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Pelvic Fracture, Emergency Medicine

Basics

Description

- 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

- 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

- Surgery: - As indicated on the basis of clinical findings and orthopedic/surgical consult - Surgical stabilization with pelvic packing - Direct operative control of pelvic bleeding

- 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)

  • 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 shockIntra-abdominal and GI tract injuriesGenitourinary and urinary tract injuriesUterine and vaginal injuriesNeurologic injuriesArterial 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 plexusesRetroperitoneal 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 fracturesA2-2: Isolated rami fractures; most common pelvic fractureA2-3: 4-pillar anterior ring injuriesA3: Transverse fractures of sacrum or coccyx
  • Type B: Partially stable pelvic ring injury (rotationally unstable, but vertically stable):B1: Unilateral open-book fractureB2: Lateral compression injury:B2-1: Ipsilateral double rami fractures and posterior injuryB2-2: 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 fractureC2: Unilateral vertical shear combined with contralateral type B injuryC3: 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 compressionAPC: Anteroposterior compressionVS: Vertical shearCM: 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 pressureAltered mental statusCool 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 archOutlet projection: 30 ‚ ° cephalic angulation; allows visualization of sacrumJudet 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 consultSurgical stabilization with pelvic packingDirect 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 pelvisPneumatic anti-shock garment (PASG): Use in ED is controversial, but allows rapid pelvic immobilization and pelvic compression to slow bleedingExternal fixator: Requires more time to place than PASG but "splints " ¯ pelvis in a similar manner; contraindicated in severely comminuted pelvic fracturePlacement 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 orthopedicsFor 4-pillar anterior ring injuries, CT should be obtained to evaluate the posterior pelvisEnsure that there are no other breaks in the pelvic ring
  • Type B and C fractures:Immediate orthopedics consultation; patient should remain NPOMay require ED pelvic stabilization measuresAssess 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 embolizationDirect operative control of pelvic bleeding
  • Prioritization of studies: CT, angiography, or surgery:In the hemodynamically unstable patient:Open B and C fractures: Surgical explorationClosed 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)