Potentially Life-Threatening

Extremity Injuries
• Pelvic Fractures (biru)
• Major Arterial Hemorrhage (merah)
• Crush Syndrome (hijau)
Pelvic Fractures
 Pelvic Fracture
Pelvic Anatomy
• It is a ring structure
• Composed of the 2 hemipelvic and the sacrum
• The pelvic ring is completed :
– Anteriorly : symphysis pubis
– Posteriorly : sacroiliac (SI) joints
• Maintenance of pelvic ring integrity is wholly dependent on
ligamentous support for stability :
– ROTATIONAL stability : short posterior SI, anterior SI,
sacrospinous, iliolumbar
– VERTICAL stability : long posterior SI, sacrotuberous,
lumbosacral
 Pelvic Fracture
Pelvic Anatomy (Bone)
Pelvic Fracture
Pelvic Anatomy (Ligament)
 Pelvic Fracture
Associated Injuries and Mortality
• The pelvic ring enclose the true pelvis and the false pelvis
– True pelvis : below the pelvic brim, extraperitoneal
– False pelvis : above the pelvic brim, peritoneal and
retroperitoneal
• The most commonly associated injuries → true pelvis :
– The internal iliac artery and venous systems and
branches
– The bladder (20%) and urethra (14%)
– The lumbo-sacral plexus
– The rectum and vaginal vault (open pelvis fractures)
• Morbidity and mortality from pelvis fractures is HIGH →
hemorrhage
 Pelvic Fracture
True Pelvis and False Pelvis
 Pelvic Fracture
Associated Injuries and Mortality
• External clues to a pelvic fracture :
– Flank, perineal, scrotal, or labial ecchymosis
– Tender abdomen
– Externally rotated lower extremities
– Leg length discrepancy
– Rectal or vaginal bleeding
– Unilateral lower extremity neurologic deficit
• Clues to urethral or bladder injury :
– Scrotal or labial ecchymosis
– Blood at the urethral meatus
– Anteroposterior (AP) compression injury or bilateral superior or
inferior pubic ramus fractures
– High-riding prostate on rectal examination
 Pelvic Fracture
Clinical Evaluation
• ABCDE
• Initiate resuscitation: address life-threatening injuries
• Evaluate injuries to the head, chest, abdomen and spine
• Identify all injuries to the extremities and pelvis
• Pelvic instability → leg-length discrepancy, rotation
• The AP-LC test for pelvic intability should be performed ONCE ONLY
and involves rotating the pelvis internally and externally → “THE
FIRST CLOTH IS THE BEST CLOTH”
• Massive flank or buttock contusions and swelling with hemorrhage
are indicative of significant bleeding
• Carefully inspected the perineum → representing an open fracture.
 Pelvic Fracture
Hemodynamic Status
• Hemorrhage → massive intravascular volume loss
• Usual cause of retroperitoneal hemorrhage secondary to pelvic fracture :
– Disruption of the venous plexus in the posterior pelvis.
– Large-vessel injury, such as external or internal iliac disruption.
• Options for immediate hemorrhage control include:
– Military antishock trousers (MAST), pelvic binder
– Anterior external fixator, pelvic C-clamp
– Open reduction internal fixation (ORIF)
• Undertaken if the patient is undergoing emergency laparotomy for
other indications
• Frequently contraindicated by itself because loss of the
tamponade effect may encourage further hemorrhage
– Angiography or embolization if hemorrhage continues despite closing
of the pelvic volume
 Pelvic Fracture
Hemodynamic Status

Pelvic binder

Military antishock trousers (MAST)

 Pelvic Fracture
Hemodynamic Status

Pelvic anterior
external fixator

Pelvic C-clamp
 Pelvic Fracture
Neurological Status
• Lumbosacral plexus and nerve root injuries may be
present, but they may not be apparent in an
unconscious patient.
• Higher incidence with more medial sacral
fractures.
• Sacral fractures: neurologic injury
• Lateral to foramen (Denis I): 6% injury
• Through foramen (Denis II): 28% injury
• Medial to foramen (Denis III): 57% injury
• Decompression of sacral foramen may be
indicated if
• progressive loss of neural function occurs.
• It may take up to 3 years for recovery
 Pelvic Fracture
Management Algorithm
 Pelvic Fracture
Management
• Operative
• Non-operative : External, Internal
 Pelvic Fracture
Non-Operative Management
• Lateral impaction type injuries with minimal (<1.5 em) displacement.
• Pubic rami fractures with no posterior displacement.
• Gapping of pubic symphysis <2.5 cm
• Protect weight bearing typically with a walker or crutches initially.
• Serial radiographs are required after mobilization has begun to monitor for
subsequent displacement.
• If secondary displacement of the posterior ring >1 cm is noted, weight
bearing should be stopped. Operative treatment should be considered for
gross displacement.
 Pelvic Fracture
Operative Management
Absolute Indications for Operative Treatment
• Open pelvic fractures or those in which there is an associated visceral perforation
requiring operative intervention
• Open-book fractures or vertically unstable fractures with associated patient
hemodynamic instability

