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 pada urethra

Cedera vaskuler

Klasifikasi fraktur pelvis

Klasifikasi Tile

Tipe A

Stable

Tipe B

Rotationally unstable

Vertically stable

(open book type)

Tipe C

Rotationally and

Vertically Unstable

Young and Burgess

proposed a different

modification of the

original Pennal

classification, adding a

new category for

combined mechanism

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

Lateral compression (LC) injuries

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

Anteroposterior compression (APC)

VS Symphyseal diastasis or Vertical displacement anteriorly

anterior vertical fracture and posteriorly, usually through

Sl joint, occasionally through

iliac wing and/or sacrum

Vertical shear (VS) injuries

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

I

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 joint’s 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 clamp’s position

radiographically

Use a firm bed for easier mobilization

Check the tightness of the c clamp’s

bolt and it’s 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.