Table Of Contents
Pelvic Ring Fractures
Pelvic ring fractures commonly occur in young individuals due to high-energy mechanisms, whereas those in the elderly population are caused by low-energy mechanisms (e.g. fall from ground level). The most common cause of death from a pelvic ring fracture is haemorrhage. CT-scan is the preferred investigation for pelvic ring fractures since they are difficult to pick up on plain films due to gas in the bowel
Mortality ranges from 5 – 50% depending on complications. Occurs more in men than women for patients < 35 years old and more in women than men in patients > 35 years old.
Mechanism of injury in pelvic fractures
| Category | Mechanisms |
|---|---|
| Low energy injury | Avulsion due to sudden contraction of muscles, fall from standing height (most common cause in older osteoporotic patients), straddle injury (motorcycle and horses) |
| High energy injury | motorvehicle accident, crush injury, motorcycle accident, fall from height |
Patterns of injury in pelvic fractures
| Injury pattern | Description | Example |
|---|---|---|
| Anteroposterior compression (APC) | Causes external rotation of the hemipelvis causing it to spring open | Motorcycle crash |
| Lateral compression | Impaction of cancellous bone into the sacroiliac joint. Lateral compression of the posterior half of the ilium is stable while compression of the anterior ilium disrupts the posterior sacroiliac ligament and can cause external rotation of the contralateral hemipelvis if the force is severe enough. Compression of the greater trochanter is associated with transverse acetabular fractures | Fall onto side, T-bone in motorvehicle accident |
| Avulsion | Bone pulled off by violent muscle contraction. Avulsion of the ASIS by sartorius, AIIS by rectus femoris, | Sportsment and athletes |
| Vertical Shear force | Posterior superior force leading to complete instability in 3 planes due to disruption of the sacrospinous, sacrotuberous, and sacroiliac ligament. Highest risk of hypovolemic shock (63%) and mortality of 25% | |
| Stress fractures | Occurs in osteoporotic bone, commonly the pubic ramus and presents with long-lasting groin pain. |
Young-Burgess Classification of Pelvic Fractures
Anterior Posterior Compression (APC)
| Classification | Description |
|---|---|
| APC I | Symphysis widening < 2.5 cm |
| APC II | Symphysis widening > 2.5 cm, anterior SI joint diastasis, posterior SI ligaments are intact, disruption of sacrospinous and sacrotuberous ligaments |
| APC III | Disruption of anterior and posterior SI ligaments (SI dislocation) |
Lateral Compression (LC)
| Classification | Description |
|---|---|
| LC I | Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture |
| LC II | Ramus fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture) |
| LC III | Ipsilateral LC and contralateral APC (windswept pelvis). Occurs in individuals rolled over by vehicle |
Vertical Shear (VS)
| Classification | Description |
|---|---|
| Vertical shear | Disruption of the sacrospinous, sacrotubierous and sacroiliac ligaments. |
Unstable pelvic ring fracture defined as 2 or more complete ring disruption (anterior or posterior) on the same or both sides of the pelvis.
| Instability | Fracture |
|---|---|
| Rotational instability | LC II – III, APC II- III |
| Vertical instability | VS, APC III |
| Combined vertical and rotational instablity | LC III, APC III, VS |
- Associated injuries
- Chest injury (63%)
- Long bone fractures (50%)
- Spine fractures (25%)
- Urogenital or sexual dysfunction (50%)
- Head and abdominal injury (40%)
- Patient history
- Fall from standing height in elderly or with osteoporosis
- Fall from height
- Motorvehicle accident
- Pedestrian vs car (especially peadiatric)
- Signs and symptoms
- Pain
- Inability to bear weight
- Limb-length discrepancy
- Leg held in external rotation
- Flank or buttock contusions and swelling (significant hemorrhage)
- Gross hematuria
- Physical examination
- Leg held in external rotation
- Limb-length discrepancy
- Lacerations and bruising
- DRE and vaginal exam (mandatory)
- Occult open fracture in the vaginal vault
- Rectal tone
- Boggy prostate (arterial/venous damage)
- High-riding/mobile prostate (urethral disruption)
- Rectal tone
- Neurological examination (focus primarily on L5 and S1)
- Foot drop (L5)
- Buttock or perianal sensation (S1 – S4)
- Saddle anaesthesia (S3 – 25) in conus medullaris and cauda equinA
- Morel-Lavallee lesion: degloving injury where the skin + subcutaneous tissue separates from the fascia. Has a high risk of infection
- Destot sign: large hematoma or swelling in the perineum, scrotum or upper thigh due to extravasation of blood from pelvic vessel (esp. in open-book and vertical shear)
- Rouxs sign: tenderness and crepitus on rectal exam when pressure is applied to the anterior wall (ramus fracture)
- Earle sign: movement of the iliac wing felt through manipulation of the iliac crest via bimanual pelvic compression (sacroiliac joint disruption)
- Investigations
- Pelvic X-ray: AP view, lateral view, inlet view, and outlet view
- 5mm displacement of the posterior sacroiliac complex
- Presence of posterior sacral fracture gap
- Avulsion fractures
- Sacroiliac joint area
- Ilium for fracture
- Teadrop for acetabular fractor
- Obturator foramen for superior and inferior pubic ramus
- Symphysis pubis for fracture or diastasis
- CT-scan pelvic: immediately obtained in significant trauma provided the patient is stable since it is easier to pick up subtle injuries.