Relative Indications for Operative Treatment

• Symphyseal diastasis >2.5 cm (loss of mechanical stability)
• Leg-length discrepancy >1.5 cm
• Rotational deformity
• Sacral displacement >1 cm
• Intractable pain
 Pelvic Fracture
Operative Management: External Fixation
• It is usually a temporary stabilizing option.
• Can be used as a definitive fixation in anterior pelvic fractures.

1. Two to three 5-mm pins spaced 1 mm apart along the anterior iliac crest
• Acetabular and Iliac wing fractures are contraindications to external fixation.
• Vertically unstable fractures usually also are treated with ipsilateral distal femoral
skeletal traction.

2. The use of single pins placed in the supraacetabular area in an AP direction

(Hanover frame), Hip flexion maybe limited with this frame.
• Ideally, two 5-mm pins are placed in between the iliac cortical tables.

3. Temporary external fixators like Ganz c clamp and Browner's fixator help control the
posterior pelvis in vertically unstable fractures in the resuscitation phase.
 Pelvic Fracture
Operative Management: External Fixation
 Pelvic Fracture
Operative Management: External Fixation
 Pelvic Fracture
Operative Management: Internal Fixation
• Iliac wing fractures; ORIF using lag screws and neutralization plates.
• Diastasis of the pubic symphysis: Plate fixation is used if no open injury or
cystostomy tube is present.
• Sacral fractures: plate fixation or sacroiliac screw fixation
• Unilateral sacroiliac dislocation: Direct fixation with cancellous screws or anterior
sacroiliac plate fixation is used.
• Bilateral posterior unstable disruptions: Fixation of the displaced portion of the
pelvis to the sacral body may be accomplished by posterior screw fixation
 Pelvic Fracture
Operative Management: Internal Fixation
• Specific fracture Treatment
• Tile: Stabilisation Options
1. Stable (A1, A2): Protected weight bearing and symptomatic treatment.
2. Open book (B1)
• Symphyseal diastasis <2 cm: protected weight bearing
• Symphyseal diastasis >2 cm: external fixation or symphyseal plate
3. Lateral compression (B2, B3)
• Ipsilateral only: No stabilisation necessary
• Contralateral (buckethandle}:
• Leg-length discrepancy <1.5 cm: no stabilisation necessary
• Leg-length discrepancy >1.5 cm: external fixation or open reduction and internal fixation (ORIF).
4. Rotationally and vertically unstable {C1, C2, C3):
• External fixation with or without skeletal traction or ORIF.
 Pelvic Fracture
Operative Management: Internal Fixation
 Pelvic Fracture
Post Op Care
• Aggressive pulmonary toilet should be pursued with incentive spirometry, early
mobilization.
• Prophylaxis against thromboembolic phenomena should be undertaken, with a
combination of elastic stockings, sequential compression devices, and chemoprophylaxis
if hemodynamic and injury status allows.
• Weight-bearing status may be advanced as follows:
• Full weight bearing on the uninvolved lower extremity/sacral side
• occurs within several days.
• Partial weight bearing on the involved side is recommended for at least 6 weeks.
Recently,weight-bearing as tolerated (WBAT) has been supported in low-energy LC1
fractures.
• Full weight bearing on the affected side without crutches is indicated by 12 weeks.
• Patients with bilateral unstable pelvic fractures should be mobilized from bed to chair
with aggressive pulmonary toilet until radiographic evidence of fracture healing is noted.
Partial weight bearing on the “less” injured side is generally tolerated by 12 weeks.
 Pelvic Fracture
Complications
1. Infections – 0-25%
2. Thromboembolism
3. Malunion- rare.
4. Nonunion- rare, seen in young.
5. Mortality
• Hemodynamically stable patients: 3%
• Hemodynamically unstable patients: 38%
• LC: head injury major cause of death
• APC: pelvic and visceral injury major cause of death
• AP3 (comprehensive posterior instability): 37% death
• VS: 25% death
Major Arterial Hemorrhage
 Major Arterial
Hemorrhage

• Bleeding (also known as

hemorrhaging) often occurs
after an injury.
• It can be the result of a disease.
• Occurs when blood vessels
become damaged.
• Can happen on the outside of
the body (external bleeding) or
inside the body (internal
bleeding)
 Major Arterial Hemorrhage
Types of Bleeding

