Major Pelvic Fractures

Abstract

Patients with major pelvic fractures present many diagnostic and management complexities. This article surveys current information on pelvic fractures, including epidemiology, hemorrhage, management of patients, and associated injuries.The spectrum of patients with pelvic fractures ranges from patients with isolated, simple fractures to critically injured patients with multiple other life-threatening injuries. Critical care nurses care for patients with major pelvic fractures in many settings, including transport, trauma resuscitation bays, perioperative areas, and intensive care units. Accordingly, they need to understand the issues involved in providing that care. In this article, we survey the current information on pelvic fractures, including epidemiology, anatomy, assessment of patients, hemorrhage, management, and associated injuries.Motor vehicle crashes, including motor vehicles crashing into pedestrians, cause about 60% of pelvic fractures. Most of the remainder result from falls.1–8 Frequency of fracture is highest for occupants of sub-compact or compact automobiles and for occupants of any vehicle struck on the side.9Pelvic fracture generally contributes to traumatic death but is not the primary cause.2 For patients with pelvic fractures who die, hypotension at the time of admission is associated with increased mortality (42% vs 3.4% for patients with stable vital signs), as are head injuries requiring neurosurgery (50% mortality); abdominal injuries requiring laparotomy (52% mortality); and concomitant thoracic, urological, or skeletal injuries (22% mortality).5,7,10–13 Survival is worse for patients with open pelvic fractures and for pedestrians struck by cars.5,7,12,13 Pelvic fractures are less common and less lethal in children than in adults.14The pelvis protects the viscera, transmits weight from the trunk to the lower limbs, and has attachment points for muscles. The abilities to stand and to bear weight require stability of the pelvic ring, made of the sacrum and aspects of the paired innominate bones. The innominate bones are formed bilaterally by the ilium, the ischium, and the pubis7,8 (Figures 1 and 2). These bones are inherently unstable and gain stability only with ligamentous support, especially around the sacroiliac joint posteriorly. Figure 3 depicts the ligamentous network. The junction of the ilium, ischium, and pubis forms the acetabulum, the concave socket for the femoral head, and the anterior aspects of the innominate bones join with a cartilaginous disk to form the pubic symphysis. The pubic symphysis is important for pelvic support, but disruption of the symphysis by itself does not make the pelvis unstable.7,15,16A stable pelvis can withstand normal vertical and rotational physiological forces, but either fractures or ligamentous injuries can disrupt pelvic stability. Disruption of the anterior pelvic ligaments creates rotational instability, whereas posterior ligamentous injury creates both rotational and vertical instability.17Pelvic blood supply comes primarily from the iliac and hypogastric arteries, which run at the level of the sacroiliac joints. Those arteries are supplemented by a rich associated network, including the superior gluteal artery, which is susceptible to injury in posterior fractures, and the obturator and internal pudendal arteries, which can be injured in fractures of the ramus8 (Figure 4).Pelvic fractures can be accurately diagnosed through physical examination, but a high index of suspicion for a fracture based on the mechanism of injury is essential.18 Examination begins with inspection for abrasions and contusions, symmetry, isolated rotation of a lower extremity, and discrepancy in limb length. Discrepancy in limb length may be due to a hip injury, a femoral injury, or a vertically unstable pelvic injury.7 A rotated iliac crest indicates a serious fracture.8 Rotational stability is evaluated by palpating for tenderness and crepitus with inward and posterior compression of the iliac crests and with posterior compression of the pubic symphysis.17 Rocking the pelvis is inappropriate, and care must be taken to avoid displacing a fracture or disrupting a pelvic hematoma during the examination. If no fracture of a lower extremity has occurred, vertical stability is assessed by longitudinal manual traction on the lower extremities.7 Tenderness over the trochanter indicates acetabular or femoral head injury. Any skin defect over the pelvis should be investigated as a possible open fracture.7,8Genitourinary injuries complicate up to one quarter of pelvic fractures, particularly those fractures with genitourinary injury at or near the pubic symphysis.19 Up to 6% of women and 11% of men who have pelvic fractures have urethral injuries; the frequency is lower in infants and children.20,21 Blood at the urinary meatus or a “high riding” prostate suggests a urethral injury and is a relative contraindication for placement of a Foley catheter.7,8If urethral injury is suspected, a retrograde urethrogram should be obtained before placement of a catheter in the bladder. For retrograde urethrograms, an abdominal plain radiograph is obtained, and then 60 mL of contrast material is injected directly into the urethra via a snugly placed syringe. Another radiograph is obtained during injection of the last 10 mL of contrast material. Extravasation of the contrast material indicates urethral injury.16Other genitourinary injury is also possible, so a urine sample should be collected. Microscopic hematuria is rarely associated with significant injury, but gross hematuria should prompt further evaluation.22 If urethral injury is excluded, gross hematuria suggests bladder or renal injury. Transmitted forces can rupture a full bladder, but only a bony fragment will injure an empty one. The bladder can be evaluated by using cystography; a Foley catheter is inserted, and radiographs are obtained when the bladder is filled with up to 400 mL of contrast material and again after the