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REFERAT

PELVIC FRACTURE


SUPERVISOR:
DR. ERWIEN ISPARNADI, SP. OT
Angeline Rosa 2016.04.2.0011
Angga Yogi Laksmana 2016.04.2.0012
PELVIC FRACTURE
Pelvic fracture

Fractures of the pelvis account for less than 5% of all skeletal injuries, but it
is important because it associated with:
tissue injuries
blood loss
Shock
Sepsis
ARDS
Urogenital trauma

Mortality rate 6-50%. In traffic accident mortality rate exceeds 10%


Fractures of the adult pelvis, exclusive of the acetabulum, generally are
either stable fractures low-energy trauma, such as falls in elderly
patients
Can be treated symptomatically with crutch- or walker-assisted
ambulation and that can be expected to heal uneventfully in most
patients.
High-energy trauma significant morbidity and mortality.
Managed operatively, with the treatment method determined by the
degree of pelvic stability remaining after the injury
Anatomy
Type of Injury
Isolated fractures with an intact ring
Avulsion fractures. A piece of bone is pulled off by violent muscle contraction usually
seen in athletes. The anterior superior iliac spine pulled off by sartorius muscle. The
anterior inferior iliac spine by rectus femoris. The pubis by adductor longus. Part of ischium
by the hamstrings. All need only resting for few days and reassurance.
Direct fractures. A direct blow to the pelvis like fall from a height may lead to fracture of
the iliac blade or the ischium. Rest until pain subsides is usually all that is needed.
Stress fractures. Fractures of the pubic rami and around the sacro-iliac joint in severely
osteoporotic and osteomalacic patients; it is usually painless and discovered
accidentally.
Fractures with broken ring (stable or unstable)
Fracture of the acetabulum; although it is ring fracture but involvement of the joint raise a
special problem
Sacrococcygeal fractures.
Mechanisms of injury

Basic mechanisms of pelvic ring injury


are:
Anteroposterior compression (APC)
Lateral compression (LC)
Vertical shear (VS)
Combinations of these
Tile Classification
Mortality rate
Lateral compression - 7%
Antero posterior - 20%
Vetikal shears- 0%
Other Classification

Based on the stability and complication


Avulsion fractures
Stable fractures
Unstable fractures
Fractures with complication
Clinical Manifestations

Oedema, deformity, subcutane bleeding arround pelvic


Anemia, and shock caused by severe bleeding
Inferior extremity function disturbance
Clinical Manifestations

TYPE A TRAUMA
Severe Shock (-)
Pain in activity
Palpation : tenderness (+)
Pelvic visceral damaged : rare
Xray : Fracture (+)
Clinical Manifestations

Type B & C Trauma


Severe shock (+)
Severe pain (+)
Hard Mixturition, meatus externus bleeding
Palpation : tenderness (+)
One or both Ala osis ilii : pain movement (+)
One of foot : anesthesia , caused by : schiatic nerve trauma
Diagnosis
inspect
- Oedema or hematoma in
Palpate :
lower abdominal,thigh,
perineum, scrotum, or skeletal structures: Assess for mobility
vulva - pubic symphysis,
- Gently compress the iliac crests
- deformity - iliac crests, to fell for instability
- wound - the posterior sacroiliac joints, - If there is no pain or movement
- ischial tuberosities as well as felt on compression, gently
the the spine extending distract the iliac crest is
inferiorly to the sacrum and important to avoid aggravating
coccyx haemorrhage if the pelvis is
fractured
Tenderness (+)
-This maneuver should only be
performed once
- Do not rock the pelvis!
Diagnosis

DRE rectal injury (e.g. blood, wounds), bony fragments, sphincter


function and a boggy or high-riding prostate
Perineum and genitalia check for coexistent genital trauma, blood at the
meatus, and scrotal or other perineal hematomas. Perform a vaginal exam
in women for vaginal tears

PHYSICAL
EXAMINATION
- Lower limb length discrepancy and malrotation, and
neurology
- The abdomen, e.g. Tenderness, distention, external sign of
trauma
Diagnosis

PELVIC XRAY
AP

Inlet Oblique
view D/S

Outlet
view
CT SCAN
Because of the complexity of this type of injury, a CT scan is commonly
ordered for pelvic fractures. A CT scan will provide a more detailed, cross-
sectional image of the pelvis.
Management
Management
young burgess classification
Management
young burgess classification
Management
Urogenital injuries
Present in 12-20% of patients with pelvic fractures
higher incidence in males (21%)
Includes
posterior urethral tear
most common urogenital injury with pelvic ring fracture
bladder rupture
may see extravasation around the pubic symphysis
associated with mortality of 22-34%
Diagnosis
made with retrograde urethrocystogram
indications for retrograde urethrocystogram include
blood at meatus
high riding or excessively mobile prostate
hematuria
Treatmen
surgical repair
rupture should be repaired at the same time or prior to definitive fixation in order to minimize
infection risk
Complications

Ilio
Vesica
femoral
vein
urinaria
Early thrombosis tears
Complications
Rectum
Urethral &
tears vaginal
injury

Schiatic & Massive


Lumbosacaral
plexus lesion bleeding
Complications

Avascular Heterotrofic
Late necrosis osteogenic

compliactions

Secondary Skoliosis
osteoarthritis kompensatoar
Sacral & Coccygeus Injury

Under-diagnosed and often mistreated fractures that may result in neurologic


compromisecommon in pelvic ring injuries (30-45%)
25% are associated with neurologic injury
mistreated fractures may result inlower extremity deficits
urinary dysfunction
rectal dysfunction
sexual dysfunction
Sacral & Coccygeus Injury
Nonoperative
progressive weight bearing +/- orthosis
indications
<1 cm displacement and no neurologic deficit
insufficiency fractures
Operative
surgical fixation
indications
displaced fractures >1 cm
soft tissue compromise
persistent pain after non-operative management
displacement of fracture after non-operative management
Acetabullar Fractures

Acetabulum fractures can involve one or more of the two columns, two walls or roof
within the pelvis
fractures occur in a bimodal distribution:
high energy trauma in younger patients (e.g., motor vehicle accidents)
low energy trauma in elderly patients (e.g., fall from standing height)
Judet and Letournel Classifications
Judet and Letournel Classifications
Management

Nonoperative :
protected weight bearing for 6-8 weeks
Indications:
patient factors
high operative risk (e.g., elderly patients, presence of
DVT)
morbid obesity
open contaminated wound
late presenting > 3weeks
Operative treatment

open reduction and internal fixation


indications
patient factors:
< 3 weeks from date of injury
physiologically stable
adequate soft-tissue

total hip arthroplasty


indications
usually elderly patients with
significant osteopenia and/or significant comminution
pre-existing arthritis
post-traumatic arthritis in all ages
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