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FRACTURAS DE PELVIS

Dr. Ramn Hernndez N. 2013

Epidemiologa
Representan el 2-8% de

todas las fracturas. Incidencia: 37/100.000 personas ao. Distribucin bimodal: - 15-30 aos: trauma de alta energa: Fx inestables - 50-70 aos: trauma de baja energa: Fx estables. Incidencia en aumento Mortalidad general 5%, fracturas por mecanismo de alta energa 6-35%.

Epidemiologa
Politraumatizados: 20%

presentan fractura de pelvis. Las fracturas plvicas expuestas representan el 2-4% del total de fracturas plvicas, con una mortalidad del 25-50%. Causas: - Accidentes de transito: 57%. - Lesiones de peatones: 18%. - Accidentes en moto: 9%. - Cadas de altura: 9%. - Aplastamiento: 4%.

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Generalidades
Alta tasa de lesiones asociadas secundarias al trauma de

alta energa:

63% trauma vejiga o uretra. 12-62% Lesiones 35% TEC. asociadas 24% Lesiones sistema nervioso. 20% Lesiones abdominales.
Factores predictores directos de mortalidad: - Injury severity score (ISS) > 25. - Revised Trauma score < 8. - Edad > 65 aos. - Requerimiento de transfusin > 6U/24 hrs.
Management of Hemorrhage in Life-threatening Pelvic Fracture

Figure 1

Posterior (A) and anterior (B) view of the pelvic ligaments. (Reproduced with permission from Tile M, Helfet DL, Kellam JF, eds: Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 13, 15.)

Anatoma anillo plvico

Estabilidad rotacional y vertical: - Ligamentos SI interoseos. - Ligamentos SI anterior y

posterior. - Ligamentos ileolumbares. - Ligamentos SE y ST.

Estabilidad anterior: - Sinfisis del pubis.

The three bones and three joints constituting the pelvic ring are stabilized by ligamentous structures, the strongest and most important of which are the posterior sacroiliac ligaments. These ligaments are made up of short oblique fibers that run from the posterior ridge of the sacrum to the posterosuperior and posteroinferior iliac spines as well as longer longitudinal fibers that run from the lateral sacrum to the posterosuperior iliac spine and merge with the sacrotuberous ligament. The anterior sacroiliac ligament is far less robust than the posterior sacroiliac ligament. The sacrotuberous ligament is a strong band that runs from the posterolateral sacrum and dorsal aspect of the posterior iliac spine to the ischial tuberosity. This ligament, along with the posterior sacroiliac ligaments, provides vertical stability

to the pelvis. The sacrospinous ligament runs from the lateral edge of the sacrum and coccyx to the sacrotuberous ligament and inserts onto the ischial spine. The iliolumbar ligaments run from the fourth and fifth lumbar transverse processes to the posterior iliac crest; the lumbosacral ligaments run from the fifth lumbar transverse process to the sacral ala (Figure 1). Major blood vessels lie on the inner wall of the pelvis. The common iliac artery divides, giving off the external iliac artery, which exits the pelvis anteriorly over the pelvic brim. The internal iliac artery lies over the pelvic brim. It courses anterior and in close proximity to the sacroiliac joint. The posterior branches of the internal iliac artery include the iliolumbar, superior gluteal, and lateral sacral arteries. The superior gluteal artery sweeps around to exit the

greater sciatic notch, where it lies directly on bone. Anterior branches of the internal iliac artery include the obturator, umbilical, vesical, pudendal, inferior gluteal, rectal, and hemorrhoidal arteries. The pudendal and obturator arteries are anatomically related to the pubic rami and can be injured with fractures or injuries to these structures. These arteries and their associated veins can all be injured during pelvic disruption (Figure 2). An understanding of pelvic anatomy will help the orthopaedic surgeon recognize which fracture patterns are more likely to cause direct damage to major vessels and result in significant retroperitoneal bleeding.

