Pelvic fractures

Pearls

Pelvic fractures are associated with:
Hemorrhage requiring transfusion - 35%
Especially with sacroiliac joint disruption
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 to this is in the elderly (isolated pubic ramus) and athletes (isolated avulsion)
Extension of fracture into the rectum or vagina = open fx

Lateral Compression
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
Malgaigne Fracture
Ipsilateral anterior and posterior ring fractures
High rate of neurovascular injury

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
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

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 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)

Anticipate hypotension
Rapidly detect hemoperitoneum
Classify fx pattern as "stable" or "unstable"
If unstable wrap with sheet or pelvic binder
Be careful not to over-reduce a lateral compression fx (places increased strain on the post. pelvis)
Pt's legs, greater trochanters, and patellae should always lie in an anatomical position
In lateral compression injury the goal is stabilization, not compression
Assess for associated injuries
Neurological
Distal motor weakness (impaired dorsi/plantar flexion of great toe)
Distal numbness (dorsal and lateral aspects of foot)
Cauda equina syndrome (perianal anesthesia, loss of sphincter tone)
Open Fx
Vaginal bleeding
Rectal bleeding

UpToDate, Harwood-Nuss

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