Pelvic fractures: Difference between revisions

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==Background==
==Background==
*Associated with:<ref>Demetriades D, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002 Jul;195(1):1-10. http://www.ncbi.nlm.nih.gov/pubmed/12113532</ref>
**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<ref>Giannoudis PV, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma. 2007 Oct;63(4):875-83. http://www.ncbi.nlm.nih.gov/pubmed/18090020</ref>
*3-Month mortality is three times higher in trauma patients with pelvic fractures<ref>Giannoudis PV, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma. 2007 Oct;63(4):875-83. http://www.ncbi.nlm.nih.gov/pubmed/18090020</ref>
*2 fractures will cause disruption of the pelvic ring
*2 fractures will cause disruption of the pelvic ring
**Exception is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
**Exception is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
*Extension of fracture into the rectum or vagina = open fx
*Extension of fracture into the rectum or vagina = open fracture


===Types of Pelvic Ring Disruptions===
===Associated Injuries<ref>Demetriades D, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002 Jul;195(1):1-10. http://www.ncbi.nlm.nih.gov/pubmed/12113532</ref>===
*Lateral Compression
*Hemorrhage requiring transfusion (esp with SI joint disruption) (35%)
**Most common
*Intraabdominal injury (16%)
**Often T-bone MVC/pedestrian hit from side
*[[Genitourinary trauma|Bladder/urethra injury]] (6%)
**Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
*[[Liver injury]] (6%)
**Associated with the unstable wind-swept pelvis fracture
*Nerve deficits (15%)
**Severe cases usually associated with bladder rupture; consider CT or retrograde cystography
**Especially with post ring fracture, upper sacral fracture
*Anteroposterior Compression
*[[Thoracic aorta rupture]] (1.5%)
**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==
{{Pelvic fracture types}}
 
==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 DDX}}
{{Hip pain DDX}}
 
==Evaluation==
[[File:Acetabularfx.png|thumb|alt=Acetabular fracture (red arrow)|Right [[acetabular fracture]] (arrow)]]
*[[Pelvic X-ray]] (plain films)
*[[Pelvic X-ray]] (plain films)
**AP - Obtain in all unconscious blunt trauma patients
**AP - Obtain in all unconscious blunt trauma patients
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**Outlet - Better defines the sacrum and SI joints
**Outlet - Better defines the sacrum and SI joints
**Judet - Better defines the acetabulum  
**Judet - Better defines the acetabulum  
**Sensitivity 78% when compared to CT as gold standard<ref>Obaid, AK, Barleben A, Porral D, et al. Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department. Am Surg. 2006; 72(10):951-954.</ref>
*CT
*CT
**Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on x-ray
**Obtain in all hemodynamically stable blunt trauma patients with pelvic fracture on x-ray
***Exceptions include isolated pubic rami fx, avulsion fx
***Exceptions include isolated pubic rami fracture, avulsion fracture
**MRI and CT are comparable in SN and SP<ref>Gill SK, Smith J, Fox R, et al. Investigation of occult hip fractures: the use of CT and MRI. The Scientific World Journal. 2013; 2013:1-4.</ref>
*Retrograde cystourethrogram
*Retrograde cystourethrogram
**Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
**Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
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==Management==
==Management==
[[File:pelvic fracture.JPG|thumbnail]]
*Classify fracture pattern as "stable" or "unstable"
*Classify fracture pattern as "stable" or "unstable"
**If unstable pelvis:
**If unstable pelvis:
***Wrap with sheet or pelvic binder: Place pelvic binder over greater trochanters
***Wrap with sheet or pelvic binder: Place pelvic binder over greater trochanters
***Do not over-reduce a lateral compression fx (places increased strain on post pelvis)
***Do not over-reduce a lateral compression fracture (places increased strain on post pelvis)
***Placing pelvic binder in vertical shear injury (fall from height) may worsen fracture
*Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding
*Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding
*FAST Exam to rapidly detect hemoperitoneum
*[[FAST exam]] to rapidly detect hemoperitoneum
**If hemoperitoneum is present--> OR
**If hemoperitoneum is present→ OR
**If vital signs are unstable--> OR for damage control laparotomy, not CT
**If vital signs are unstable→ OR for damage control laparotomy, not CT<ref>Davis, J. W., Moore, F. A., McIntyre, R. C., Cocanour, C. S., Moore, E. E. and West, M. A. (2008) ‘Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture With Hemodynamic Instability’, The Journal of Trauma: Injury, Infection, and Critical Care, 65(5), pp. 1012–1015.</ref>
**If vital signs are stable and no hemoperitoneum--> CTAP w/IV contrast
**If vital signs are stable and no hemoperitoneum→ CTAP with IV contrast
***Contact IR for possible pelvic angiographic embolization
***Contact IR for possible pelvic angiographic embolization
*Look for vaginal or rectal bleeding, suggests open fx (uncommon)
*Pre-peritoneal packing can rescue failed angiography (usually in venous bleeding)
**Also an option for primary hemorrhage control<ref>Burlew, Cothren, C., Moore, E. E., Smith, W. R., Johnson, J. L., Biffl, W. L., Barnett, C. C., Stahel, P. F. and Burlew, C. C. (2011) ‘Preperitoneal Pelvic Packing/External Fixation with Secondary Angioembolization: Optimal Care for Life-Threatening Hemorrhage from Unstable Pelvic Fractures’, Journal of the American College of Surgeons, 212(4), p. 628.</ref>
*Look for vaginal or rectal bleeding, suggests open fracture (uncommon)


