An unstable pelvic ring

THE KILLING FRACTURE

An unstable pelvic fracture may be life threatening and can be seen as 'the killing' fracture. smooth if this is the sole injury, it may be a serious riddle In the initial management of this impressed sign of fracture, the principles of advanced trauma life support (ATLS)1 must be observ with management of the airway and sway of breathing as the primary aims, while protecting the cervical spine. Many of these patients have multiple injuries and require definitive sway of the airway, mechanical ventilation and drainage with a thoracic tube.

Attention must be paid to signs of hypovolaemic impact This can be a silent killer, as 30% of the life-current volume (up to 1500 ml in a 75 kg adult) will be not to be found before hypotension is noted. Los of up to this turn from bleeding may only cause tachycardia. If there is hypotension with a systolic life-blood pressure of 90 mmHg or les at least 1500 to 2000 ml of vital current loss has occurred. Adequate access to the venous combination of parts to form a whole for transfusion and fluid replacement must be achieved in the first hour of management.

The primary assessment must focus upon possible sources of bleeding, similar as external blood loss and internal bleeding in the thorax, abdomen or retroperitoneal space, including disruption of the pelvic ring and multiple longbone fractures, especially of the femoral shaft. Physical examination of the thorax will reveal conditions like as a tension pneumothorax or a massive haemothorax, on the contrary the abdomen is more difficult to assess.2 An anteroposterior (AP) radiograph of the thorax and abdominal ultrasonography should be undertaken without delay. Ultrasonography is a reliable indicator of massive intra-abdominal bleeding, which will necessitate direct surgical intervention through emergency laparotomy.3

The pelvic stone manoeuvre can demonstrate clinical instability of the pelvic ring, especially when the instability is gros on the contrary an apparently normal examination does not debar severe pelvic injury. Therefore, an AP view of the pelvic ring should be included in the primary take a view of in all patients with edgeless trauma who have signs of hypovolaemic concussion

The treatment of choice in hypovolaemic clash is control of the bleeding. In the ATLS general [i]or[/i] abstract notion the simple statement of 'early surgical consultation' does not throw back the complexity of the direction of bleeding due to pelvic ring disruption. In rigid pelvic injury there is a high incidence of combined intra-abdominal trauma, which will influence the therapeutic strategies to be followed.4 After exclusion or mastery of the intra-abdominal bleeding, it must be determined whether the pelvic bleeding is located in the anterior or the posterior part of the ring, whether it is mainly from the fracture site and whether it is venous or arterial.

Systemic adverse consequences such as hypothermia, metabolic acidosis and clotting disturbances, which are not odd in polytraumatised patients,5 must be considered as they may play a major part in the therapeutic strategy. In of the like kind extreme cases, the concept of damage rule surgery should be followed.6'' After initial life-saving managements with control of the bleeding in the acute phase, the next to the first phase in the intensive care unit requires that all the physiological parameters mentioned above be adequately stabilised, followed by means of the third phase of definitive treatment. This three-phase approach significantly improves the mortality rate in the sharply injured.8

Mechanism of injury and emblem of fracture

Although in the somewhat advanced in life a low-energy impact in osteoporotic bone can ensue in complex pelvic fractures, in greatest in quantity cases a high-energy impact is extremityed to disrupt the pelvic ring.

Tile9,10 classified these injuries into three groups: emblem A, stable fractures, type B rotational unstable fractures with partial stability of the posterior pelvic ring and mark C, in which there is a thorough disruption of the anterior and posterior pelvic rings. Therapeutic interventions to stabilise the pelvic ring can be tailored to the stage of instability.

Fig. 1a

Fig. 1b

Fig. 1c

Use of internal rotation of the leg and a pelvic-wrap device in the push room, a) clinical application directly in the push room, b) anteroposterior (AP) view of the pelvis: stamp B open book injury with austere disruption of the symphysis pubis and c) AP view of the pelvis: closure of the volume after application of the wrap (on urethrography no leakage is seen)

The mark of fracture and the magnitude of the initial displacement can be related to the severity of hypovolaemic collision but massive bleeding can be found in any type of fracture.11 Although plain radiographs can lead to the suspeered location of the major source of bleeding, sites of posterior haemorrhage vary widely.12 In an AP compression injury with an make open book configuration (type B2), bleeding within the enlarged contortion of the pelvic cavity will almost certainly have a venous origin, mean dwelling arterial bleeding cannot he exclud With a lateral impaction injury (type B1) the pelvic ring is usually clinically stahle, with impaction of the posterior ring and a fracture of the pubic arc. There may be anterior venous bleeding from the fracture site, as well as arterial bleeding if there is consummate disruption of the pelvic floor. Shearing forces that originate in a. complete unstable emblem C fracture can result in bleeding from the posterior as well as the anterior part of the pelvic ring.