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Pelvic Fracture

Pelvis Fracture

Pelvic fractures are considered life-threatening conditions caused by high or low energy injuries, and should be diagnosed and stabilized in the primary survey of patients with major trauma.


Presentation

Lower back or groin pain is the most common presentation in patients with pelvic fractures. In severe fractures, both anterior superior iliac spines may be compressed resulting in severe pain and indicating instability. Patients may not be able to walk because of the fracture.

Pelvic fractures also result in genitourinary or gynecological symptoms, such as scrotal or perineal hematoma, hematuria, blood at the urethral meatus, anuria, high-riding prostate, and vaginal bleeding. Intestinal or rectal injuries due to pelvic fractures include abdominal pain, rectal bleeding, and peritonitis.

Neurological features may also result from pelvic injuries including incontinence, urinary retention, weakness or loss of sensation in the lower limbs, affected reflexes in the rectum, perineum or the lower extremities.

Hemorrhagic shock may develop from pelvic fractures, which leads to high mortality rates. Unstable fractures also increase the risk of mortality.

The energy sustained by the patient may be measured indirectly depending on the resulting soft-tissue injuries. Intrapelvic hemorrhage is indicated by hematomas in the scrotum, labia, flank and inguinal region [9]. Several soft-tissue injuries may be observed, such as abrasions, lacerations, closed internal degloving, and open wounds [10]. Urethral disruption is suspected if there was external bleeding on the urethral meatus, perineal or genital swelling.

In males, a high-riding prostate may be detected by digital rectal exam, which also indicates urethral disruption [11]. Vascular injuries may occur as lacerations of venous structures [12]. The most common neurological injuries involve the L5 and S1 nerve roots [12] [13]. S2-S5 sacral nerve roots injuries may also occur, especially in cases where sacral fractures accompany pelvic ring injuries, which leads to sexual dysfunction, and bowel or bladder incontinence.

Splenectomy
  • A cesarean section and splenectomy could rescue the maternal life from the hemorrhage situation.[ncbi.nlm.nih.gov]
Hip Pain
  • The patient was complaining of left hip pain and hitting his head. The patient had fallen backward upon standing from a wheelchair, lost his balance, and suffered an occipital laceration with hematoma.[ncbi.nlm.nih.gov]
  • Patients tend to present following trauma with pelvic/hip pain. They will often be immobilized by ambulance crews on arrival and potentially have other life-threatening conditions associated with high-energy trauma.[radiopaedia.org]
  • A more serious fracture caused by a fall or other accident produces significant hip pain, swelling, and bruising. This type of fracture may prevent you from putting any weight on the affected hip.[nyulangone.org]
  • The primary symptoms of a pelvic fracture besides pain include: Bruising of the abdomen Pain in the back Worsened pain with walking Difficulty walking Hip pain Leg pain Pelvic Swelling Bloody urine Dizziness Shock Fainting spells Incontinence Lower abdominal[autoaccident.com]
Low Back Pain
  • Five weeks posthospitalization, the patient initiated chiropractic care with complaints of severe low back pain with lower extremity involvement. He also complained of neck pain and occipital headache.[ncbi.nlm.nih.gov]
Neck Pain
  • He also complained of neck pain and occipital headache. The patient had several positive low back orthopedic tests with bilaterally absent Achilles deep tendon reflexes.[ncbi.nlm.nih.gov]
Foot Drop
  • We present an unusual case of a 15-year-old boy who was involved in a bicycle accident, and who, a week after his injury, developed a delayed hypogastric branch artery pseudoaneurysm causing sciatic nerve compression with a right foot drop.[ncbi.nlm.nih.gov]
Irritability
  • Complications include lateral femoral cutaneous nerve irritation, heterotopic bone, loss of fixation if the implants are applied incorrectly.[ncbi.nlm.nih.gov]
Pelvic Pain
  • Patients present with pelvic pain , reduced range of motion, and hematomas. Concomittant injuries such as urethral injury are common.[amboss.com]
  • CPT 2017 Changes offers the following clinical example of 27198: A patient who was involved in a vehicular crash presents with pelvic pain and pain with attempted weight bearing.[aapc.com]
  • Pelvic splint indications Indications for a pelvic splint after severe blunt or blast injury include one or more of the following: Pelvic pain Any major limb amputation or near amputation Physical exam findings suggestive of a pelvic fracture Unconscious[ems1.com]
  • Symptoms of Pelvic Fracture The main symptom of a pelvic fracture is severe pelvic pain, although the degree of pain depends on the severity of the injury. Serious situations involving pelvic fracture are related to the degree of hemorrhage.[autoaccident.com]
  • If you have an awake patient who complains of lower abdomen pain, lower back pain, hip or pelvic pain, lower extremity numbness and tingling, be suspicious of a pelvic fracture and investigate that complaint during the rapid trauma assessment.[emsworld.com]
Urinary Retention
  • Neurological features may also result from pelvic injuries including incontinence, urinary retention, weakness or loss of sensation in the lower limbs, affected reflexes in the rectum, perineum or the lower extremities.[symptoma.com]
Renal Stone
  • No symptomatic renal stone formation was observed during the study period. CONCLUSIONS: Immobilization even in short term causes hypercalciuria in orthopedic patients.[ncbi.nlm.nih.gov]

