INTRODUCTION

Background: Pelvic fracture is a disruption of the bony structure of the pelvis. In elderly
persons, the most common cause is a fall from a standing position. However, the most
significant fractures involve significant forces such as a motor vehicle crash or fall from a
significant height.

Frequency:

 In the US: Pelvic fractures represent 3% of all skeletal fractures, with single
pubic rami and avulsion fractures the most common.

Mortality/Morbidity: Over half of all pelvic fractures occur as a result of minimal-to-

moderate trauma, such as a fall from a standing position. Of these, 95% are minor. On the
other hand, the more severe pelvic fractures involve significant trauma. Most of this
discussion relates to the more severe pelvic fractures.

 The complication rate is significant and is related to injury of underlying organs

and bleeding. Because of the tremendous force necessary to cause most unstable
pelvic fractures, concomitant severe injuries are common and are associated with
high morbidity and mortality rates. In addition, pelvic fractures increase the
incidence of pulmonary emboli.

 Overall mortality rate is approximately 10% in adults and 5% in children. Pelvic

hemorrhage is the direct cause of death in fewer than half of patients with pelvic
fractures who die. Retroperitoneal hemorrhage and secondary infection are the
main causes of death in children and adults with pelvic fractures.

 If hypotension is present on arrival to the emergency department, the mortality

rate approaches 50%. If the fracture is open, the mortality rate reaches 30%.

Sex:

 Associated genitourinary (GU) injuries vary greatly between men and women and
are discussed in other articles. For many years, it was felt that women did not
suffer urethral injuries. It is now well known that, while women suffer urethral
injuries at a much lower incidence than men, injuries do occur. Women suffer
partial lacerations and partial disruption with complete disruption being rare.

Age:

 Age distribution largely matches that of motor vehicle crashes, with car-car
injuries more prevalent in adults, especially younger adults, and car-pedestrian
injuries more likely to cause injury in children. The other group is the elderly who
tend to suffer pubic rami fractures without internal injuries in standing falls.
  Urethral injuries vary widely by age with injuries to the prostatic urethra and
bladder neck limited to children. Direct lacerations to the urethra occur only in
boys (small prostate) and women.

 The incidence of urethral injuries also varies by the type of pelvic fracture.
Straddle fractures associated with sacroiliac diastasis have the highest incidence
(odds ratio of 24). Without diastasis, the odd ratio dropped to 3.85. Urethral
injuries were essentially nonexistent for fractures not involving the ischiopubic
rami.

Causes:

 Adults with significant pelvic fracture

o Motor vehicle crash (50-60%)

o Motorcycle crash (10-20%)

o Pedestrian versus car (10-20%)

o Falls (8-10%)

o Crush (3-6%)

 Children

o Pedestrian versus car (60-80%)

o Motor vehicle crash (20-30%)

Pathophysiology: Pelvis consists of the ilium (ie, iliac wings), ischium, and pubis, which
form an anatomic ring with the sacrum. Disruption of this ring requires significant
energy. Because of the forces involved, pelvic fractures frequently involve injury to
organs contained within the bony pelvis. In addition, as the pelvis is supplied with a rich
venous plexus as well as major arteries, fractures may produce significant bleeding.

The Young classification system incorporates anatomic mechanism of injury and

identifies 4 types of ring disruption. Acetabular fractures, with or without ring disruption,
also may occur. Falls in elderly persons may involve fracture (usually of the pubic rami)
without disruption of the ring.

Lateral compression (LC) fractures involve transverse fractures of the pubic rami, either
ipsilateral or contralateral to a posterior injury.

 Grade I - Associated sacral compression on side of impact

 Grade II - Associated crescent (iliac wing) fracture on side of impact
  Grade III - Associated contralateral "open book" injury

Anterior-posterior compression (APC) fractures involve symphyseal diastasis or

longitudinal rami fractures.

 Grade I - Associated widening (slight) of pubic symphysis or of the anterior

sacroiliac (SI) joint, while sacrotuberous, sacrospinous, and posterior SI ligaments
remain intact
 Grade II - Associated widening of the anterior SI joint caused by disruption of the
anterior SI, sacrotuberous, and sacrospinous ligaments, while posterior SI
ligaments remain intact
 Grade III (open book) - Complete SI joint disruption with lateral displacement
and disrupted anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments

Vertical shear (VS) involves symphyseal diastasis or vertical displacement anteriorly and
posteriorly, which is usually through the SI joint, though occasionally through the iliac
wing or sacrum.

Combined mechanical (CM) fractures involve a combination of these injury patterns,

with LC/VS the most common.

Acetabular fractures most commonly involve disruption of the acetabular socket when
the hip is driven backward in a motor vehicle accident. Occasionally, they will occur in a
pedestrian struck by a vehicle moving at a significant rate of speed.

CLINICAL

History:

 Basic mechanism of significant blunt trauma should prompt consideration of a

pelvic fracture.

Physical:

 Tenderness over the pelvis that can be appreciated with pelvic springing indicates
fracture. Pelvic springing involves applying alternating gentle compression and
distortion over the iliac wings.

