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Pelvic Fracture
From WikiSM
Contents
Other Names
- Pelvic ring fractures
- Pelvic fractures
- "Open Book" injury
Background
- This page describes fractures of the pelvis or pelvic ring
- These fracture patterns often co-occur with other injuries which will not be reviewed on this page in detail
History
Epidemiology
- Pelvic fractures comprise 2% to 8% of all skeletal injuries[1]
- Overall incidence estimated to be 24-37 per 100,000 person years[2][3]
- In patients over 55, that incidence increases to 446 per 100,000 person years
- Bimodal distribution
- In younger patients age 15-30, there is a male predominence
- In elderly patients 50-70, there is a female predominence
- Open pelvic fractures make up only 2-4% of all pelvic fractures[4]
Pathophysiology
Etiology
- High energy trauma including
- MVC
- Fall from height
- Low energy
- Fall from height in patients with osteoporosis
- Force vector helps determine injury pattern
- Lateral compressive forces
- Apply internal rotation to the pelvis
- Lead to fractures of the sacroiliac joint and pubic rami
- Anterior-posterior forces
- lead to external rotation of the hemi-pelvis,
- Injuries include diastasis of the pubic symphysis ("open book" injuries), fractures of the iliac bone
- Vertical sheer forces
- Lead to vertical displacement of the hemipelvis
Pathoanatomy
- Pelvic Ring
- Composed of Inonominate, of which there are 2, and the Sacrum
- Inominate formed by ilium, ischium, and pubis
- Anterior: pubis bones meet at midline and stabilized by the pubic symphisis
- Posterior: ilium meets sacrum to form Sacroiliac Joint
- Functions of pelvis
- Protect viscera, traversing neurovascular structures
- Transfer of load from lower extremities and axial skeleton during movement
- Ligament stability
- Anterior: Symphaseal ligaments
- Pelvic foor: sacrospinous ligaments, scarotuberous ligaments
- Posterior: anterior sacroiliac ligaments, interosseus sacroiliac ligaments, posterior sacroiliac ligaments, iliolumbar ligaments
Associated Injuries
- 12% to 62% of patients with pelvic fractures had additional injuries[5]
- Bladder or urethra (63%)
- Head injuries (35%)
- Neurologic injuries (24%)
- Gastrointestinal injuries (20%)
- Chest injuries (63%)
- Long bone fractures (50%)
- Spine fractures (25%)
- Morel Lavallee Lesion
Risk Factors
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Typically involves acute trauma
- Patients endorse hip and leg pain
- Physical Exam: Physical Exam Hip
- Test stability by gently placing a rotational force on each iliac crest
- Inability to bear weight
- May have deformity or abnormal positioning of lower extremity depending on degree of displacement
- Emphasis on skin, urogenital, vaginal and rectal examinations
- Neuro exam is especially important
- Special Tests
Evaluation
Radiology
- Standard Pelvic Radiographs
- Anteroposterior (AP) Radiograph
- Initial trauma evaluation
- Eseful for major pelvic disruption
- Look for asymmetry, rotation, displacement
- Inlet pelvic radiograph
- useful for anteroposterior and mediolateral translations
- can diagnosis internal and external rotary deformities
- Outlet pelvic radiograph
- useful for superior and inferior translations
- can diagnosis flexion and/or extension rotational deformities
- Lateral sacral radiograph
- may demonstrate transverse sacral fracture
- Findings suggesting instability
- > 5 mm displacement of posterior sacroiliac joint
- presence of posterior sacral fracture gap
- Avulsion fractures
CT
- Routine in evaluation of pelvic fractures
- Gives better characterization of osseous injuries
- Pelvic angiography
- Useful for hemorrhage unresponsive to fluids
Contrasted Imaging
- Retrograde urethrography
- used to rule out urtheral tear
- Cystography
- used to rule out associated bladder injury
Classification
Tile Classification
- A: Stable[6]
- A1: Fracture not involving the ring (avulsion or iliac wing fracture)
- A2: Stable or minimally displaced fracture of the ring
- A3: Transverse sacral fracture (Denis zone III sacral fracture)
- B: Rotationally unstable, vertically stable
- B1: Open book injury (external rotation)
- B2: Lateral compression injury (internal rotation)
- B2-1: With anterior ring rotation/displacement through ipsilateral rami
- B2-2: With anterior ring rotation/displacement through contralateral rami (bucket-handle injury)
- B3: Bilateral
- C: Rotationally and vertically unstable
- C1: Unilateral
- C1-1: Iliac fracture
- C1-2: Sacroiliac fracture-dislocation
- C1-3: Sacral fracture
- C2: Bilateral with one side type B and one side type C
- C3: Bilateral with both sides type C
- C1: Unilateral
Young-Burgess Classification
- Anterior Posterior Compression (APC)
- APC I: Symphysis widening < 2.5 cm
- APC II: Symphysis widening > 2.5 cm.
- Anterior SI joint diastasis
- Posterior SI ligaments intact
- Disruption of sacrospinous and sacrotuberous ligaments.
