Open book pelvic fracture

Background

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.

• Results from an anteroposterior compression injury to the pelvis
• Often seen in elderly falls vs MVA or other high speed trauma
• Causes disruption of pubic symphysis and the pelvis opens like a book
• Results in tears of the strong pelvic ligaments that hold the pelvis bones together
• Large arteries pass near these ligaments and can get torn resulting in massive blood loss

Clinical Features

• pelvic/Hip pain
• Unstable pelvis
• hypotension if large amounts of bleed
• Consider concomitant GU injury

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

Evaluation

• Unstable pelvis on exam
• Xr pelvis in acute trauma setting
• CT Pelvis

Management

• Stabilize fracture with pelvic binder or bed sheet wrapped around greater trochanter (physician's often make mistake of wrapping around the iliac crest)
• If suspect pelvic injury and patient is unstable, place pelvic binder/sheet immediately then obtain X-ray when patient is stable
  • If patient persistently hypotensive even after binder and suspect pelvic artery bleed consider IR for embolization
• Long term management requires orthopedic consultation

Complications

• Hypotension from exsanguination
• infection
• Loss of function
• Genitourinary injury

Disposition

Admission

See Also

• Pelvic fractures