5.9 E) Ix) I. Pelvic Fractures

Front 1

What Classification System is used for pelvic

fractures?

Back 1

The Young and Resnik Classification

( Young and Burgess)

Front 2

What 2 components is the Young and Resnik Classification System for pelvic fractures based upon?

Back 2

1. Mechanism of injury
2. Direction of the causative force

Front 3

What are the main Mechanism types in the Young and Resnik Pelvic fracture classification?

Back 3

1. Lateral Compression [ Types I to III ]

2. AP Compression [ Types I to III]
3. Vertical shear

Front 4

Which is incorrect regarding Lateral

compression pelvic fractures?
1. They account for 50% of pelvic fractures
2. Most are stable
3. Usually due to pedestrian / car occupant being hit from side.
4. Usually unilateral
5. May involve disruption of the pubic symphysis.

Back 4

4. LC pelvic fractures can be can be unilateral or bilateral

Front 5

Which is incorrect regarding pelvic fractures?
1. Lateral compression Type 1 = SI joint and pubic ramus
2. Lateral compression Type II = SI joint + Iliac wing + pubic ramus
3. Lateral compression Type III = Type II + AP compression to ipsilateral hemipelvis
4. Type I fractures are the most common
5. Type I and II fractures are "stable" fractures.

Back 5

3. Type II + AP compression to contralateral hemipelvis

Front 6

In regards to Lateral compression fractures of the pelvis, which is incorrect?
1. There is always a transverse fracture of at least one pubic rami.
2. There is a high potential for associated injuries
3. Type I = posterior sacral fracture and oblique pubic ramus fracture
4. Type I usually involves significant ligamentous disruption around the sacrum
5. XR usually shows discontinuity with the sacral foramina posteriorly.

Back 6

4. Type I LC Usually = sacral fracture without

ligamentous disruption

Front 7

In regards to Anteroposterior compression

fractures of the pelvis, which is incorrect?
1. They account for 25% of pelvic fractures
2. Type I injury = anterior pubic symphysis disruption with less than 2.5 cm diastasis
3. Type I fractures are stable
4. Type I fractures can have significant posterior pelvic injury
5. Type II injuries cause the classic open-book fracture

Back 7

4. Type I usually has no significant posterior pelvic injury.

Front 8

Which is incorrect regarding Type II

Anteroposterior pelvic fractures?
1. They involve rupture of posterior sacroiliac / sacrospinous and

sacrotuberous ligaments

2. There is widening of the sacroiliac joint posteriorly
3. There is pubic symphysis diastasis > 2.5 cm
4. Neurovascular injuries are common
5. The pelvis is unstable

Back 8

1. APC Type II

= Rupture of Anterior ligaments only.

[ Sacrotuberous and sacrospinous

NOT sacroiliac ]

Front 9

AP compression fractures of the pelvis, Type III : which is incorrect?
1. They have the highest rate of neuromuscular injury and

haemorrhage
2. They are completely unstable
3. They are involved with significant traumatic forces
4. They involve disruption of all the pelvic ligaments on one side of the pelvis
5. There is disconnection of the affected hemipelvis from the sacrum

Back 9

all correct

Front 10

Which is incorrect regarding Vertical shear pelvic fractures?
1. They occur in 5% of pelvic fractures
2. Usually involved with fall from height
3. Usually bilateral
4. They can be associated with significant intra-abdominal injury
5. They are also called "Malgaigne Fractures"

Back 10

3. Usually unilateral - can be bilateral

Front 11

In regards to the Clinical assessment of major pelvic injuries, which is incorrect?

1. The pelvis exam occurs during the secondary survey

2. The pelvic compression test should be avoided in the

haemodynamically unstable patient.
3. Abdominal, rectal, vaginal and perineal exams are all required in

significant pelvic trauma.
4. Prostate position is important to assess in major pelvic trauma
5. In males, the urethral meatus is inspected for blood.

Back 11

2. Pelvic compression Test should be

performed only once in the

haemodynamically unstable patient.

Front 12

List the 3 major Complications / Injuries

associated with Pelvic fractures

Back 12

1. Haemorrhage
2. Genitourinary / bladder injuries
3. Urethral / genital injuries

Front 13

Where does the haemorrhage occur from in pelvic trauma?

Back 13

1. Fracture sites
2. Local venous / arterial tears
3. Disruption of major vessels ***

Catastrophic bleeding can occur from internal iliac arteries passing over sacroiliac joint

Front 14

Which are the 2 main pelvic fractures

associated with significant haemorrhage?

