Pelvic fractures

Background

• Associated with:
  • 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
• 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

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
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Diagnosis

Imaging

• 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
• CT
  • Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on x-ray
    • Exceptions include isolated pubic rami fx, avulsion fx
• 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)
• 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
• 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
  • Early ortho consultation and hospital admission is indicated for all
• 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

See Also

• Fractures (Main)
• Pelvic X-ray