[MUSIC] [MUSIC] [MUSIC] [MUSIC] [NO_AUDIO] In order to be able to understand how fractured pelvis injuries are treated, it is helpful to recall briefly the basic principles of anatomy and function. The pelvis is shaped like a ring and distributes the weight of the upper body onto two legs. In order to achieve this, there are some joints which can only be moved to a small extent or almost not at all, dorsal to the iliosacral joints and ventral to the symphysis, which form the pelvic ring. The load is transferred via both hip joints. This means that any weakening in the ring structure brings with it an impairment of the transfer of strength. The ligamentary structures on the dorsal side are of the greatest importance for ensuring stability. A series of organs and varying guiding structures are contained within the pelvis. Furthermore, nerve structures for supplying the lower limbs run in direct proximity to the pelvic bones. Here is a list of organs and structures which are associated with the pelvis and which can be affected in cases of injury. This is important as occult injuries are only seen if a search is made for them. The epidemiology of pelvic fractures shows that approx. 3-6% of all fractures incurred by people relate to the pelvis. Approx. 60% of patients with pelvic fractures indicate injuries to other parts of the body and 20% of polytraumatised patients suffer from pelvic injuries. There are two age peaks. The first age peak is found between 25 and 35. The cause of the accident in these cases is essentially to be found in high speed trauma with a considerable rate of fatality of up to 33%. The second age peak is to be found from the age of about 70 onwards. The cause in these cases is mainly related to osteoporosis. The most frequent cause of accidents is to be found in traffic accidents. In addition to this are falls from a great height or other causes. In addition to this are falls from a great height or other causes. In order to be able to understand pelvic injuries, it is important to know from which side the destroying force has exerted an effect. If the energy stems from the front, we refer to a compression fracture. The wing of ilium can break due to the exertion of force in the case of lateral compression and with vertical shearing, the force penetrates obliquely through the pelvis. [NO_AUDIO] [MUSIC] [MUSIC] [NOISE] >> Hello. My name is Huber-Wagner. >> Niemann. >> I am the trauma surgeon on duty. You have been transferred to us from the hospital in Schneizlreuth? >> Exactly. >> Could you please tell me briefly what happened in your own words? >> I was travelling to work by motorbike four days ago and the only other road user was this silly cab driver. I was not really travelling so fast, but I was suddenly lying there in the road >> Aa. >> and I cannot recall anything else. >> Mhm. Okay. OK, roughly how fast were you travelling? >> Well, at least 60 km/hr. >> 70, 60, that makes everything clear. Were you wearing a helmet? >> Yes, certainly. >> Okay. Was this inside the town? >> Mhm, yes. >> Then you were taken to the local hospital? >> Mhm. There, they.... >> They fitted this frame over the injury. >> ... fitted this fixateur. That was good work by our colleagues. Are you experiencing any strong pains or such-like at the moment? Whilst lying down? >> I can feel what I would call medium-strong pains. >> According to the information I have received, you have fortunately not incurred any further injuries. I would now like to examine you. We’ll conduct an ultrasound examination, take a blood sample etc. First of all, however, a question: Did you receive tetanus protection... >> Yes, yes. >> ... from our colleagues there? From your perspective: Can you also move your legs? >> Everything OK. >> Okay. Okay. And you have been fitted with a bladder catheter. I’ll take a look at that now. And your bowel movements? They are normal as well. >> When did that last occur? >> This morning, I think. This morning, everything went well, OK. It is important for us that we can see that the appropriate functions are all behaving well. >> Mhm. [NO_AUDIO] >> The complication which is most feared among pelvic injuries is haemorrhaging. Approx. 90% of haemorrhages occur with venous injuries and only approx. 5% stem from the arterial system. Very great importance is attached to the initial clinical examination in the case of pelvic injuries. You can see here two typical clinical images which give rise to a very strong suspicion of a pelvic injury having occurred. A clinical examination envisages inspection and examination for contusions or effusions. Testing for stability should only be conducted by an experienced examiner. When doing this, it is important to know that in every test for stability, for example with an “open book” injury, considerable amounts of blood can flow from the fractured bone sections. Furthermore, the usual vital parameters, such as pulse status, blood pressure etc., should be examined. It is important that the peripheral neurology is examined and recorded. If a Pelvic Binder has been fitted at the pre-clinical stage, then this should be left in place for the time being. The anogenital region must also be examined. Caution must be applied when a bladder catheter is being fitted as injuries can possibly be caused to the urethra. Radiological diagnostic investigation provides for a FAST ultrasound examination in order to detect any free fluid present. In order to improve the contrast, the bladder can be filled retrospectively. The standard x-ray images consist of an anterior-posterior pelvic overview image, together with inlet- and outlet-projections. Due to the complex