PELVIC INJURY

 A-46-year male came to emergency unit by ambulance with pain on the pelvic area and unable to stand. Four hours ago he fall and got struck by a big stone while working in sand mining. Patient was able to communicate and to tell the history of trauma.

Fig. 1 A. AP View of Pelvis

Fig. 2 B. Outlet View of Pelvis

Fig. 3 B. Intlet View of Pelvis

Physical examination:  Blood pressure: 100/70, pulse rate 100/minuts, respiration 24. Head, chest, abdominal and urinary system were normal. Special clinical tests: The right side: Vertcal test was positive and compression test of the left side was positive. Conclusion the patient was rotational instability of the left side and vertical instability of the right side of the pelvic.

X-rays showed deformed of the pelvic ring, bilateral fractures sacroiliac joint, bilateral superior and inferior of the rami pubic fractures and symphysis diastasis > 2.5 cm. Conclusion of diagnosis is a rotational and vertical unstable of the pelvic fractures, type C2 according to Tile classification. 

INTRODUCTION

Pelvic injury is commonly caused by high energy trauma (fall from a height, motor accident or crushing injuries) and associated with other regions injury for example:

• Head injury: It can be classified as mild/grade I (80%, without loss of consciousness and retrograde amnesia), moderate/Grade II (10%, loss consciousness <5 min, retrograde amnesia and confusion regarding the injury itself) and severe/grade III (10%, prolonged unconsciousness, permanent retrograde amnesia and confusion and disorientation). Head injury can lead to increase intracranial pressure (normal 10 mmHg) and contribute skull fracture, intracranial lesion: epidural or subdural or intra-cerebral hematoma, and concussion.
• Spine/vertebral injury: Spine injuries include cervical spine trauma (55%), thorax spine (T1_T10), thoraco-lumbal injuries (T11- L1) and lumbar spine injuries with spinal cord.
• Chest injury: Mortality rate of chest injury is 10%. The Candidate should concern imminently lethal injuries include tension pneumothorax, open pneumothorax, flail chest, massive hemothorax, cardiac tamponade, and commotion cordis.
• Abdominal injury: Abdominal injury can be from blunt trauma, penetrating injury or rapid deceleration (automobile accident). More common sources of bleeding are from pancreas or liver. But the most common injuries in passengers restrained by lap belts are bowel injuries and lumbar spine fracture. The Candidate should be performed radiographs examination, diagnostic peritoneal lavage (DPL), ultrasound and CT scan for diagnostic peritoneal bleeding.
• Harmorrhagge (75% patients) is the most common cause of patient’s death in pelvic fractures
• Musculoskeletal (60-80% patients) injuries,
• Urogenital system injury (12% patients), and
• Lumbosacral plexus injuries (8% patients).

The incidence of pelvic fractures is 3% of all fractures in US. The mortality rate of pelvic fracture is 15-25% but open pelvic fractures have a high mortality rate (30-50%) caused usually by hypovolemic shock (hemorrhage). There are three sources of bleeding: osseous, vascular (disruption venous plexus/10-15% of patient and open pelvic fracture is the venous plexus which lead to a large retroperitoneal hematoma/4L of blood)), and visceral (intra-abdominal bleeding in up to 40% of patients). The other sources of bleeding are vascular injury in gastrointestinal and genitourinary injuries. Crescent fracture is a fracture-dislocation of the S1 joint may involve a portion of the sacrum or ilium.

   The Candidate should be able to understand the anatomy of pelvis:

The Candidate should be able to evaluate the common vascular injuries in pelvic fractures include common iliac artery divides into internal and external iliac arteries. The internal iliac artery is important in pelvic injury. It divides into anterior: inferior gluteal artery, internal pudendal artery, Obturator artery anastomosis with external iliac artery by corona mortis and crosses the superior pubic ramus, inferior vesical artery, and middle rectal artery. Posterior division includes superior gluteal artery, iliolumbar artery and lateral sacral artery.