Arterial Bleeding Venous Bleeding Capillary Bleeding

• Spurting blood • Steady, slow flow • Slow, even flow
• Pulsating flow • Dark red color
• Bright-red color
 Major Arterial Hemorrhage
First Aid for Arterial Bleeding

• The wound will be pulsating, and it will likely

take several dressing pads to control the
bleeding.
• If the victim is conscious and can assist, this
will help.
• Ask the victim to maintain pressure over the
dressing pad or cloth.
• The blood will probably soak through, so
apply a second pad on top of the first, rather
than removing it.
• Continue to apply firm, direct pressure over
the wound.
 Major Arterial Hemorrhage
First Aid for Venous Bleeding
• Cover the wound as long as no impaled objects are protruding from it.
• Ideally, a sterile pad or bandage would work best, but use whatever you
have available, so long as it's clean.
• Apply direct and constant pressure to the wound.
• If the victim is conscious and can assist, this will help.
• Apply new dressing pads or bandages as needed, if blood begins to soak
through the one(s) already applied.
 Major Arterial Hemorrhage
First Aid for Capillary Bleeding
• Clean the wound using clean, potable water. Pour or run water over the
abrasion while brushing off blood and debris – dirt, loose pebbles, etc.
• Dab the wound with (ideally) a sterile pad or bandage.
• Once the wound is clean and dry and the bleeding has stopped, apply an
antibacterial cream (if you have one) to stop any chance of infection.
• Apply a bandage large enough to cover the entire wound
Crush Syndrome
 Crush Syndrome
• Also termed rhabdomyolysis
• Involves a series of metabolic changes produced due to an injury of the
skeletal muscles of such a severity as to cause a disruption of cellular
integrity and release of its contents into the circulation

Etiology:
• Vehicular accidents (trapped under a vehicle)
• Industrial, construction, or agricultural accidents
• Major earthquakes (structure collapse, entrapment > 24 hours is
associated with increased mortality)
• Stampede
Crush Syndrome
Pathophysiology
 Crush Syndrome
Clinical Features
• Casualties normal at rescue, however, soon go into shock.
• Petechiae, blisters, muscle bruising, and superficial injuries are seen.
• Myalgia, muscle paralysis and sensory deficit are common.
• Fever, cardiac arrhythmia, pneumonia, ‘tea or cola’ coloured urine, oliguria
and renal failure are the sequence of events.
• Nausea, vomiting, agitation and delirium are seen in the delayed rescue
patients.
 Crush Syndrome
Investigation
• Serum creatinine kinase (CKMM) >1000 IU/l with associated clinical features is
generally taken as an indicator of crush syndrome.
• Among the other investigations, serum aldolase may be of some help
• Serum myoglobin and myoglobin degradation products are highly sensitive tests;
• Serum lactic acid, AST, ALT and LDH show a steady rise;
• Serum uric acid -moderate rise may be noticed;
• Serum urea and creatinine – steep rise is seen especially after a prolonged crush;
• Serum potassium levels show an early rise and is a predictor for dialysis
• Hypocalcaemia and stress related hyperglycaemia may be seen.
• Urine RE may show presence of myoglobin products.
• Blood gas analysis, haemogram and ECG are also helpful.
• Intracompartmental pressure monitoring is useful as it is generally accepted that
levels >30 mm Hg point towards the need for a fasciotomy
• Doppler studies are done to look for limb ischaemia, and the body weight is
recorded.
 Crush Syndrome
Management

Initial management:
• Evaluation of ABC (airway, breathing, circulation)
• Rehydration
• Venous access preferably before the limb is decompressed
• CVP and monitoring urine (catheterization)

Further management:
• Large amount of saline infusion with forced diuresis
• Debridement of crushed tissue
• Fasciotomy for compartment syndrome
• Dialysis if renal failure
• Amputation
 Crush Syndrome
Hyperbaric Therapy
• At high pressures, physically dissolved levels of oxygen increases in the
plasma, tissue viability is enhanced, some vasoconstriction occurs and so
fluid outflow from the vascular compartments decrease thus reducing
tissue edema.
• It directly assists wound healing by fibroblast proliferation.
• Finally it can reduce anaerobic bacterial growth in necrosed muscles
• The usual dose is about 2.5 atmospheres for about one and half hours
twice a day for a week
 Crush Syndrome
Predisposing Factors and Prevention of Infection
 Crush Syndrome
Complications
• Hypovolemic
• Metabollic acidosis
• Hyperkalemia
• Acute kidney injury
• DIC (Disseminated Intravascular Coagulation)
• Sepsis
• Multiple organ failure