bone structures involved, the computerised tomogram has become accepted as the usual form of tomography. Despite this, however, it is still necessary to be familiar with the standard projections, in particular so as to be able to recognise instances of intraoperative plate osteosynthesis. [NO_AUDIO] [MUSIC] >>Okay. so I’ll now take your pulse. Yes, that’s fine, not too quick. Everything is in order there as well. I’ll just uncover you first. [NOISE] My word, you have some very pronounced pressure marks there, don’t you? I’ll now test once again whether you can feel that. Close your eyes, please. Can you feel that - here? >> Okay. >> Can you feel everything? Here? >> Mhm. >> Here? >> Yes. >> Just like before the accident? >> No. >> Okay. Back of the foot. >> Everything would appear to be in order. >> Everything would appear to be in order. OK. Could you now please pull both feet up towards you? Very good. That's fine. Downwards. Feet, there the toes in the direction of your head, direction of your face. I’m going to apply resistance. OK, but you can manage to do that well. Push firmly, downwards, as you were stepping on the gas. Okay. That’s fine as well. If it is possible in terms of the pain felt, could you try and lift your knee for me, please? [MUSIC] >> [NOISE] >> That’s OK. And lift once on the left side. Okay. OK, very good. That’s fine. And then there’s the bladder catheter. We need to take a look at the urine. It is clear and does not contain any blood. That information is very important in enabling us to see that the urinary tracts are obviously not injured. And now I would like to feel your abdomen. [MUSIC] If I press down there? >> Nothing. >> Good. Does that hurt at all? >> No. It feels a bit tender under the pressure, I would say, but it is bearable. >> OK. That means we are finished for the moment. I would now like to conduct another ultrasound examination and then we’ll have a chat about where things go from here, Mr. Niemann, Okay? >> Everything fine with me. Good. Danke. >> I’ll cross over to the device. [NOISE] [MUSIC] Let's do it, Niemann was the name, right? >> Mhm. >> Abdomen. Okay. >> With 2 "N". >> 2 and 2, everything clear. OK, now we’ll take a look up here at your heart and take a look at its chambers. I can see there, [MUSIC] okay, no pericardial effusion, which is also not to be expected. Let's have a look at the liver now. [MUSIC] I can’t see any free fluid here either, [MUSIC] which is normal. No free fluid. The same applies here in the splenic lodge. Breathe in deeply, Mr. Niemann, and hold it in. No free fluid here either. OK. That’s fine as well. And now we’ll take a look in the direction of the bladder. This, of course, is empty. [MUSIC] No free fluid here either. OK, fine, that’s normal. That’s all good news for you. [NOISE] >> Excellent. >> And now I’ll show you the x-ray images >> Mhm. >> and then I have a proposition to make to you. [NO_AUDIO] Pelvic ring fractures are classified according to AO into Types A-C. You can see Type A fractures on the left hand side, Type B ones in the centre and Type C ones on the right. Type A fractures are stable, with just the anterior pelvic ring being affected and non-operative treatment is frequently sufficient to deal with them. This provides for early functional follow-up treatment and weight-bearing, adapted according to the pain the patient can bear, from the first postoperative day onwards. Typical fracture lines in Type A injuries are shown here. What can be clearly noticed is that these fractures do not cause any interruption in the structure of the ring. This x-ray image shows a Type A fracture in the region of the pubic branch. Type B fractures are partially stable. They are accompanied by an interruption of the pelvic ring in the vertical axis. The sacroiliac joint is affected in external rotation injuries. Internal rotation injuries lead to the ala of sacrum being injured. This slide shows the fracture lines which are typical of a B injury. It can be clearly recognised that a typical sign of a B injury is when the posterior ring is not completely interrupted. A typical example of a Type B injury is an “open book” injury, as shown on this slide. They are called “open book” as the pelvis is folded open, like an opened book. This anterior-posterior x-ray image of a pelvic injury shows an “open book” injury. What can be clearly recognised are the dorsal debris zone sas well as the break in the symphysis in the ventral region. From this is derived the treatment for the “open book” injury. This consists of the Iliosacral joints being stabilised with screws, together with a symphysis plate. Type C fractures are distinguished by translational and rotational stability. In this case, the dorsal pelvic structures are completely interrupted. This slide shows in diagrammatic form the fracture lines typical for a Type C injury. What can be clearly recognised here is the complete interruption of the dorsal ring. What can be seen here are corresponding clinical pictures of a Type C pelvic injury. What can be clearly recognised here is the dislocation and complete interruption of the dorsal structures. As Type C injuries frequently occur in polytraumatised patients, the initial treatment is usually provided in the form of a fixateur externe to begin with. The definitive form of treatment can then be administered in the interval following the stabilisation of the patient. A further way in which pelvic injuries can be categorised is by classifying them as simple, uncomplicated and complex pelvic fractures. Within such classifications, 90% of pelvic injuries are simple and uncomplicated, while 10% are complex. These are