Pelvic fractures

Background

• 3-Month mortality is three times higher in trauma patients with pelvic fractures
• 2 fractures will cause disruption of the pelvic ring
  • Exception is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
• Extension of fracture into the rectum or vagina = open fracture

Associated Injuries

• Hemorrhage requiring transfusion (esp with SI joint disruption) (35%)
• Intraabdominal injury (16%)
• Bladder/urethra injury (6%)
• Liver injury (6%)
• Nerve deficits (15%)
  • Especially with post ring fracture, upper sacral fracture
• Thoracic aorta rupture (1.5%)

Clinical Features

Lateral Compression

• Most common
• Often T-bone MVC/pedestrian hit from side
• Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
• Associated with the unstable wind-swept pelvis fracture
• Severe cases usually associated with bladder rupture; consider CT or retrograde cystography

Anteroposterior Compression

• Usually unstable as the iliac wings are forced outward, increasing pelvic volume
• Often head on MVC
• Often assocciated with pelvic and retroperitoneal hemorrhage
• Coincident injuries of the thorax and the abdomen are the rule
• Associated with the unstable open book fracture
• Urethral disruption should also be considered

Vertical Shear

• Result from vertically oriented force (fall) delivered to the pelvis via the extended femurs
• Unstable; pelvic volume is increased
• Associated with the unstable Malgaigne fracture or bucket handle fracture

Differential Diagnosis

Abdominal Trauma

• Liver trauma
• Splenic trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Genitourinary trauma
• Retroperitoneal hemorrhage
• Renal trauma
• Ureter trauma
• Abdominal compartment syndrome
• Trauma in pregnancy

Hip pain

• Femur fracture
• Hip dislocation
• Hip bursitis
• Psoas abscess
• Piriformis syndrome
• Meralgia paresthetica
• Septic Arthritis (Hip)
• Obturator nerve entrapment
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Avascular necrosis of hip

Evaluation

• Pelvic X-ray (plain films)
  • AP - Obtain in all unconscious blunt trauma patients
  • Inlet - Better defines the pelvic brim
  • Outlet - Better defines the sacrum and SI joints
  • Judet - Better defines the acetabulum
  • Sensitivity 78% when compared to CT as gold standard
• CT
  • Obtain in all hemodynamically stable blunt trauma patients with pelvic fracture on x-ray
    • Exceptions include isolated pubic rami fracture, avulsion fracture
  • MRI and CT are comparable in SN and SP
• Retrograde cystourethrogram
  • Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
• US
  • May confuse hemoperitoneum for uroperitoneum

Management

• Classify fracture pattern as "stable" or "unstable"
  • If unstable pelvis:
    • Wrap with sheet or pelvic binder: Place pelvic binder over greater trochanters
    • Do not over-reduce a lateral compression fracture (places increased strain on post pelvis)
    • Placing pelvic binder in vertical shear injury may worsen fracture
• Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding
• FAST exam to rapidly detect hemoperitoneum
  • If hemoperitoneum is present→ OR
  • If vital signs are unstable→ OR for damage control laparotomy, not CT
  • If vital signs are stable and no hemoperitoneum→ CTAP with IV contrast
    • Contact IR for possible pelvic angiographic embolization
• Pre-peritoneal packing can rescue failed angiography (usually in venous bleeding)
  • Also an option for primary hemorrhage control
• Look for vaginal or rectal bleeding, suggests open fracture (uncommon)

Specific Pelvic Fractures

• Open book pelvic fracture
  • Disruption of pubic symphysis >2.5cm and the pelvis opens like a book and may be accompanied by sacroilial joint disruption
  • External rotation of the hemipelvis requires binding and likely surgical fixation
• Straddle pelvic fracture
  • Unstable
  • Both rami fractured on both sides or both rami on one side with pubic symphysis diastasis
  • High rate of urinary tract and bowel injury
• Acetabular pelvic fractures
• Pelvic avulsion fracture
  • Anterior superior iliac spine
    • Occurs from forceful sartorius muscle contraction (adolescent sprinters)
    • Bed rest for 3-4 wk with hip flexed and abducted, crutches, ortho follow up in 1-2wk
  • Anterior inferior iliac spine
    • Occurs from forceful rectus femoris muscle contraction (adolescent soccer players)
    • Bed rest for 3-4 wk with hip flexed, crutches, ortho follow up in 1-2wk

Pain control

• Pain control in ED with femoral nerve blocks.
  • Nerve Block: Fascia Iliaca Compartment
  • 3 in 1 block (femoral, obturator, lateral cutaneous nerve of thigh)
  • No difference in 2 blocks listed above

Disposition

• ICU/Intermediate Care if hemodynamically unstable
• Floor for stable fractures requiring services
• Discharge non-op stable fractures with follow up (ex isolated pubic rami fracture)

See Also

• Fractures (Main)
• Pelvic X-ray

References

Authors

Neil Young, Kian Preston-Suni, Jordan Swartz, Ross Donaldson, Kurt Hansen, Kevin Lu, Aaron Snyder, James Cunningham, Ben Isakson, Marissa Camilon, Daniel Ostermayer, Michael Holtz