- Trauma Management:
-
fluid management;
- IV access is secured with at least 2 large-bore catheters;
- ref:
Predicting blood loss in isolated pelvic and acetabular high-energy trauma.
- Physical Exam:
-
vascular injuries
-
inspection of soft tissues:
- palplation:
- symphysis, pubic rami, iliac crests,
sacroiliac;
- bimanual compression & distraction of the iliac wings, & abduction & adduction of the hip should be done to detect instability;
- manual traction can aid in the determination of vertical instability
-
gyn / urinary / rectal injuries:
- RUG vs. suprapubic catheter placement;
- gross hematuria has been shown to be an extremely reliable indicator for significant lower genitourinary tract injury,
whereas microscopic hematuria is not associated with such injury;
-
neurologic injury:
- references:
-
Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries.
- Radiology of the Pelvis
- r/o concomitant Hip or Femur Fractures;
- CT Scan: Protocol;
- 3.0 mm axial cuts from
SI joint to the acetabulum;
- 1.5 mm axial cuts thru the acetabulum;
-
Anteroposterior:
-
LC-II: look for pattern of all 4 rami fractured anteriorly;
-
40-degree cephalad (Outlet)
- demonstrates sacral foramina & displacements of ischial tub.
-
40-degree caudad (Inlet)
- visualizes pelvic
Inlet & magnitude of
sacroiliac joint
-
associated fractures:
-
Spine:
-
Femur:
- ref:
Femoral Shaft Fractures Associated With Unstable Pelvic Fractures.
- Classification:
-
posterior pelvic injury:
-
anterior pelvic injuries:
- the most basic classification should always be whether the frx is stable or unstable, which is best assessed under flouroscopy if available;
- the most severe degree of instability will allow motion in all three planes (medial-lateral, AP, and cephalad-caudad);
- lesser degree of instability will allow motion in only one plane;
- an example of this would be the
lateral compression injury, which is unstable to internal rotation
but is stable to external rotation (and actually reduces in external rotation);
- Initial Treatment by System:
-
c-spine
-
spine
-
pelvis: (
bleeding w/ pelvic frx)
-
frx - menu
-
neuro: document any preoperative neurological deficits;
-
cranio-maxillo-facial
-
spine
-
cardiac
-
pulmonary
-
gyn / urinary / rectal injuries: suprapubic vs. foley catheter (consider RUG)
- patients with displaced rami fractures and sacroiliac joint disruptions may be at especially high risk of urethral injuries,
and consideration is given to initial retrograde urethrograms before urethral instrumentation;
-
bleeding w/ pelvic frx
-
compartments
- hepatic / GI tract: need for diversion w/
open fractures;
- coag:
DVT & PE from pelvic fractures:
- Checklist:
-
Anesthesia: - request GEA if compartment syn is possible;
- Cardiology
-
Blood (4 units)
- X-rays and Template
- Consent
-
ATB (High dose Vanc if pt has been in SICU)
- Posting
- Implant Selection;
- Positioning
- Table type and Flouro
- Incision
- Sulcatrans / Cell Saver
- Bone Graft
- Initial Orders: (
Post Op Orders)
- NPO p Midnight x Meds
- IVF D5W 1/2 NS c 20 KCL at 100 ml/hr
- 2 large bore IV;
- Foley
- Type & Cross 2-4 units pRBC and/or
FFP
-
Meds
-
Insulin (1/2 NPH dose) + S.S. - Accu Check in AM and on call
-
ATB:
-
Heparin 5000 units SQ q8 hrs;
- Zantac
- Morphine
- PreOp Labs:
- Musculoskeletal Labs:
-
EKG
- CXR
- Urinalysis
- Buck's Traction
- Egg Crate / Pillow and turn 20 deg q2hr;
- Hiboclens Shower and Bactroban to nares q12 hrs until OR
- Cleocin solution 300 mg per 100 ml NS q6hr as mouth wash;
Comminuted fractures of the iliac wing.
Does colostomy prevent infection in open blunt pelvic fractures? A systematic review.
Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German trauma registry: is there an influence on outcome?