 Palpable instability of the pelvis on bimanual compression or distraction of the

iliac wings also indicates fracture. Be very gentle when pelvic tenderness is
appreciated. Do not rock or apply great force until radiographs exclude skeletally
unstable pelvic fractures, since an overly aggressive examination can increase
hemorrhage unnecessarily. Likewise, examination should be limited to one
 examiner. Remember that, in the later stages of pregnancy, the pelvic ligaments
become stretched and may mimic instability.

 Instability on hip adduction and pain on hip motion suggests an acetabular

fracture (in addition to possible hip fracture).

 Signs of urethral injury in males include a high-riding or boggy prostate on rectal

exam, scrotal hematoma, or blood at the urethral meatus.

 Vaginal bleeding or palpable fracture line on careful bimanual exam suggests

pelvic fracture in females.

 Other signs of pelvic fracture include the following:

o Hematuria

o Rectal bleeding or Earle sign, the appreciation of a large hematoma or

palpable fracture line on careful rectal exam

o Destot sign, a hematoma above the inguinal ligament, on the proximal

thigh, or over the perineum

o Grey Turner sign, a flank ecchymosis associated with retroperitoneal

bleeding

o Roux sign, a bilateral asymmetry in the distances between the greater

trochanter and the pubic spine on each side (indicating an overriding
fracture of the anterior pelvic ring)

o Neurovascular deficits of the lower extremities

WORKUP

Lab Studies:

 Serial hemoglobin and hematocrit measurements monitor ongoing blood loss.

 Urinalysis may reveal gross or microscopic hematuria.

 Pregnancy test is indicated in females of childbearing age to detect pregnancy as

well as potential bleeding sources (eg, miscarriage, abruptio placentae).

Imaging Studies:

 Radiographs
 o Anteroposterior pelvic radiograph is the basic screening test and uncovers
90% of pelvic injuries.

o Additional views include outlet (40 degrees cephalad) and inlet (40
degrees caudad) views.

o Judet (oblique) views show better detail of the acetabulum.

 Findings may be divided into 1 of 4 categories according to the Kane

classification system.

o Kane type I represents fractures of only 1 pelvic bone and no interruption

of the anatomic ring, such as an avulsion of the anterior superior iliac
spine. In general, these fractures have no significant associated injuries
and require only rest and analgesia.

o Kane type II represents single breaks in the ring near the pubic symphysis
or an SI joint (since this can occur only near a flexible area). These are
skeletally stable, requiring only rest and analgesia, but may be associated
with significant GU/intra-abdominal injuries.

o Kane type III represents double breaks in the ring and therefore is
skeletally unstable. These include straddle (bilateral double rami)
fractures, Malgaigne (double vertical; unilateral double rami plus iliac)
fractures, and open book disruption (of pubic symphysis and SI joint).
Most are associated with significant hemorrhage and GU/intra-abdominal
injuries.

o Kane type IV represents acetabular fractures, which frequently are

associated with GU/intra-abdominal injuries because of the force required.

 Computed tomography

o If a fracture is present or suspected and the patient is medically stable,

order a pelvic CT scan, in addition to other necessary CT scans, to
determine whether concomitant injury is present.

o CT scan is the best imaging study for evaluation of pelvic anatomy and
degree of pelvic, retroperitoneal, and intraperitoneal bleeding. CT scan
also confirms hip dislocation associated with an acetabular fracture. CT
scanning has largely replaced plain radiographs except for screening, and
it has virtually eliminated the use of auxiliary views.

 Ultrasonography
 o As part of the Focused Assessment with Sonography for Trauma (FAST)
examination, the pelvis should be visualized for intrapelvic bleeding/fluid.
In addition, the FAST examination should determine intraperitoneal
bleeding to explain shock.

o Absence of intraperitoneal fluid and lack of a hemothorax in a patient in

shock would indicate the pelvis as a likely source.

 Urethrography: Retrograde urethrography is necessary for males with a displaced

or boggy prostate or blood at the urethral meatus and for females in whom a Foley
catheter cannot easily pass on gentle attempts. This study should also be used in
females with a vaginal tear or palpable fracture fragments adjacent to the urethra.

 Arteriography

o Consider this study in hemodynamically unstable patients when

ultrasonography, CT scanning, or peritoneal tap excludes significant
intraperitoneal bleeding and after external pelvis is stabilized.
o This study allows for determination of the bleeding site and, potentially,
embolization as a means of control.

 Cystography: Consider this study in any patient with hematuria and an intact
urethra.

Procedures:

 Use a suprapubic catheter for patients in whom urethral injuries are suspected but
a urethrogram cannot be obtained.

 Use an external compression device, sheets, or possibly a pneumatic antishock

garment (PASG) to control bleeding and temporarily stabilize pelvis.

 External pelvic fixation may be necessary to decrease bleeding and prevent

further damage.

TREATMENT

Prehospital Care:

 Address acute life-threatening conditions. Be very aware that the amount of force
necessary to cause a significant pelvic fracture is likely to have caused other
significant injuries.

