporotic patients who may have sustainedisolated fractures of the pubic rami or nondisplaced fractures of the acetabulior sacrum from a fall. +hese fractures usually do not have disruption of thepelvic ring or weight-bearing segments and are considered stable.

Cigh-energy injuries are the result of automobile collisions, pedestriansand cyclists being struck by motor vehicles, or falls from signicant heights.!!@A PAR* ++ #PC+F+C C.#+DRA*+.#+hese injuries are caused by direct crush, either from the anterior or lateraldirection or vertical shear, or combinations of rotational stress on the iliacwings. >nitial evaluation of pelvic injuries includes an 1P radiograph. 3urtherimaging includes inlet and outlet views. 1ssociated acetabular fracturesand lumbar spine injuries reuire @)-degree obliue 2Judet5 views and 1Pand lateral radiographs of the lumbosacral spine. 'ost pelvic injuries willalso need a ?+ scan with -mm cuts to evaluate a posterior injury to thepelvis. 1 ?+ scan is best used for evaluation of the sacrum and sacroiliacjoints.?ontinued, une(plained blood loss despite fracture stabili8ation and aggressiveresuscitation is an indication for angiography.


8/8

the presence of intraarticular bony fragments. Dondisplaced or minimallydisplaced fractures are determined after complete evaluation of theradiographs and acetabular ?+ scans. 7adiographs should be taken withtraction removed and preferably with stress applied. 1ny degree of incongruenceinvolving the weight-bearing surface of the acetabulum is unacceptableand is an indication for surgical treatment. Dondisplaced fracturesmay be treated with a period of traction followed by progressive weightbearing.Cip ;islocation;islocation of the hip often is caused by a force applied to the femur andcan be associated with fractures of the acetabulum or femoral head. +he mostcommon mechanism of injury is motor vehicles accidents. 3orce applied toan abducted hip can result in anterior dislocation, although striking the kneeon a car dashboard with the hip 9e(ed and adducted, results in posterior dislocations.Posterior dislocations often are associated with a fracture of theposterior wall of the acetabulum. ;irect trauma to the greater trochanter froma lateral direction can result in medial wall fractures or central acetabularfracturesHdislocations.+horough evaluation of hip dislocations often reuires Judet radiographicviews and additional ?+ scans. 6imilar to patients with pelvic fractures, thesepatients may have other major injuries and careful evaluation of the chest,abdomen, spine, and neurologic status is necessary. Prompt reduction of hipdislocations is essential in minimi8ing the incidence of osteonecrosis of the

femoral head.

Documents

Pelvic Ring Disruptions