Patient Evaluation
Complete evaluation of the patient with a high-energy pelvic fracture is

Dr. Hak or a member of his immediate family is affiliated in an unpaid capacity with the publications Journal of Orthopaedic Trauma and Orthopedics, is a member of a speakers bureau or has made paid presentations on behalf of Medtronic and Eisai, serves as a paid consultant to or is an employee of Medtronic, and has received research or institutional support from Synthes and Stryker. Dr. Smith or a member of his immediate family is affiliated in an unpaid capacity with the publication Patient Safety in Surgery, is a member of a speakers bureau or has made paid presentations on behalf of Stryker and Synthes, serves as a paid consultant to or is an employee of Synthes, and has received research or institutional support from Acumed. Neither Dr. Suzuki nor a member of his immediate family has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article.

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Biomecnica y estabilidad plvica

Lesin estable se defino

como aquella que puede soportar las fuerza fisiolgicas normales sin deformarse. Estudio de Pennal, Tile y cols. (1980): - Snfisis: diastasis pbica <2,5 cms. - Snfisis + SE + SIA: diastasis pbica >2,5 cms. - Snfisis + SE + ST + SIA + SIP: inestable completa.

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Estabilidad plvica
1) Estable rotacional y vertical. 2) Inestabilidad rotacional: - Ligamento SI anterior. - Ligamento iliolumbar. - Ligamento SE. 3) Inestabilidad vertical: - Complejo ligamentoso SI posterior. - Ligamento ST. - Ligamento Lumbosacro lateral.

Clasificacion de Fx Pelvis
Estables tipo A Inestables

Rotacionales tipo B
Inestables Vertical tipo

Evaluacin clnica
ATLS - Rx AP pelvis. - ECO FAST. Examen fsico: - Acortamiento extremidad o rotacin externa-interna. - Palpacin gap snfisis pubiana. - Test por compresin: EIAS y crestas iliacas. - Examen rectal y plvico: descartar exposicin y

sospechar lesin uretral. - Evaluacin neurolgica: nervio citico y plexo sacro.

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Valoracin de urgencia
La valoracin de la circulacin incluye la inspeccin y la

exploracin clnica

rganos plvicos
- Uretra/prstata - Recto - Vagina - Esfnteres/otros

Radiologa adicional

INLET

OUTLET

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Radiologa adicional
TAC

Manejo
Fracturas mecnicamente estables: - Fracturas Tile: A1-A2. - Manejo definitivo.

Fracturas mecnicamente inestables: - Manejo inicial - Manejo definitivo.

Hemodinmicamente estables Hemodinmicamente inestables

Tratamiento de urgencia
Objetivo: - Detener la hemorragia. Alternativas: - Estabilizar la pelvis. - Taponamiento quirrgico. - Embolizacin (sangrado arterial).

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Fracturas mecnicamente inestables: HD inestables

1) Fluidos EV + Fajado 2) 3) 4)

5)

Estabilizacin plvica
Fajado plvico.

Prehospitalario

Fijador externo anterior: - A: Crestas iliacas. - B: Supra-acetbular.