Back 14

1. Anteroposterior Type III
2. Vertical shear **

{ highest risk of hypovolaemic shock = 63% )

Front 15

Treatment to minimise / stop haemorrhage

associated with pelvic fractures?

Back 15

A MULTIDISCIPLINARY TEAM APPROACH

1. Urgent Interventional Radiology

[angiography + embolisation ]

2. Pre-peritoneal packing in Theatre.
3. external fixation
4. ORIF

Front 16

CLASSIC SIGNS OF URETHRAL RUPTURE

ASSOCIATED WITH PELVIC FRACTURES

Back 16

1. Blood at urethral meatus
2. high-riding prostate
3. perineal / scrotal haematoma
4. Urinary retention
5. displaced anterior pelvic fracture

Front 17

mainstay of pelvic fracture management in the ED?

Back 17

1. Identify and assess the DEGREE of pelvic

injury
2. Adequate fluid resuscitation
3. Pain relief

Front 18

Average blood transfusion requirement for each class of pelvic fracture - link :

1. Anteroposterior compression - # 9U

2. Lateral compression - # 3.5 U

3. Vertical shear - # 15 U

Back 18

APC # = 15 Unit PRBC
Lateral compression # = 3.5 Units
Vertical shear # = 9 Units

Front 19

Advantages of External Fixation in the ED of pelvic fractures?

Back 19

Designes to stabilize and immobilise pelvis to

REDUCE PELVIC HAEMORRHAGE PRIOR TO

DEFINITIVE MX

1. Rapid
2. Simple
3. Can allow continued Mx of multiply injured

patient

Front 20

Disadvantages of External Fixation of pelvic

fractures in the ED?

Back 20

1. Poor support for posterior pelvic ring
2. Difficult in the obese
3. Can reduce pelvic surgical access with

laparotomy

Front 21

Break

Back 21

Break

Front 22

What is the FABER Clinical test?

Back 22

Looks for isolated pubic rami fractures
Involves pain being reproducible when the

ipsilateral foot is placed on the contralateral knee, forcing the ipsilateral hip to be Flexed,

ABducted and Externally Rotated-causing typical pain to exacerbate.

Front 23

Predictors for arterial bleeding in pelvic

fractures ? {3}

Back 23

1. Haemodynamic instability

2. Age > 65
3. Absence of long bone fractures

Front 24

Which statement is incorrect regarding pelvic fractures and imaging:

1. up to 15% of posterior fractures involving the sacrum and sacroiliac joints will not be seen on plain AP XR
2. The Young and Resnik classification system provides a graded

probability of bleeding related to the fracture
3. If the FAST exam is negative in the haemodynamically unstable patient, they should proceed to angiography.
4. Pelvic fractures that disrupt the posterior aspect of the pelvic ring can cause considerable venous/arterial haemorrhage
5. Open book fractures are more likely to have venous than arterial bleeding.

Back 24

1. Up to 30% of posterior pelvic fractures

involving sacrum and sacroiliac joints will not be seen on plain XR

Front 25

List Urinary bladder injuries associated with blunt trauma to pelvis {pelvic fractures}

Back 25

1. Bladder wall contusions
2. extraperitoneal bladder rupture ** [85%]
3. intraperitoneal bladder rupture

Front 26

True / False:

Patients with severe pelvic fractures who may have pelvic arterial

bleeding [that might require angiography] SHOULD NOT

UNDERGO retrograde cystography prior to

angiography. extravasation of bladder contrast into the pelvis may

obscure the angiographic images.

Back 26

True

Retrograde cystography -No
Retrograde urethrogram (RUG)

- Can be performed.

Front 27

Indications for Angiography in Pelvic fractures? [EMRAP 2006 ]

Back 27

1. Haemodynamic instability
2. Dropping Hb
3. Pelvic fracture patterns

[ open book : pubic symphysis widening ;

Butterfly # ; vertical shear ]
4. Ct scan findings: pelvic haematoma ; blush

Front 28

Angiography "Downsides" [ EMRAP 2006]

Back 28

1. Transport to Angiography Suite
2. Invasive procedure
3. Difficult to resuscitate in Angio Suite
4. Post embolisation ischaemia

[ bladder / rectum ; gluteal mm]

Front 29

Which is incorrect regarding pelvic fractures?
A. 75% arteriograms are negative due to venous bleeding being

predominant.
B. Embolisation can occur via coiling or gel foam administration to bleeding vessels.
C.Ideally, a haemodynamically unstable pelvic bleed should get to the

angiography suite within 45-90 minutes of presentation
D. Lateral compression pelvic fractures are high risk for bleeding

Back 29

D. LC fractures can bleed, BUT

They are not as concerning as AP

compression (APC) or Vertical Shear (VC)

fractures.

