Pelvic fractures: Difference between revisions

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==Pearls==
==Background==
* Pelvic fractures are associated with:
*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>
** Hemorrhage requiring transfusion - 35%
*2 fractures will cause disruption of the pelvic ring
*** Especially with sacroiliac joint disruption
**Exception is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
** Intraabdominal injury - 16%
*Extension of fracture into the rectum or vagina = open fracture
** 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==
===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>===
===Pelvic Ring Disruptions===
*Hemorrhage requiring transfusion (esp with SI joint disruption) (35%)
* Lateral Compression
*Intraabdominal injury (16%)
** Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
*[[Genitourinary trauma|Bladder/urethra injury]] (6%)
* Anteroposterior Compression
*[[Liver injury]] (6%)
** Usually unstable as the iliac wings are forced outward, increasing pelvic volume
*Nerve deficits (15%)
** Often assocciated with pelvic and retroperitoneal hemorrhage
**Especially with post ring fracture, upper sacral fracture
** Coincident injuries of the thorax and the abdomen are the rule
*[[Thoracic aorta rupture]] (1.5%)
* 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===
{{Pelvic fracture types}}
* 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===
==Clinical Features==
# Plain films
===Lateral Compression===
## AP - Obtain in all unconscious blunt trauma patients
*Most common
## Inlet - Better defines the pelvic brim
*Often T-bone MVC/pedestrian hit from side
## Outlet - Better defines the sacrum and SI joints
*Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
## Judet - Better defines the acetabulum
*Associated with the unstable wind-swept pelvis fracture
# CT
*Severe cases usually associated with bladder rupture; consider CT or retrograde cystography
## Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on xray
## Exceptions include isolated pubic rami fx, avulsion fx
# Retrograde cystourethrogram
## Obtain (before foley!) if blood at the meatus, high riding prostate, or gross hematuria
# US
## May confuse hemoperitoneum for uroperitoneum
## If FAST negative but pt is persistently hypotensive consider DPA (aspirate)


===Management===
===Anteroposterior Compression===
# Anticipate hypotension
*Usually unstable as the iliac wings are forced outward, increasing pelvic volume
# Rapidly detect hemoperitoneum
*Often head on MVC
# Classify fx pattern as "stable" or "unstable"
*Often assocciated with pelvic and retroperitoneal hemorrhage
## If unstable wrap with sheet or pelvic binder
*Coincident injuries of the thorax and the abdomen are the rule
## Be careful not to over-reduce a lateral compression fx (places increased strain on the post. pelvis)
*Associated with the unstable open book fracture
## Pt's legs, greater trochanters, and patellae should always lie in an anatomical position
*Urethral disruption should also be considered
# In lateral compression injury the goal is stabilization, not compression
 
# Assess for associated injuries
===Vertical Shear===
# Neurological
*Result from vertically oriented force (fall) delivered to the pelvis via the extended femurs
## Distal motor weakness (impaired dorsi/plantar flexion of great toe)
*Unstable; pelvic volume is increased
## Distal numbness (dorsal and lateral aspects of foot)
*Associated with the unstable Malgaigne fracture or bucket handle fracture
## Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)
 
# Open Fx
==Differential Diagnosis==
# Vaginal bleeding
{{Abdominal trauma DDX}}
# Rectal bleeding
{{Lower GU trauma DDX}}
{{Hip pain DDX}}
 
==Evaluation==
[[File:Acetabularfx.png|thumb|alt=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<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
**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<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
**Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
*US
**May confuse hemoperitoneum for uroperitoneum
 
==Management==
[[File:pelvic fracture.JPG|thumbnail]]
*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<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 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<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===
*[[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===
*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==
[[Pelvic X-ray]]
*[[Fractures (Main)]]
*[[Pelvic X-ray]]


===Reference===
==References==
UpToDate, Harwood-Nuss
<references/>


[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Latest revision as of 19:43, 3 August 2022

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

Genitourinary 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.
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