1.    The Candidate should be able to evaluate the unstable pelvic fractures

The Candidate must be able to determine the energy injury and associated trauma firstly:

a.       Low energy trauma usually occurs in elderly caused by osteoporosis problem

b.      High energy trauma is commonly caused by traffic accident with associated other regions injuries (head, chest, abdominal, urogenital and locomotor system)

c.       This patient had got a bigger stone on his pelvis directly form ± 4 meters height (high energy trauma)

Therefore, the Candidate should be able to perform physical examination of the pelvic fractures patient include:

a.       Determining of life threatening (ATLS procedures)

b.      Evaluation of the pelvic stabilization by bimanual compression and distraction of the iliac wings (should be carefully caused by pain)

d.      The Candidate should evaluate the location of prostate to indicate urethral tear and to assess the regularity of the sacrum bone

e.       The Candidate should assess the peroneal skin for determining of open pelvic fractures

2.    The Candidate should be able to recognize unstable pelvic fracture patient shock as soon as possible

The Candidate should be able to explain about shock caused by unstable pelvic fractures. The most common complication of pelvic fracture is a hemorrhagic caused by bleeding and can lead to hypovolemic shock. There are two group of shock in general:

a.       Hemorrhagic (hypovolemic) shock

Definition of shock is an inadequate organ perfusion and tissue oxygenation

The clinical manifestations are:

§  Tachycardia:

o   infant: heart rate is more than 160/beats/min

o   preschoole age: heart rate is more than 140 beats/min

o   school age (child): heart rate is 120 beats/min

o   adult: heart beats is 100 beats/min

§  Narrow pulse pressure cause by vasoconstriction and indicates significant blood loss.

§  Hypotension

Table 1. Classification hemorrhagic

Class	Blood volume loss (%)	Treatment
I	More than 15	Fluid replacement
II	15 - 30	Fluid replacement
III	30 - 40	Fluid replacement and blood replacement
IV	More than 40	Fluid replacement and blood replacement

Blood loss suspected in fracture:

o   Long bone fracture: blood loss is approximately 1.5 units

o   Femur fracture: blood loss is approximately 3 units

o   Pelvic fracture: blood loss is more than 3 units

Fluid replacement:

o   Lactated Ringer’s is the fluid choice or normal saline (The candidate has to evaluate if normal saline given in large volumes because it can be a hyperchloremic acidosis).

o   Initial replacement should be given 1-2 L for adult and 20 ml/kg for children

o   Total replacement is approximately three times the estimated blood loss, crystalloid should be used

o   Favorable response to fluid resuscitation includes:

ü  Increased urinary output: adequate urinary output in the adult is 0.5 ml/kg/hr; in child is 2.0 ml/kg/hr

ü  Improve level of consciousness,

ü  Increased peripheral perfusion, and

ü  Change in vital signs (blood pressure, increased pulse pressure and decreased pulse rate)

Table 2. Response to initial fluid resuscitation

Response	Vital signs	Estimated blood loss	Need for more crystaloid	Need for blood
Rapid	Return to normal	Minimal (10-20%)	low	low
Transient	Improve transiently, recurrence of decrease blood pressure and increased heart rate	Moderate and ongoing (20-30%)	High	Moderate to high
None	Remain abnormal	Severe  (>40%)	high	Immediate

The Candidate should be able to understand the complications of hemorrhage in pelvic fracture

Fig.1. Lethal triad cycle

a.       The candidate should be able to predict hypothermia caused by hemorrhage in pelvic fractures. Hypothermia can lead to cardiac arrhythmia, decrease cardiac output, increase systemic vascular resistance, and oxygen-hemoglobin dissociation curve shift to the left. Hypothermia is also contributed coagulopathy by blocking of the coagulopathy cascade. A low temperature can damage patient’s immunologic function. Hypothermia can increase the body temperature release by external factors and surgery intervention. Multidiscipline management approach can prevent the body temperature release and hypothermia correction.

b.      The candidate should be able to explain coagulopathy caused by hemorrhage in pelvic fractures. Coagulopathy occurring cause by hypothermia, platelet and coagulation factors dysfunction in a low temperature, system fibrinolytic activation and hemodilution in massive resuscitation. Platelet dysfunction caused by imbalance between thromboxane and prostacyclin in hypothermia. Hypothermia and hemodilution produces coagulopathy addictive. The platelet is only 30-40% in circulation after 5.000 mL or 5 units PRC blood transfusion. Prothrombin time (PT), partial prothrombin time (PTT), fibrinogen level, and lactate level cannot severe coagulopathy prediction.

c.       The candidate should be able to suspect acidosis caused by hemorrhage in pelvic fractures. Acidosis is caused by anaerobic metabolism in a long time of shock state hypo perfusion therefore it can produce lactate. Acidosis may decrease myocardial contractility and cardiac output. Acidosis may be produced by multiple transfusions, vasopressor using, aortic cross-clamping and can lead to myocardial activity. and

d.      Finally, ARDS (adult respiration distress syndrome) and MODS (multiple organ dysfunction syndromes) will happen.

b.      Non-hemorrhagic shock

The Candidate should be able to describe include:

§  Cardiogenic shock; it should be assessed by ECG and blood creatine phosphokinase with isoenzymes. Shock is the result of myocardial dysfunction. The etiology includes blunt cardiac trauma, cardiac tamponade, dysrhythmias, air embolus and myocardial infarction. Symptoms are tachycardia, muffled heart sounds, jugular venous distension and hypotension.

