Rosen & Barkin's 5-Minute Emergency Medicine Consult (517 page)

• 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
    

• 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
    

• 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)
  

• 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

• 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 of trauma (fall, vehicular trauma, crush injuries, athletic injuries)
  
• Pain on hip movement, ambulation, sitting, standing, defecation
  

• 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
    

• 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
    

• Type and cross-match
  
• Hemoglobin/hematocrit, platelet count, and coagulation studies (prothrombin time, partial thromboplastin time)
  

• 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
  

• 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
    

• 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

• IV fluid resuscitation as indicated
  
• Consider stabilization or immobilization measures for pelvis
  

• 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)
    

• 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
  

• 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)
  

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