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1、Fracturesanddislocationsofthepelvis IntroductionIntroductionPelvic fractures are among the most serious injuries and account Pelvic fractures are among the most serious injuries and account for 3% of all fractures.for 3% of all fractures.Etiology:Low energy stable fractures e.g. Falls in elderly pat
2、ients treated symptomatically with crutch- or walker-assisted ambulation expected to heal uneventfully in most patientsHigh energy significant morbidity and mortalitye.g. motor vehicle accidents, falls, motorcycle accidents, automobile-pedestrian encounters, industrial crush injuriesOften managed op
3、eratively, determined by the degree of remaining stability of the pelvisAppropriate treatment to the resuscitation and reconstructionMortality rate: 9% 20% 1980s 5% 10% now (more than 50%, severe open fracture)IntroductionIntroduction40% 50% hemodynamically unstable patients inemergency departmentRi
4、sk factors: age injury severity score associated head or visceral injury life-threatening hemorrhage (e.g. ) hypotension coagulopathy unstable / open fractureOther complications: neurologic injury genitourinary injury peritoneum injuryrectum injury Closed and open pelvic fractureClinical findingsCli
5、nical findings1、History of high-energy caused injury2、Physical examination: palpation of the pelvic bony landmarks compression maneuvers to access stabiliy rectovaginal examination Tips: pay attention of the bruise in perineal area3、Associated injuries lower urinary tract distal vascular status neur
6、ologic examinations4、Accessory examination X-ray: AP inlet outlet CT scanningAcute managementAcute managementImmediate goals: Cessation of blood loss minimization of septic sequelae stabilization of fracture Emphasize the multidisciplinary approachUsually, we should pay attention to retroperitoneal
7、hemorrhage, pelvic ring instability, and injuries to the genitourinary system and rectum as well as fractures open to the peritoneum.Circumferential pelvic binderSuperior to external fixation for its ease and rapidness of applicationGeneral resuscitative principlesExternal fixationFragments stabiliz
8、ed pelvic space for fluids decreased C-clamp type of external fixatorAngiographyPersistent hypotension with the mentioned method performedArteriography5% 10% bleed from arterial sources embolizationUse of Circumferential pelvic binderAcute managementAcute managementAcute managementAcute managementOp
9、en pelvic fracturesExtremely difficult to manageRetroperitoneal space openSepsis Large avulsion flaps (ischemic pelvic tissue)Acute managementAcute managementSelective fecal diversion in complex open pelvic fractures from blunt traumaZone IZone IIZone IIIHow to decide the colostomy? Initial evaluati
10、on and management of patient with pelvic ring fracture. Protocols should be individualized accordingto resources and facilitiesAcute managementAcute managementAnatomy and stabilityAnatomy and stabilityBone componentsInnominate bone: ilium ischium pubissacrumJointsPubic symphysis sacroiliac jointLiga
11、mentsAnterior sacroiliac ligamentPosterior sacroiliac ligament complex: interosseous sacroiliac ligamentPosterior sacroiliac ligamentSacrospinous ligamentSacrotuberous ligamentAnatomy and stabilityAnatomy and stabilityIliolumbar ligamentPosterior sacroiliac ligamentSacrotuberous ligamentSacrospinous
12、 ligamentPelvic brimTrue pelvisSacrotuberous ligamentSacrospinous ligamentL5 transverse processInterosseous sacroiliac ligamentsIliolumbar ligamentPosterior superior iliac spineAnatomy and stabilityAnatomy and stabilityExternal rotation of hemipelvis:symphysis sacrospinous ligament anterior sacroili
13、ac ligamentRotation in the sagittal plane:Sacrotuberous ligamentVertical forces:all the mentioned ligamentous structuresTips:interosseous sacroiliac posterior sacroiliac ligaments iliolumbar ligamentrotationally unstable hemipelvis may remain vertically stableAnatomy and stabilityAnatomy and stabili
14、tyClassification and treatmentClassification and treatmentTile modified classification (predominant method):Type A: stableType B: rotationally unstable but vertically stableType C: rotationally and vertically unstableIIIIIIsacral alaforaminal regionspinal canalClassification and treatmentClassificat
15、ion and treatmentType A1: avulsion fractures or isolated iliac wing fractures occur in adolescents conservative treatment displacement is marked, reattachment by open operationType A2: stable fractures of the pelvic ring with minimal displacement symptomatic treatment and early ambulation or weightb
16、earing.Type A3: transverse lesions of the sacrum or coccyx spinal injury rather than pelvic disruption.Classification and treatmentClassification and treatmentType B1: “Open book” fractures; anterior pelvis opens through a diastasis of the symphysis or through a fracture of the anterior pelvic ring
17、significant associated injuries to perineal and urogenital structures displaced symphysis 2.5cm symptomatic treatment 2.5cm “close the book” operationType B2: inward displacement of the hemipelvis through the sacroiliac complex and ipsilateral pubic rami fracturesType B3: inward displacement of the
18、hemipelvis through the sacroiliac complex and contralateral pubic rami fractures Type B2 and B3 usually need operative treatment major hemorrhage external fixation or internal fixation, or bothType B1Type B2Classification and treatmentClassification and treatmentType C: the hemipelvis is completely unstable massive hemorrhage open reduction and internal fixation as a definitive treatmentCase exerciseCase exerciseCase exerciseThanks for the attention !
