29 PELVIC FRACTURES
Steven J. Morgan M.D., Wade R. Smith M.D.

1. What are the first steps in the evaluation and treatment of a patient with pelvic trauma?

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The ABCs (airway, breathing, and circulatory assessment). The answer to this first trauma question is always the same. Trauma patients with displaced pelvic fractures have a high incidence of associated injuries to the head, chest, and abdomen.

2. What are the sources and potential volume of bleeding in the displaced pelvic fracture?

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Pelvic fractures bleed from exposed cancellous bone surfaces, pelvic veins, and pelvic arteries. Cadaveric injection studies have demonstrated that 90% of patients with trauma fatalities with pelvic fractures bleed to death from exposed bone and injured veins. Only 10% bleed from arteries. The total volume the pelvis can hold is 4-6 L before a tamponade effect slows venous and bone bleeding.

3. Should a Foley catheter be placed in trauma patients with displaced pelvic fractures?

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Yes. Contraindications include urethral injuries, which should be suspected when blood is observed at the penile meatus or vaginal introitus. A manual rectal examination in men and a bimanual examination in women are mandatory to exclude an open fracture into the vagina or rectum or a high-riding prostate. If a urethral injury is present, a suprapubic catheter can be easily inserted percutaneously, and both a urethrogram and cystogram are performed.

4. What is the incidence of urologic injury associated with pelvic fractures?

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The overall incidence is 16%.

5. What are the commonly used radiographic classification schemes for pelvic fractures?

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The mechanistic classification describes pelvic fractures as anteroposterior compression (APC), lateral compression (LC), vertical shear (VS), or combined mechanism (CM). The Tile classification categorizes fractures into three groups, A, B, or C, with numbered subgroups based on increasing severity of ligamentous and bony disruption.

6. What is an open pelvic fracture?

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An open fracture has been contaminated via a laceration in the skin, vagina, or rectum. When an open pelvic fracture is suspected, patients should receive a rectal examination with an ano-scope, as well as a vaginal examination performed bimanually and with a speculum. With open fractures, the morbidity and mortality rates are increased both in the acute period (because of hemorrhage) and in the delayed period (because of infection). Open injuries in the rectal or perirectal region often require a diverting colostomy to prevent deep pelvic infection.

7. When is acute mechanical stabilization of a pelvic fracture indicated?

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Open-book and vertical shear fractures with displacement may benefit from acute mechanical stabilization. When hemodynamic instability persists in the face of ongoing aggressive resuscitation, pelvic stabilization with a beanbag, external wrap, or external fixation device may help to decrease pelvic bleeding by decreasing pelvic volume (tamponade effect), stabilizing fracture surfaces, and promoting clot formation.

8. What is the role of angiography in an acute pelvic fracture?

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It is both diagnostic and therapeutic. Angiography can identify and embolize arterial bleeding caused by pelvic fractures. But only a low percentage of pelvic bleeding is from arterial injury. Suspicion should be increased when patients with hypotension fail to respond to pelvic ring stabilization and aggressive fluid resuscitation.

9. Why do patients die from pelvic fractures?

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Mortality is usually caused by associated injuries rather than the pelvic fracture. Only 2% of patients with a pelvic fracture experience isolated trauma to the pelvis. For example, patients with LC pelvic fractures are more likely to die secondary to associated head injuries rather than from pelvic hemorrhage. Death related to pelvic hemorrhage is generally seen in patients with massive pelvic displacement associated with APC or VS injury patterns. Early stabilization and mobilization, however, decrease the mortality from 26% to 6%.
KEY POINTS: BLOOD LOSS FROM PELVIC FRACTURES

1. 90% of deaths related to pelvic bleeding result from venous and bony bleeding.
2. The remaining 10% are due to arterial bleeding-most commonly from the superior gluteal artery.
3. Normally the pelvis can hold 4-6 L of blood before a tamponade effect occurs.
4. Pelvic wraps or fixation can limit bleeding, reduce bony shear, and promote clot formation.
5. Angiography is therapeutic and diagnostic, but only 10% of injuries are predominantly arterial.

10. What is external fixation?

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External fixation by the use of pins placed into the iliac wings and connected to a frame or by pins placed into the bone just superior to the acetabulum and connected to a C clamp can be used as a temporary method of fracture reduction and stabilization. External fixation does not prevent vertical and posterior displacement of the pelvis in the case of complete posterior disruption. The fixation device must be placed in a manner that permits abdominal access for laparotomy, diagnostic imaging, and the definitive operative approach for open reduction and internal fixation.

11. Is there a role for pneumatic antishock garments (PASGs) in the treatment of pelvic fractures?

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PASGs are falling out of favor in the treatment of pelvic fractures. Their potential role is limited to emergency transportation and initial stabilization of patients with a complex pelvic fracture. PASGs can reduce displacement of anteroposterior compression fractures but may increase the displacement of a lateral compression fracture. The garment also restricts access to the patient, compromises pulmonary reserve, and is associated with increased risk of compartment syndrome.

12. When can patients with a pelvic fracture ambulate?

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Patients with fractures involving only the anterior pelvic ring, such as unilateral or bilateral pubic rami fractures, may bear weight immediately. If the fracture pattern involves the posterior structures, such as the sacroiliac joint or iliac wing, patients must not bear weight for 10 weeks.

13. What is the most common source of arterial bleeding associated with a pelvic fracture?

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The superior gluteal artery.

14. Which gender and what portion of the urethra is most commonly injured in patients with a displaced pelvic fracture?

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The male urethra is more commonly injured. The urethra passes through the urogenital diaphragm or pelvic floor, transitioning in an abrupt fashion from the membranous to the bulbous urethra. The urethra at this point is attenuated and relatively fixed above, accounting for the large number of injuries at the membranous bulbous junction. The female urethra is much shorter and the pelvic floor is less well developed, allowing for greater mobility of the female urethra (or perhaps it is because girls are smarter, more cautious, and do not get injured as often). The most common site of urethral injury in girls and women is at the bladder neck.

15. Describe the mechanism that results in a bladder rupture.

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The bladder is both an intraperitoneal and extraperitoneal structure. Compression of a distended bladder results in an intraperitoneal rupture along the bladder dome. Extraperitoneal rupture, a more common injury, results from the laceration of the bladder by displaced pubic rami fracture fragments.
16. What are the three radiographic views required to evaluate patients with pelvic fractures? Show answer

1. Anteroposterior pelvis view
2. Inlet view
3. Outlet view

17. What is the appropriate insertion location for a diagnostic peritoneal lavage catheter in the presence of a pelvic fracture?

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A supraumbilical location avoids inadvertent decompression of the pelvic hematoma and a false-positive result.

18. What percent of patients with an unstable pelvic fracture will suffer an associated neurologic injury?

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Associated injuries of the lumbosacral plexus, sacral foramina, and sacral canal are reportedly as high as 50%.

19. What is a potential pitfall of aggressive blood transfusion of hemodynamically unstable pelvic fracture patients?

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Coagulopathy. Forty percent of patients with unstable pelvic fractures may require ≥ 10 units of blood. Fresh frozen plasma and platelets should be transfused early in the resuscitation.

20. What is the significance of an L5 transverse process (TP) fracture in a patient with a pelvis fracture?

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A TP fracture at the level of L5 may indicate vertical instability of the pelvic fracture. The iliolumbar ligaments attach to the TP and the iliac wing, often resulting in the avulsion of the TP when the pelvis vertically displaces.

References
WEB SITE
http://www.east.org/tpg/pelvis.pdf

BIBLIOGRAPHY
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