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What is the importance of pelvic injuries?
What is the importance of pelvic injuries?
Pelvic injuries are associated with blood loss, shock, sepsis, ARDS, and visceral injuries.
What bones make up the pelvic ring?
What bones make up the pelvic ring?
The pelvic ring is composed of two innominate bones (ilium, ischium, and pubis) and the sacrum.
What structures are protected by the viscera?
What structures are protected by the viscera?
The viscera is protected by the iliac vessels and their branches, lumbar and sacral plexuses, bladder, urethra, uterus, vagina, and rectum and anal canal.
Fracture pelvis needs high energy to create such damage.
Fracture pelvis needs high energy to create such damage.
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What is the mortality rate for open fractures?
What is the mortality rate for open fractures?
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What are the associated injuries with a pelvic fracture?
What are the associated injuries with a pelvic fracture?
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What is the priority in clinical assessment of a pelvic fracture?
What is the priority in clinical assessment of a pelvic fracture?
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What are the signs of a suspected pelvic fracture?
What are the signs of a suspected pelvic fracture?
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What is the technique for testing stability of the pelvic ring in a physical examination?
What is the technique for testing stability of the pelvic ring in a physical examination?
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Why is rectale exam to evaluate sphincter tone and perirectal sensation important?
Why is rectale exam to evaluate sphincter tone and perirectal sensation important?
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Urethral catheter should always be used to test the urethra in cases of suspected pelvic fracture.
Urethral catheter should always be used to test the urethra in cases of suspected pelvic fracture.
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X-rays are the only imaging modality necessary for diagnosing pelvic fracture.
X-rays are the only imaging modality necessary for diagnosing pelvic fracture.
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What imaging study is used for suspected urethral or bladder injuries?
What imaging study is used for suspected urethral or bladder injuries?
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What are the types of fractures that can occur with a pelvic fracture?
What are the types of fractures that can occur with a pelvic fracture?
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What kind of treatment is recommended for an isolated fracture with an intact pelvic ring?
What kind of treatment is recommended for an isolated fracture with an intact pelvic ring?
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Describe the three main mechanisms of injury in pelvic fractures.
Describe the three main mechanisms of injury in pelvic fractures.
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How does a lateral compression fracture occur?
How does a lateral compression fracture occur?
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What are the clinical features of a stable pelvic fracture?
What are the clinical features of a stable pelvic fracture?
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Pelvic binder is mandatory at the accident scene for every suspected pelvic fracture.
Pelvic binder is mandatory at the accident scene for every suspected pelvic fracture.
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What is the goal of early management for a pelvic fracture?
What is the goal of early management for a pelvic fracture?
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What kind of treatment is recommended for open book injuries with an anterior gap less than 2 cm?
What kind of treatment is recommended for open book injuries with an anterior gap less than 2 cm?
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What is the purpose of a posterior sling in treating open book injuries?
What is the purpose of a posterior sling in treating open book injuries?
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What are the benefits of early external fixation in severe unstable pelvic fractures?
What are the benefits of early external fixation in severe unstable pelvic fractures?
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What are the secondary complications of pelvic fractures?
What are the secondary complications of pelvic fractures?
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What are the common causes of acetabular fractures?
What are the common causes of acetabular fractures?
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What is the significance of acetabular fractures?
What is the significance of acetabular fractures?
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What are the treatment options for acetabular fractures?
What are the treatment options for acetabular fractures?
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What is the common cause of injuries to the sacrum and coccyx?
What is the common cause of injuries to the sacrum and coccyx?
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What are the symptoms associated with injuries to the sacrum and coccyx?
What are the symptoms associated with injuries to the sacrum and coccyx?
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Which of these options are options for treatment of sacral and coccyx injuries?
Which of these options are options for treatment of sacral and coccyx injuries?
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Study Notes
Lower Limb Trauma: Fracture Pelvis
- Lecture presented by Dr. Muthanna Hashim Hammoshi, Orthopedic Specialist, Ninevah Medical College.
- The lecture covered the 5th stage.
- Objectives included:
- Pelvic anatomy, imaging, fracture classification, initial and definitive treatment, complications.
- Acetabulum injuries (causes, significance, and treatment).
- Coccyx fracture (epidemiology and treatment).
Pelvic Injuries: Importance
- Pelvic fractures are associated with significant blood loss, shock, sepsis, ARDS, and visceral injuries.
- Mortality rates can be as high as 10% in these cases.
- Often related to road traffic accidents (RTA) or falls from height (FFH) involving pedestrians or occupants.
Pelvic Surgical Anatomy
- Composed of two innominate bones (ilium, ischium, pubis) and the sacrum.
- Anteriorly articulated by the pubic symphysis, and posteriorly at the sacroiliac joint.
- The pelvis transmits weight and protects visceral organs.
- Posteriorly: iliac vessels, lumbar and sacral plexuses.
- Anteriorly: bladder, urethra, uterus (in females), vagina (in females), rectum, and anal canal.
- The male and female pelvis present similar components but with anatomical differences.
Pelvic Vascular Anatomy
- Diagrams of major arteries and veins of the male pelvis are included.
