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Pelvic Fracture

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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


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

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


References

  1. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1-13.
  2. Melton LJ 3rd, Sampson JM, Morrey BF, Ilstrup DM. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res. 1981;155:43-7
  3. Ragnarsson B, Jacobsson B. Epidemiology of pelvic fractures in a Swedish county. Acta Orthop Scand. 1992;63(3):297-300
  4. 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.
  5. Gänsslen A, Pohlemann T, Paul C, et al. Epidemiology of pelvic ring injuries. Injury. 1996;(27 Suppl 1):S-A13-20.
  6. https://www.orthobullets.com/trauma/1030/pelvic-ring-fractures
  7. 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
Last edited:
5 October 2022 13:03:27
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