§  Neurogenic shock: hypotension without tachycardia and vasoconstriction

§  Septic shock: tachycardia, vasoconstriction, decrease urinary output and decreased blood pressure. Septic shock is the most common causes is a penetrating abdominal trauma

§  Tension pneumothorax can be caused by collapse of the lung. The breaths of sound are absent but not cardiac tamponade. The mortality rate of approximately 10%. The Candidate has to concern every scapula fractures and he/she should be evaluated the chest for pulmonary contusion

3.    The Candidate should be able to classified the pelvic fracture

The Candidate should be able to clarify stable and unstable pelvic fractures based on anatomy of the pelvis:

Tile classification of pelvic fractures:

     

§  Type A: Stable pelvic fracture. Stable fracture of the pelvis terminology is one that can withstand normal activities or physiologic forces without pelvic deformation. There are two types

o   Type A1 is an avulsion injuries and without involving the pelvic ring, , and

o   Type A2 is a stable fracture of the pelvic ring with minimal displaced. History of the patient is usually difficulty in walking after trauma or after excluding of the femur neck fracture.

§  Type B: Rotationally unstable, but vertically stable: Unstable fracture of the pelvis terminology is the components of that pelvic are rotational instability or vertical instability or both. The characteristic of instability sign in the radiographs are displacement of the posterior sacroiliac complex more than 1 cm in any plane.

. There are three types of rotationally unstable pelvic fractures.

o   Type B1 is an external rotation instability with vertically stable (antero-posterior compression fractures or open book fracture) but posterior sacroiliac ligaments are remain intact and without vertical instability. Pubic symphysis diastasis is < 2.5 cm.

o   Type B2 is lateral compression (LC) with internal rotation instability (ipsilateral only). Lateral compression injuries can lead to rami fractures or overlapping of the pubic bones, the posterior sacroiliac ligaments remain intact or with crushing of the anterior margin sacroiliac joint and pubic symphysis diastasis is > 2.5 cm.

o   Type B3 is contralateral compression injuries that can lead two rami fractures on opposite side from posterior injury and pubic symphysis diastasis is > 2.5 cm. The hemipelvis rotates causing leg-shortening without vertical migration of the hemipelvis

§  Type C:  Rotationally and vertically unstable: The pelvic ring is completely disrupted at two or more level:

o   Type C1: Unilateral injury. Ipsilateral anterior and posterior pelvic injuries. Symphysis is disrupted (anterior) and total loss of continuity between sacrum and ilium (posterior) that can lead to a complete ligamentous ruptures and dislocation of sacroiliac joint.

o   Type C2: Bilateral injury, one side rotationally unstable with the contralateral side vertically unstable.

o   Type C3: Bilateral injury; both sided rotationally and vertically unstable with an associated acetabular fractures (associated with acetabular fracture)

The Candidate should also be able to classify based on BUCHOLZ CLASSIFICATION: The severity of classification is divided by the posterior pelvic ring integrity

o   Type I: The injury involves an anterior ring injury (may have a nondisplaced sacral fracture or an injury to the anterior S1 ligaments)

o   Type II: The injury involves an anterior ring injury along with partial disruption of the S1 joint; the posterior S1 ligaments remain intact

o   Type III: The injury involves a complete disruption of the S1 joint (including the posterior S1 ligaments) with displacement of the hemipelvis

4.    The Candidate should be able to analyze the investigations of pelvic fractures

§  The Candidate must be able to evaluate AP projection of the pelvis include:

a.         Anterior lesion: pubic rami fractures and symphysis diastasis or displacement

b.        Sacroiliac joint and sacral

c.         Iliac fractures, and

d.        L5 transverse process fractures

e.         90% evaluation of AP projection of the pelvis; the Candidate should be able to  determine the pelvic fractures diagnosis

