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Pelvic Fractures (excluding Acetabular fractures)

Description

Pelvic fractures are the result of high-energy trauma and display significant mortality ranging from 5.6% to 15%. The mortality rate for pelvic fracture with hemorrhagic shock ranges from 36.4%-54%. 

Structure and function

Pelvis is the key link between the axial skeleton and the lower extremities. The pelvic ring consists of two innominate bones (right and left ilium), which are formed from the fusion of three ossification center; ilium, ischium and pubis, connected anteriorly at the symphysis pubis and posteriorly to the sacrum at the sacroiliac (SI) joints. Pelvis is divided anatomically into false pelvis (portion of pelvis from the iliac crest superiorly to the pelvic brim inferiorly) and true pelvis (from the pelvic brim inferiorly to the pelvic floor).

The stability of pelvic ring is imparted by the ligamentous complex which includes –

1)      Transversely places ligaments that resists rotational forces includes, the strongest posterior sacroiliac (SI) ligaments (short component resist rotational force), the anterior SI, iliolumbar ligament and sarcospinous ligament             

2)      Vertically placed ligaments resisting vertical shear includes, long component of posterior SI, sarcotuberous ligament and lumbosacral

 The major vascular, neurologic, genitourinary and gastrointestinal structures pass through the pelvic ring and reside in approximation of the bony pelvis and sacrum. 
http://www.wikiradiography.com/page/Pelvis+Radiographic+Anatomy

Epidemiology

Pelvic fractures are encountered in 10% of patients admitted to urban trauma centers in North America. The risk factors for increased morbidity and mortality include the old age, female gender and increased impact forces sustained during injury. The incidence is greatest in people aged 15-28 years.

Clinical presentation

Clinical features – Most patients with pelvic fractures are injured by high energy blunt force impacts caused by motor vehicle crashes, pedestrian-stuck mechanism and fall from height > 15 feet, impact injury and crush injury. Low-energy pelvic fracture occurs commonly in adolescent or elderly.  In addition to the mechanism of injury, the position of the victim, duration of the crush and the direction of the force are crucial to define the fracture pattern.

Type of Injury -

-          A stable injury is defined as one that can withstand normal physiologic forces without abnormal deformation.

-          An unstable injury can be rotationally unstable (externally or internally rotated, open or compressed) or vertically unstable.

Table -  Young and Burgess classification of pelvic fracture, based on the mechanism of injury. 

Category of fracture

Type

Description

Anteriorposterior compression – open book fracture 

I

Symphyseal diastasis < 2.5 cm, no significant anterior or posterior pelvic injury

 

II

Symphyseal diastasis > 2.5 cm, tearing of the anterior sacroiliac, sacrotuberous and sacrospinous ligaments, posterior intact

 

III

Symphyseal disruption with complete hemipelvis separation and disruption of anterior and posterior ligament complex.

Lateral compression -Windswept pelvis

I

Posterior compression of sacroiliac joint + anterior transverse fracture of pubic rami without ligament disruption

 

II

Rupture of posterior sacroiliac joint + crush injury of the sacrum + crescent fracture of the iliac wing without ligament disruption

 

III

Type II + evidence of contralateral anterioposterior injury

Vertical shear

 

Vertical displacement anterior and posterior through the sarco-iliac joint

Combined mechanical injury

 

Combination of other injury patterns: lateral compression/vertical shear or
lateral compression/anteroposterior compression

Examination –

Pelvic fractures might be relatively occult on physical examination and the only clues might be the external contusion, abrasions and/or ecchymoses which are indicative of intrapelvic hemorrhage and should be looked for meticulously.

Manual palpation reveal crepitus from fractures and can assist with determination of pelvic stability.

Axial and appendicular skeletal injuries are frequently associated with pelvic ring fractures. Careful examination of the spine and extremities is indicated as part of complete patient evaluation.

Leg-length discrepancy with shortening on involved side or a markedly internally or externally rotated limb signifies pelvic instability.  

Arterial injury – Most common arteries involved are superior gluteal > internal pudendal > obturator > lateral sacral. However, internal pudendal bleed is most symptomatic.

Neurologic injury – including cauda aquina syndrome, plexopathies and radiculopathies might develop; difficult to evaluate in acute presentation. 

