Pelvic Fractures: soft tissue trauma

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Pelvic Fractures soft tissue trauma

• Luke Leenen, MD, PhD, FACS
• Professor of Trauma
• UMC Utrecht
• The Netherlands

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Pelvis complex anatomy
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Pelvis complex anatomy
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Pelvis complex anatomy
Nervous structures
Vascular structures
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Overwhelming injuries
..... to virtually every internal organ........
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Structures at risk

• Anorectum
• Bladder
• Vagina
• Urethra
• Nerves / Plexus
• Venous plexus
• Arterial supply
• Abdominal wall

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Incidence of soft tissue injury
Hauschild et al J Trauma 64 449 (2008)
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Mortality with concomitant soft tissue injury
Hauschild et al J Trauma 64 449 (2008)
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Is it a risk?
Hauschild et al J Trauma 64 449 (2008)
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Treatment protocol
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Current structured approach.....

• Control the bleeding
• Obtain stability
• Packing
• Lavage / debridement
• Packing / embolization
• Control contamination
• Colostomy?
• Bladder repair
• Suprapubic catheter

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Motor Straddle Injury
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Pelvic clamp
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Soft tissue injury
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Embolisation
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Urethral injury

• Diagnosis Urethrography
• Incomplete lesion drainage and repeat
  investigation in 3 weeks
• Complete lesion
• Anterior pelvic reconstruction pivotal
• Primary (early) reconstruction
• Impotence 56
• Continence 21
• Stricture rate 49
• Secondary reconstruction (suprapubic catheter)
• Impotence 36
• Continence 21
• Stricture rate 97

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Bladder injury

• In 10-25 of pelvic fractures
• Diagnosis
• Cystogram
• CT
• During exploration
• Repair
• Intraperitoneal ? direct repair
• Extraperitoneally ? drainage

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Bladder injury
Be aware!!
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Anorectal injury

• Diagnosis
• High index of suspicion
• Blood from anus
• Direct inspection
• Endoscopy
• At exploration

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Anorectal injury

• Repair
• Washout
• Diversion (colostomy)
• Second look

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Severe soft tissue injury
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Combined problems
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Complex cases
Abdominal packing
Colonic diversion
Skeletal stabilisation
Suprapubic catheter
Pelvic packing
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Secondary abdominal closure
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Staged internal fixation
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Nerve injury

• In up to 50 of cases
• 40 in Sacrum fractures
• 57 with SI joint involvement
• 14 in B-type fractures
• Segment L4-S2
• Mostly Ischial nerve
• Proximal muscle groups have better prognosis than
  distally (peroneal group)
• Final result after 2 years (up to 53 remission!)

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Outcome
Siegmeth et al (2000) Unfallchirurg 103572-581
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Outcome
Siegmeth et al (2000) Unfallchirurg 103572-581
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In conclusion

• Severe open fractures of the pelvis remain a
  challenge
• Many organs can be injured
• A structured stepwise approach results in an
  optimal care
• Nevertheless the results remain disappointing