Pelvic fractures: Difference between revisions
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*Hemorrhage requiring transfusion (esp with SI joint disruption) (35%) | *Hemorrhage requiring transfusion (esp with SI joint disruption) (35%) | ||
*Intraabdominal injury (16%) | *Intraabdominal injury (16%) | ||
*[[ | *[[Genitourinary trauma|Bladder/urethra injury]] (6%) | ||
*[[Liver injury]] (6%) | *[[Liver injury]] (6%) | ||
*Nerve deficits (15%) | *Nerve deficits (15%) | ||
Revision as of 02:40, 3 September 2015
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 fx
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%)
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
Diagnosis
- 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 ~65%
- CT
- Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on x-ray
- Exceptions include isolated pubic rami fx, avulsion fx
- Obtain in all hemodynamically stable blunt trauma pts with pelvic fx 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 fx (places increased strain on post pelvis)
- Placing pelvic binder in vertical shear injury 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
- If vital signs are stable and no hemoperitoneum--> CTAP w/IV contrast
- Contact IR for possible pelvic angiographic embolization
- Pre-peritoneal packing can rescue failed angiography (usually in venous bleeding)
- Look for vaginal or rectal bleeding, suggests open fx (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 w/ 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 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
- 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 [3]
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
- ↑ 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.