Pelvic Ring Fracture – Symptoms, Diagnosis, Treatment

Due to the high energy nature of pelvic ring injuries, associated morbidities require thorough assessment. Incidence of associated trauma includes:

• Chest trauma 63%
• Long bone fractures 50%
• Head injuries 40%
• Visceral organ damage 40%
• Spinal fractures 25%
• Intestinal injuries 14%
• Genitourinary injuries 6 to 15%

• Open fractures 5%

  • Mortality of open pelvis fractures is around 50%, urgent antibiotic administration is necessary
  • Perform a rectal and vaginal exam and look for breaks in the skin around the perineum

A pelvic ring injury can be a life-threatening injury or may be associated with a life-threatening injury, and a thorough exam is necessary.

• Advanced trauma life support (ATLS)
• Motor and sensory exam
• Physical exam of the pelvis including push/pull test and lateral compression test
• Look for leg length inequality not explained by a limb fracture
• A high riding prostate or blood at urethral meatus may indicate genitourinary injury
• Rectal and/or vaginal exam
• Perineum exam may reveal swollen and/or mobile genitalia

Destot sign – Palpable hematoma in perineum above inguinal ligament or proximal thigh, may represent pelvic fracture with active bleeding.

Grey Turner sign – Flank bruising indicative of retroperitoneal bleeding.

Morel-Lavallee lesion – Internal degloving injury from skin shear at time of injury, may require intervention and may affect surgical planning, look for significant soft tissue abrasions, ecchymosis or subdermal hematoma. May also be identified on CT scan with the assessment of soft tissues.[rx][rx]

Imaging

      X – rays – CXR, AP pelvis

Classification

Tile Classification[rx]

Type A – Stable

• A1 – Fractures not involving the pelvic ring
• A2 – Stable minimally displaced fractures of the pelvic ring

Type B – Rotationally unstable, vertically stable

• B1 – Open book
• B2 – Lateral compression ipsilateral
• B3 – Lateral compression contralateral

Type C – Rotationally and vertically unstable

• C1 – Unilateral
• C2 – Bilateral
• C3 – Associated with an acetabular fracture

Young and Burgess Classification[rx]

Denis Classification of Sacral Fractures[rx]

• Zone 1 – Lateral to the sacral foramen
• Zone 2 – Entering sacral foramen
• Zone 3 – Medial to sacral foramen – Highest incidence of neurologic injury including nerve root or cauda equina

Lumbopelvic Dissociation[rx]

• Fracture pattern which renders the base of the spine discontinuous with the pelvis requiring fixation
• Beyond the scope of this activity
• Bilateral sacral fractures have a high incidence of lumbopelvic dissociation, and CT scan should be reviewed carefully for coronal plane sacral disruptions.

Imaging

• Computed tomography (CT) – scans of the abdomen/pelvis will provide the best visualization of pelvic anatomy and allow for evaluation of any pelvic, retroperitoneal or intraperitoneal bleeding. A CT scan will also allow for confirmation of hip dislocation and help determine whether or not there is an associated acetabular fracture. [rx][rx][rx]
• The best screening test for a pelvic fracture however, is an anteroposterior (AP) pelvic radiograph – this will reveal 90% of pelvic injuries.  Although most trauma patients undergo routine CT scans to the abdomen and pelvis, AP pelvic radiograph should be considered (as a rapid diagnostic tool) for hemodynamically unstable patients, to allow for earlier intervention.
• The pelvis should also be examined as part of the Focus Assessment with Sonography for Trauma (FAST) examination – this may help identify intraperitoneal bleeding (potentially pinpointing a source of shock) if it is present.
• Retrograde urethrography – should also be performed in patients suspected of having a urethral tear (e.g., males presenting with blood at the urethral meatus or females whom, after careful attempts, are unable to have a Foley catheter inserted, or have a vaginal tear or palpable fragments adjacent to the urethra).
• Cystography – Individuals presenting with hematuria in the setting of an intact urethra (e.g., suspected of having a urinary bladder injury) should undergo a cystography.
• Pelvic Angiography – may be performed if a patient is experiencing persistent hemorrhage despite adequate intravenous fluid resuscitation and pelvic stabilization – this may detect occult or obvious injuries and allow for embolization of any damaged arteries in addition to helping visualize before manipulative reduction.

Treatment of Pelvic Ring Fracture

Prehospital management

Prehospital management of a suspected pelvic fracture should adhere to the following principles:

• Read the mechanism of injury.
• Ask the alert patient about the presence of pain in the pelvic, back or groin regions and routinely immobilize the pelvis if there is any positive reply.
• The examination is unreliable (especially if reduced GCS, or distracting injuries) and the pelvis should not be palpated, to avoid further internal hemorrhage.
• If there is any suspicion of fracture, immobilize the pelvis using an external compression splint (commercial or modified eg, sheet).
• Do not fully log roll the patient.
• Use a scoop stretcher to facilitate the patient’s movement on to a spinal board or vacuum mattress for transport. In the emergency department, this process should be reversed.
• Fluid resuscitation to maintain a radial pulse only.
• Do not remove a pelvic splint in the presence of a suspected unstable pelvic injury until it is radiologically confirmed that there is no fracture or the patient is in a theatre.

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for pelvic fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and pelvic fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital pelvic fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your radial head fractures  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the pelvic fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of pelvic fracture can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. A figure-eight splint wraps around both hip and the base of your back in order to support the injured hip and keep it positioned up and back. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your hip and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks of femur fracture movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your necks of femur fracture and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Rx

References