Basics
Description
- 3% of all bony fractures
- Pelvis is made up of sacrum and 2 innominate bones:
- The innominate bones consist of the ilium, ischium, and pubis
- Boney structures are stabilized by a network of ligaments, musculature, and other soft tissues in the pelvic area
- Anterior stability and support are provided by the symphysis pubis and pubic rami
- Posterior stability and support are provided by the sacroiliac (SI) complex and pelvic floor
- Pelvis provides protection for lower urinary tract; GI tract; gynecologic, and vascular, and nervous structures contained in the region:
- Pelvic fractures have a high associated morbidity and mortality rate and require urgent diagnosis and therapy.
- Unstable pelvic fractures are high risk for associated injuries including:
- Pelvic hemorrhage and hemorrhagic shock
- Intra-abdominal and GI tract injuries
- Genitourinary and urinary tract injuries
- Uterine and vaginal injuries
- Neurologic injuries
- Arterial and venous plexus injuries
Etiology
- 65% of pelvic fractures are caused by vehicular trauma, including pedestrians struck by automobiles
- 10% caused by falls
- 10% caused by crush injuries
- The remainder caused by athletic, penetrating, or nontraumatic injuries
- Mortality rate from pelvic fractures is 6 " “19%:
- Increases with open fractures or evidence of hemorrhagic shock
- Significant hemorrhage can occur in unstable, high-energy pelvic fractures (Tile type B and C fractures):
- Bleeding most common with posterior injuries involving the vascular plexuses
- Retroperitoneal hematoma may tamponade in the enclosed pelvic space
Tile Classification System
- Includes stable single bone and avulsion fractures as well as pelvic ring fractures
- Predicts need for operative repair
- Type A: Stable pelvic ring injuries:
- A1: Avulsion fractures of the innominate bone (ischial tuberosity, iliac crest)
- A2-1: Iliac wing fractures
- A2-2: Isolated rami fractures; most common pelvic fracture
- A2-3: 4-pillar anterior ring injuries
- A3: Transverse fractures of sacrum or coccyx
- Type B: Partially stable pelvic ring injury (rotationally unstable, but vertically stable):
- B1: Unilateral open-book fracture
- B2: Lateral compression injury:
- B2-1: Ipsilateral double rami fractures and posterior injury
- B2-2: Contralateral double rami fractures and posterior injury (bucket-handle fracture)
- B2-3: Bilateral type B injuries
- Type C: Unstable pelvic ring injury " ”rotationally and vertically unstable, Malgaigne fracture:
- Anterior disruption of symphysis pubis or 2 " “4 pubic rami with posterior displacement and instability through sacrum, SI joint, or ileum:
- C1: Unilateral vertical shear fracture
- C2: Unilateral vertical shear combined with contralateral type B injury
- C3: Bilateral vertical shear fracture
- Acetabular fractures (posterior lip, central/transverse, anterior column, or posterior column fractures)
Young Classification System
- Based on mechanism of injury
- Only fractures that result in disruption of pelvic ring included; no single bone, avulsion, or acetabular fractures
- Predicts chance of associated injuries and mortality risk:
- LC: Lateral compression
- APC: Anteroposterior compression
- VS: Vertical shear
- CM: Combination of injury patterns
- Children can have greater hemorrhage
- Nonaccidental trauma is a concern
Gravid uterus may be at risk for injury, including uterine rupture. ‚
Diagnosis
Signs and Symptoms
- Pain, swelling, ecchymosis, tenderness over hips, groin, perineum, and lower back
- Often presents with other traumatic injuries including neurologic, intra-abdominal, genitourinary, perineal, rectal, vaginal, and vascular injury
- Evidence of hemorrhagic shock
- Gross pelvic instability
History
- History of trauma (fall, vehicular trauma, crush injuries, athletic injuries)
- Pain on hip movement, ambulation, sitting, standing, defecation
Physical Exam
- Ecchymosis, swelling, tenderness over bony prominences, pubis, perineum, pelvic region, lower back
- Lower extremities may be shortened or rotated
- Inability to actively or passively perform range of motion of involved hip
- Tenderness on LC of pelvis, palpation of symphysis pubis or SI joints
- Gross pelvic instability, deformity, asymmetry in lower extremity
- Wounds over pelvis or bleeding from rectum, vagina, or urethra may indicate open fracture
