Pelvic fractures

Background

• Associated with:
  • Hemorrhage requiring transfusion (esp w/ SI joint disruption) - 35%
  • 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 is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
• Extension of fracture into the rectum or vagina = open fx

Pelvic Ring Disruptions

• Lateral Compression
  • Most common
  • 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

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 x-ray
      1. Exceptions include isolated pubic rami fx, avulsion fx
3. Retrograde cystourethrogram
   1. Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
4. US
   1. May confuse hemoperitoneum for uroperitoneum

Management

1. Anticipate hypotension
2. Rapidly detect hemoperitoneum
3. Classify fx pattern as "stable" or "unstable"
   1. If unstable:
      1. Wrap with sheet or pelvic binder
         1. Do not over-reduce a lateral compression fx (places increased strain on post pelvis)
      2. Contact IR for possible pelvic angiography
4. 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)
5. Open Fx suggested by vaginal bleeding or rectal bleeding

Other Pelvic Fractures

• Straddle Injury
  • Unstable
  • Both rami fractured on both sides or both rami on one side w/ pubic symphysis diastasis
  • High rate of urinary tract and bowel injury
• Pelvic Avulsion Fracture
  • Anterior superior iliac spine
    • Occurs from forceful sartorius muscle contraction (adolescent sprinters)
    • Bed rest for 3-4 wk w/ hip flexed and abducted, crutches, ortho f/u in 1-2wk
  • Anterior inferior iliac spine
    • Occurs from forceful rectus femoris muscle contraction (adolescent soccer players)
    • Bed rest for 3-4 wk w/ hip flexed, crutches, ortho f/u in 1-2wk

See Also

• Pelvic X-ray

Reference

• UpToDate
• Harwood-Nuss
• Tintinalli