Diferencia entre revisiones de «Pelvic fractures»

Revisión del 23:42 1 mar 2011

Pearls

Pelvic fractures are associated with:
Hemorrhage requiring transfusion - 35%
Especially with sacroiliac joint disruption
Intraabdominal injury - 16%
Bladder/urethra injury - 6%
Nerve deficits - 15%
Especially with post. ring fx, upper sacral fracture
Thoracic aorta rupture - 1.5%
If pelvic ring is disrupted there are usually two fractures
Exception to this is in the elderly (isolated pubic ramus) and athletes (isolated avulsion)
Extension of fracture into the rectum or vagina = open fx

Fracture Types

Pelvic Ring Disruptions

Lateral Compression
Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
Anteroposterior Compression
Usually unstable as the iliac wings are forced outward, increasing pelvic volume
Often assocciated with pelvic and retroperitoneal hemorrhage
Coincident injuries of the thorax and the abdomen are the rule
Vertical Shear
Result from vertically oriented force delivered to the pelvis via the extended femurs
Unstable; pelvic volume is increased
Malgaigne Fracture
Ipsilateral anterior and posterior ring fractures
High rate of neurovascular injury

Other Pelvic Fractures

Straddle Injury
Unstable
Both rami fractured on both sides or both rami on one side and pubic symphysis diastasis
High rate of urinary tract and bowel injury
Avulsion Fracture
Stable; occur usually in skeletally immature athletes aged 14-17 yrs
Can rarely occur in association with trauma in adults; if lack of trauma pathological until proven otherwise

Imaging

Plain films
AP - Obtain in all unconscious blunt trauma patients
Inlet - Better defines the pelvic brim
Outlet - Better defines the sacrum and SI joints
Judet - Better defines the acetabulum
CT
Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on xray
Exceptions include isolated pubic rami fx, avulsion fx
Retrograde cystourethrogram
Obtain (before foley!) if blood at the meatus, high riding prostate, or gross hematuria
US
May confuse hemoperitoneum for uroperitoneum
If FAST negative but pt is persistently hypotensive consider DPA (aspirate)

Management

Anticipate hypotension
Rapidly detect hemoperitoneum
Classify fx pattern as "stable" or "unstable"
If unstable wrap with sheet or pelvic binder
Be careful not to over-reduce a lateral compression fx (places increased strain on the post. pelvis)
Pt's legs, greater trochanters, and patellae should always lie in an anatomical position
In lateral compression injury the goal is stabilization, not compression
Assess for associated injuries
Neurological
Distal motor weakness (impaired dorsi/plantar flexion of great toe)
Distal numbness (dorsal and lateral aspects of foot)
Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)
Open Fx
Vaginal bleeding
Rectal bleeding

Reference

UpToDate, Harwood-Nuss

Authors:

@@ Línea 1: / Línea 1: @@
-Normal anatomy: pelvis and proximal sacrum are angled posteriorly
+==Pearls==
-pubic symphysis: up to 5mm in width, up to 2mm offset, no overlap
-SI joints: 2-4 mm in width
-checklist-
-)obturator foramina for symmetry-clue for rotation of film
-)diastasis of pubic symphysis and both SI joints
-)assymetry of illiac wings (rotation or deformity)
-)sacral foramina-especially the superior cortical margins
-)transverse processes of L5
-)integrity of all cortical lines, especially around acetabulum.
-Outlet views-sacral fxs, SI joint abnormalities
-Inlet view-displacement of ant. Fragments into pelvis..
-(posterior abnormalities usually need CT )
+* Pelvic fractures are associated with:
+* Hemorrhage requiring transfusion - 35%
+* Especially with sacroiliac joint disruption
+* Intraabdominal injury - 16%
+* Bladder/urethra injury - 6%
+* Nerve deficits - 15%
+* Especially with post. ring fx, upper sacral fracture
+* Thoracic aorta rupture - 1.5%
+* If pelvic ring is disrupted there are usually two fractures
+* Exception to this is in the elderly (isolated pubic ramus) and athletes (isolated avulsion)
+* Extension of fracture into the rectum or vagina = open fx
-Kane classification system:
+==Fracture Types==
-type I-(stable) fracture of individual bones without a break in continuity of pelvic ring.
-lower urinary tract injury;
+===Pelvic Ring Disruptions===
-pathway:
-males-retrograde urethrogram, foley, retrograde cystogram, IVP
-females-careful foley, retrograde cystogram, IVP.
+* Lateral Compression
+* Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
+* Anteroposterior Compression
+* Usually unstable as the iliac wings are forced outward, increasing pelvic volume
+* Often assocciated with pelvic and retroperitoneal hemorrhage
+* Coincident injuries of the thorax and the abdomen are the rule
+* Vertical Shear
+* Result from vertically oriented force delivered to the pelvis via the extended femurs
+* Unstable; pelvic volume is increased
+* Malgaigne Fracture
+* Ipsilateral anterior and posterior ring fractures
+* High rate of neurovascular injury
-Neurologic injuries
+===Other Pelvic Fractures===
-posterior ring or sacral fractures
-/3 of sacral fractures have neurologic involvement.
-check bowel/bladder fxn , sensory levels...
-sacral lesions can cause neurogenic bladder with overflow incontinence, sphincter dysfunction, or sexual dysfunction (eek)...
-typeII-(stable) single breaks in the pelvic ring, non displaced, must look very hard for displacement.If anterior still a high rate of urinary tract infection.
-type III- (unstable) double breaks or more in the ring:IIIA-Straddle fracture,IIIB Malgaigne fracture, IIIC severe multiple fractures
-type IV- Acetabular fractures
+* Straddle Injury
+* Unstable
+* Both rami fractured on both sides or both rami on one side and pubic symphysis diastasis
+* High rate of urinary tract and bowel injury
+* Avulsion Fracture
+* Stable; occur usually in skeletally immature athletes aged 14-17 yrs
+* Can rarely occur in association with trauma in adults; if lack of trauma pathological until proven otherwise
-Straddle Fracture:
+===Imaging===
-Both rami fractured on both sides, or both rami on one side and diastasis of pubic symphysis.
-caused by straddle injury or lateral compression., high rates of urinary tract injury and abdominal visceral injuries. Leg lengths are normal.
+* Plain films
+* AP - Obtain in all unconscious blunt trauma patients
+* Inlet - Better defines the pelvic brim
+* Outlet - Better defines the sacrum and SI joints
+* Judet - Better defines the acetabulum
+* CT
+* Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on xray
+* Exceptions include isolated pubic rami fx, avulsion fx
+* Retrograde cystourethrogram
+* Obtain (before foley!) if blood at the meatus, high riding prostate, or gross hematuria
+* US
+* May confuse hemoperitoneum for uroperitoneum
+* If FAST negative but pt is persistently hypotensive consider DPA (aspirate)
-Malgaigne Fracture:
+===Management===
-Anterior and posterior ring fractures on same side .
-high rates of urinary and vascular injuries.
-leg lngths areunequal, anterr illiac crest is displaced and or mobie
+* Anticipate hypotension
+* Rapidly detect hemoperitoneum
+* Classify fx pattern as "stable" or "unstable"
+* If unstable wrap with sheet or pelvic binder
+* Be careful not to over-reduce a lateral compression fx (places increased strain on the post. pelvis)
+* Pt's legs, greater trochanters, and patellae should always lie in an anatomical position
+* In lateral compression injury the goal is stabilization, not compression
+* Assess for associated injuries
+* Neurological
+* Distal motor weakness (impaired dorsi/plantar flexion of great toe)
+* Distal numbness (dorsal and lateral aspects of foot)
+* Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)
+* Open Fx
+* Vaginal bleeding
+* Rectal bleeding
-Bucket handle fracture
+===Reference===
-Anterr and poterior ring fractures on opposite sides. Anterior fracture is usually both pubic rami.
-high rates ofurinary and vascular injuries
+UpToDate, Harwood-Nuss
-III-C Open book or sprung pelvis fracture
-bilateral posterior ring fractures.