(Adapted permission from not be used because it will lead to further opening up of posteafter 48 hours for pack removal. Sepsis and multi-organ failure with 7 Krieg JC, Mohr M, Ellis TJ, rior injury. A C-clamp or its variants are indicated (Figure 3). are life-threatening complications of pelvic packing. External Fixation Simpson TS, Madey SM, Bottlang In this, two pins are inserted laterally; one on each side, cenComplications of embolization include variable ischemic Treatment Methods Emergent stabilization of pelvic Standard Anterior External tered over the SI joint, and compression force is applied in the necrosis in the pelvic region, which may further be M: compliring injuries by controlled coronal plane to close the posterior injury using a C-shaped cated by infection and sepsis.8 Other drawbacks of angioFixation cicumferential compression: A Military Antishock or a trapezoidal clamp. The cost of C-clamp is a limiting factor. Trousers graphic embolization are that the facility may not be available Multiple studies have reported a clinical trial. J Trauma Such an assembly can also be made with Schanz pins and tuon a 24-hour basis in many places. Also, if the patient is unstaMilitary antishock trousers (MAST) benefit of emergent pelvic external 2005;59:659-664.) bular external fixator rods and clamps, although the amount of ble, it is not possible to shift the patient to the radiology decan provide temporary compression fixation in the resuscitation of the freedom available with a C-clamp (by virtue of its rotational partment. Many authors have reported packing and external and immobilization of the pelvic ring hemodynamically unstable patient movements around the lateral pins) is not possible with such a fixator to be better than embolization.9,10 Osborn et al found and lower via pneumatic with an unstable pelvic fracture.2,5,23 rise in mortality hasPenetration been shown as pelvic construct. into the cavity andextremity neurovascular reduced 24-hour blood transfusion requirements in patients 10 pressure. In the 1970s injury in the greater notch are rare but potentially disas- and 1980s, The beneficial effects of external undergoing packing, but not in those undergoing angiography. the APC grade increases. Thesciatic pattern trous in complications of posterior external application. Suzuki et al advocated angiography for those patients who use fixator of MAST was advocated to fixation in pelvic fractures may arise of injuries seen the APC type III the Overcompression of sacral foramina can also cause neurologiwere hemodynamically stabilized and pelvic packing for those fracture has been correlated with the induce pelvic tamponade and in- from several factors. Immobilization cal damage. C-clamp may not be used in cases of osteoporosis with hemodynamic instability, followed by angiography if inTrikha and Gupta 1 crease venous return to aid resuscita- may limit pelvic displacement during greatest fluid requirements. and also hemodynamically stable patients. It is used as a temstability persisted.5 Definitive protocols for the management of 24-hour 19 tion. However, MAST In a hosseries porary of 210 consecutive pameasure to ward off the acute stage of hemodynamic in- use limits patient movements and transfers, acute pelvis injuries need to be incorporated in individual In patients with posterior ring injury, anterior fixator canAfter pelvic packing, the patient requires a re-look surgery abdominal examination and may of pelvis fractures, not amenable to the anterior fixator pital depending upon its own resources and skilled manpower decreasing the possibility of clot tients with stability pelvic fractures, Burgess not be used because it will lead to further opening up of posteafter 48 hours for pack removal. Sepsis and multi-organ failure 2 application. available. cause lower extremity compartment 7 et alof found transfusion riorrequireinjury. A C-clamp or its variants are indicated (Figure 3). disruption. In certain patterns (eg, are life-threatening complications pelvicthat packing. syndrome or aggravate an existing ments for patients with LC injuries In this, two pins are inserted laterally; one on each side, cen- APC II), reduction of pelvic volComplications of embolization include variable ischemic External Fixation still useful stabilitered over the SIone. joint,Although and compression force isfor applied in the ume may be achieved by applicanecrosis in the pelvic region, which may further be compliaveraged External fixators act as adjuncts to the initial management of 3.6 units of packed red coronalwith plane tozation close the a C-shaped cated by infection and sepsis.8 Other drawbacks of angioof posterior patientsinjury withusing pelvic frac- tion of the external fixator. Experiblood cells (PRBCs), compared pelvic injuries and are performed to take care of the initial heor a trapezoidal clamp. The cost of C-clamp is a limiting factor. graphic embolization are that the facility may not be available modynamic instability. They are broadly of two types: a anterior mean of 14.8 units for patients tures, MAST has largely been re- mental studies have shown that Such an assembly can also be made with Schanz pins and tuon a 24-hour basis in many places. Also, if the patient is unstaand posterior. For patients with anterior pubic diastasis, placed by the use of commercially withrami APC the same bular series, external fixator rods and clamps, although the amount of reduction of open book pelvic injury ble, it is not possible to shift the patient to theinjuries. radiologyIn defractures and intact posterior ligaments, an anterior external available pelvic binders. patients with injuriesfreedom averaged available with a