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TRAUMA PELVIS

Humaryanto
Tujuan
Mengetahui jenis-jenis
fraktur pelvis dan
penatalaksanaannya
Mengetahui indikasi dan
tehnik pemasangan c-
clamp
Pelvis
Anatomi pelvis :
Berbentuk cincin, terdiri dari tulang
ilium, ischium, pubis dan sacrum
Di bagian anterior berartikulasi
pada simfisis pubis dan di posterior
pada sendi sakroiliac
Di rongga pelvis banyak terdapat
organ penting : saraf, pemb.darah,
buli-buli dll
Pelvis
Stabilitas pelvis tergantung dari integritas
ligamen dan tulang
Ligamen yang terpenting dan terkuat
adalah ligamen pada bagian posterior
yaitu lig. sacroiliac dan iliolumbar
Pada trauma pelvis yang tidak stabil
dapat terjadi kehilangan darah yang
sangat besar dan dapat terjadi
komplikasi pada organ viscera pada
rongga pelvis
Fraktur pelvis
Fraktur pelvis menyebabkan terbukanya
cincin pelvis dan dapat mengakibatkan
ketidakstabilan
Derajat ketidakstabilan tergantung dari
cincin bagian mana yang terputus
Ketidakstabilan secara mekanik dapat
mengakibatkan ketidakstabilan
hemodinamik bila disertai dengan
kerusakan vaskuler dalam rongga pelvis
syok
Fraktur pelvis
Mortalitas akibat fraktur
pelvis
3% pada pasien yang MRS
dengan hemodinamik stabil
38% pada pasien dengan
hemodinamik tidak stabil
Fraktur Pelvis
Pelvic ring

Cedera vaskuler

Cedera pada urethra


Klasifikasi fraktur
pelvis
Klasifikasi Tile

Tipe A Tipe B Tipe C


Stable Rotationally unstable Rotationally and
Vertically stable Vertically Unstable
(open book type)
Young and Burgess
proposed a different
modification of the
original Pennal
classification, adding a
new category for
combined mechanism
injuries
Lateral compression (LC) injuries
Category Common characteristic Differentiating characteristic
LC 1 Anterior transverse Sacral compression
fracture (pubic rami) on side of impact
LC 2 Anterior transverse Crescent (iliac wing) fracture
fracture (pubic rami)
LC 3 Anterior transverse Contralateral open book
fracture (pubic rami) (APC) injury
Anteroposterior compression (APC)
APC 1 Symphyseal diastasis Slight widening of pubic symphysis
and/or Sl joint; stretched but intact
anterior and posterior ligaments
APC 2 Symphyseal diastasis Widened Sl joint,
or anterior vertical disrupted anterior ligaments;
fracture intact posterior ligaments
APC 3 Symphyseal diastasis Complete hemipelvis separation but no
or anterior vertical joint disruption; complete anterior and
posterior ligament disruption
Vertical shear (VS) injuries
VS Symphyseal diastasis or Vertical displacement anteriorly
anterior vertical fracture and posteriorly, usually through
Sl joint, occasionally through
iliac wing and/or sacrum

CM Anterior and/or posterior, Combination of other injury


vertical and/or transverse patterns; LC/VS or LC/APC
components
In a subsequent series, lateral compression (LC)
injuries were the most common injury pattern,
accounting for 41% of the patients, followed by
anteroposterior compression (APC) injuries
(26%), acetabular fractures (18%), combined
mechanism (CM) injuries (10%), and vertical
shear (VS) injuries (5%). Hypovolemic shock
and large blood requirements were more
common in patients with vertically unstable
APC type 3 injuries than in those with vertically
stable anteroposterior or lateral compression
injuries.
Pelvic Fracture
Type & Outcome
Mortality Shock ARDS Visceral

