Pelvic fractures: Difference between revisions

No edit summary
Line 46: Line 46:
**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  
**Sensitivity ~65%
**Sensitivity 78% when compared to CT as gold standard<ref>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.</ref>
*CT
*CT
**Obtain in all hemodynamically stable blunt trauma pts with pelvic fx on x-ray
**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
**MRI and CT are comparable in SN and SP<ref>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.</ref>
*Retrograde cystourethrogram
*Retrograde cystourethrogram
**Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria
**Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria

Revision as of 21:44, 4 September 2015

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 fx

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

Acute Trauma

Chronic/Atraumatic

Diagnosis

  • 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 pts with pelvic fx on x-ray
      • Exceptions include isolated pubic rami fx, avulsion fx
    • 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

  • 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)
      • 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
    • If vital signs are stable and no hemoperitoneum--> CTAP w/IV contrast
      • Contact IR for possible pelvic angiographic embolization
  • Pre-peritoneal packing can rescue failed angiography (usually in venous bleeding)
  • 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
  • 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

Pain control

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. 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.