Workup

Pelvic fractures should be suspected in patients who present to the emergency department with history of trauma and pain in the pelvic region. Most fractures can be seen using an anteroposterior pelvis X-ray. Specialized X-rays views, such as Judet views, may be needed if another fracture or ligamentous disruption is suspected as a result of a displaced fracture. In pelvic fractures due to high-energy injuries, CTs are usually used as they are more sensitive than X-rays. However, in low-energy injuries or small avulsion fractures, CTs are not necessary.

Signs observed on physical examination that suggest the presence of a pelvic fracture include abrasions and contusions, isolated rotation of a lower limb, and limb length discrepancy. Evaluation of the bladder and the urethra, including urinalysis to test for hematuria, is important in patients with pelvic fractures. Neurological examination is necessary in order to rule out any neurological injuries. Pelvic and gynecological examination is important in women to exclude for vaginal injuries. Digital rectal examination is indicated in men presenting with pelvic fractures to look for a high-riding prostate, which is an indicator of an increased risk of urethral injury.

Laboratory studies are obtained for patients once they arrive to the emergency department, including complete blood count (CBC), coagulation profile, renal panel, toxicology studies, and serial hematocrits to monitor resuscitation.

Treatment

Treatment of pelvic fractures depends on whether the fracture is stable or unstable. Symptomatic treatment is enough in patients with stable fractures who can walk with no aid. However, acetabular fractures resulting from high-energy injuries may require surgical intervention, especially if there is displacement or instability after closed reduction of the fracture. If it is accompanied by posterior wall injuries, it is usually managed non-surgically.

If the patient presents to the emergency department with an unstable pelvic fracture, stabilization with wrapping is essential to decrease or stop bleeding. Followed by orthopedic consultation to determine whether external screw fixation or open reduction with internal fixation (ORIF) is needed. Symphyseal disruptions are treated surgically with external fixation or open reduction with internal fixation (ORIF). Blood transfusion may be required for hemodynamic stability in patients suffering from severe bleeding.

Prognosis

It is important to decrease blood loss by stabilizing pelvic fractures early. This leads to a better prognosis [4]. Pelvic displacement may result in worse prognosis, especially if it is 5 mm or more [5]. If the displacement is more than 1 cm it may also cause increased levels of pain when compared to other patients with less or no displacements at all. Worse prognosis and poor results have also been implicated in cases with limb length discrepancy more than 2.5 cm [6].

Unstable pelvic ring fractures may result in permanent neurological injury, mainly involving the L5 and S1 nerve roots, in 20% of patients, which leads to poorer outcomes and worse prognosis. [7] [8]. 

The risk of mortality and morbidity is high in patients with pelvic fractures. It is estimated that more than 75% of patients deaths from motor vehicle accident prior to arrival to the hospital is secondary to pelvic fractures [2].

Etiology

Pelvic fractures occur after either high-energy or low-energy events with most of the fractures resulting from trauma. There are different mechanisms for high-energy fractures, the most common one is a motor vehicle accident. Others include motorcycle crashes, falls, and pedestrians. Crush injuries may also result in high-energy pelvic fractures, however, they are rare.

Low-energy fractures occur mainly in adolescents and elderly people. The most common presentation in adolesecents is avulsion fractures of the inferior or superior iliac spines, or apophyseal avulsion fractures of the iliac wing or the ischial tuberosity in athletic injuries. The most frequent mechanism of low-energy fractures in elderly people is falls while walking, which results in stable fractures in the pelvic ring; insufficiency fractures of the anterior pelvic ring and sacrum may also occur [1] [2]. Osteoporosis increases the risk of developing pelvic fractures from low-energy injuries.

Epidemiology

The incidence of pelvic fractures differs between males and females. In people less than 35 years of age, the risk is higher among men than women, however, it is higher among women in people older than 35 years [3]. Usually, the pelvic fracture is due to a high-energy injury from a motor vehicle accident. Elderly patients have higher incidence of developing low-energy fractures from falls while walking. Osteoporosis is one of the risk factors predisposing to this [3]. It is estimated that 37 individuals of 100,000 suffer from pelvic fractures every year in the United States.

