Assessment and management of pelvic and acetabular trauma
by James Donaldson

Scenario: called to A&E to assess a 34 year old involved in a high speed road traffic accident.

History:

Age – often young, involved in high energy blunt trauma
Assess for other injuries

Time/date of injury

Past medical/surgical history

Last ate / drank – timing of emergency surgery

Medication/drugs and allergies

Pelvic Trauma

Radiographs / imaging

• Trauma series of x-rays (chest, AP pelvis and lateral cervical spine)
• FAST scan (to rule out intra-abdominal bleeding)
  
• CT scan only when haemodynamically stable

Symptoms and Signs

• Pain, inability to weight bear
• Assess lower limb: shortening, rotationally malaligned
• ‘Balloting’ the pelvis has little value and can disrupt tamponade
• Skin

            - Perineal lacerations
            - De-gloving
            - Flank haematoma

• Uro-genital injury

            - Haematuria, scrotal bruising, blood at meatus
            - Do urethrogram prior to Foley. May need supra-pubic catheter
            - PR and PV mandatory - ?open #

• Neurology:

            - Lumbosacral injury
            - Anal sphincter tone
Inform senior urgently

Advanced Trauma Life Support (ATLS)

• Haemorrhage is the major source of death
• Mortality 15-50%
• Often associated injuries – chest, long bone, head, spine, abdomen, uro-genital
• Resuscitation with blood, platelets and FFP (1:1:1)
• Pelvic binder or sheet over greater trochanters, can combine with internal rotation of lower limbs
• Sources of bleeding

            - Intra-abdominal
            - Intra-thoracic
            - Retroperitoneal
            - Extremity
            - Pelvic
                - Venous (80%)
                        - Post venous plexus
                        - Cancellous bone
                - Arterial (10-20%)
                        - Sup gluteal artery
                        - Int pudendal artery
                        - Obturator artery

Trauma team and seniors involved early

External fixator application


Angiography

• To be done in theatre only, may be combined with laparotomy
  


• May be helpful depending on resources
• More useful for arterial bleeding
• Perform after pelvis has been stabilised

Classification

Tile
    A) Stable
    B) Rotationally unstable
    C) Rotationally and vertically unstable
Young and Burgess
    AP compression type
    Lateral compression
    Vertical shear

BOAST guidelines:

• Early pelvic binder and control of haemorrhage
• PRC, platelets, FFP initially; if ongoing haemorrhage and pelvis is stabilized a laparotomy with pelvic packing +/- embolisation may be needed
• Early CT scan once haemodynamically stable
• High index of suspicion for associated injuries
• Open pelvic fractures may require urgent bladder drainage and bowel diversion by specialists
• Urethral injury diagnosed and managed appropriately
• Definitive plan by pelvic surgeon within 5 days
• Image transfer and referral to specialist centre within 24hrs
• Specialist unit to follow the patient up

Acetabular trauma

Bimodal age distribution – young, high energy; elderly low energy

Radiographs

• AP pelvis initially
• May also need (ask specialist centre)

            - Judet views
            - Inlet and outlet views
            - +/- CT scan

AP x-ray demonstrating Left acetabular fracture and pelvic binder insitu

Symptoms and Signs

• Pain, swelling, inability to weight bear
• Abnormal lower limb position / profile
• 50% have an associated injury
• 36% have an ipsilateral limb injury
• Document neurovascular status

Management

• In the high energy cases follow ATLS principles and management similar to pelvic fractures
• A dislocated hip needs emergent reduction
• Skin traction in A&E may be helpful
• Inform senior urgently if high energy injury, haemodynamic instability, neurovascular compromise, open fracture or dislocation
• Admit all cases for CT scan, analgesia and discussion

Letournel classification

• Elementary fracture types (20%):

            - Anterior wall, anterior column, posterior wall, posterior column, transverse fracture

• Associated fracture types (80%)

            - Involve 2 or more of the elementary types

Surgery

• Non-surgical if minimally displaced or medically unfit
• ORIF +/- total hip replacement if displaced

Complications

• Secondary osteoarthritis
• Heterotopic ossification
• Femoral head avascular necrosis
• DVT, PE
• Nerve injury
• Infection, bleeding, weakness, nerve injury  if surgery is performed

BOAST guidelines:

• Reduce hip dislocations urgently. Document neurovascular status before and after the procedure. Apply skeletal traction. If irreducible or unstable urgent specialist transfer
• CT scan within 24 hours of hip reduction and early referral / transfer of images
• Reconstruction in a specialist unit within 5 days (no later than 10)
• Chemical thromboprophylaxis within 48hrs of injury assuming no contraindications