- Key anatomical structures mentioned include branches such as the superior and inferior gluteal arteries, internal pudendal vessels, and the lumbosacral plexus.
Fracture Pelvis: Importance
- High-energy trauma is often involved in fracture pelvis, such as in road traffic accidents.
- Mortality rate is 15-25%, higher in open fractures, often due to hemorrhage.
- High mortality risk associated with low systolic blood pressure (<90 mmHg).
- Advanced age (>60 years) is another factor associated with higher risk of mortality.
- Blood transfusion requirement exceeding four units is also a higher mortality risk factor.
Associated Injuries
- Pelvic fractures are often accompanied by other injuries, such as chest injuries (up to 63%), long bone fractures (up to 50%), head and abdominal injuries (up to 40%), spinal fractures (up to 25%) and urogenital injuries (12-20%).
Clinical Assessment
- Priority is to stabilize the patient, correct any medical conditions affecting circulation, reduce major blood loss, and ensure resuscitation.
- Every RTA/FFH/crush injury case should be investigated.
- Clinical assessment includes looking for swelling, bruising of the abdomen, thighs or perineum (scrotum or vulva), tenderness around the symphysis pubis or sacroiliac region.
Physical Examination
- Skin examination for signs of injury (e.g., swelling or ecchymosis).
- Neurological examination (e.g., evaluating lumbosacral plexus) to rule out injuries to nerves.
- Urogenital examination may reveal gross hematuria.
- Vaginal and rectal examinations are done to check for occult open fractures.
- Imaging (X-rays, CT scan with 3D reconstruction, and other imaging for specific suspected injuries) is crucial as well.
Imaging Studies
- X-rays are essential for all suspected cases.
- CT scans with 3D reconstructions are used for complex patterns.
- Additional tests like IVU, urethrograms, or cystograms assist in evaluating injuries to the urinary system.
Types of Fractures
- Isolated fractures with an intact pelvic ring, such as iliac blade, pubic rami, or anterior superior iliac spine.
- Fractures of the pelvic ring (stable or unstable).
- Acetabular fractures. The stability of each type may depend on the number and severity of bone fractures involved.
Mechanisms of Pelvic Ring Injury
- Anteroposterior compression: frontal collision (for example, pedestrian versus car); anteriorly, pubic rami fractures or symphysis pubis diastasis; posteriorly, sacroiliac joint separation or iliac or sacral fractures.
- Lateral compression: side-on impact (RTA or falls); pubic rami fractures (in one or both sides); posterior sacroiliac joint strain or fracture of the ilium (on same or opposite side); linked to potential damage to the abdomen, chest or head.
- Vertical shear: usually after a fall from height (FFH); pubic rami fractures and sacroiliac joint disruption; innominate bones displacement vertically; unstable pelvis; gross soft tissue tearing and retroperitoneal hemorrhage.
Clinical Features
- Stable injuries - patient not severely shocked, pain on trying to walk, tender points (in the pelvic region), and less commonly, visceral injury.
- Unstable injuries - severe shock, inability to stand, widespread tenderness, and potential for visceral injury.
Early Management
- Applying the Advanced Trauma Life Support (ATLS) protocol.
- Pelvic binder is essential at the accident scene for suspected pelvic fractures.
- Airway, breathing, circulation (ABC) assessment to maintain oxygenation and circulation.
- Further tests such as intravenous (IV) line setup and blood loss management are crucial.
- Management of internal or external bleeding.
- Evaluating and treating head injuries (if any).
- Treating associated abdominal injuries.
- Also treating injuries involving the bladder and urethra are necessary.
Treatment of Fractures
- Stable injuries: bed rest (4-6 weeks), sometimes with traction, possibly followed by walking with crutches.
- Open book injuries (with anterior gap <2 cm): Bed rest, posterior sling to close the gap.
Severe Unstable Injuries
- Early external fixation.
- Reduction of bleeding.
- Relieving pain.
- Preventing further soft tissue damage.
- Open reduction and internal fixation if needed.
Secondary Complications
- Sciatic nerve injuries.
- Urogenital injuries.
- Persistent sacroiliac pain.
Fractures of the Acetabulum
- Common causes: fall from height (e.g., FFH) or dashboard injury.
- There are various classifications for acetabular fractures.
- Associated problems may include sciatic nerve injury, fracture of the femur, hip dislocation, and prolonged pain, stiffness, and secondary osteoarthritis (OA).
- Non-operative management – skeletal traction.
- Operative management – open reduction and internal fixation (ORIF) is often recommended.
Sacrum and Coccyx Injuries
- Common causes: falls onto the tailbone, more common in women than men.
- Symptoms: bruising, sitting/standing pain, and painful proctology/rectal examination.
- Treatment: reducing the injury via finger placement into the rectum, using a rubber ring cushion or injection of local steroids, potential removal of the coccyx (if needed).
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Description
This quiz focuses on lower limb trauma with an emphasis on pelvic fractures. Topics covered include pelvic anatomy, imaging techniques, fracture classification, and treatment options. It also addresses complications and specific injuries such as acetabulum and coccyx fractures.
