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==Pearls==
==Background==
* Pelvic fractures are associated with:
*Associated with:
** Hemorrhage requiring transfusion - 35%
**Hemorrhage requiring transfusion (esp w/ SI joint disruption) - 35%
*** Especially with sacroiliac joint disruption
**Intraabdominal injury - 16%
** Intraabdominal injury - 16%
**Bladder/urethra injury - 6%
** Bladder/urethra injury - 6%
**Nerve deficits - 15%
** Nerve deficits - 15%
***Especially with post ring fx, upper sacral fracture
*** Especially with post. ring fx, upper sacral fracture
**Thoracic aorta rupture - 1.5%
** Thoracic aorta rupture - 1.5%
*If pelvic ring is disrupted there are usually two fractures
* If pelvic ring is disrupted there are usually two fractures
**Exception is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
** Exception to this is in the elderly (isolated pubic ramus) and athletes (isolated avulsion)
*Extension of fracture into the rectum or vagina = open fx  
* Extension of fracture into the rectum or vagina = open fx  


==Fracture Types==
==Fracture Types==
===Pelvic Ring Disruptions===
===Pelvic Ring Disruptions===
* Lateral Compression
*Lateral Compression
** Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
**Most common
* Anteroposterior Compression
**Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
** Usually unstable as the iliac wings are forced outward, increasing pelvic volume
*Anteroposterior Compression
** Often assocciated with pelvic and retroperitoneal hemorrhage  
**Usually unstable as the iliac wings are forced outward, increasing pelvic volume
** Coincident injuries of the thorax and the abdomen are the rule
**Often assocciated with pelvic and retroperitoneal hemorrhage  
* Vertical Shear
**Coincident injuries of the thorax and the abdomen are the rule
** Result from vertically oriented force delivered to the pelvis via the extended femurs
*Vertical Shear
** Unstable; pelvic volume is increased  
**Result from vertically oriented force delivered to the pelvis via the extended femurs
* Malgaigne Fracture
**Unstable; pelvic volume is increased  
** Ipsilateral anterior and posterior ring fractures
** High rate of neurovascular injury
 
===Other Pelvic Fractures===
* 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===
===Imaging===
# Plain films
#Plain films
## AP - Obtain in all unconscious blunt trauma patients
##AP - Obtain in all unconscious blunt trauma patients
## Inlet - Better defines the pelvic brim
##Inlet - Better defines the pelvic brim
## 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  
# CT
#CT
## Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on xray
##Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on x-ray
## Exceptions include isolated pubic rami fx, avulsion fx
###Exceptions include isolated pubic rami fx, avulsion fx
# Retrograde cystourethrogram
#Retrograde cystourethrogram
## Obtain (before foley!) if blood at the meatus, high riding prostate, or gross hematuria
##Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
# US
#US
## May confuse hemoperitoneum for uroperitoneum
##May confuse hemoperitoneum for uroperitoneum
## If FAST negative but pt is persistently hypotensive consider DPA (aspirate)


===Management===
===Management===
# Anticipate hypotension
#Anticipate hypotension
# Rapidly detect hemoperitoneum
#Rapidly detect hemoperitoneum
# Classify fx pattern as "stable" or "unstable"
#Classify fx pattern as "stable" or "unstable"
## If unstable wrap with sheet or pelvic binder
##If unstable:
## Be careful not to over-reduce a lateral compression fx (places increased strain on the post. pelvis)
###Wrap with sheet or pelvic binder
## Pt's legs, greater trochanters, and patellae should always lie in an anatomical position
####Do not over-reduce a lateral compression fx (places increased strain on post pelvis)
# In lateral compression injury the goal is stabilization, not compression
###Contact IR for possible pelvic angiography
# Assess for associated injuries
#Neurological
# Neurological
##Distal motor weakness (impaired dorsi/plantar flexion of great toe)
## Distal motor weakness (impaired dorsi/plantar flexion of great toe)
##Distal numbness (dorsal and lateral aspects of foot)
## Distal numbness (dorsal and lateral aspects of foot)
##Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)   
## Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)   
#Open Fx suggested by vaginal bleeding or rectal bleeding
# Open Fx
 
# Vaginal bleeding
===Other Pelvic Fractures===
# Rectal bleeding
*Straddle Injury
**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
*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==
==See Also==
[[Pelvic X-ray]]
*[[Pelvic X-ray]]


===Reference===
===Reference===
UpToDate, Harwood-Nuss
*UpToDate
*Harwood-Nuss
*Tintinalli


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

Revisión del 04:20 12 feb 2012

Background

  • Associated with:
    • Hemorrhage requiring transfusion (esp w/ SI joint disruption) - 35%
    • Intraabdominal injury - 16%
    • 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 is in elderly (isolated pubic ramus) and athletes (isolated avulsion)
  • Extension of fracture into the rectum or vagina = open fx

Fracture Types

Pelvic Ring Disruptions

  • Lateral Compression
    • Most common
    • Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
  • Anteroposterior Compression
    • Usually unstable as the iliac wings are forced outward, increasing pelvic volume
    • Often assocciated with pelvic and retroperitoneal hemorrhage
    • Coincident injuries of the thorax and the abdomen are the rule
  • Vertical Shear
    • Result from vertically oriented force delivered to the pelvis via the extended femurs
    • Unstable; pelvic volume is increased

Imaging

  1. Plain films
    1. AP - Obtain in all unconscious blunt trauma patients
    2. Inlet - Better defines the pelvic brim
    3. Outlet - Better defines the sacrum and SI joints
    4. Judet - Better defines the acetabulum
  2. CT
    1. Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on x-ray
      1. Exceptions include isolated pubic rami fx, avulsion fx
  3. Retrograde cystourethrogram
    1. Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
  4. US
    1. May confuse hemoperitoneum for uroperitoneum

Management

  1. Anticipate hypotension
  2. Rapidly detect hemoperitoneum
  3. Classify fx pattern as "stable" or "unstable"
    1. If unstable:
      1. Wrap with sheet or pelvic binder
        1. Do not over-reduce a lateral compression fx (places increased strain on post pelvis)
      2. Contact IR for possible pelvic angiography
  4. Neurological
    1. Distal motor weakness (impaired dorsi/plantar flexion of great toe)
    2. Distal numbness (dorsal and lateral aspects of foot)
    3. Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)
  5. Open Fx suggested by vaginal bleeding or rectal bleeding

Other Pelvic Fractures

  • Straddle Injury
    • 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
  • 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

Reference

  • UpToDate
  • Harwood-Nuss
  • Tintinalli
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