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Injuries of Pelvis METHOD GUIDANCE
For the 5th year students of medical faculties
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2015 Injuries of Pelvis: Independent Study Manual for the 5th year Students of
Medical Faculties / compiled by: Golka G.G., Oliynyk A.O., Fadeyev O.G.,
Istomin D.A., Bitchuyk D.D. - Kharkiv: KhNMU, 2015. - 21 p.
Compilers G.G. Golka
Oliynyk A.O.
Fadeyev O.G.
Istomin D.A.
Bitchuyk D.D. ?????? ???? : ???????????? ???????? ??? ???????????? ?????????,
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Background information
Pelvic fractures are devastating injuries that are associated with a number
of complications that often require extensive rehabilitation. Pelvic
fractures represent about 0.3% to 6% of all fractures and occur in 20% of
all polytrauma cases.1 High-velocity trauma accounts for most pelvic
fractures, including motor vehicle accidents, motor vehicle-pedestrian
accidents, crush injuries, and falls.2 A bimodal distribution of age is
seen in pelvic trauma, as most injuries occur between the ages of 15 to 30
and 50 to 70 years. The overall average age is reportedly 31.5 years. Men
account for more pelvic fractures than women, representing about 57% to 75%
of all pelvic injuries. Reported mortality rates range from 6.4% to 30%,5
depending on the type of pelvic fracture and extrapelvic injuries and
complications.
Rapid assessment and diagnosis during the emergent period, along with
rehabilitation that begins as soon as the individual stabilizes, are vital
to good outcomes. Pelvic Anatomy
Three major bones compose the pelvis: ilium, ischium, and pubis. The ilium
is situated superiorly. The uppermost portion forms the iliac crest. The
right and left ilium form the pelvic girdle and articulate with the sacrum
posteriorly to form the sacroiliac joint. The ischium lies inferiorly and
posteriorly. The superior and inferior rami join the pubis, which lies
inferiorly and anteriorly. Eventually, the three bones fuse into one at the
acetabulum, which forms a socket for the head of the femur. Anterior fusion
of the right and left pubi form the symphysis pubis. The circumference of
the pelvic brim is shaped by the oblique plane across the sacrum on the
posterior side, symphysis pubis on the anterior side, and several lateral
points along the ilium. The greater pelvis, sometimes called the false
pelvis, lies above this landmark. Its borders include the lumbar vertebrae,
ilium laterally, and abdomi-nal wall anteriorly. The lesser or true pelvis
is below the pelvic brim, bounded by the sacrum and coccyx, inferior
portions of the ilium and ischium, and pubic bones
The pelvis houses several large vascular structures. The common iliac
artery branches of the abdominal aorta. The internal iliac ar-tery branches
off the common iliac and supplies most of the blood supply to the pelvic
wall and viscera via several tributaries, includ-ing the superior vesicle,
obturator, rectal, uterine, vaginal, pudendal, and superior and inferior
gluteal arteries. The external iliac artery traverses the brim of the
lesser pelvis then becomes the femoral artery as the vessel passes through
the leg. The lumbar and sacral arteries, which divide off the aorta, also
lie in the pelvic cavity. The veins in the pelvis, for the most part,
correspond to the arteries. The in-ternal and external iliac veins fuse to
form the common iliac vein. The internal iliac vein receives blood from the
pelvic organs, including the uterus, vagina, urinary bladder, rectum,
prostate gland, and vas deferens as well as blood from the medial thigh and
gluteal muscles. The external iliac vein continues off the femoral vein and
empties blood from the anterior abdominal wall and lower extremities. Other vital structures within the pelvis include the reproductive organs,
sigmoid colon and rectum, bladder, ureters, and urethra. Important nervous
system structures that traverse the pelvis include the sacral plexus, which
is composed of the 4th and 5th lumbar nerves and sacral nerves 1 through 3.