Red flags

  • Hemorrhage being the leading cause of death should be looked for meticulously.  
  • The initial evaluation of patients with anterior pelvic ring fracture should include perineum, vagina and rectum to rule out occult open injuries.
  • Anteroposterior compression injury, suspect visceral injury and retroperitoneal hemorrhage.
  • Lateral compression injury suspect closed head injury and intra-abdominal injury
  • Most common nerve root involved are L4-S1 of the lumbosacral plexus. 

Differential diagnosis

Associated organ injury that occurs in conjuction with pelvic fractures includes genitourinary injury, bowel injury, muscular and soft tissue injury and neurovascular injury.

Acetabular fracture with or without dislocation of hip might be associated with pelvic fracture.

Bladder Injury - Most common sign of bladder injury is the gross hematuria and suprapubic pain. In patients with widening of the symphysis pubis and sacroiliac joint; bladder injury should be suspected and a CT cystogram with distended bladder and postemptying view are favored for bladder injury. 

Urethral injury - The clinical presentation of bleeding from the urethral meatus and a high riding prostrate on digital rectal examination indicates the urethral injury. The urethral injury usually occurs at the junction of membranous and bulbar urethra, with male urethra being more vulnerable to be injured than female urethra. The fractures of inferior and superior rami are associated with urethral injuries. Complete urethral imaging should be performed when there is suspicion of urethral injury including retrograde urethrogram for posterior urethral disruption.

Bowel injury - Infrequently, entrapment of bowel in the fracture site with gastrointestinal obstruction may occur. If either is present, the patient should undergo diverting colostomy.

Objective evidence

Serial haemoglobin and hematocrit measurements to monitor blood loss, CBC, chemistry panel, coagulation studies, and type and cross. 

Urinalysis for gross or microscopic hematuria, if no evidence of urethral injury, Foley catheter in situ to monitor urine output.

Pregnancy test in females of child bearing age group

Full trauma evaluation includes – AP view of chest, lateral view of cervical spine and an AP view of pelvis.

On AP view of pelvis detailed evaluation of pubic rami fracture and symphysis disruption, sacroiliac joint and sacral fractures and iliac fractures should be performed.

Inlet radiographs – It allows more accurate determination of degree of anterior or posterior displacement of SI joint, the degree of internal or external rotation of the hemipelvis, the degree of symphysis diastasis or overlap and presence of subtle sacral fractures. This is taken with patient supine with the tube directed 60 degrees caudally, perpendicular to the pelvic brim. 

Outlet radiographs- This is utilized to determine the magnitude of vertical displacement of the hemipelvis. Additionally, it allows better visualization of subtle sacral and pubic rami fractures and the sacral neural foramina. This is taken with the patient supine with the tube directed 45 degrees cephalad.

Pull-push radiograph or stress image for assessment of vertical instability.

CT scan for posterior segments, MRI for genitourinary and pelvic vascular injury

Stable patients should receive a pelvic CT scan, and unstable fractures should be considered of angiography and embolization

Abdominal injury and internal haemorrhage assessed by CT scan or diagnostic peritoneal lavage. 
Open book fracture – Black arrow head – right SI joint disruption, blue arrow head – Symphysis pubis diastasis

http://img.medscape.com/pi/emed/ckb/radiology/336139-394515-2075.jpg

Risk factors and prevention

-          Motor vehicle accidents account for 50% to 60% of traumatic pelvic fractures

-          Old age due to low bone mass and propensity of falling 

-          Athletic injury involving avulsion fractures of the superior or inferior iliac spines or apophyseal avulsion fractures of the iliac wing or ischial tuberosity

-          Stress fracture in joggers – stable pelvic fracture heals with non-operative measures 

Treatment options

Non-operative treatment is employed in lateral impaction injuries with minimal displacement, fracture of pubic rami with no posterior displacement, gapping of pubic symphysis < 2.5cm
Multidisciplinary protocols including control of hemorrhage, management of other associated injuries and stabilization of the pelvic fracture has increased the rate of favorable outcomes.

