II. Pathophysiology

  1. Pelvis is composed of five bony regions (ilium, ischium, pubis, Sacrum, Coccyx) held together by strong ligaments
    1. Significant force is required to result in Fracture of ligament disruption
  2. Pelvic Fractures are associated with significant bleeding
    1. Venous plexus that overlies the posterior arch of the Pelvis are at risk for tearing
    2. Fractured Pelvic Bones may also bleed significantly
    3. Pelvic Fracture bleeding is retroperitoneal and may be occult by external exam
  3. Mechanisms have a bimodal distribution
    1. Young Men in high energy Trauma accidents
    2. Elderly women with Osteoporosis, low energy mechanism (e.g. fall from standing)

III. Types: General

  1. Single Bone Pelvic Fractures
    1. Most common (esp. Pubic Ramus Fracture)
    2. See Pubic Ramus Stress Fracture
  2. Acetabular Fracture
    1. Less, common
    2. Typically involve posterior acetabulum
  3. Pelvic Ring Fracture
    1. Associated with highest mortality (venous plexus and arterial related Hemorrhage)
    2. Divided into 3 categories (Young-Burgess Classification System) - see below

IV. Types: Unstable, Pelvic Ring Fracture Patterns (associated with other injuries)

  1. General
    1. Young-Burgess Classification System categorizes Pelvic Ring Fractures
  2. Lateral Compression Pelvic Fracture
    1. Mechanism: Motor Vehicle Accident (e.g. rollover MVA)
    2. Pubic Ramus Fracture is most common manifestation
    3. Bladder injury or Urethral disruption are most common associated injuries
  3. Anterior Compression Pelvic Fracture (Open Book Fracture)
    1. Mechanism: Pedestrian struck by Motor Vehicle Accident
    2. Symphysis PubisFracture (anterior compression) with displacement is most common manifestation
    3. Associated injuries
      1. Thoracic aorta rupture
      2. Sacroiliac joint opening and venous plexus disruption
      3. Marker for significant multisystem Trauma (due to force) such as Closed Head Injury
  4. Vertical Shear Pelvic Fracture
    1. Mechanism: High force injury (e.g. MVA or fall from height)
    2. Unstable Pelvis
    3. Vertical displacement may be apparent on exam of the Symphysis Pubis
    4. Associated with significant gastrointestinal and genitourinary injuries

V. Types: Stable Pelvic Fractures

  1. Stable Fractures external to pelvic ring
    1. Avulsion Fractures
    2. Single Pubic Ramus Fracture
    3. Single ischial ramus Fracture
    4. Iliac wing Fracture
    5. Isolated sacral Fracture
    6. Coccyx Fracture
  2. Stable Fractures within the pelvic ring
    1. Two ipsilateral pubic or ischial ramus Fractures
    2. Sacroiliac joint subluxation
    3. Symphysis Pubis Subluxation
      1. Displacement >2.5 cm is unstable

VI. Precautions

  1. All Pelvic Fractures (and Femur Fractures) risk signficant Hemorrhage (even those that are minimally displaced)
    1. Most significant bleeding is associated with Fractures that disrupt the posterior Pelvis
  2. All Pelvic Fractures are a risk for urologic, gastrointestinal and retroperitoneal injuries
  3. Pelvic Fracture may give a false positive Diagnostic Peritoneal Lavage (rarely done in U.S.)

VII. Exam

  1. Perform a complete Trauma Examination
    1. See Primary Survey
    2. See Secondary Survey
  2. Compress the Pelvis by pushing both iliac crests together with force
    1. Assess for anterior or posterior Pelvis injury
    2. If the Pelvis moves inward on compression, hold this position and apply a Pelvic Binder for stabilization
    3. Do not repeat this exam in an unstable Pelvis (keep bound)
  3. Perform a careful distal CMS exam
    1. Distal extremity circulation (pulses, Capillary Refill)
    2. Distal Motor Exam
    3. Distal Sensory Exam
  4. Other examination
    1. Abdominal exam
    2. Associated lower limb Fractures
    3. Perineal exam for Ecchymosis
    4. Rectal Examination (gross blood, tone, Sensation)
    5. Vaginal and pelvic exam in all women with Pelvic Fracture
    6. Male Genitourinary Trauma (blood at Urethral meatus, perineal Ecchymosis, boggy Prostate)
      1. Perform Retrograde Urethrogram to exclude Urethral Trauma if external findings
      2. Perfrom cystogram if urethrogram negative