Also, the femoral, sciatic, and obturator nerves pass through the pelvis
Classification of Pelvic Fractures Pelvic fractures are classified in several ways. The simplest method
evaluates the nature of a pelvic-ring fracture and presence of an
acetabular fracture. The pelvic-ring fracture is classified as
anteroposterior compression, vertical shear, or lateral compression. Pelvic-
ring stability is a second method. Because anterior structures, such as the
symphysis pubis and pubic rami, provide about 40% of pelvic rigidity, this
classification system is based on posterior stability at the sacroiliac
fusion. In Type A fractures, the pelvic ring is stable. Gansslen and
colleagues reported that, of 3260 pelvic injuries, 54.8% were Type A
fractures. Ninety-one percent of Type A fractures affected the anterior
pelvic or iliac rim. Type B fractures are rotationally unstable. Lateral
compression and complete separation at the symphysis pubis ("open-book"
fractures) account for most Type B injuries and are caused by internal and
external rotational forces. Concomitant acetabular fractures are commonly
associated with Type B fractures. In Type C injuries, the posterior
sacroiliac articulation is completely disrupted. Seventy percent to 80% of
all pelvic fractures are Type A and B (Table 1). Communication with adjacent tissue forms the basis for a third approach
to the classification of pelvic injuries. Reportedly 2.7% of all pelvic
fractures are open fractures. Although relatively rare, they are associated
with much higher morbidity and mortality than closed fractures. Open
fractures most commonly result from motor-vehicle crashes. [pic]
(Figure1) Type C fracture, the posterior sacroiliac junction
and anterior part is completely fractured and displaced
with vertical and horizontal instability
The student should know:
1. Frequency and classification of the pelvic bones injuries.
2. The reasons of the shock development at patients with the fractures of
the pelvic
rings and their treatment.
3. Meaning of the intrapelvic Novocain blockade by L. G. Shkolnikov and V.
P.
Selivanov and its technique.
4. Meaning of the intraosseous anesthesia of the pelvis . Its
advantages in comparison with the other methods.
5. Complications at injuries of the pelvic rings and their diagnostics.
6. The basic methods of treatment of isolated fractures of the pelvic bones
and
pelvic rings.
7. Stable osteosynthesis of the symphysis pubis,
8. A method of the x-ray control of the front pelvic semi-ring posterior
surface,
The student should be able:
1. To make the general examination of the patient with the fractures of the
pelvis, to define the pulse rate, arterial pressure. He should be able to
define the most painful places, displacement of the fragments, skewness and
the position of the bony prominences.
2. To be able to measure and research the functions of the lower extremity.
3. To be able to carry out the anesthesia
4. To be able to estimate the preliminary and final diagnosis.
5. To be able to plan the general plan of treatment.
Classification of Fractures(Table 1). |Type |Pelvic ring |Percentage of |
| | |injuries (%) |
| | | |
|A |Stable |54.8 |
|B |Partially stable |24.7 |
| |Rotationally unstable | |
| |"Open book" | |
| |"Bucket handle" | |
|C |Unstable |20.5 |
| |Disruption of | |
| |sacroiliac joint | |
| | | | DIAGNOSTICS OF PELVIC BONES INJURIES AND METHODS OF TREATMENT
Fractures of the pelvic bones are referred to the severe injuries. They
make from 5 up to 6 % of all fractures of motor and support apparatus.
Fractures the pelvis occur as the result of the pelvic ring compression in
the lateral or anteroposterior direction. The weakest place in it are
branches of the pubic and ischial bones which break more often. The
avulsion and impact fractures occur less often.
Classification of the pelvic bones fracturesFractures of the pelvic
bones are divided
into three groups.
The first group - simple fractures of the pelvic bones. The following
are referred to them: 1) avulsion of the anterior upper and lower spines;
2) fracture of the iliac wing; 3) fracture of the iliac crest; 4) fracture
of one of the branches of the pubic and ischial bones; 5) fracture of the
sacral bone; 6) Fracture of the coccygeal bone.
The secon