§  The Candidate must be able to assess the obturator and iliac oblique views of the pelvis for determining of the acetabular fractures

§  The Candidate must be able to evaluate inlet view for evaluating of the sacroiliac joint anterior-posterior displacement, sacrum or iliac wing and also determining of the internal rotation deformities of the ilium and sacral impaction injuries

§  The Candidate must be able to assess outlet view for deciding of vertical displacement of the hemipelvis and may allow for visualization of subtle signs of pelvic disruption

§  The Candidate must be able to conclude the instability sign of the pelvic fracture based on radiographic include:

a.       Sacroiliac displacement of 5 mm in any plane

b.      Posterior fracture gap (rather than impaction)

c.       Avulsion of the fifth lumbar transverse process, the lateral border of the sacrum or the ischial spine

§  The Candidate must be able to evaluate the laboratory data caused by hemorrhage, coagulopathy and acidosis patient’s condition.

5.    The Candidate should be able to performed an emergency management

The Candidate should be able to perform an emergency management of pelvic fractures include

a.    The Candidate can use military antishock trousers (MAST) for initial emergency management, but the disadvantageous of MAST are the limitation of physical examination, decreases lung expansion and progression of a lower extremity compartment syndrome.

b.      The Candidate has to perform fluid resuscitation as soon as possible in hypovolemic shock.

§  Two large-bore intravenous lines (≥ 16 gauge) should be placed on the upper extremities with 2 L of crystalloid administered over 20 minutes and then evaluates the patient response.

§  Blood transfusion should be administered in transient improvement or no response. A total of 50-60% of unstable pelvic fracture requires 4 or more units of blood; 30-40% requires 10 or more units. Platelet and frozen plasma are required with massive transfusion to correct coagulopathy dilution.

§  Hypothermia should be avoided or corrected by warming fluid, increasing the ambient temperature, and avoiding heat loss, because it can lead to coagulation problems, ventricular fibrillation, and acid-based disturbances.

§  Urinary output by catheter should be assessed. Urine product approximately 50 ml/hr in an adult

c.       The Candidate should be able to perform external fixation (EF) technically.

§  Indication EF is in hemodynamically unstable who does not respond to initial fluid resuscitation.

§  Function of EF is to stabilize the pelvic, preventing redisruption of clot and may decrease the pelvic volume

§  EF is not indication for posterior pelvic ring disruption because it does not adequate posterior stabilization.

§  Technique: After aseptic procedure had been performed the Candidate should be able to orientate the right and left sides of pelvic brim by a spinal needle or a small of K-wire for determination of its direction. Two schanz screws set up on right and left of the pelvic brim based on pelvic brim direction and then the bars should be placed far enough away from the abdomen wall  

d.      The Candidate can also use pelvic C-clamp, but this clamp is a higher risk of iatrogenic complications

e.       If no response after hemodynamic procedure and EF or C-clamp fixation, the Candidate has to perform angiography with embolization for management of bleeding.

6.    The Candidate should be able to performed definitive management of pelvic fracture

Definitive management of pelvic fracture, the Candidate is able to explain:

a.       Operative management

Absolut indication:

o   Open pelvic fractures which there is an associated visceral perforation that requiring operative surgery.

o   Open book fractures or vertically unstable fractures with associated hemodynamic instability

Relative indication:

o   Symphysis diastasis > 2.5 cm (loss of mechanical stability)

o   Leg-length discrepancy > 1.5 cm

o   Rotational deformity

o   Sacral displacement > 1 cm

o   Intractable pain

§  EF performing had been mentioned above and it uses a temporary stabilization for emergency and resuscitation management, but open book pelvic fractures may be used definitively with intact the posterior S1 ligaments.

§  Internal fixation in pubic symphysis diastasis greater than 2 cm (open book injuries/type B is a rotationally unstable with vertically stable ) and posteriorly displaced hemipelvis (posterior pelvis ring fracture) by plating after reduction or screwing for iliosacral disruption after reduction of S1 joint or sacral fracture

§   Internal fixation is indicated if disruptions of symphysis combine with abdominal exploration (type B and C).