VIII. Imaging

  1. FAST Exam (for Hemorrhage)
    1. Indicated in all Unstable Patients with suspected Pelvic Fractures
    2. High False Negative Rate for Hemoperitoneum (e.g. may miss retroperitoneal Hematoma)
  2. CT Abdomen and Pelvis
    1. Defines Pelvic Fracture
    2. Defines associated genitourinary and intestinal injuries
  3. Other imaging and diagnostic modalities
    1. Pelvis XRay
      1. Identifies 90% of bony pelvic injuries
      2. Poorly predicts bleeding extent (based on Fracture appearance or type)
      3. Obtain if performing other bedside XRays if there is a delay for CT Pelvis
      4. May be sufficient in stable Trauma patients with benign Abdomen and Pelvis
      5. Minimum imaging in Unstable Patients with positive FAST requiring emergent Trauma surgery
    2. Diagnostic Peritoneal Lavage
      1. Completely replaced by CT Abdomen and Pelvis in the United States
    3. Retrograde Urethrogram (followed by cystogram if negative) Indications
      1. Men with blood at Urethral meatus or boggy Prostate
      2. Gross Hematuria
      3. Voiding difficulty
      4. Perineal Bruising

IX. Evaluation

  1. Stable: CT Abdomen and Pelvis
    1. Injury or peritonitis in addition to Pelvic Fracture requiring laparotomy
      1. Laparotomy for other indication and visualize Pelvic Fracture region at same time
    2. Isolated Pelvic Fracture
      1. Evaluation by Trauma surgery
      2. Intervention Radiology (angiography) for concerning findings (e.g. soft tissue blush or Hematoma near Fracture site)
  2. Unstable: FAST Exam
    1. FAST Positive for Hemorrhage
      1. Emergent Laparotomy to identify and manage bleeding source
      2. Source may be from concurrent Liver Laceration, Ruptured Spleen or Mesenteric Artery bleeding
    2. FAST Negative for Hemorrhage
      1. Blood Transfusion (see below)
      2. Consider Intervention Radiology to identify bleeding source (and consider internal iliac embolization)
      3. Consider Laparotomy for persistent instability if above measures are unsuccessful
      4. Consider Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
        1. See management below

X. Management

  1. Pelvic Binder (e.g. T-POD or bed sheet)
    1. See Pelvic Binder
    2. Provides pain relief and Fracture stabilization (similar to external fixation)
    3. Does not reduce Hemorrhage significantly (although may reduce Blood Transfusion requirements)
    4. Does not affect arterial bleeding
  2. Manage Hemorrhagic Shock
    1. Start replacing Blood Products early
    2. Replace Red Blood Cells (as well as Platelets and Fresh Frozen Plasma 1 unit/unit pRBC)
  3. Emergent surgical Consultation
    1. Trauma surgery, orthopedics, general surgery or urology depending on extent of injuries
      1. Determine management (laparotomy, Intervention Radiology or observation)
    2. Surgical management options (both followed by angiography by Intervention Radiology)
      1. Laparotomy with direct packing and possibly internal iliac artery ligation OR
      2. Preperitoneal packing via short suprapubic space incision
        1. Indicated only if other Hemorrhage sources have been excluded
  4. Angiography by Intervention Radiology indications
    1. See Evaluation above
    2. Indicated for persistent bleeding from Pelvic Fracture
    3. Do not delay emergent surgery in an Unstable Patient if angiography is not immediately available (e.g. <30 min)
    4. Managed with pelvic embolization (typically internal iliac embolization)
  5. Other possible measures
    1. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
      1. Percutaneous balloon delivered via groin catheter and inflated in aorta above level of Hemorrhage
      2. Indicated in severe Pelvic Fractures without Cardiac Arrest who need immediate temporizing measures
        1. May be considered in Peri-Arrest patient without obvious source of Hemorrhage
        2. Best used for short-term bridging to definitive procedure (risk of distal ischemia)
  6. Ineffective Measures
    1. Bladder Distention with foley (Bladder is too anterior to provide adequate posterior compression)
  7. Stable Fractures not requiring surgery
    1. Pubic Ramus Fracture
    2. Anterior-Posterior Compression (APC) Fracture Type 1
    3. Lateral Compression Fracture Type 1

XI. Prognosis: Acute Mortality

  1. Mortality 15-40% for an isolated Pelvic Fracture with secondary bleeding and Hypotension
  2. Mortality 50% for a Pelvic Fracture AND intraabdominal injury
  3. Mortality 90% for a Pelvic Fracture AND intraabdominal injury AND Head Injury

XII. References

  1. Eiff (1998) Fracture Management for Primary Care, p. 174-7
  2. Inaba in Herbert (2013) EM:Rap 13(11): 3-4
  3. Inaba and Herbert in Herbert (2014) EM:Rap 14(4): 10-11
  4. Orman and Hicks in Herbert (2017) EM:Rap 17(2): 8-9
  5. Perkins (2022) Crit Dec Emerg Med 36(6): 18-9 [PubMed]

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