contrast material is drained.16 In patients with stable hemodynamic status, both the bladder and the kidneys can be evaluated by using computed tomography (CT).Male sexual dysfunction is associated with pelvic trauma, and the frequency of impotence both with and without urethral rupture is significant.8 Gynecologic and vaginal injuries are rare with pelvic fracture, and most gynecologic injuries occur in women who are pregnant.7Gastrointestinal injury associated with pelvic fracture can occur either as a separate traumatic injury or as a laceration by the sharp edge of a fractured bone. Both rectal and vaginal examinations are necessary to rule out communication through a laceration. Especially in obtunded patients, it is important to keep from creating such a communication during the examination.7,16 Gastrointestinal injury can be difficult to detect, because even guaiac testing for occult blood is not a completely reliable indicator.23The proximity of neurological structures to the sacrum and acetabulum creates the possibility for nerve injury.16 Spinal cord injury is most often associated with pelvic fracture when patients have vertical sacral fractures at or above the level of L5 or any transverse sacral fracture.16 Injuries at specific levels cause specific deficit patterns, so the dermatomes at and below L5 should be assessed carefully. Particular attention should be paid to plantar flexion and dorsiflexion of the great toe, sensation in the foot, and the Achilles deep tendon reflex.8,16 Table 1 describes expected nerve function. The cauda equina syndrome, a saddle-shaped area of defect with leg weakness and plantar flexion weakness, also sometimes occurs.7,8Advanced Trauma Life Support guidelines24 recommend an anteroposterior pelvic radiograph for all patients with multiple trauma. That radiograph alone is adequate for classification and management of most pelvic fractures, but it does not reveal some sacral fractures or sacroiliac injuries, and it does not reliably indicate the amount of bony displacement.8 Some patients with multiple trauma may not need routine anteroposterior pelvic radiographs. In patients who are awake and alert and have no clinical evidence of pelvic fracture, anteroposterior radiographs reveal unexpected injuries less than 1% of the time. The radiographs are essential for some patients, however, because physical examination by itself is inadequate in adults who are not alert and is only 69% to 90% sensitive for detection of pelvic fractures in infants and children.25–28On radiographs, a normal pubic symphysis is less than 5 mm wide and has less than 3 mm of vertical offset. Overlap is abnormal. Generally, the pelvic structures should be symmetrical about the midline, and edges and curves should be generally smooth (Figure 2). Positioning and technique can cause pelvic rotation on plain radiographs, and the degree of rotation should be evaluated by looking at the size and shape of the iliac wings.7Other radiological views can provide additional information. An inlet projection, in which the x-ray beam is angled from the head toward the feet, offers improved views of superiorly and posteriorly displaced posterior fractures, posteriorly displaced anterior arch injuries, and sacroiliac widening. The outlet view, with the x-ray beam angled toward the head, gives better views of sacral fractures and sacroiliac joint injuries.8 These views are less commonly used now, because CT scans and reconstructions are widely available. The greater detail and multiple views with CT scanning are especially useful for evaluating sacral, sacroiliac, posterior arch, and acetabular injuries, and CT scans also allow visualization of retroperitoneal hematomas.7,8When injury is found, a number of classification systems to describe pelvic fractures are available. Two of the most prominent are the Tile classification10 and the Young and Burgess classification,29 which are based on the direction of the injury, pelvic stability, and forces involved (Table 2). Classification helps in identifying associated injuries, correlates with the degree of pelvic injury, and is useful in preparing for definitive orthopedic repair.10,29–31 Fracture classification, however, is not essential for developing early strategies for management of patients with pelvic fractures.Patients with low-force injuries generally have stable fractures and stable vital signs. One third of all pelvic fractures are individual bone fractures without involvement of the pelvic ring.10 An isolated, nondisplaced fracture of the pubic ramus is the most common pelvic fracture; it often occurs in elderly patients who fall. It should be considered in the differential diagnosis of any patient with hip pain. Fractures of both the superior and inferior pubic rami on the same side are also common and are also typically stable.8,18A special type of ramus fracture is the straddle fracture, caused by direct injury of the pubic arch or by lateral compression forces. The injury either a fracture of all rami or rami fractures with disruption of the pubic symphysis. injury is common with straddle fractures, and clinical often or acetabulum is involved in about of pelvic fractures in adults and may injury of the femoral head or fracture of the pelvic A classification for acetabular injuries describes the of fractures or the acetabulum, as as fractures of the posterior A posterior hip is common with a posterior fracture of the acetabular and of the femoral head is of some acetabular by of the greater trochanter or the is also of acetabular Injuries to the nerve complicate than of acetabular injuries greater and hemodynamic to both the pelvis and other with patients with fractures, patients with fractures of the pelvic have and and than have associated head injury, or or genitourinary the pelvis has a shape and because the sacroiliac are of the pelvic a in plain radiographs to only an isolated displaced anterior fracture, bone scans and indicate that all patients who have anterior pelvic have a