pelvic fractures 2 nd northern trauma network conference p fearon consultant orthopaedic trauma...
TRANSCRIPT
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Pelvic Fractures
2nd Northern Trauma Network Conference
P FearonConsultant Orthopaedic Trauma Surgeon - RVI
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Overview
• Identify the priorities of life saving, limb saving, and disability-limiting surgery
• Outline the general and local factors affecting decision-making
• Importance of teamwork
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• Orthopedic and trauma surgeons naturally concentrate on the fracture
• It is vital to realise that there are other factors that may dominate decision making in the management of a particular fracture
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Injury Patient
Care team Resources
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Injury• Fracture• Vascular injury• Compartment syndrome• Open wound• Crush injury• Nerves
Patient• Previous Condition
• Age (physiologic)• Diagnoses• Medications!
• Other injuries• Physiologic response• Expectations/needs
Care Team• Surgeon• Assistants• Anesthesia• Other specialties• OR nurses• Postoperative• Rehabilitation• Social supports
Resources• OR • Instruments• Implants• Imaging• ICU• (Other Patients)
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Classification systemsSurvivors Non-survivors
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Non-survivorsEarly Death Late Death
HaemorrhageBrain injury
SepsisMOF
Bleeding# bones, venous plexus, arterial injury, extra-pelvic sources
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Survivors• Mental health problems• Chronic pain• Pelvic obliquity• Leg length discrepancy• Gait abnormalities• Sexual & urological dysfunction• Long term unemployment
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Pre-Hospital• Goals:-
– Early suspicion
– Identification – no need to spring/log roll
– Management
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Pelvic immobilisation should be routine
MOISymptomsClinical findings– deformity, bruising or swelling over the bony prominences, pubis, perineum or
scrotum. – Leg length discrepancy or rotational deformity of a lower limb (without fracture
in that extremity) may be evident.– Wounds over the pelvis or bleeding from the patient's rectum, vagina or urethra
may indicate an open pelvic fracture. – Neurological abnormalities may also rarely be present in the lower limbs after a
pelvic fracture.
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Ease of applicationAccess for interventionShown just as good as external fixators
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• Prevent re-injury from pelvic motion (clot disruption)
• Tamponade bleeding pelvic bones & vessels
• Decrease pain
• Decrease pelvic volume (lesser)
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ED• Resuscitation / Management
• MHP
• WBCT – trauma series
– TEAM – TEAM TEAM TEAM
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Illustrated case• 29 yr female• Motor cyclist• GCS 14/15• BP 90/40• Hr 110• PV bleeding• Binder applied
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Pathway• Resuscitation on going
via CT scanner
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All bets off!
Team Huddle – Senior Decision making
Modify Plan
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• Aorta stented• Evaluation of coeliac
– Common hepatic– Left hepatic
• Both internal iliac– Left pudendal branch
embolised (anterior division of internal iliac)
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• Prehospital• ED• ITU & anaesthetics• Ortho• Gen Surg• HBP• CT/radiology• Interventional radiology• Urology• Rehab• Pain team• Sexual dysfunction clinic• Clinical psychology
Holistic Approach
Improve disability
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How much blood loss from pelvic #?• WBV
– (true pelvic vol 1.5L, but ↑ with disruption)– Retroperitoneal space 5L– Loose tamponade effect/disruption parapelvic
fascia– Escape into peritoneum & thighs
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? Arterial Bleeding• MOI
• Open fractures• Elderly patients (gluteal injuries)• Sacrum/SIJ, symphyseal separation–gluteal, pudendal• CT scan – vascular blush/large haematoma≡sig bleed
Head on collisions
Jumpers
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Binder
MHP
Trauma CT
Urology
Surgery
Pelvic fixation
Holistic Rehab
Coordinated Team Approach
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• Isolated haemodynamically unstable pelvic trauma uncommon– Associated injuries due to high MOI
• Resuscitation/intervention team based with better understanding & cooperative team working
– surgeons included
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Thank you