associated with additional peripelvine injuries to the skin, muscles, genito-urinary tract or intestines or the major vessels or neural pathways. A further classification is derived from the systemic reaction. Within this, we distinguish unstable pelvic ring injuries with simultaneous unstable circulation. Acute danger to life can occur in the case of haemorrhages and an Hb < 8 mg/dl. A traumatic hemipelvectomy is particularly critical. Due to the considerable loss of blood involved, this usually turns out to be a fatal injury. [MUSIC] OK, Mr. Niemann, I’m now going to show you the x-ray and CT images to make it easier for you to understand the kind of injury you have sustained. Well: First of all, that is the topogram, that is to say the overview image. You can see the iliac wing here. Here is the lumbar spine. This is where both the thigh bones begin. These are all kinds of possible things such as cables, bladder catheters etc. This connection is usually joined together. «There’s already quite a wide gap.» «Here at the front is this symphysis, this joint can be said to have been torn apart and the parts are now far too widely apart from each other, while here at the back we can see the connection between the sacral and the iliac bones. In the bilateral comparison, you can see it is intact here and you can see that the pelvic ring is broken here at the front. These parts should be closer together. Therefore, what we are dealing with is a Type B pelvic ring fracture, that is to say, it has been completely separated here at the front, is unstable at the front and partially unstable at the back, in other words a Type B fracture. Now that is a really serious injury to begin with, but there is worse to follow. So that was what we might call the good news to begin with. You can now see a single cross-section view from the CT. You can see that the sections are too far apart. They should really be joined up. That is what we also call a symphysis fracture and if we look at the rear pelvic ring, where the connection between the sacral and iliac bones is intact, we can see that here the sections are considerably wider apart, meaning an injury has been incurred here as well. I can also show you the image which my colleagues have provided and, to be precise, you can see these pins here, which are positioned correctly, down there the pelvic ring is again roughly stabilised so that you could even be transported, the haemorrhaging has been stopped and we can undertake what we propose to do and what we would recommend, which is to transfer you to our normal ward to begin with. Fortunately, you do not need to be transferred to an intensive care ward, but to Ward 1/17, and we’ll make sure that the soft tissue recovers a bit and we will then operate in a few days’ time, when we will do the following; to provide treatment at the front of the pelvic ring - I’ll show you where on the image once again - to enable us to pull these sections at the front together again and to keep them held together with a plate, with a screw being inserted here. «And will that then poke through the frame somehow?» « That will be covered with a plate and fixed in place with screws when the operation is conducted. The frame can then be removed... ... in all probability.» «In all probability..» «That will then be removed. We will need to check at the intraoperative stage, but the probability is a very high one. Okay? OK?» «Everything understood.» «We’ll explain everything once again in detail. So that’s it for the moment and we’ll meet again on the ward. You are now free to eat and drink for the time being. We’ll conduct the operation in about three or four days when the soft tissue has healed a bit first. In the meantime, I wish you all the best, Mr. Niemann.» «Goodbye.» Non-operative treatment can be administered with non-dislocated Type B injuries and with all Type A injuries, such as an isolated fracture of the pubic bone or of the ischial bone. Emergency treatment for an unstable pelvic ring fracture can be administered in the pre-clinical stage by means of a Pelvic Binder. In the clinic, this can be carried out by means of fixateur externe. Pelvic clamps tend to be dispensed with due to the high rate of complications associated with them. In the event of extensive haemorrhaging, the lesser pelvis can be treated by means of packing. Arterial haemorrhages can be coiled by radiological intervention. Here in the upper image, you can see that a Pelvic Binder has been fitted to stabilise the pelvis. Underneath, a pelvic clamp can be seen which has been fitted. These clinical images show a fixateur externe which has been fitted in order to stabilise the pelvis. Open reduction by means of plate or screw osteosynthesis is available in terms of definitive surgical treatment. Sacroiliac joint injuries can also be stabilised by means of percutaneous screw fixation. Follow-up treatment for pelvic ring injuries provides for partial weight-bearing of the limb affected for 6-8 weeks with 10-20 kg. This list shows the frequency of concomitant injuries with pelvic ring injuries. What can be clearly seen is that these injuries are frequently linked to other injuries. Allow me to summarise: Pelvic injuries are incurred either following high speed trauma in combination with other forms in polytraumatised patients or as an insufficiency fracture of osteoporotic bones. Assessment of the degree of stability is important for ensuring the optimum form of treatment is administered. 90% of such injuries are not complicated. 10%, on the other hand, require the highest level of surgical knowledge. Many thanks for having listened so attentively. [MUSIC]