C-clamp (by virtue of its rotational leads to increases in retroperitoneal partment. Many authors have reported packing and VS external fixator is applied. Pins are inserted either in the iliac 9,10 blade movements around the lateral pins) is not possible with such a pressures, which may aid in tamponfixator to be better than embolization. Osborn al found with 9.2 units, andet patients CM injufrom the crest (Figure 2A), or if there is associated blade fracconstruct. Penetration into the pelvic cavity and neurovascular ade of venous bleeding.24 Apposireduced 24-hour blood transfusion requirements in patients Pelvic Binders and Sheets had ture, then pins are inserted anteroposteriorly from theries region of an average transfusion reinjury in the greater sciatic notch are rare but potentially disasundergoing packing, but not in those undergoing angiography.10 quirement of 8.5 units. The overall Circumferential compression can be tion of the displaced fracture can antero-inferior iliac spine (Figure 2B). These supra-acetabular trous complications of posterior external fixator application. Suzuki et al advocated angiography for those patients who pins have stronger hold, but iliac crest pins are quicker and mortality rate in this series was readily achieved in the prehospital facilitate the hemostatic pathway Overcompression of sacral foramina can also cause neurologiwere hemodynamically stabilized and pelvic packing for those safer to insert. Proximal and distal transverse connecting rods setting and provides early, 8.6%. higher mortality rate wasC-clamp cal damage. may not be used in cases ofbeneficial osteoporosis to control bleeding from any raw with hemodynamic instability, followed by A angiography if inare used. In this type of configuration, the proximal rod can be stabilization during transport seen APC (20%) and CM and also hemodynamically stable patients. It is usedand as a retem- bony surfaces. stability persisted.5 Definitive protocols forin thethe management of removed for a laparotomy while still maintaining the stability porary measure to ward off the A acute stage of hemodynamic inacute pelvis injuries need to be incorporated in individual hossuscitation. folded sheet wrapped (18%) patterns than in the LC (7%) with the distal rod, and the distal rod can be removed leaving 2 stability of pelvis fractures, not amenable to the anterior fixator pital depending upon its own resources and skilled manpower circumferentially around the pelvis is C-Clamp andIfVS the proximal rod in place once the patient starts sitting. the(0%) patterns. Burgess et al application. available. fixator is not applied in the above fashion, care should be cost effective, noninvasive, and easy Standard external pelvic fixation noted that exsanguination from peltaken to ensure free access to the entire abdomen from xivicthe injuries resulting from lateral to apply.20 Various commercial pelvic does not provide adequate posterior External Fixation Figure 3 A posterior C-clamp applied for the posterior pelvic disruption. phisternum till the pubic region for the general surgeons. was rare, External fixators act as adjuncts tocompression the initial management of and the au- binders have been devised. A tension pelvic stabilization. This limits its efpelvic injuries and are performed to take care of the initial hethors attributed death in patients of about 180 N has been shown to fectiveness in fracture patterns that A B anterior modynamic instability. They are broadly of two types: and posterior. For patients with anterior 452 pubic diastasis, rami Journal of the American Academy of Orthopaedic Surgeons fractures and intact posterior ligaments, an anterior external fixator is applied. Pins are inserted either in the iliac blade from the crest (Figure 2A), or if there is associated blade fracture, then pins are inserted anteroposteriorly from the region of antero-inferior iliac spine (Figure 2B). These supra-acetabular pins have stronger hold, but iliac crest pins are quicker and safer to insert. Proximal and distal transverse connecting rods are used. In this type of configuration, the proximal rod can be removed for a laparotomy while still maintaining the stability with the distal rod, and the distal rod can be removed leaving the proximal rod in place once the patient starts sitting. If the fixator is not applied in the above fashion, care should be Figure 2 An anterior external fixator applied on the iliac crest (A) and supra acetabular external fixator (B). taken to ensure free access to the entire abdomen from the xiFigure 3 A posterior C-clamp applied for the posterior pelvic disruption. phisternum till the pubic region for the general surgeons.
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with LC injuries to other causes. The most common identifiable cause of death in patients in this series with LC fractures was closed head injury. In contrast, the identifiable cause of death in patients with APC injuries was combined pelvic and visceral injury. These findings indicate that the ability to recognize the pelvic fracture pattern and the direction of the corresponding injury force can help the resuscitation team anticipate requirements for fluids and blood transfusion as well as help to direct Illustration demonstrating proper early assessment and treatment. The application of a pelvic Trikha and Gupta patient with complete posterior incircumferential compression device (pelvic binder), with an adjustable stability can be anticipated to present to control tension. In patients with posterior ringwith injury, anteriorhemorrhage. fixator canAfter pelvic packing, the patient requires a re-look buckle surgery (arrow) a severe
Figure 4

