Pelvic fractures: Difference between revisions
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==Background== | ==Background== | ||
*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 | *Extension of fracture into the rectum or vagina = open fracture | ||
=== | ===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>=== | ||
* | *Hemorrhage requiring transfusion (esp with SI joint disruption) (35%) | ||
* | *Intraabdominal injury (16%) | ||
* | *[[Genitourinary trauma|Bladder/urethra injury]] (6%) | ||
** | *[[Liver injury]] (6%) | ||
** | *Nerve deficits (15%) | ||
**Especially with post ring fracture, upper sacral fracture | |||
*[[Thoracic aorta rupture]] (1.5%) | |||
* | |||
== | {{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 | **Obtain in all hemodynamically stable blunt trauma patients with pelvic fracture on x-ray | ||
***Exceptions include isolated pubic rami | ***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 | ***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 | *[[FAST exam]] to rapidly detect hemoperitoneum | ||
**If hemoperitoneum is | **If hemoperitoneum is present→ OR | ||
**If vital signs are | **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 | **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 | *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) | |||
= | ===Specific Pelvic Fractures=== | ||
==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 | **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]] | ||
*[[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 | ***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 | ***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: | [[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]
- 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%)
Pelvic fracture types
- Acetabular pelvic fractures
- Open book pelvic fracture
- Straddle pelvic fracture
- Pelvic avulsion fracture
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
- Abdominal compartment syndrome
- Diaphragmatic trauma
- Duodenal hematoma
- Genitourinary trauma
- Liver trauma
- Pelvic fractures
- Retroperitoneal hemorrhage
- Renal trauma
- Splenic trauma
- Trauma in pregnancy
- Ureter trauma
Hip pain
Acute Trauma
- Femur fracture
- Proximal
- Intracapsular
- Extracapsular
- Shaft
- Mid-shaft femur fracture (all subtrochanteric)
- Proximal
- Hip dislocation
- Pelvic fractures
Chronic/Atraumatic
- Hip bursitis
- Psoas abscess
- Piriformis syndrome
- Meralgia paresthetica
- Septic arthritis
- Obturator nerve entrapment
- 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[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]
- Obtain in all hemodynamically stable blunt trauma patients with pelvic fracture on x-ray
- 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 (fall from height) may worsen fracture
- If unstable pelvis:
- 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
- Anterior superior iliac spine
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 [7]
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
- ↑ 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
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.