Uro
Pelvic Fracture
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Pelvic Fracture
, Pelvis Fracture
See Also
Hip Fracture
Femoral Neck Fracture
Femoral Shaft Fracture
Hip Avulsion Fracture
Pathophysiology
Pelvic Fractures are associated with significant bleeding
Venous plexus that overlies the posterior arch of the
Pelvis
are at risk for tearing
Fracture
d
Pelvic Bone
s may also bleed significantly
Pelvic Fracture bleeding is retroperitoneal and may be occult by external exam
Types
Unstable Pelvic Fracture Patterns (associated with other injuries)
Lateral Compression Pelvic Fracture
Mechanism:
Motor Vehicle Accident
Pubic Ramus
Fracture
is most common manifestation
Bladder
injury or
Urethra
l disruption are most common associated injuries
Anterior Compression Pelvic Fracture (Open Book
Fracture
)
Mechanism: Pedestrian struck by
Motor Vehicle Accident
Symphysis Pubis
Fracture
(anterior compression) with displacement is most common manifestation
Associated injuries
Thoracic aorta rupture
Sacroiliac joint opening and venous plexus disruption
Marker for significant multisystem
Trauma
(due to force) such as
Closed Head Injury
Vertical Shear Pelvic Fracture
Mechanism: High force injury
Unstable
Pelvis
Vertical displacement may be apparent on exam of the
Symphysis Pubis
Associated with significant gastrointestinal and genitourinary injuries
Types
Stable Pelvic Fractures
Stable
Fracture
s external to pelvic ring
Avulsion
Fracture
s
Single pubic ramus
Fracture
Single ischial ramus
Fracture
Iliac wing
Fracture
Isolated sacral
Fracture
Coccyx
Fracture
Stable
Fracture
s within the pelvic ring
Two ipsilateral pubic or ischial ramus
Fracture
s
Sacroiliac joint subluxation
Symphysis Pubis Subluxation
Displacement >2.5 cm is unstable
Precautions
All Pelvic Fractures (and
Femur Fracture
s) risk signficant
Hemorrhage
(even those that are minimally displaced)
Most significant bleeding is associated with
Fracture
s that disrupt the posterior
Pelvis
All Pelvic Fractures are a risk for urologic, gastrointestinal and retroperitoneal injuries
Pelvic Fracture may give a false positive
Diagnostic Peritoneal Lavage
(rarely done in U.S.)
Exam
Compress the
Pelvis
by pushing both iliac crests together with force
Assess for anterior or posterior
Pelvis
injury
If the
Pelvis
moves inward on compression, hold this position and apply a
Pelvic Binder
for stabilization
Do not repeat this exam in an unstable
Pelvis
(keep bound)
Perform a careful distal CMS exam
Distal extremity circulation (pulses,
Capillary Refill
)
Distal
Motor Exam
Distal
Sensory Exam
Other examination
Vaginal and pelvic exam in all women with Pelvic Fracture
Imaging
FAST Exam
(for
Hemorrhage
)
Indicated in all unstable patients with suspected Pelvic Fractures
High
False Negative Rate
for Hemoperitoneum (e.g. may miss retroperitoneal hematoma)
CT Abdomen and Pelvis
Defines Pelvic Fracture
Defines associated genitourinary and intestinal injuries
Other imaging and diagnostic modalities
Pelvis XRay
Poorly predicts bleeding extent (based on
Fracture
appearance or type)
Obtain if performing other bedside XRays if there is a delay for CT
Pelvis
May be sufficient in stable
Trauma
patients with benign
Abdomen
and
Pelvis
Diagnostic Peritoneal Lavage
Completely replaced by
CT Abdomen and Pelvis
in the United States
Evaluation
Stable:
CT Abdomen and Pelvis
Injury or peritonitis in addition to Pelvic Fracture requiring laparotomy
Laparotomy for other indication and visualize Pelvic Fracture region at same time
Isolated Pelvic Fracture
Evaluation by
Trauma
surgery
Intervention Radiology
(angiography) for concerning findings (e.g. soft tissue blush or hematoma near
Fracture
site)
Unstable:
FAST Exam
FAST Positive for
Hemorrhage
Emergent Laparotomy to identify and manage bleeding source
Source may be from concurrent
Liver Laceration
,
Ruptured Spleen
or
Mesenteric Artery
bleeding
FAST Negative for
Hemorrhage
Blood Transfusion
(see below)
Consider
Intervention Radiology
to identify bleeding source (and consider internal iliac embolization)
Consider Laparotomy for persistent instability if above measures are unsuccessful
Consider
Resuscitative Endovascular Balloon Occlusion of the Aorta
(
REBOA
)
See management below
Management
Pelvic Binder
(e.g.
T-POD
or bed sheet)
See
Pelvic Binder
Provides pain relief and
Fracture
stabilization (similar to external fixation)
Does not reduce
Hemorrhage
significantly (although may reduce
Blood Transfusion
requirements)
Does not affect arterial bleeding
Manage
Hemorrhagic Shock
Start replacing
Blood Product
s early
Replace
Red Blood Cell
s (as well as platelets and
Fresh Frozen Plasma
1 unit/unit
pRBC
)
Emergent surgical
Consultation
Trauma
surgery, orthopedics, general surgery or urology depending on extent of injuries
Determine management (laparotomy,
Intervention Radiology
or observation)
Surgical management options (both followed by angiography by
Intervention Radiology
)
Laparotomy with direct packing and possibly internal iliac artery ligation OR
Preperitoneal packing via short suprapubic space incision
Indicated only if other
Hemorrhage
sources have been excluded
Angiography by
Intervention Radiology
indications
See Evaluation above
Indicated for persistent bleeding from Pelvic Fracture
Do not delay emergent surgery in an unstable patient if angiography is not immediately available (e.g. <30 min)
Managed with pelvic embolization (typically internal iliac embolization)
Other possible measures
Resuscitative Endovascular Balloon Occlusion of the Aorta
(
REBOA
)
Percutaneous balloon delivered via groin catheter and inflated in aorta above level of
Hemorrhage
Indicated in severe Pelvic Fractures without
Cardiac Arrest
who need immediate temporizing measures
May be considered in
Peri-Arrest
patient without obvious source of
Hemorrhage
Best used for short-term bridging to definitive procedure (risk of distal ischemia)
Ineffective Measures
Bladder Distention
with foley (
Bladder
is too anterior to provide adequate posterior compression)
Prognosis
Acute Mortality
Mortality 15-40% for an isolated Pelvic Fracture with secondary bleeding and
Hypotension
Mortality 50% for a Pelvic Fracture AND intraabdominal injury
Mortality 90% for a Pelvic Fracture AND intraabdominal injury AND
Head Injury
References
Eiff (1998)
Fracture
Management for Primary Care, p. 174-7
Inaba in Herbert (2013) EM:Rap 13(11): 3-4
Inaba and Herbert in Herbert (2014) EM:Rap 14(4): 10-11
Orman and Hicks in Herbert (2017) EM:Rap 17(2): 8-9
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