posterior pelvic injury as Patients with in the pelvic are These fractures, from either anteroposterior or lateral rotational and may or may not be vertically If the compression is to cause both rotational and vertical instability, the significant ligamentous and bony injuries are typically by to both and nerve The direction of injury helps common of fracture is caused by a anteroposterior compression such as a motor vehicle that disruption at the pubic symphysis (Figure The sacroiliac joint by the posterior ligaments and a creating a pelvis that is vertically stable but injuries to the neurological and structures in the posterior arch are and increased pelvic the of a amount of Patients with anteroposterior injuries have the highest and blood of all patients with pelvic lateral forces such as a motor vehicle or a a cause inward rotation of the and rotational Pelvic is with injuries, and critically patients generally have lower resuscitation than other patients with pelvic injuries caused by vertical forces to the pelvis via can injury fractures are anterior fractures through the rami pubic symphysis with posterior fracture of the ilium, or sacroiliac of anterior and posterior injury creates both rotational and vertical instability, and mortality and in patients with fractures are The fracture is with the posterior injury on the These injuries be caused by motor vehicle in which the of a is through or by a with a most common cause of death in patients with lateral compression pelvic fractures is an associated death in patients with anteroposterior pelvic injuries is to pelvic and patients in death is due to pelvic fracture, because of 90% of associated with pelvic fractures is from fractured bone The fracture itself is the primary in about of injuries. An to occurs in only about of injury is even less it occurs in 1% or less of Patients with injury to have high mortality up to and are typically at the time of struck by have the highest of from pelvic fractures typically into the which can up to An is important in retroperitoneal and during examination, or can the by the abdominal in patients with pelvic fractures particularly because the pelvic by can also into the or and retroperitoneal can through the are for the management of pelvic fracture and associated begins with some form of pelvic with some form of management by hemodynamic that after and injury has out or by a blood greater than in trauma management recommend that early pelvic be considered in patients with unstable pelvic fractures and that laparotomy that is to be adequate rotational stability and by bony and It may provide an in pelvic of an at the time of admission to the can the mortality of patients with unstable pelvic injuries to the level of patients with stable injuries and can the mortality of patients who are does not vertical stability, which posterior and it does not provide adequate posterior assessment and care should be with of an is with a simple that has or 3 in iliac can be placed either above the anterior superior iliac or the anterior iliac and can be placed either through an or placement may allow better abdominal and the of both is The can be in the trauma in as as by but the of the trauma and that of the is the to greater compression of the posterior of the pelvis at the of and to the of The has placed on the posterior of the ilium, near the sacroiliac joints. The to the and lower extremities.7 In an of the of in patients with the need for blood and blood The can be placed in as as 10 to be useful in pelvic fractures, because the provide of injuries to and fractures. The may be particularly useful in a patients must be to trauma for definitive In a of patients with pelvic fractures who than of that alone in of the In that mortality when the are to can be and are they also to significant of patients, vital and and can cause The have used for up to and have used in An of mm is and the bony of the and should be before the are for pelvic stability are available. can be by the pelvic with a and then the in The Trauma Pelvic a has used with some as have the and a by is in patients with pelvic such an injury does however, is definitive and the blood by about The most injuries are to the superior gluteal or internal pudendal the from to is generally when hemodynamic after of have excluded, and many recommend before Injuries to the posterior arch are most often associated with so may be for patients with such injuries. the of should be for patient and to and and to the in of a critically injured patient should be during to in pelvic fractures typically is for injuries to at of an pelvic hematoma are rarely because of the of from the and the early internal of pelvic fractures is rarely is possible as pelvic fractures pelvic injury and are for about of rectal or often and from and genitourinary disruption the of patients who of patients with multiple trauma is by the of pelvic fractures. the pelvic fracture is management as The to fracture the however, associated injury and other injuries occur in than 90% of patients with disruption of the pelvic injury is concomitant in of such patients and injury in with the of patients with trauma, patients with anteroposterior pelvic injury have an in pelvic fracture is by head, or extremity injury, management trauma in a specific to the associated injuries with the specific management of the pelvic a of hypotension or from head injury, the hemodynamic possible with pelvic fracture can be particularly for patients with head to of patients with pelvic fractures also have abdominal injuries, and trauma patients with blood and pelvic fractures present a diagnostic and management for which no on the abdominal from retroperitoneal in patients with pelvic fractures is difficult but because a laparotomy that no is associated with a high mortality and should be pelvic fractures the of diagnostic diagnostic and are useful but are by the of pelvic fractures. has up to for but the is and in patients with pelvic An early diagnostic by using an