Pelvic fractures

Background

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

Types of Pelvic Ring Disruptions

• 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

Imaging

1. Pelvic X-ray (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. Classify fx pattern as "stable" or "unstable"
   1. If unstable pelvis:
      1. Wrap with sheet or pelvic binder: Place pelvic binder over greater trochanters
      2. Do not over-reduce a lateral compression fx (places increased strain on post pelvis)
2. Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding
3. FAST Exam to rapidly detect hemoperitoneum
   1. If hemoperitoneum is present--> OR
   2. If vital signs are unstable--> OR for damage control laparotomy, not CT
   3. If vital signs are stable and no hemoperitoneum--> CTAP w/IV contrast
      1. Contact IR for possible pelvic angiographic embolization
4. Look for vaginal or rectal bleeding, suggests open fx (uncommon)

Specific Pelvic Fractures

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

See Also

• Fractures (Main)
• Pelvic X-ray