Pelvic fractures

Pearls

• Pelvic fractures are associated with:
  • Hemorrhage requiring transfusion - 35%
    • Especially with sacroiliac joint disruption
  • Intraabdominal injury - 16%
  • Bladder/urethra injury - 6%
  • Nerve deficits - 15%
    • Especially with post. ring fx, upper sacral fracture
  • Thoracic aorta rupture - 1.5%
• If pelvic ring is disrupted there are usually two fractures
  • Exception to this is in the elderly (isolated pubic ramus) and athletes (isolated avulsion)
• Extension of fracture into the rectum or vagina = open fx

Fracture Types

Pelvic Ring Disruptions

• Lateral Compression
  • Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
• Anteroposterior Compression
  • Usually unstable as the iliac wings are forced outward, increasing pelvic volume
  • Often assocciated with pelvic and retroperitoneal hemorrhage
  • Coincident injuries of the thorax and the abdomen are the rule
• Vertical Shear
  • Result from vertically oriented force delivered to the pelvis via the extended femurs
  • Unstable; pelvic volume is increased
• Malgaigne Fracture
  • Ipsilateral anterior and posterior ring fractures
  • High rate of neurovascular injury

Other Pelvic Fractures

• Straddle Injury
  • Unstable
  • Both rami fractured on both sides or both rami on one side and pubic symphysis diastasis
  • High rate of urinary tract and bowel injury
• Pelvic Avulsion Fracture
  • Stable; occur usually in skeletally immature athletes aged 14-17 yrs
  • Can rarely occur in association with trauma in adults; if lack of trauma pathological until proven otherwise

Imaging

1. Plain films
   1. AP - Obtain in all unconscious blunt trauma patients
   2. Inlet - Better defines the pelvic brim
   3. Outlet - Better defines the sacrum and SI joints
   4. Judet - Better defines the acetabulum
2. CT
   1. Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on xray
   2. Exceptions include isolated pubic rami fx, avulsion fx
3. Retrograde cystourethrogram
   1. Obtain (before foley!) if blood at the meatus, high riding prostate, or gross hematuria
4. US
   1. May confuse hemoperitoneum for uroperitoneum
   2. If FAST negative but pt is persistently hypotensive consider DPA (aspirate)

Management

1. Anticipate hypotension
2. Rapidly detect hemoperitoneum
3. Classify fx pattern as "stable" or "unstable"
   1. If unstable wrap with sheet or pelvic binder
   2. Be careful not to over-reduce a lateral compression fx (places increased strain on the post. pelvis)
   3. Pt's legs, greater trochanters, and patellae should always lie in an anatomical position
4. In lateral compression injury the goal is stabilization, not compression
5. Assess for associated injuries
6. Neurological
   1. Distal motor weakness (impaired dorsi/plantar flexion of great toe)
   2. Distal numbness (dorsal and lateral aspects of foot)
   3. Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)
7. Open Fx
8. Vaginal bleeding
9. Rectal bleeding

Reference

UpToDate, Harwood-Nuss