Front 30

ETM Course Manual

In regards to Haemodynamically unstable Pelvic fractures, State the contributing

mortality rates for the following :

A. Haemorrhage

B. Head Injury

C. Sepsis and Multiorgan failure

D. Cardiorespiratory Failure

Back 30

A Haemorrhage = 42%

B. Head Injury = 32%

C. Sepsis and MODS = 14%

D. Cardiorespiratory Failure = 8%

Front 31

ETM Course Manual.

What is the overall mortality rate for

haemodynamically unstable pelvic fractures?

Back 31

20%

Front 32

ETM Course Manual.

List the Potential Sites of Major Blood loss in Haemodynamically unstable trauma patients with pelvic fractures .

Back 32

1. External Blood loss

2. Long Bone Fractures 40%

3. Chest - Intrathoracic haemorrhage 4-29%

4. Abdomen -intraperitoneal bleeding

Front 33

ETM Course Manual

List 3 predictors of ongoing arterial bleeding from pelvic fractures. ***

Back 33

1. Persistent haemorrhagic shock without a non-pelvic bleeding source.

2. Transient improvement in BP after rapid

fluid infusion

3. Persistent acidosis despite massive

resuscitation.

Front 34

ETM Course Manual

Which of the following is correct regarding

bleeding in haemodynamically unstable pelvic fractures.

A. The probability of an associated intraperitoneal bleeding source is 27%

B. The liver is the predominant bleeding source in the abdomen .

C. 57% of pelvic arterial bleeding source are from the anterior pelvis.

D. Arterial bleeding occurs in 10% of cases.

Back 34

D. Arterial bleeding in 10%

A = 32%

B = Spleen 22%

Liver 20%

Bladder 15%

Bowel Mesentery 10%

Renal 7%

C= 57% bleeding posterior pelvis

( 43% anterior pelvis)

Front 35

ETM Course Manual

What 3 potential interventions are

available for haemodynamically unstable pelvic

fractures ?

Back 35

1. Interventional angiographic embolisation

2. Pre-peritoneal packing. (Theatre)

3. External fixation of pelvis.

Front 36

ETM Course Manual

List the indications for Interventional

Angiography.

Back 36

Haemodynamic instability

1. Pelvic fracture + no extra-pelvic bleeding

Haemodynamic status negligible

1. Age > 60 years and major pelvic fracture

2. Intravenous contrasts extravasation on CT

3. Bladder compression from haematoma

formation

At Laparotomy

Bleeding ruptured pelvic haematoma

Front 37

ETM Course Manual

List the indications for Emergency laparotomy in Pelvic fracture management.

Back 37

1. Haemodynamic instability AND intrabdominal bleeding ( FAST + )

2. Haemodynamic instability and delays to

angiography:

a. availability

b. Institutional transfer

3. Exsanguinating patient.Only life saving

option

Front 38

ETM Course Manual

In regards to pelvic fractures , Which of the

following is incorrect ?

A. The majority of pelvic fractures are from a low energy mechanism.

B. They make up < 3% of all skeletal fractures.

C. The overall mortality is 23%

D. Associated urogenital injuries occur in 16% of high energy pelvic

fractures in males.

Back 38

C. Overall mortality of pelvic fractures = 16%

Front 39

ETM Course Manual

In regards to pelvic fractures, Which of the

following is correct ?

A. Up to 45% of patients with high-energy pelvic injuries are

haemodynamically unstable.

B. The majority of bleeding is venous in origin

( pre-sacral venous plexus ).

C. Arterial bleeding occurs in 15% patients.

D. Bleeding from the Bladder occurs in 25% of intrabdominal bleeding cases.

Back 39

B.

A = 15-30% are haemodynamically unstable

C = Arterial bleeding in 10%

D = 15%

Front 40

ETM Course Manual

In regards to pelvic fractures and the RUG

(retrograde urethrogram), which is incorrect?

A. Typically performed in males.

B. Gastrograffin is used

C. 2 images are obtained at 90 degrees.

D. A suprapubic catheter (SPC) is placed if a urethral injury is identified .

Back 40

B. Intravenous contrast -20 mL