Pelvic fractures

From WikEM
Jump to: navigation, search

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]

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

Hip pain

Evaluation

  • 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

Error creating thumbnail: File missing
  • 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 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.