外科学教学课件：Fractures and dislocations of the pelvis

Fracturesanddislocationsofthepelvis

IntroductionPelvicfracturesareamongthemostseriousinjuriesandaccountfor3%ofallfractures.Etiology:Lowenergystablefracturese.g.Fallsinelderlypatientstreatedsymptomaticallywithcrutch-orwalker-assistedambulationexpectedtohealuneventfullyinmostpatientsHighenergysignificantmorbidityandmortalitye.g.motorvehicleaccidents,falls,motorcycleaccidents,automobile-pedestrianencounters,industrialcrushinjuriesOftenmanagedoperatively,determinedbythedegreeofremainingstabilityofthepelvisAppropriatetreatmenttotheresuscitationandreconstructionMortalityrate:9%—20%1980s5%—10%now(morethan50%,severeopenfracture)Introduction40%—50%hemodynamicallyunstablepatientsinemergencydepartmentRiskfactors:ageinjuryseverityscoreassociatedheadorvisceralinjurylife-threateninghemorrhage(e.g.…)hypotensioncoagulopathyunstable/openfractureOthercomplications:neurologicinjurygenitourinaryinjuryperitoneuminjuryrectuminjury…ClosedandopenpelvicfractureClinicalfindings1、Historyofhigh-energycausedinjury2、Physicalexamination:palpationofthepelvicbonylandmarkscompressionmaneuverstoaccessstabiliyrectovaginalexamination

Tips:payattentionofthebruiseinperinealarea3、Associatedinjurieslowerurinarytractdistalvascularstatusneurologicexaminations4、AccessoryexaminationX-ray:APinletoutletCTscanningAcutemanagementImmediategoals:CessationofbloodlossminimizationofsepticsequelaestabilizationoffractureEmphasizethemultidisciplinaryapproachUsually,weshouldpayattentiontoretroperitonealhemorrhage,pelvicringinstability,andinjuriestothegenitourinarysystemandrectumaswellasfracturesopentotheperitoneum.CircumferentialpelvicbinderSuperiortoexternalfixationforitseaseandrapidnessofapplicationGeneralresuscitativeprinciplesExternalfixationFragmentsstabilizedpelvicspaceforfluidsdecreasedC-clamptypeofexternalfixatorAngiographyPersistenthypotensionwiththementionedmethodperformedArteriography5%—10%bleedfromarterialsourcesembolizationUseofCircumferentialpelvicbinderAcutemanagementAcutemanagementOpenpelvicfracturesExtremelydifficulttomanageRetroperitonealspaceopenSepsisLargeavulsionflaps(ischemicpelvictissue)AcutemanagementSelectivefecaldiversionincomplexopenpelvicfracturesfromblunttraumaZoneIZoneIIZoneIIIHowtodecidethecolostomy?Initialevaluationandmanagementofpatientwithpelvicringfracture.ProtocolsshouldbeindividualizedaccordingtoresourcesandfacilitiesAcutemanagementAnatomyandstabilityBonecomponentsInnominatebone:iliumischiumpubissacrumJointsPubicsymphysissacroiliacjointLigamentsAnteriorsacroiliacligamentPosteriorsacroiliacligamentcomplex:interosseoussacroiliacligamentPosteriorsacroiliacligamentSacrospinousligamentSacrotuberousligamentAnatomyandstabilityIliolumbarligamentPosteriorsacroiliacligamentSacrotuberousligamentSacrospinousligamentPelvicbrimTruepelvisSacrotuberousligamentSacrospinousligamentL5transverseprocessInterosseoussacroiliacligamentsIliolumbarligamentPosteriorsuperioriliacspineAnatomyandstabilityExternalrotationofhemipelvis:symphysissacrospinousligamentanteriorsacroiliacligamentRotationinthesagittalplane:SacrotuberousligamentVerticalforces:allthementionedligamentousstructuresTips:interosseoussacroiliacposteriorsacroiliacligamentsiliolumbarligamentrotationallyunstablehemipelvismayremainverticallystableAnatomyandstabilityClassificationandtreatmentTilemodifiedclassification(predominantmethod):TypeA:stableTypeB:rotationallyunstablebutverticallystableTypeC:rotationallyandverticallyunstableIIIIIIsacralalaforaminalregionspinalcanalClassificationandtreatmentTypeA1:avulsionfracturesorisolatediliacwingfracturesoccurinadolescentsconservativetreatmentdisplacementismarked,reattachmentbyopenoperationTypeA2:stablefracturesofthepelvicringwithminimaldisplacementsymptomatictreatmentandearlyambulationorweightbearing.TypeA3:

transverselesionsofthesacrumorcoccyxspinalinjuryratherthanpelvicdisruption.ClassificationandtreatmentTypeB1:“Openbook”fractures;anteriorpelvisopensthroughadiastasisofthesymphysisorthroughafractureoftheanteriorpelvicringsignificantassociatedinjuriestoperinealandurogenitalstructuresdisplacedsymphysis＜2.5cmsymptomatictreatment

＞2.5cm“closethebook”operationTypeB2:inwarddisplacementofthehemipelvisthroughthesacroiliaccomplexandipsilateralpubicramifracturesTypeB3:inwarddisplacementofthehemipelvisthroughthesacroiliaccomplexandcontralateralpubicramifracturesTypeB2andB3usuallyneedoperativetreatmentmajorhemorrhageexternalfixationori