Diferencia entre revisiones de «Pelvic fractures»

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Normal anatomy: pelvis and proximal sacrum are angled posteriorly
==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>
*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


pubic symphysis: up to 5mm in width, up to 2mm offset, no overlap
===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%)


SI joints: 2-4 mm in width
{{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


checklist-
===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


1)obturator foramina for symmetry-clue for rotation of film
===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


2)diastasis of pubic symphysis and both SI joints
==Differential Diagnosis==
{{Abdominal trauma DDX}}
{{Lower GU trauma DDX}}
{{Hip pain DDX}}


3)assymetry of illiac wings (rotation or deformity)
==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


4)sacral foramina-especially the superior cortical margins
==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)


5)transverse processes of L5
===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>


6)integrity of all cortical lines, especially around acetabulum.
==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==
*[[Fractures (Main)]]
*[[Pelvic X-ray]]


Outlet views-sacral fxs, SI joint abnormalities
==References==
<references/>


Inlet view-displacement of ant. Fragments into pelvis..
[[Category:Trauma]]
 
[[Category:Orthopedics]]
(posterior abnormalities usually need CT )
 
 
Kane classification system:
 
type I-(stable) fracture of individual bones without a break in continuity of pelvic ring.
 
 
lower urinary tract injury;
 
pathway:
 
males-retrograde urethrogram, foley, retrograde cystogram, IVP
 
females-careful foley, retrograde cystogram, IVP.
 
 
Neurologic injuries
 
posterior ring or sacral fractures
 
1/3 of sacral fractures have neurologic involvement.
 
check bowel/bladder fxn , sensory levels...
 
sacral lesions can cause neurogenic bladder with overflow incontinence, sphincter dysfunction, or sexual dysfunction (eek)...
 
typeII-(stable) single breaks in the pelvic ring, non displaced, must look very hard for displacement.If anterior still a high rate of urinary tract infection.
 
type III- (unstable) double breaks or more in the ring:IIIA-Straddle fracture,IIIB Malgaigne fracture, IIIC severe multiple fractures
 
type IV- Acetabular fractures
 
 
Straddle Fracture:
 
Both rami fractured on both sides, or both rami on one side and diastasis of pubic symphysis.
 
caused by straddle injury or lateral compression., high rates of urinary tract injury and abdominal visceral injuries. Leg lengths are normal.
 
 
Malgaigne Fracture:
 
Anterior and posterior ring fractures on same side .
 
high rates of urinary and vascular injuries.
 
leg lngths areunequal, anterr illiac crest is displaced and or mobie
 
 
Bucket handle fracture
 
Anterr and poterior ring fractures on opposite sides. Anterior fracture is usually both pubic rami.
 
high rates ofurinary and vascular injuries
 
 
III-C Open book or sprung pelvis fracture
 
bilateral posterior ring fractures.
 
 
 
 
[[Category:Ortho]]

Revisión actual - 19:43 3 ago 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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