Academe Learn
CBME Curriculum Preview

Page 13 of 13

OR2.7-8 | Axial Skeleton Injuries — PBL Case

CLINICAL SETTING

Ravi, a 26-year-old construction supervisor, is brought to the emergency department of a district hospital by ambulance after a scaffolding collapse. A steel beam fell across his lower abdomen and pelvis while he was 3 metres above the ground. The ambulance crew report he was found conscious at the scene, lying on his back, unable to move his legs. They applied a cervical collar as a precaution and placed him on a long spinal board. On arrival in the resuscitation bay: BP 85/55 mmHg, HR 138 bpm, respiratory rate 24/min, SpO2 97% on 15 L O2 via non-rebreather mask, temperature 36.8°C, GCS 14 (E4 V4 M6). He is anxious and crying out in pain. He tells you he cannot feel or move his legs. A primary survey reveals patent airway, equal air entry bilaterally with no obvious pneumothorax, and a distended, bruised lower abdomen. There is obvious asymmetry of the pelvis with the left hemipelvis appearing elevated. The perineum shows bruising and there is blood at the urethral meatus. A single gentle manual spring test of the iliac wings confirms gross pelvic instability. No IV access is yet established.

Trigger 1: Initial Assessment and Life-Threatening Haemorrhage

Two large-bore IV cannulae are inserted. Point-of-care haemoglobin is 7.8 g/dL. FAST examination reveals no free intraperitoneal fluid. A Pelvi-binder (commercial pelvic binder) is applied. A plain AP pelvic radiograph shows a Tile C (vertical shear) fracture with the left hemipelvis displaced 4 cm superiorly. The emergency physician calls for 4 units of packed red cells and 4 units of FFP. Despite this, after 15 minutes his BP is 82/48 mmHg and HR 142 bpm. The nearest CT scanner is in the same building.

DISCUSSION POINTS

  • What is the pathophysiology of haemorrhage in a Tile C vertical shear pelvic fracture, and why was FAST negative?
  • Where exactly should the pelvic binder be placed and why? What is it achieving physiologically?
  • The patient remains haemodynamically unstable despite binder application and blood product resuscitation. What is the next most important intervention and why? Is this a 'scoop and run' or 'stay and play' situation?
  • What is permissive hypotension and when is it applied in pelvic trauma?
Click to reveal Trigger 2: CT Results, Urological Injury, and Neurological Clarification (discuss previous trigger first!)

Trigger 2: CT Results, Urological Injury, and Neurological Clarification

Ravi is stabilised enough for a trauma CT (pan-scan). CT pelvis confirms: Tile C left vertical shear fracture, left sacroiliac joint disruption, left superior and inferior pubic rami fractures. CT angiography identifies active extravasation from a left internal iliac artery branch. MRI spine (obtained as part of the trauma protocol) shows a burst fracture at L2 with 40% canal compromise and posterior ligamentous complex disruption. There is cord signal change at the conus. Urology is called regarding blood at the urethral meatus. A retrograde urethrogram confirms a partial posterior urethral tear. Neurological examination shows Grade 1 power in right hip flexors, Grade 0 left lower limb, saddle anaesthesia, and urinary retention.

DISCUSSION POINTS

  • CT angiography shows active arterial extravasation from a branch of the left internal iliac artery. What is the next definitive haemostatic intervention? How does it work?
  • What is the correct management sequence for the urological injury? Why is urethral catheterisation absolutely contraindicated here?
  • Using the ASIA Impairment Scale, classify Ravi's spinal cord injury. What is the expected anatomical level and what functional implications does this have?
  • What is posterior ligamentous complex disruption and why does it change the surgical decision for this spinal fracture?
Click to reveal Trigger 3: Post-operative Rehabilitation and Complications (discuss previous trigger first!)

Trigger 3: Post-operative Rehabilitation and Complications

Day 2 post-injury: Ravi has undergone emergency angioembolisation of the internal iliac branch, definitive ORIF of the pelvic fracture, and posterior decompression with instrumented fusion at L1–L3. A suprapubic catheter is in place. He is transferred to the spinal rehabilitation unit. On day 5, during his first tilt-table session, his BP drops from 118/76 to 72/45 mmHg and he feels faint. On day 9, he develops a sudden severe headache, profuse sweating, blotchy red skin above the nipple line, and his BP is 210/120 mmHg. The nursing staff find his suprapubic catheter tubing kinked.

DISCUSSION POINTS

  • What is the cause of the BP drop during the tilt-table session? What is the mechanism? How should the physiotherapy team manage this to allow progressive mobilisation?
  • Describe autonomic dysreflexia: mechanism, trigger in this case, and the immediate step-by-step management. What would happen if this is not treated promptly?
  • What other rehabilitation complications is Ravi at risk for given his injury level and pelvic fracture? How are each prevented?
  • What are the realistic short-term (6 weeks) and long-term (1 year) rehabilitation goals for Ravi, and who comprises his multidisciplinary team?

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OR2.7] What are the biomechanical classifications of pelvic ring fractures (Tile and Young-Burgess systems)? For each type, what is the expected haemorrhage source (venous plexus vs arterial), the recommended initial stabilisation method, and the indications for angioembolisation vs pelvic packing?
  2. [OR2.7] What are the urological injuries associated with pelvic fractures? Describe the investigation protocol for blood at the urethral meatus and the definitive management options for partial vs complete urethral injury.
  3. [OR2.8] Describe the ASIA Impairment Scale in full. For a patient with an L1–L2 burst fracture, what are the indications for surgical decompression and stabilisation versus conservative management? What imaging findings confirm posterior ligamentous complex disruption?
  4. [OR2.8] What is autonomic dysreflexia? At what cord level does it occur, what are the common triggers, and what is the step-by-step emergency management protocol? How does neurogenic shock differ from autonomic dysreflexia?