- APC III: Disruption of anterior and posterior SI ligaments (SI dislocation).
- Disruption of sacrospinous and sacrotuberous ligaments.
- APCIII associated with vascular injury
- Lateral Compression (LC)
- LC I: Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture.
- LC II: Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture).
- LC III: Ipsilateral lateral compression and contralateral APC (windswept pelvis).
- Common mechanism is rollover vehicle accident or pedestrian vs auto.
- Vertical Shear (VS)
- Posterior and superior directed force.
- Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%
Management
Prognosis
- Mortality estimates range from as low as 5-10% to as high as 50-60%[4]
- Due to hemodynamic instability, multi-organ failure
- Open fractures have a mortality rate as high as 50% (need citation)
- Predictors of mortality[7]
- Injury Severity Score (ISS)
- Revised Trauma Score (RTS)
- Age >60
- Transfusion requirement of more than 6 units in the first 24 hours
- APC III injury
- Mortality is bimodal
- Early death is due to hemorrhage or brain injury
- Late death is due to sepsis, multi-organ failure
- Predictors of poor outcome (need citation)
- SI joint incongruity of > 1 cm
- high degree initial displacement
- malunion or residual displacement
- leg length discrepancy > 2 cm
- nonunion
- neurologic injury
- urethral injury
Acute
- Prehospital
- Patient should be transported via EMS
- Follow pre-hospital protocols such as cervical spine stabilization, airway management, resuscitation, etc
- ED Management
- Patients with high energy mechanism, concern for or confirmed pelvic fractures should be prioritized
- Advanced Trauma Life Support (ATLS) algorithm should be followed
- Careful evaluation of hemodynamic status and resuscitation as appropriate
- Evaluation for secondary injuries
- Management should be directed at confirmed or suspected injuries in addition to pelvic fracture
- Pelvic Binder
- Centered over greater trochanters
- Can be helpful to control hemorrhage in the setting of hemodynamically unstable pelvic fractures
- Theoretically apply compression and stabilization to fractures
- Most commonly applied to open book fractures but should be considered for all hemodynamically unstable fractures
- Have largely replaced external fixation and anti-shock trousers
- Angiography Embolization
- Interventional radiology can sometimes embolize the bleeding source
- External Fixation
- Pelvic ring injuries with an external rotation component
- Unstable ring injury with ongoing blood loss
- Should be placed before emergent laparotomy
Nonoperative
- Recommend orthopedic surgery and trauma consultation on all pelvic fractures
- Indications
- Mechanically stable pelvic ring fractures
- Lateral Compression 1 (LC1)
- Anterior-Posterior Compression 1 (APC1)
- Isolated pubic ramus fractures
- Parturition (birth) induced pelvic diastasis
Operative
- Indications
- Open fractures
- Unstable pelvis fractures who are requiring operative managment for other reasons
- Symphysis diastasis > 2.5 cm
- SI joint displacement > 1 cm
- sacral fracture with displacement > 1 cm
- displacement or rotation of hemipelvis
- chronic pain and diastasis in parturition-induced diastasis or acute setting >4-6cm
- Technique
- Open reduction, internal fixation
- Anterior subcutaneous pelvic fixator (INFIX)
- Consider diverting colostomy
Rehab and Return to Play
Rehabilitation
- Stable, non-surgical fractures
- Early mobilization with protected weight bearing
- Unstable fractures treated surgically
- Mobility, weight bearing dependent on location of fracture
- As radiographic evidence of healing occurs, weight bearing can be advanced
Return to Play
- Needs to be updated
Complications
- Early
- Hemorrhagic shock
- Death
- Urogenital injuries
- Uretheral tear
- Bladder rupture
- Neurological injury
- L5 nerve root can be involved
- Venous Thromboembolism
- In up to 60% of pelvic fractures (need citation)
- Infection
- Risk factors include DM, obesity, prolonged OR time, ICU stay, etc
- Long term
- Mental health issues
- Chronic pain
- Pelvic obliquity
- Leg length or rotational discrepancy
- Gait abnormalities
- Urological dysfunction
- Sexual dysfunction (in up to 50% of patients, need citation)
- Socioeconomic problems
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1-13.
- ↑ Melton LJ 3rd, Sampson JM, Morrey BF, Ilstrup DM. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res. 1981;155:43-7
- ↑ Ragnarsson B, Jacobsson B. Epidemiology of pelvic fractures in a Swedish county. Acta Orthop Scand. 1992;63(3):297-300
- ↑ 4.0 4.1 McCormack, Richard, et al. "Diagnosis and management of pelvic fractures." Bulletin of the NYU hospital for joint diseases 68.4 (2010): 281.
- ↑ Gänsslen A, Pohlemann T, Paul C, et al. Epidemiology of pelvic ring injuries. Injury. 1996;(27 Suppl 1):S-A13-20.
- ↑ https://www.orthobullets.com/trauma/1030/pelvic-ring-fractures
- ↑ Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21(1):31-7.
Created by:
John Kiel on 5 July 2019 08:28:35
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Last edited:
5 October 2022 13:03:27
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