- In hemorrhagic shock:
- Tachycardia, hypotension, narrowed pulse pressure
- Altered mental status
- Cool and pale extremities
Essential Workup
- Pelvic radiograph is the most common initial test
- A single AP view of the pelvis can confirm diagnosis and should be obtained as early as possible when fracture suspected:
- Most significant unstable pelvic fractures will be seen on the single AP view
- Other views include:
- Inlet projection: 30 ‚ ° caudal view; allows visualization of posterior arch
- Outlet projection: 30 ‚ ° cephalic angulation; allows visualization of sacrum
- Judet oblique views: Allow evaluation of acetabulum
Diagnosis Tests & Interpretation
Lab
- Type and cross-match
- Hemoglobin/hematocrit, platelet count, and coagulation studies (prothrombin time, partial thromboplastin time)
Imaging
- CT may further delineate pelvic fracture(s), retroperitoneal hematoma, visceral injuries:
- CT contrast angiography may delineate source of bleeding (particularly arterial), but should be considered only in hemodynamically stable patients
- Abdominal US focused abdominal sonography for trauma in patients with significant traumatic injury, but differentiation of intraperitoneal from extraperitoneal hemorrhage from pelvic fracture can be difficult
- MRI indicated for neurologic injury
Diagnostic Procedures/Surgery
- Although largely supplanted by US and CT, diagnostic peritoneal lavage (DPL) remains a rapid bedside evaluation for intraperitoneal hemorrhage
- Angiography and selective vessel embolization in the setting of pelvic hemorrhage:
- Particularly for small-vessel arterial bleeding
- Surgery:
- As indicated on the basis of clinical findings and orthopedic/surgical consult
- Surgical stabilization with pelvic packing
- Direct operative control of pelvic bleeding
Differential Diagnosis
- Normal variants (i.e., os acetabuli epiphyseal line can mimic type I fracture on radiograph)
- Ligamentous injury
- Spinal injury
- Intra-abdominal injury and hemorrhage
Treatment
Pre-Hospital
- IV fluid resuscitation as indicated
- Consider stabilization or immobilization measures for pelvis
Initial Stabilization/Therapy
- ABCs of trauma care
- IV fluid resuscitation with blood or crystalloid, O-negative or type-specific blood if hemodynamically unstable:
- Avoid using lower extremity IV sites
- Stabilize and immobilize the pelvis to prevent further injury and decrease bleeding:
- Compression device: Folded sheet with clamp or commercial compression device wrapped circumferentially around greater trochanters to stabilize and compress pelvis
- Pneumatic anti-shock garment (PASG): Use in ED is controversial, but allows rapid pelvic immobilization and pelvic compression to slow bleeding
- External fixator: Requires more time to place than PASG but "splints " ¯ pelvis in a similar manner; contraindicated in severely comminuted pelvic fracture
- Placement of a stabilization device should not interfere with further workup and care (e.g., US, DPL)
Ed Treatment/Procedures
- Determine which pelvic fractures are stable and which are unstable
- Type A fractures are generally stable
- Type B and C fractures are unstable
- Type A fractures:
- Treated conservatively with bed rest, analgesics, and comfort measures; management decisions may be made in conjunction with orthopedics
- For 4-pillar anterior ring injuries, CT should be obtained to evaluate the posterior pelvis
- Ensure that there are no other breaks in the pelvic ring
- Type B and C fractures:
- Immediate orthopedics consultation; patient should remain NPO
- May require ED pelvic stabilization measures
- Assess for pelvic hemorrhage
- Malgaigne fractures:
- Anticipate significant hemorrhage and associated injuries
- Acetabular fractures:
- Immediate orthopedics consultation; patient should remain NPO
- Pelvic hemorrhage:
- Mechanical stabilization of unstable pelvic fractures (usually by application of external pelvic fixation)
- Angiography and selective vessel embolization
- Direct operative control of pelvic bleeding
- Prioritization of studies: CT, angiography, or surgery:
- In the hemodynamically unstable patient:
- Open B and C fractures: Surgical exploration
- Closed fractures: DPL or US can help determine management in terms of need for immediate surgical exploration or selective angiography/embolization