§   The aim of fixation is early mobilization. Thromboembolic prevention should be performed by medical drugs combined with elastic stocking, sequential compression devices, vena caval filter placement. The Candidate should be able to advice full weight bearing on the involved side and partial weight bearing on involved side at 6 weeks after trauma and full weight bearing after 12 weeks. Bilateral unstable pelvic fractures should mobilized from bed to chair with aggressive pulmonary toilet until pelvic fracture is union

b.      Non-operative management include

§  Stable, nondisplaced or minimally displaced with bed rest until pain settles and then mobilization

§   Simple open-book fractures (symphysis diastasis < 2 cm/type B1) with canvas pelvic sling as long as 6 weeks and then mobilization. Treatment is conservative if spontaneous reduction of type B2 (pubic symphysis diastasis > 2.5 cm) or EF for control instability.

§  Unstable and severely displaced fractures with poor results

§  Early mobilization for preventing complications

§  Skeletal traction for vertically unstable fractures in patients in whom there is a contraindication

ALGORITHMA OF PELVIC FRACTURES CARE

Rehabilitation/follow up:

Protect weight bearing with walker or crutches initially and serial radiographs should be evaluated after mobilization has begun to monitor for detection of displacement. If displacement of posterior ring > 1 cm, weight bearing should be stopped and operative management should be performed for more than 1 cm

7.    The Candidate should be able to explain the complication of pelvic fracture and it’s management

The Candidate should be able to inform the complications of the pelvic fractures include:

a.       Nerve injury: prevalence nerve injury in pelvic fracture 10-15% patients especially lumbosacral plexus and nerve root in medial sacral fractures. It may take up to 3 years for recovery. The Candidate should be able to explain nerve injury depends on the location of the fractures and the amount of displacement:

§  L2 to S4 are possible

§  L5 and S1 are most common

§  Sacral fractures with neurologic injury:

o   Lateral to foramen (Denis I: 6%)

o   Through foramen (Denis II: 28%)

o   Medial to foramen (Denis III: 57%)

§  Decompression of sacral foramen

b.      Thromboembolism:

§  DVT is 35-50%. Venography is a gold standard for diagnosis (accuration is 97%) and 70% for iliac veins. Prophylaction DVT after pelvic injury with low-dose warfarin given to patient or placement of a vena caval filter.

§  Pulmonary embolism (PE) is 2-10%

Note: PE can be suspected in pelvic trauma patient with acute onset pleuritic pain, tachypnea and tachycardia. The Candidate should be performed ECG and chest radiograph and pulmonary angiography (gold standard) for making diagnosis. Prophylactic and treatment option include low dose heparin, low-molecular-weight heparin, warfarin (Coumadin’s, and inferior vena c), mechanical compression devices, and inferior vena caval filters.

c.       Closed internal degloving injuries occur as a result of a shear injury to the soft tissues in which the subcutaneous tissue is torn from underlying fascia.

d.      The incidence of genitourinary injury is up to 20%. The Candidate should concern blood at meatus or high-riding prostate in rectal touché for urinary system injuries. Retrograde urethrogram is indicated and intraperitoneal bladder rupture are require repair.

e.  Nonunion is rare complication with chronic pain, abnormal gait and nerve root compression. Treatment is stable fixation and bone grafting. Malunion may result in disability, leg length discrepancy, gait disturbances and difficulty of sitting, low back pain and pelvic outlet obstruction.

f.        Infection ranging from 0-25%. The presence of contusion or shear injuries to soft tissues is a risk factor of infection in posterior approach surgery performing of pelvic fractures. The risk is minimized by percutaneous posterior ring fixation.

g.       Mortality of pelvic fracture in hemodynamic stable patients is 3% death, hemodynamic unstable is 38% death. Lateral compression forces combined with head injury and anterior posterior compression (APC) with visceral injury major cause of death. Mortality rate in comprehensive posterior instability is 37% death but vertically instability is 25% death.

REFERNCES:

1.      Brinker MR (2001). Review of Orthopaedic Trauma. WB Saunder Comp. Philadelphia

2.      Burgess AR, Eastridge BJ, et al. (1990). Pelvic ring disruption: Effective classification system and treatment protocols. J Trauma 30: 848-856

3.      Egol KA, Koval KJ, and Zuckerman JD (2010). Handbook of Fractures. Fourth Edit. Lippincott Williams & Wilkin. Philadelphia.

4.      MacLeod M and Powell JN (1997). Evaluation of pelvic fractures. Clinical and radiologic. Orthop Clin North Am 23: 299-319

5.      McRae R (2001). Pocketbook of Orthopaedics and Fracture. Churchill Livingstone. London