Pelvic Fractures. ICU Fellowship Training Radboudumc

Transcription

1 Pelvic Fractures ICU Fellowship Training Radboudumc

2 Classification Young-Burgess system Three main patterns of injury AP compression Lateral compression Vertical shear

3 AP compression External rotation of one or both hemipelves Iliac wings move outward - pubic diastasis Associated injuries - sacroiliac joint diastasis and less commonly sacral fractures Increased pelvic volume - spontaneous tamponade of hemorrhage unlikely

4 AP compression AC1 - pubic diastasis < 2.5 cm = stable AC2 - pubic diastasis > 2.5 cm + anterior SIJ disruption = vertical stable but rotational unstable (classic open book) AC3 - pubic diastasis > 2.5 cm + anterior and posterior SIJ disruption = vertical + rotational unstable

5 AC2 fracture

6 Lateral compression Most common type of pelvic fracture Internal rotation of hemipelvis with coronal ramal fractures, contralateral SIJ disruption and central ace tabular fractures High incidence of sacral fractures (80-90%) Reduction in pelvic volume

7 Lateral compression LC 1 - Ipsilateral buckle sacral and coronal pubic rami fractures = stable LC2 - LC1 + ipsilateral iliac wing # or posterior SIJ disruption = rotational unstable but vertical stable LC3 - LC2 + external rotation of conttralateral hemipelvis ± contralateral saggital ramal fractures = rotational unstable but vertical stable

8 LC2 Fracture Right sided pubic rami # Ipsilateral sacral buckle #

9 Vertical shear fractures Vertically and rotationally unstable due to disruption of posterior ligaments Vertical force is often the femur with ramal fractures anteriorly and ligamentous jury posteriorly Hemipelvis shifted cranially High rate of associated injuries to torso and spine and often hemodynamic instability

10 Vertical shear fracture

11 Sacral fractures Is high rate of neurologic injury Zone 1 - sacral ala lateral to sacral foramina (L5 nerve root impingement with 6% sustained injury) Zone 2 - neuroforamina with unilateral sacral anesthesia (no involvement of central sacral canal) Zone 3 - body of sacrum (up to 50% neurological compromise including cauda equina syndrome)

12 Sacral fracture

13 General management Recognition of life-threatening injuries (ATLS) Recognition of acute injuries Fracture classification (suspicion for undetected injuries) Severe pelvic # in 80% associated with at least 2 other injuries CT-scan versus pelvic radiograph

14 Multiple # pubic rami, sacrum and right femur Left epidural hematoma with intracranial air Complicated liver injury with active contrast extravasation

15 Major risk - bleeding Mortality up to 60% in case of haemodynamic instability Bleeding: arterial, venous or from cancellous bone Injured artery related to fracture site used to predict which artery has been injured. Artery injured Fracture site Most common Superior gluteal Internal pudendal Obturator Femoral Lateral sacral Iliolumbar Greater sciatic foramen, ischial spine or tuberosity AP compression fracture involving lesser sciatic foramen, inferior pubic ramus Superior obturator foramen, superior pubic ramus, pubic acetabulum Acetabulum, injured posterior to inguinal canal Sacral foramina or posterior trans-sacral fracture Posterior fracture involving ilium or anterior SIJ s

16

17 Arterial bleeding - therapy Depends on several factors including associated injuries - hemodynamic instability - reaction to external fixation/pelvic packing Angiography very effective (85-100%) in isolated injury when performed early Proposed management algorithm should incorporate early CT scanning if possible

18

19

20

21 Risk for rectal ischemia and necrosis

22

23 Urological injury Especially with separation of pubic symphysis or fractured pubic ramus Usually extraperitoneal Intraperitoneal with blunt trauma to a distended bladder CT cystography

24 Neurological injury 10% following pelvic fractures Bladder, bowel and erectile dysfunction Transverse sacral # - intraspinal and intraforaminal nerve root injury Greater sciatic notch # or posterior acetabulum # - sciatic nerve injury

25 Urethra injury

26 Perineal wounds Rectal examination with blood - recognition essential - otherwise mortality up to 50% Exploration in OR < 6 hours with complete assessment and debridement Diverting colostomy Drainage and secondary healing (vacuum dressings)

27