plvico. ATLS: Rx trax-pelvis + ECO FAST. Pinza plvica Ganz + Transfusiones mltiples. Ciruga de urgencia: Laparotoma + Packing plvico + Estabilizacin. Angiografa y embolizacin.

Management of Hemorrhage in Life-threatening Pelvic Fracture

provide maximum effectiveness.21 One study reported that pelvic binders reduced transfusion requirements, length of hospital stay, and mortality in patients with APC injuries22 (Figure 4). External rotation of the lower extremities is commonly seen in persons with displaced pelvic fractures, and forces acting through the hip joint may contribute to pelvic deformity. Correction of lower extremity external rotation can be achieved by taping the knees or feet together, and this may improve the pelvic reduction that can be achieved with circumferential compression.

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Pinza plvica Ganz (C-clamp)

Figure 2 An anterior external fixator applied on the iliac crest (A) and supra acetabular external fixator (B).
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Fijador externo v/s Pinza plvica

Fijador externo: - Fracturas del anillo plvico anterior. - Preferir insercin supra-acetbular. Pinza plvica Ganz: - Fracturas anillo plvico posterior. - Zona de insercin pins:

mission were randomized to either rFVIIa treatment or placebo. In the rFVIIa group, the number of red cell transfusions was significantly reduced (approximately 2.6 red blood cell units; P = 0.02), and there was a trend toward a reduction in mortality and complications.

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Illustrations demonstrating the retroperitoneal packing technique. A, An 8-cm midline vertical incision is made. The bladder is retracted to one side, and three unfolded lap sponges are packed into the true pelvis (below the pelvic brim) with a forceps. The rst is placed posteriorly, adjacent to the sacroiliac joint. The second is placed anterior to the rst sponge at a point corresponding to the middle of the pelvic brim. The third sponge is placed in the retropubic space just deep and lateral to the bladder. The bladder is then retracted to the other side, and the process is repeated. B, Illustration demonstrating the general location of the six lap sponges following pelvic packing. (Adapted with permission from Smith WR, Moore EE, Osborn P, et al: Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: Report of two representative cases and a description of technique. J Trauma 2005;59:1510-1514.)

Evaluation of Resuscitation Status

End points of resuscitation are determined based on the combination of laboratory data and physiologic signs. A hemoglobin level reading is known to be inaccurate during the acute phase of resuscitation. The commonly considered end points of resuscitation include normal blood pressure, decreased heart rate, adequate urine output (30 mL/hr), and normal central venous pressure.14 However, even after normalization of these parameters, inadequate tissue oxygenation may persist. Additional laboratory measures that can be used to evaluate tissue oxygenation include base deficit, bicarbonate, and lactate. All of these assess anaerobic glycolysis. The terms base deficit and base excess are used interchangeably, the only difference being that base deficit is expressed as a positive number and base excess is expressed as a negative number. A normal base deficit is 0 to 3 mmol/L; this is routinely measured with an arterial blood gas analysis. A persistent base deficit suggests insufficient resuscitation.