Initial assessment of (ABCDE) airway, breathing, circulation, disability and exposure including full trauma evaluation and identification of neurovascular injury

A) Hemorrhage - major cause of death from displaced fractures of the pelvic ring and most commonly occurs from unstable fractures due to disruption of the presacral and paravesical venous plexuses. Predictors of major haemorrhage in pelvic fracture are: an emergency department haemocrit value of ? 30%,  pulse rate of 130 beats/min, a displaced fracture of the obturator ring, a wide pubic symphyseal diastasis. Control of hemorrhage is achieved by application of military antishock trousers (MAST), pelvic binders/sling, application of external fixator, ORIF, pelvic tamponade/packing, angiographic embolization

B) Associated Injury –

-          In case of open fractures; adequate debridement and irrigation of wound is paramount.

-          Suspected bowel injury should be dealt with by bowel diversion and washout with a colostomy which should be sited away from potential pelvic surgical fixation approaches.

-          Urgent bladder drainage by a cystostomy tube for bladder injury; intraperitoneal bladder ruptures are repaired and extraperitoneal may be observed.

-          Urethral injuries are treated endoscopically or on delayed basis.

-          The effective multidisciplinary management allows orthopedic stabilization of pelvic fracture within 24 to 72 hours of injury. The safest window for definitive operative internal fixation is between 6 days and 2 weeks after injury.

C) Definitive pelvic fracture treatment -  

-          Stable fractures are usually treated with bed rest until patient can tolerate mobilization and weight bearing on the affected side.

-          The treatment of unstable fracture depends on the fracture pattern.

-          Open book fracture with symphyseal diastasis < 2cm requires symptomatic treatment and protected weight bearing; symphyseal diastasis > 2 cm demands anterior external fixation with possible fixation for the posterior injury.

-          For ipsilateral lateral compression fracture usually does not require surgical fixation, elastic recoil might suffice, while for the posterior crush injury of sacrum if the leg length discrepancy is > 1.5 cm, external fixation or ORIF should be performed.

-          Rotationally and vertically unstable injury requires external fixation with or without skeletal traction and ORIF with posterior screw fixation. 

-          External fixation is a resuscitative fixation that can only be used for definitive fixation of anterior pelvis injuries and not for posteriorly unstable injuries.

-          Internal fixation is performed with lag screws and neutralization plates for iliac wing fracture, cancellous screw or anterior SI plate fixation for SI dislocation, posterior screw fixation foe posterior unstable fracures and plate fixation for symphysis pubis disruption. 

Outcomes

-          Outcome depends on the severity of the fracture and any associated injury. The majority of those with stable fractures will be pain and morbidity free.

-          Factors associated with poor outcomes are SI incongruity, high degree of initial displacement, malunion or residual displacement > 1 cm, length discrepancy > 2cm, associated neurologic and urethral injury.

-          In unstable and open fracture, the mortality is a bimodal distribution, with early death commonly due to hemorrhage (APC) or associated brain injury (LC) and late death due to overwhelming sepsis and multi-organ failure.

-          The incidence of deep venous thrombosis (DVT) with pelvic fracture is 60%, disruption of the pelvic venous vasculature and immobilization constitute major risk factors for the development of DVT. The rate of pulmonary embolism is 2% in pelvic fracture compared to 0.2% in polytrauma patients without pelvic fracture.

-          Long term medical and socio-economic complications that are eminent in pelvic fracture include painful walking; paresthesias, muscle weakness, and sexual dysfunction are the most important sources of long-term disability after pelvic fracture.

Holistic medicine

-        Weight bearing and muscle strengthening exercise for prevention of fall.

-        Maintain the body acidity to prevent the osteoporosis, as over-acidity cause loss of alkaline minerals such as calcium, magnesium and phosphorus

Miscellany

Clinical pearls

-          Patient with pelvic fractures are usually brought in on a stretcher and have a variety of other injuries.

-          Manual compression should be attempted cautiously as this maneuver might dislodge clot and cause severe uncontrolled haemorrhage.

-          Redudant large-bore IV access should be obtained above the diaphragm as femoral vasculature might have been disrupted.   

Key terms

Pelvic ring fracture, anteroposterior compression, lateral compression, symphysis pubis, haemorrhage 

Skills

1)      Recognition of life-threatening acute and occult injuries associated with pelvic ring fractures.

2)      Initial resuscitation and prompt identification of neuro-vascular, bladder and bowel injury.

3)      Fracture classification to aid decision of surgical versus non-surgical management. 

Content

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Famous Quote
"Fractures well cured make us more strong." Ralph Waldo Emerson
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