- In the hemodynamically stable patient, the patient can go to CT for evaluation of the abdomen, pelvis, and retroperitoneum with external fixation as appropriate
Medication
- Crystalloid fluids: 2 L IV bolus of normal saline or lactated Ringer (peds: 20 mL/kg)
- Blood products: 4 " “6 U cross-matched, type specific, or O-negative (peds: 10 mL/kg)
Follow-Up
Disposition
Admission Criteria
- Hemodynamic instability, and pelvic hemorrhage to the ICU
- Type B or C pelvic fracture
- Acetabular fracture
- Other related injuries (e.g., genitourinary, intra-abdominal, neurologic)
- Intractable pain
Discharge Criteria
Type A pelvic fracture; hemodynamically stable with no evidence of other injuries ‚
Issues for Referral
Close follow-up should be ensured for discharged patients. ‚
Followup Recommendations
Discharged patients should be referred to an orthopedist for follow-up. ‚
Pearls and Pitfalls
- Pelvic fractures can be a marker for high-energy traumatic mechanism and injury:
- Assess for underlying abdominal/pelvic injuries including GI, genitourinary, vascular, and neurologic injuries
- In addition to initial resuscitation, immobilization and stabilization of the pelvis should be considered for unstable or open fractures or where hemorrhage is suspected
- Determination of diagnostic/therapeutic pathways including CT with or without angiography, selective IR angiography, and surgery are dictated by the patients hemodynamic status, suspected underlying injuries, and type of pelvic fractures
- All patients with Malgaigne fractures should be admitted with consultation by trauma and orthopedic services
Additional Reading
- American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support for Doctors, 9th ed. Chicago, IL: American College of Surgeons; 2012.
- Flint ‚ T, Cryer ‚ H. Pelvic Fracture: The Last 50 Years. J Trauma. 2010;69:483 " “488.
- Geeraerts ‚ T, Chhor ‚ V, Cheisson ‚ G, et al. Clinical review: Initial management of blunt pelvic trauma in patients with haemodynamic instability. Crit Care. 2007;11:204.
- Hak ‚ DJ, Smith ‚ WR, Suzuki ‚ T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009;17:447 " “457.
- Rice ‚ PL Jr, Rudolph ‚ M. Pelvic fractures. Emerg Med Clin North Am. 2007;25:795 " “802.
See Also (Topic, Algorithm, Electronic Media Element)
- Hemorrhagic Shock
- Hip Injury
Codes
ICD9
- 808.8 Closed unspecified fracture of pelvis
- 808.41 Closed fracture of ilium
- 808.42 Closed fracture of ischium
- 808.2 Closed fracture of pubis
- 805.6 Closed fracture of sacrum and coccyx without mention of spinal cord injury
- 808.0 Closed fracture of acetabulum
- 808.43 Multiple closed pelvic fractures with disruption of pelvic circle
- 808.44 Multiple closed pelvic fractures without disruption of pelvic circle
- 808.49 Closed fracture of other specified part of pelvis
- 808.4 Closed fracture of other specified part of pelvis
ICD10
- S32.9XXA Fracture of unsp parts of lumbosacral spine and pelvis, init
- S32.309A Unsp fracture of unsp ilium, init encntr for closed fracture
- S32.609A Unsp fracture of unsp ischium, init for clos fx
- S32.509A Unsp fracture of unsp pubis, init encntr for closed fracture
- S32.10XA Unsp fracture of sacrum, init encntr for closed fracture
- S32.399A Oth fracture of unsp ilium, init encntr for closed fracture
- S32.409A Unsp fracture of unsp acetabulum, init for clos fx
- S32.499A Oth fracture of unsp acetabulum, init for clos fx
- S32.599A Oth fracture of unsp pubis, init encntr for closed fracture
- S32.699A Oth fracture of unsp ischium, init for clos fx
- S32.810A Multiple fx of pelvis w stable disrupt of pelvic ring, init
- S32.811A Mult fx of pelvis w unstable disrupt of pelvic ring, init
- S32.82XA Multiple fx of pelvis w/o disrupt of pelvic ring, init
- S32.89XA Fracture of oth parts of pelvis, init for clos fx
SNOMED
- 77493009 Fracture of pelvis (disorder)
- 7687006 Fracture of ilium (disorder)
- 263220002 Fracture of ischium (disorder)
- 36127009 Fracture of pubis (disorder)
- 125872003 Fracture of sacrum (disorder)
- 263222005 Multiple pelvic fractures (disorder)
- 39408006 Closed fracture of innominate bone (disorder)
- 59962009 Multiple closed fractures of pelvis with disruption of pelvic circle (disorder)
- 64455005 Fracture of acetabulum (disorder)