Packing plvico retroperitoneal

Indicado en pacientes que persisten inestables, a pesar de

estabilizacin plvica y resucitacin con fluidos + transfusiones. Abordaje: - Laparotoma media, desde la snfisis pubiana 6-8 cms ceflico. - Posicin packing: Blood 1 adyacente a la SI, 2 anterior a esta, en la zona Products and Recombinant Factor VIIa media del anillo plvico, 3 espacio retro pbico adyacente a la Hypotensive patients who do not revejiga. spond to initial fluid resuscitation require massive amounts of fluid subsequently, leading to deficiency of the hemostatic pathway. Therefore, all such patients should be assumed to require platelets and fresh-frozen plasma (FFP). In general, 2 or 3 units of FFP and 7 to 8 units of platelets

it also takes the most time to obtain (approximately 60 minutes).14 When the response to crystalloid infusion is transient or blood pressure fails to respond, 2 additional liters of crystalloid solution are given, and type-specific or noncross-matched universal-donor (ie, group O negative) blood is administered immediately. A lack of response indicates that ongoing blood loss is likely, and angiographic and/or surgical control of the bleeding may be needed.14

are required for every 5 L of volume replacement.14 Massive blood transfusion has potential risks of immunosuppression, inflammatory effects, and dilutional coagulopathy. Thus, the optimal volume and relative requirements of blood products for resuscitation remain controversial. In addition, the amount of PRBC transfusion is an independent risk factor for postinjury multiple organ failure.6,40 Some authors have proposed that coagulopathic trauma patients should be primarily resuscitated with more aggressive use of FFP, with a transfusion composed of PRBCs, FFP, and platelets in a 1:1:1 ratio to prevent early coagulopathy promotion.7,41 Recombinant factor VIIa (rFVIIa) may be considered as a final intervention when coagulopathy and lifethreatening bleeding persist despite other treatment. This is an off-label use of rFVIIa. Boffard et al42 performed

Treatment Algorithms and Survival Rates

Retrospective analysis of outcomes before the institution of treatment algorithms dramatically illustrates the

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HD estables: Exmenes complementarios:

Radiografas AP, inlet y outlet de pelvis. TAC pelvis.

Otros exmenes: - Uretrografa: lesin uretra asociada 15-20% pacientes (inestables). - TAC otros segmentos. - Arteriografa.

Fracturas mecnicamente estables (A1-A2)

Manejo ortopdico:
- Apoyo en carga protegida (4-6 semanas). - Tratamiento sintomtico.

Ejemplo:

Fracturas sin afectacin del anillo: - Avulsivas en deportistas: EIAS: Sartorio. EIAI: Recto femoral. EI: Isquiotibiales. EP: Erectores de la columna. CI: Abdominales.

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Fracturas mecnicamente inestables: Fijacin definitiva:

Tratamiento ortopdico de fracturas inestables desplazadas tiene mltiples complicaciones
Trikha and Gupta

Quirrgico
Objetivo: Limitar complicaciones. Movilizacin precoz. Tiempo quirrgico: Paciente estable HD y desde el punto de vista anestsico. Partes blandas en buenas condiciones.

Figure 5 A pelvic diastasis fixed internally with a 4-hole plate.

(Figures 7A and B). It can also be used for fractures involving the adjacent sacral ala. A previous C-clamp applied in emergency situations may compromise soft tissue condition in that region of pin insertion and predispose to infection following percutaneous SI screw fixation. An alternative is plate fixation anteriorly using either the iliofemoral approach or the lateral window of ilioinguinal approach (Figure 8). This is indicated where closed reduction of fracture fragments cannot be achieved and an open reduction is required, or where fracture line extends too antero-lateral to be fixed by a SI screw. If the fracture is comminuted enough not to permit adequate SI screw purchase, or in bilateral sacral ala fractures, a posterior transiliac plating is done. Two small incisions are made, one over each PSIS region, and are connected through a subcutaneous tunnel. A contoured plate is slid through this tunnel and fixed across both SI joints, acting as a posterior tension band (Figure 9). In late cases of pelvis fracture with vertical shear injury, sometimes it is difficult to reduce the vertical component by traction or mobilization of fracture fragments.
Trikha and Gupta

Figure 5 A pelvic diastasis fixed internally with a 4-hole plate. Figure 6 Pubic rami fractures fixed with percutaneous screws.