Sex distribution
Age distribution

Pathophysiology

The pelvis is very important as it protects the internal organs of the body and transmits the weight from the trunk to the lower limbs. The pelvic ring, which is made of aspects of the innominate bones and the sacrum, should be stable in order for the pelvis to bear weight. Ligamentous support plays an important role in the stability of these bones. Injuries in these ligaments or fractures may result in pelvic instability.

Prevention

Most pelvic fractures are due to motor vehicle accidents. Encouragement of safe driving behaviors prevent these fractures, including the use of seat belts, airbags, and other protective tools. Promotion of anti-drunk driving programs and regulations also helps in the prevention of pelvic fractures.

Summary

Different bones may be involved in pelvic fractures, including innominate bones, pubic symphysis, acetabulum, sacroliliac joint or sacrum. The most common mechanism of fracture is trauma, however, they could result from high- or low-energy injuries.

The symptoms and clinical features depend on the severity of the fracture and include pain, genitourinary or gynecological symptoms, or neurological involvement. X-rays and CT scans are used in the diagnosis of pelvic fractures.

Symptomatic treatment is enough in stable minor fractures; however, unstable fractures or in cases where there is severe hemorrhage, surgical intervention is required, which makes pelvic fractures among the most serious fractures treated by orthopedic surgeons.

Pelvic fractures may occur in people of all ages and both genders, however, fractures due to high-energy injuries are more common in young males, and low-energy injuries are usually seen in older women due to osteoporosis. In the United States, it is reported that every year 37 out of 100,000 people suffer from pelvic fractures.

Minor stable fractures heal well with symptomatic treatment and have good prognosis, however, severe unstable fractures may have higher risk of morbidity and mortality.

Patient Information

Pelvic fractures are serious injuries in the pelvic bones, which could be life-threatening. The most common cause of these fractures is trauma due to a motor vehicle accident especially in young men (great force injuries). Older women have weak bones, due to a condition called osteoporosis, which may lead to pelvic fractures from simple falls while walking (slight force injuries).

Pain in the groin region or lower back is the most common presentation in patients with pelvic fractures. The pain usually increases when trying to walk or move the legs. Other symptoms may include blood with urine, decreased amount of urine, rectal or vaginal bleeding. Neurological features may also develop including weakness in the lower limbs and decreased reflexes. There might also be other injuries in the chest, abdomen, legs, or head especially in great force injuries, such as high falls or motor vehicle accidents.

The doctor will do a full thorough examination and a digital rectal examination to look for signs of injury to the urethra. X-rays and CT scans will be ordered to identify the fracture. Gynecological and pelvic examination is also done in women patients to rule out vaginal injuries.

The management of pelvic fractures depends on stability. In stable simple fractures, symptomatic treatment and bed rest will be enough. However, surgical intervention with different procedures may be required in patients with unstable fractures and severe hemorrhage. Blood transfusion may be needed if the patient lost big amounts of blood.

Early stabilized and managed fractures result in better outcomes. However, unstable fractures with severe bleeding may carry a death risk. Using seat belts and airbags while driving, as well as not driving while drunk will decrease motor vehicle accidents, which is the most common cause of pelvic fractures.

References

Article

  1. Gotis-Graham I, McGuigan L, Diamond T, et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br. November 1994; 76(6): 882-6.
  2. Broadwell SR, Ray CE. Transcatheter embolization in pelvic trauma. Semin Intervent Radiol. 2004; 21(1): 23-35.
  3. Melton LJ 3rd, Sampson JM, Morrey BF, et al. Epidemiologic features of pelvic fractures. Clin Orthop. March-April 1981; (155): 43-7.
  4. Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery. March 1973; 73(3): 454-62.
  5. Pohlemann T, Bosch U, Gansslen A, et al. The Hannover experience in management of pelvic fractures. Clin Orthop. August 1994; (305): 69-80.
  6. Tile M. Pelvic ring fractures: should they be fixed?. J Bone Joint Surg Br. January 1988; 70(1): 1-12.
  7. Tile M. Anatomy. In: Tile M, ed. Fractures of the Pelvis and Acetabulum. Baltimore, Md: Williams & Wilkins. 1995; 12-21.
  8. Reilly MC, Zinar DM, Matta JM. Neurologic injuries in pelvic ring fractures. Clin Orthop. August 1996; (329): 28-36.
  9. Peltier LF. Complications associated with fractures of the pelvis. J Bone Joint Surg Am. July 1965; 47: 1060-9.
  10. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallee lesion. J Trauma. June 1997; 42(6): 1046-51.
  11. Watnik NF, Coburn M, Goldberger M. Urologic injuries in pelvic ring disruptions. Clin Orthop. August 1996; (329): 37-45.
  12. Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery. March 1973; 73(3): 454-62.
  13. Huittinen VM, Slätis P. Nerve injury in double vertical pelvic fractures. Acta Chir Scand. 1972; 138(6): 571-5.

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Last updated: 2018-06-22 10:06