Work Up for Pelvic Fracture

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- Trauma Management:
    - fluid management; 
            - hypotension is associated with an increased risk of mortality, ARDS, and multiple organ failure;
            - IV access is secured with at least 2 large-bore catheters; 
            - transfusion requirements w/ active bleeding:
                   - LC injuries: average 3.6 units of packed red blood cells
                   - APC average 14.8 units packed cells;
    - references:
            - Predicting blood loss in isolated pelvic and acetabular high-energy trauma.
            - Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome.
            - Pelvic ring disruptions: effective classification system and treatment protocols.

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- 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.

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- 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.

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- 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);

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- 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:

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     - 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;

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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?