(Figures 7A and B). It can also be used for fractures involving the adjacent sacral ala. A previous C-clamp applied in emergency situations may compromise soft tissue condition in that region of pin insertion and predispose to infection following percutaneous SI screw fixation. An alternative is plate fixation anteriorly using either the iliofemoral approach or the lateral window of ilioinguinal approach (Figure 8). This is indicated where closed reduction of fracture fragments cannot be achieved and an open reduction is required, or where fracture line extends too antero-lateral to be fixed by a SI screw. If the fracture is comminuted enough not to permit adequate SI screw purchase, or in bilateral sacral ala fractures, a posterior transiliac plating is done. Two small incisions are made, one over each PSIS region, and are connected through a subcutaneous tunnel. A contoured plate is slid through this tunnel and fixed across both SI joints, acting as a posterior tension band (Figure 9). In late cases of pelvis fracture with vertiFigure 8 A case of APC III with postoperative radiograph showing anterior cal shear injury, sometimes it is difficult to reduce the vertical sacroiliac and pubic plating. component by traction or mobilization of fracture fragments.

Anillo plvico anterior

Diastasis snfisis pubiana: - Reduccin + OTS con placa. - Abordaje tipo Pfannenstiel.
Trikha and Gupta
Figure 7 Pubic diastasis along with sacroiliac (SI) disruption (A) fixed with anterior plate and posterior 7A percutaneous SIcan screw (B).be used for fractures involving (Figures and B). It also
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Rama pbica o extensin columna anterior: - Reduccin + OTS con placa. - Abordaje ilioinguinal. Fracturas aisladas de columna anterior: - Tornillos percutneos si se logra

reduccin cerrada.

the adjacent sacral ala. A previous C-clamp applied in emer2011, DOA gency situations may compromise soft tissue condition in that Figure 8 A case of APC III with postoperative radiograph showing anterior region ofand pinpubic insertion and predispose to infection following Figure 6 Pubic rami fractures fixed with percutaneous screws. sacroiliac plating. percutaneous SI screw fixation. An alternative is plate fixation anteriorly using either the iliofemoral approach or the lateral window of ilioinguinal approach (Figure 8). This is indicated A B where closed reduction of fracture fragments cannot be achieved and an open reduction is required, or where fracture line extends too antero-lateral to be fixed by a SI screw. If the fracture is comminuted enough not to permit adeTrikha and Gupta quate SI screw purchase, or in bilateral sacral ala fractures, a posterior transiliac plating is done. Two small incisions are (Figures 7A andeach B). It can region, also beand used for fractures through involving made, one over PSIS are connected a the adjacent sacral ala. previous C-clamp applied in emersubcutaneous tunnel. AA contoured plate is slid through this gency situations may compromise soft tissue condition in that tunnel and fixed across both SI joints, acting as a posterior tenregion of pin insertion predispose to infection following sion band (Figure 9). In and late cases of pelvis fracture with vertiFigure 5 A pelvic diastasis fixed internally with a 4-hole plate. percutaneous SI screw fixation. alternative is plate cal shear injury, sometimes it is An difficult to reduce the fixation vertical anteriorly using either the iliofemoral approach or fragments. the lateral component by traction or mobilization of fracture window of ilioinguinal approach (Figure 8). This is indicated where closed reduction of fracture fragments cannot be Figure 7 Pubic diastasis along with sacroiliac (SI) disruption (A) fixed with anterior plate and posterior percutaneous SI screw (B). achieved and an open reduction is required, or where fracture line extends too antero-lateral to be fixed by a SI screw. JCOT Vol 2 No 1 16 2011, DOA If the fracture is comminuted enough not to permit adequate SI screw purchase, or in bilateral sacral ala fractures, a posterior transiliac plating is done. Two small incisions are made, one over each PSIS region, and are connected through a subcutaneous tunnel. A contoured plate is slid through this tunnel and fixed across both SI joints, acting as a posterior tension band (Figure 9). In late cases of pelvis fracture with vertiFigure 5 A pelvic diastasis fixed internally with a 4-hole plate. cal shear injury, sometimes it is difficult to reduce the vertical Trikha and Gupta component by traction or mobilization of fracture fragments.
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Figure 6 Pubic rami fractures fixed with percutaneous screws.