- Urinalysis: for gross or microscopic hematuria for bladder/urethral injury
- CBC, RBS, U/E/Cs, LFTs, GXM, PT/PTT
- Pelvic X-ray: AP view, lateral view, inlet view, and outlet view
- Radiographic signs of instability
- Sacroiliac displacement > 5mm in any plane
- Posterior fracture gap (rather than impaction)
- Avulsion of the 5th lumbar transverse process, lateral border of the sacrum, or ischial spine
X-ray views in pelvic fracture
| View | Description |
|---|---|
| AP view | Obtained as part of the trauma series (ATLS). Asess asymmetry, rotation or displacement of each hemipelvis |
| Inlet view | X-ray beamed angled of 40 degrees caudad. S1 should overlap S2 body (perpendicular ot S1 endplate) to visualize anterior or posterior translation of the hemipalvis, internal or external rotation, widening of the SI joint and sacral ala impaction |
| Outlet view | X-ray beam angled 40 degrees cephalad. Pubic symphysis should overly S2 body. Visualize vertical translation, flexion/extension, disruption of sacral foramina and presence of sacral fractures |
| Single-leg stance (”flamingo view) | Alternate right and left foot up while AP view is obtained. For suspected chronic pelvic ring instability by measuring vertical translation |
- Initial treatment of pelvic fractures
- Resuscitation (ATLS): to prevent mortality. Pelvic fractures coincide with venous injury and hemorrhage.
- Close (binder or ex-fix)
- Fill (2 large bore IVs, massive blood transfusion, tranexamic acid)
- Find (CT angiography for stable or damage control laparotomy for unstable)
- Assess ****skin, urology and neurovasculature
- Attempt passage of 16 fr foley after ruling out urethral injury
- Manage other sustained injuries
- Deep venous thrombosis prophylaxis
- Pain meds PRN
- Resuscitation (ATLS): to prevent mortality. Pelvic fractures coincide with venous injury and hemorrhage.
- Options for immediate control of hemorrhage in pelvic fractures (close)
- Pelvic binder or sheet: always applied if pelvic injury is suspected. Stabilizes the pelvis via circumferential compression which reduces pelvic volume and provides a tamponade effect.
- Apply at the level of the greater trochanters
- Consider internal rotating lower limbs and tie sheet around the knees if pre-hospital
- Left until the patient is hemodynamically stable (at least 6 hours). Pad pressure points and inspect the skin 6 hourly for pressure sores if the binder is left on for longer durations
- External fixator: rarely required. Placed in open book fractures, open fractures or damage control post-laparotomy/packing
- Iliac wing ex-fix is easier to place but offers less control
- Supra-acetabular window Ex-fix is more stable and better posterior pelvis stability
- +- traction: very rarely required. Used for vertical shear injury
- +/- C-Clamp: rarely used. For unstable posterior ring injury (dislocated SI joint or vertical shear that remains unstable despite binder)
- Embolization: 85-90% effective in controlling pelvic fracture related hemorrhage
- Open packing of the pelvis (retroperitoneum): if the patient is undergoing damage control laparatomy or exploration. May be the last result in exsanguinating patients
- Pre-sacral packing to stop bleeding from the pre-sacral venous plexus
- Greater sciatic notch to stop bleeding from the superior gluteal artery
- Obturator foramen and superior pubic ramus to stop bleeding from the coronar mortis (”crown of death”)
- Open reduction and internal fixation (ORIF) if the patient is undergoing another emegrency surgery)
- Pelvic binder or sheet: always applied if pelvic injury is suspected. Stabilizes the pelvis via circumferential compression which reduces pelvic volume and provides a tamponade effect.
- Conservative treatment of pelvic ring fracture
- Walkers or Crutches to protect weight bearing
- Serial radiographs after beginning mobilization to monitor for displacement
- Operative treatment of pelvic ring fractures
- External fixation: for emergency stabilization or definitive treatment of anterior pelvic fractures
- Internal fixation
- Iliac wing fractures: lag screws and neutralization plates
- Diastasis of pubic symphisis: plate fixation
- Sacral fracture: plate fixation ornoncompressive iliosacral screw fixation
- Unilateral sacroiliac dislocation: iliosacral screws or anterior sacroiliac plate fixation
- Bilateral posterior unstable disruption: posterior screw fixation
- Indications for conservative treatment of pelvic fractures
- Stable LC-1 and APC-1 fracture
- Symphisis diastasis < 2.5 cm
- Tile B if deformity is minimal
- Pubic ramus fractures with no isolated posterior displacement
- Absolute indications for operative treatment of pelvic fractures
- Open pelvic fracture
- Open-book fractures with hemodynamic instability
- Vertically unstable fractures with hemodynamic instability
- Associated visceral perforation requiring surgery
- Displaced sacral fractures with neurological injury
- Relative indications for operative treatment of pelvic fractures
- Symphiseal diastasis > 2.5 cm
- Leg-length discrepance > 1.5 cm
- Rotational deformity
- Sacral displacement > 10 mm
- Intractable pain
- Risk factors for mortality in pelvic fractures
- Older patient > 60 years
- SBP < 90 mmHg on arrival
- Severe displacement (APC III, LC III and Vertical shear fracture)
Complications of pelvic fractures
| Timeline | Complications |
|---|---|
| Acute complications | Vascular injury (venous >> arterial), urethral injury, neurological injury, visceral injury, hypovolemic injury |
| Intermediate complications | Venous thromboembolism, shock, infection |
| Long-term complications | Impotence, urethral strictures, non-union, obstetric complications, chronic pain |