==Differential Diagnosis==
===Specific Pelvic Fractures===
{{Abdominal trauma DDX}}
 
==Specific Pelvic Fractures==
*[[Open book pelvic fracture]]
*[[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
**Disruption of pubic symphysis >2.5cm and the pelvis opens like a book and may be accompanied by sacroilial joint disruption
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*[[Straddle pelvic fracture]]
*[[Straddle pelvic fracture]]
**Unstable
**Unstable
**Both rami fractured on both sides or both rami on one side w/ pubic symphysis diastasis
**Both rami fractured on both sides or both rami on one side with pubic symphysis diastasis
**High rate of urinary tract and bowel injury
**High rate of urinary tract and bowel injury
*[[Acetabular pelvic fractures]]
*[[Acetabular pelvic fractures]]
**Early ortho consultation and hospital admission is indicated for all
*[[Pelvic avulsion fracture]]
*[[Pelvic avulsion fracture]]
**Anterior superior iliac spine
**Anterior superior iliac spine
***Occurs from forceful sartorius muscle contraction (adolescent sprinters)
***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
***Bed rest for 3-4 wk with hip flexed and abducted, crutches, ortho follow up in 1-2wk
**Anterior inferior iliac spine
**Anterior inferior iliac spine
***Occurs from forceful rectus femoris muscle contraction (adolescent soccer players)
***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
***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 <ref>Reavley P, et al. Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department. Emerg Med J. 2014 Nov 27.</ref>
 
==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==
==See Also==
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[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Revision as of 22:33, 17 March 2021

Background

  • 3-Month mortality is three times higher in trauma patients with pelvic fractures[1]
  • 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[2]

Pelvic fracture types

The skeleton of the human pelvis: 1. Sacrum; 2. Ilium; 3. Ischium; 4. Pubic bone (4a. corpus, 4b. ramus superior, 4c. ramus inferior, 4d. tuberculum pubicum); 5. Pubic symphysis, 6. Acetabulum (of the hip joint), 7. Foramen obturatum, 8. Coccyx/tailbone; Dotted. Linea terminalis of the pelvic brim.
Pelvis anatomy, medial view.
Pelvis anatomy, lateral view.

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

Hip pain

Acute Trauma

Chronic/Atraumatic

Evaluation

Acetabular fracture (red arrow)
Right acetabular fracture (arrow)
  • 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[3]
  • 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[4]
  • Retrograde cystourethrogram
    • Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
  • US
    • May confuse hemoperitoneum for uroperitoneum

Management

Pelvic fracture.JPG
  • 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 (fall from height) 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[5]
    • 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[6]
  • 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

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

References

  1. Giannoudis PV, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma. 2007 Oct;63(4):875-83. http://www.ncbi.nlm.nih.gov/pubmed/18090020
  2. Demetriades D, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002 Jul;195(1):1-10. http://www.ncbi.nlm.nih.gov/pubmed/12113532
  3. Obaid, AK, Barleben A, Porral D, et al. Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department. Am Surg. 2006; 72(10):951-954.
  4. Gill SK, Smith J, Fox R, et al. Investigation of occult hip fractures: the use of CT and MRI. The Scientific World Journal. 2013; 2013:1-4.
  5. Davis, J. W., Moore, F. A., McIntyre, R. C., Cocanour, C. S., Moore, E. E. and West, M. A. (2008) ‘Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture With Hemodynamic Instability’, The Journal of Trauma: Injury, Infection, and Critical Care, 65(5), pp. 1012–1015.
  6. Burlew, Cothren, C., Moore, E. E., Smith, W. R., Johnson, J. L., Biffl, W. L., Barnett, C. C., Stahel, P. F. and Burlew, C. C. (2011) ‘Preperitoneal Pelvic Packing/External Fixation with Secondary Angioembolization: Optimal Care for Life-Threatening Hemorrhage from Unstable Pelvic Fractures’, Journal of the American College of Surgeons, 212(4), p. 628.
  7. Reavley P, et al. Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department. Emerg Med J. 2014 Nov 27.