Pelvic Fracture Complications Early complications Associated conditions Delayed

Pelvic Fracture Complications Early complications (Associated conditions) Delayed complications

Early complications

Multiple trauma Skull Chest Abdomen Extremities

Hemorrhage The most dangerous & life threatening condition ( hypovolemic shock ) Sources : Retroperitoneal ( Bone- Small & Large vessels ) Multiple trauma (Chest- Abdomen- Long bone Fx )

Epidemiology • Evaluating Pelvic Hemorrhage (EPH) Study – 724 consecutive pelvic fractures at Harborview • 62 % male • Average = 34 • Mechanism – Motor vehicle crash – Car versus pedestrian Fall (>3. 3 meters) 11% – Crush 57% 21% 5%

• Hemodynamic shock in Emergency Dept. – Blood pressure<90 27% – Pulse>130 30% – Transfuse in ED 29% • Blood requirement – Any 80% – 6 or more units 41% – Range (0 to 171 units) • Death 13%

Sign & Symptom Back pain Abdominal pain Swelling & Echymosis (Flank – Buttock – Inguinal – Perineum ) Hypotension & Shock

X ray X-ray : Soft tissue shadow displacement (Int. obturator, Iliopsoas, Gluteal Fat pad Bladder , Uterus) CT scan : Hematoma Angigraphy :

Fx type APC & VS ( high risk) Artery & Vein Inj. Iliac – Iliolumbar – Sup. Gluteal – Internal Pudental. LC (rare) Fx site – Visceral Inj. Stable Fx (very rare)

Treatment Transfusion Pelvic belt Antishock garment Reduction & Fixation Angiographic embolization

Thromboembolism Pelvic bone trauma & Immobilization Ipsilateral or contralateral Calf – Thigh – Pelvic veins Proximal thrombosis has Greatest risk of emboli sm

Increased risk of DVT Older age Spinal cord Inj. Lower extremity Inj. History of DVT

Rate MR Venography 35% Thrombosis Contrast Venography 29% Dopler Sonography Pulmonary Embolism Fatal Pulmonary Embo. 9% 2 – 12% 0. 5 – 10%

Prophylaxy Routin prophylaxis is mandatory Method is controversial Drug : Aspirin – Warfarin Low dose Heparin Low M. W. Heparin Mechanical devices : Compresion stocking Foot pump Compresion device thigh & leg Vena cava filter

Fat Embolism

Gasterointestinal Inj. Open fracture Deep pelvic infection Retroperitoneal absces Peritonitis High mortality rate

Gasterointestinal Inj. Wound in perineum Blood in rectum More proximal Injury (Contrast CTscan) Direct Inj. (Bone fragment) Indirect Inj. (Ext. Rot. Streching)

Management Irrigation & Debridment Early Colostomy Broad spectrum antibiotic

Gasterointestinal inj. BOWEL OBSTRACTION Paralytic Ileous Entrapment in Fx site

Genitourinary inj. Men > Women Overall Rate 16%

Bladder Contusion …………Rupture : Gross Hematuria Mortality Rate 22 – 34% 85% Extra peritoneal Vesico colic fistula Foley catheter 15% Intera peritoneal Repair & Foley catheter

Urethral Inj. Men > Women (Vagina & Urethra) Blunt , Avulsion Inj. Commonly Distal to Urogenital Diaphragm - Blood on meatus Triad - Distended Bladder - Inability to void Retrograde Urethrography

Urethral Inj. Repairing time is controversial Primary Repair ……. . More Impotence rate Delayed Repair ……. . More Stricture rate

Neurologic Inj. Lumbosacral & Sacral plexus Inj. Sciatic N. (Proneal) Inj. Post. Pelvic Ring Fx (VS 40 – 50% ) oraminal 28% Medial to Foramen 57% APC – VS (Traction)

Management Physical Examination ( Before & After Reduction ) Early Reduction & Fixation of Fx Neurolysis Repair Nerve graft ?

Open Fx Rate 4% Iliac crest wound Rectum & Perineum wound Vaginal wound

Open Fx Iliac Crest Wound Often minor & stable Fx ( mortality 0 – 5% ) Sometimes APC – VS ( mortality 25% ) Irrigation & Debridment Control of hemorrhage

Open Fx Rectum & Perineum Wound Mortality Rate 44 – 50% Hemorrhage Hemipelvectomy ) Sepsis (Irrigation & Debridment – Early Colestomy – Packing the wound – Debridment )

Open Fx Vaginal Laceration Debridment & Repair & External Fixation

Delayed Complication

Post Op. Infection 6% Increased Risk - Open Fx - Ilio. Inguinal Approach - Febrile Patient Percutaneous Screw - Very Rare Open Reduction - Not Common

Treatment - Irrigation & Debridment - Deep Culture - Antibiotic Beeds - Leave the Hardware if possible - External Fixation

Fixation Failure > 1 Cm Displacement Percutaneous Iliosacral Screw Sacral Fx > SI Dx 10% Prevention : - Spinopelvic Fixation - Screw across the Sacrum to far Ileum - Multiple Screw

Fixation Failure Percutaneous Sup. Pubic Ramus Screw 10% - Eldery & Osteoprotic Female - Medial & Shaft Fx > Lateral Fx External Fixator - Pin Loosening - Pin Tract Infection

Sexual Dysfunction Urethral Vascular Neruologic Psychologic Inj. Unstable & Marked Displaced Fx

Men, s Sexual Dysfunction Posterior Urethral Inj. : Impotence Rate 50% Poorly Scored on Sex Drive Erection Ejaculation Satisfication Eldery > Young

Women, s Sexual Dysfunction Ant. Pelvic Ring Fx More Dysfunction Dyspareunia 38% ( > 5 mm displacement ) Decreased Interest & Orgasm 45% Dysmenorrhea Vaginal Delivery Problem Incontinence

Other Complications Myositis Ossificant 20% Malunion Up to 90% in Non Operative Method Nonunion ? Ligamentous Inj. may not healed Low Back Pain SI Joint Inj. Chronic Pelvic Pain Sacral Plexus Inj.

Case Reports - Acute Compartment Synd. In Gluteal & Thigh comp. - Gluteal Soft Tissue Necrosis After Angiographic Embolization Herniation - Bladder Herniation In Pub. Symphisis Diastasis -Flail Penis In Open Book Fx Due to Suspensory Lig. Inj.