Figure 5 A pelvic diastasis fixed internally with a 4-hole plate.

Anillo plvico posterior

1) Tornillos SI posteriores: -Reduccin cerrada : percutneo.

(Figures 7A and B). It can also be used for fractures involving the adjacent sacral ala. A previous C-clamp applied in emergency situations may compromise soft tissue condition in that region of pin insertion and predispose to infection following percutaneous SI screw fixation. An alternative is plate fixation anteriorlyFigure using8 either the approach or radiograph the lateral showing anterior A case of iliofemoral APC III with postoperative window of ilioinguinal approach (Figure 8). This is indicated sacroiliac and pubic plating. where closed reduction of fracture fragments cannot be achieved and an open reduction is required, or where fracture line extends too antero-lateral to be fixed by a SI screw. If the B fracture is comminuted enough not to permit adequate SI screw purchase, or in bilateral sacral ala fractures, a posterior transiliac plating is done. Two small incisions are made, one over each PSIS region, and are connected through a subcutaneous tunnel. A contoured plate is slid through this tunnel and fixed across both SI joints, acting as a posterior tension band (Figure 9). In late cases of pelvis fracture with vertical shear injury, sometimes it is difficult to reduce the vertical component by traction or mobilization of fracture fragments.
Figure 8 A case of APC III with postoperative radiograph showing anterior sacroiliac and pubic plating.

Figure 6 Pubic rami fractures fixed with percutaneous screws.

Figure 7 Pubic diastasis along with sacroiliac (SI) disruption (A) fixed with anterior plate and posterior percutaneous SI screw (B).
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Figure 6 Pubic rami fractures fixed with percutaneous screws.

Figure 8 A case of APC III with postoperative radiograph showing anterior sacroiliac and pubic plating.

Figure 7 Pubic diastasis along with sacroiliac (SI) disruption (A) fixed with anterior plate and posterior percutaneous SI screw (B).
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2) Placa SI anterior: -Lnea de fractura muy anterolateral. -Reduccin abierta. -Ampliacin de abordaje ilioinguinal.
Figure 7 Pubic diastasis along with sacroiliac (SI) disruption (A) fixed with anterior plate and posterior percutaneous SI screw (B).
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Complicaciones
Mortalidad: - Precoz: Hemorragia. - Tarda: Sepsis y FOM. Morbilidad: - Estables: mnima discapacidad. - Inestables:

Alta tasa de discapacidad y de deformidad. Desplazamiento residual > 1cm: 70% dolor severo con funcionalidad anormal.
Neurolgicas: - Fracturas inestables verticalmente o que afectan al anillo plvico posterior. Lesin genitourinaria: - Mas frecuente en varones, incidencia general 4,6 %. - Hombres: lesiones anteriores producen disfuncin erctil y lesiones posteriores

disfuncin eyaculatoria. 60% se recuperan en 2 aos.

Trauma pelvis
0-5 min
Sangrado externo masivo Lesin por aplastamiento si
Pabelln: Laparotoma + Hemostasia + Packing + Estabilizacin plvica

Soporte vital Rx torax-pelvis; ECO FAST

Inestabilidad pelvica + inestabilidad HD si

no

Continuar estudio Manejo del Politrauma

10-15 min

Pinza plvica Ganz Transfusiones multiples si

Estabilizacin HD
no
Pabelln: Laparotoma + Hemostasia + Packing + Estabilizacin plvica

20-30 min

Estabilizacin HD
no

si

UCI

Angiografa Embolizacin

Chirurgische Techniken in Orthopdie und Traumatologie 8 Bnde: Chirurgische Techniken In Orthopdie und Traumatologie: Handgelenk und Hand [Gebundene Ausgabe] Jacques Duparc (Herausgeber), Fracturen und Luxationen des Beckenrings. T. Pohlemann, A Gnsslen, H. Tscherne, 2004.