technique helps especially those associated with a pelvic hematoma the abdominal can also be used to but information on the of in patients with pelvic fractures is In one for abdominal but the high in patients with fractures of the pelvic ring, patients with the most serious injuries. The that patients with fractures of the pelvic and normal on should have CT scans to avoid detection of injury. The of in trauma is scanning accurately the of but the can be and in and for is associated with a for in clinical for CT of patients with unstable hemodynamic trauma management recommend that pelvic laparotomy laparotomy is for early is not and it may not be used by all trauma Both early laparotomy and early are also The care should be in trauma orthopedic and and to some patients with pelvic fractures in the care in stable hemodynamic have and require resuscitation to of patients both during and after resuscitation is and is with for full of resuscitation is the of this article, but such resuscitation does require of including and in patients with blood and is due to of and to be after of of a blood and in when the are than A on occurs and generally after of of will the will be for the The of both should be by specific One is to and and levels of and with of 5 of is by because of both and of of at by about also and to the of a is associated with increased and so all used in resuscitation should be other of blood are also blood is with a and of blood by itself to or the to blood it is patients have and of is the to the is also by a of the in This in less from the an hemodynamic stability may not adequate or levels should be The deficit at the time of admission to the correlates with degree of the need for the of and for should and for when the deficit 5 to is also associated with and levels greater than after admission with the of multiple and levels of at are associated with injuries. Accordingly, the deficit or levels should be evaluated at the time of admission and up An level of even with adequate vital indicates and should be by via or orthopedic can be with or internal and generally is to after injury, when the patient is and and does not have or stable pelvic fractures not require and can be with and early anterior fractures, however, require some of with either a or an the and of an and can sometimes be without the must be If a to less than 1 of is not about of patients require with of those in is in for to and require care of the to with is The should some compression to or need and of the with of even with This type of is a generally through a above the pubis and some of and is unstable posterior injuries can also be with either or internal An is not with a but through placement of This to neurological and structures in and near the but it is associated with when used by with with the is sometimes difficult to with a open before placement of the The is to directly to open and internal (Figure patients generally are for to 3 and have in for is early in important in and Patients with anterior injuries can weight when and can as Patients with posterior injuries with a of of weight on the side and to at to Patients with posterior injuries can but no other weight after to who have multiple trauma may have primary injury and are also at for the of and attention to early diagnosis and of or is as are early of and and for in function. for primary injury is increased in patients with fractures, and the for when is of strategies with lower and may and also the for and so is and early or early of a should be is associated with and is a of pelvic fracture because of and direct injury. occurs in up to of patients with multiple trauma, and clinical in about of those An number may have from in patients with pelvic fractures may be as high as of the high patients with pelvic fractures need for deep with weight by or associated compression are orthopedic injury and the placement of a may be useful other of are or out of is also Critical care nurses should a high index of suspicion for in patients with a of pelvic fracture in or management is important and also as an in and due to and of are both generally than The of Critical for recommend as the of with for patients who are to or in hemodynamic the associated with of of the for so an should be when are with pelvic fractures, all other trauma patients, require prompt and to for is associated with than is and is only patients than of by A should and should after resuscitation is Patients who have a laparotomy should have via either a or a Patients who have not a laparotomy may with and a of is of levels to be the most useful to care is a for patients with pelvic fractures. The patients may have other traumatic injuries and may have from internal of the pelvic fractures or of other injuries. skin care. fractures generally require and in the for at and is a common of the management of injury and is but not necessary for patients with open pelvic fractures. If the laceration is in the or areas, a is the of the laceration from those areas, the need for is A is not without the can disrupt retroperitoneal on the can that may not have and also for attention must be paid to the of the to the and to of and the for skin and inadequate and the to skin management, adequate and or of with of patients are all in and can from open fractures, skin and a of other may cause up to of in patients with pelvic with and is and based on the of is also is also an essential of the care of patients with pelvic fractures. The physical should be early in the and should up the patients Critical care nurses have an important as in to that are and are and involvement of physical and is one of the of care at a trauma fractures can from stable injuries to a of injury in trauma. Critical care nurses should have a high index of suspicion for pelvic injury, should a examination for fractures and associated injuries, and should be for of patients and from pelvic fracture is a and can and trauma and an of the of pelvic injuries are important to care