AP Compression 33% 60% 20% +

Lateral comp. 33% 30% 20% ++

Vertical shear 6% 60% 15% ++

Combined 12% 40% 15% +


Pelvic trauma
Major trauma
Polytrauma patients
Life threatening
Haemorrhagic shock
Traffic accident
Injuries
Major trauma
Polytrauma
Head
Chest
Abdomen
Spine
Pelvis
Extremities
Polytrauma
Anatomy
Bones
Ligaments
Vessels
Nerves
Visceras
Pelvic bones
Pelvic Ring Anatomy
Pelvic ligaments
Pelvic Ring Anatomy
Vessels
Pelvic Ring Anatomy
Nerves
Pelvic visceras
Diagnosis
Pada setiap trauma abdomen bawah dan tungkai
selalu pikirkan kemungkinan fraktur pelvis
Perhatikan mekanisme cedera
Pemeriksaan klinis :
Jejas pada pelvis/abdomen bagian bawah
Nyeri tekan pada pelvis
Ketidakstabilan pada perabaan
Perbedaan panjang kedua tungkai
Rectal examination & darah pada mue
Hipotensi & tachycardia (bila disertai gangguan
hemodinamik)
Radiologis : foto pelvis AP, CT scan
Diagnosis
History
Physical examination
Radiographic examination
Mechanisms of Injury
low-energy fractures: generally
resulting in isolated fractures of
individual bones
do not damage the true integrity of
the ring structure
domestic falls: "straddle" injury
from a fall in the bathtub, an
etiology frequently found in the
elderly population
avulsion injuries of the muscle
apophyses in skeletally immature
patients.
Mechanisms of Injury
high-energy fractures: generally
producing pelvic ring disruption
motor vehicle, 57%; pedestrian,
18%; motorcycle, 9%; falls from
heights, 9%; and crush, 4%
often result in two or more
fractures of the pelvic ring
AP force, lateral impacts,
vertical shear
Penetrating mechanisms:
associated visceral and
neurovascular injuries
History of trauma
Physical examination
Pemeriksaan fraktur pelvis
Tekan kearah posterior
dan anterior pada
krista iliaka (stabilitas
anteroposterior)
Lakukan traksi pada
salah satu tungkai
dengan memfiksasi
pelvis (stabilitas
vertikal)
Pemeriksaan
radiologis
Bila keadaan pasien memungkinkan
segera dilakukan pemeriksaan foto
pelvis AP
CT scan
3 dimensional CT
Radiographic examination
Outlet and inlet view

O
Emergency management

Comprehensive
Evaluation
Treatment
Priorities
Other life threatening
injuries
Retroperitoneal
bleeding
Retroperitoneal bleeding
Fracture stabilization
Pelvic volume
Angiography + embolization
Exploration + packing
Pelvic volume
Pneumatic antishock garment
Pelvic sling
External fixation
Pelvic C clamp
Fraktur Pelvis - terapi konservatif

Pelvic sling
EXTERNAL COMPRESSION WITH A BED
SHEET TO REDUCE PELVIC VOLUME
Fracture stabilization
Pelvic c clamp

External fixation

Pelvic sling
Stabilisasi pelvis

Mengecilkan
rongga
pelvis :
berfungsi
sebagai
tampon
Pelvic sling,
stagen
Fiksasi
eksterna
Fiksasi
interna
Angiography
Source of the
bleeding
Embolization
Guide for surgical
procedure
External fixation

Ext fix
Pelvic C clamp
Posterior C-clamp Cx: inferior gluteal artery
and sciatic nerve damage
Placement of a stab incision
Pelvic C clamp
Pelvic C clamp

C clamp will compress the SI joints gap


Apply traction before tightening the C
clamp
C clamp

Traction of the afected leg first before


tightening the C clamp in vertical
shearing pelvic injury !
Improper treatment

Internal rotasional unstable pelvis injury was treated by


using pelvic sling.
Patient with c clamp
Check the c clamps position
radiographically

Use a firm bed for easier mobilization

Check the tightness of the c clamps


bolt and its attachment to the pelvic
bone.

Check the wound at the pin insertion.


C clamp removal
Stable haemodynamic condition.
Planning for definitive treatment of
the pelvic injury.
PREPERITONEAL
PACKING
Conclusion
A major, life threatening pelvic injury should be
treated comprehensively, with priority to manage
the dangerous associated injuries and to achieve
pelvic stability that provide tamponade
mechanism to stop the bleeding so haemorrhagic
shock can be prevented.

Choose the methods and instruments to treat the


pelvic injury based on proper evaluation and
diagnosis.

The procedure to treat the pelvic injuries should


be done correctly to achieve a good result and to
prevent complications.