 Consider use of PASG to mechanically stabilize the pelvis if grossly unstable.

 Avoid excessive movement of pelvis.

  Establish large-bore intravenous (IV) access and administer fluids as needed.

 Closely monitor vital signs.

Emergency Department Care:

 Investigate associated intra-abdominal and intrapelvic injuries. A FAST exam

should be performed as soon as possible, as well as a chest radiography to look
for other bleeding sources, especially in the unstable patient.

 Avoid excessive movement of the pelvis. The pelvis should be rapidly stabilized
with a sheet or commercial pelvic external stabilizer. This is very important prior
to neuromuscular blockade because the muscles may be the only thing
maintaining pelvic stability.

 Consider orthopedic applied external fixation for skeletally unstable fractures.

 Administer fluid replacement and analgesics as needed.

 Do not place urinary catheter until urethral injury has been ruled out by physical
exam or retrograde urethrography.

 Obtain CT scan of pelvis as soon as practical.

 Consider angiography as soon a possible in the unstable patient without other

bleeding sources.

Consultations:

 Consult an orthopedic surgeon when a pelvic fracture is diagnosed.

Hemodynamically unstable patients (with unstable pelvic fractures) require
emergent orthopedic consultation for possible external fixation.

 Consult an interventional radiologist for embolization in the unstable patient.

 Consult a urologist for any suspected urethral injury.

MEDICATION

Primary treatment is for pain with narcotic analgesics. Administer antibiotics whenever
disruption of bowel, vagina, or urinary tract is suspected. Since bleeding is the major life-
threatening complication of pelvic fractures, avoid nonsteroidal anti-inflammatory drugs
in initial treatment. They may be considered later if inflammation is a concern.

Drug Category: Analgesics -- Narcotic analgesics are the treatment of choice in the
acute setting. Pain control is essential to quality patient care. It ensures patient comfort,
promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have
sedating properties that benefit patients who have sustained fractures. Adequate pain
control helps keep the patient quiet and avoids movement of the pelvis.

Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive

and should cover all likely pathogens in the clinical setting.

FOLLOW-UP

Further Inpatient Care:

 Monitor patient for signs of ongoing blood loss and signs of infection.

 Monitor for development of neurovascular problems in lower extremities. The

sacral nerves, lower lumbar nerves, and the sympathetic chain can be injured.

 Consider deep venous thrombosis (DVT) prophylaxis in all patients. Pelvic

fractures give an odds ratio for venous thromboembolic events (VTE) of 2.93.
What the appropriate preventative measures are is somewhat controversial at this
time.

 Pain management is very important to facilitate early mobilization and reduce risk
of thrombophlebitis. Early pelvic stabilization is important for pain control as well
as for limiting bleeding. The orthopedic specialist should determine the exact
techniques and procedures.

 Degree and timing of mobilization depends on the exact injury as well as

associated injuries and should be determined by orthopedic and trauma surgeons.

 Management of urethral injuries requires urologic consultation, as the correct

approach to minimize complications is controversial. As soon as a urethral injury
is suspected, a urologist should be consulted. If a urinary catheter is required prior
to a urologist arrival, a suprapubic catheter should be placed.

Further Outpatient Care:

 Elderly patients with isolated pubic rami fractures can be safely discharged if they
can be cared for at home or in another facility. They will require sufficient pain
management to allow them to ambulate, or they should have sufficient help. If
they are nonambulatory, DVT prophylaxis should be considered.

Transfer:
  Achieve hemodynamic stabilization and consider pelvic stabilization before
transfer.

 Transfer all patients except those with minor pelvic fractures to a trauma center.

 Complex acetabular fractures may require transfer to a specialist in acetabular

fractures.

Deterrence/Prevention:

 Encourage use of seat belts, airbags, and other protective gear.

 Promote anti–drunk-driving programs and laws.

Complications:

 Increased incidence of thrombophlebitis

 Intrapelvic compartment syndrome

 Continued bleeding from fracture or injury to pelvic vasculature

 GU problems from bladder, urethral, prostate, or vaginal injuries. Sexual

dysfunction may be a long-term problem.

 Infections from disruption of bowel or urinary system

Prognosis:

 Prognosis varies depending on severity of fracture and associated injuries.

MISCELLANEOUS

Medical/Legal Pitfalls:

 Failure to diagnose an underlying injury, especially urethral disruption

 Failure to consider a urethral injury in a female

 Failure to clinically (or radiographically) exclude urethral injury prior to

attempting to insert a urinary catheter in a male
 Failure to obtain urethroscopy in women with suspected urethral injuries

 Failure to cease attempted Foley catheterization in a female after encountering

resistance
  Failure to document the presence or absence of vaginal bleeding in a female with
a pelvic fracture

 Failure to diagnose a hip dislocation associated with an acetabular fracture

 Failure to appreciate ongoing blood loss

 Failure to diagnose concomitant intra-abdominal or retroperitoneal injuries

 Failure to obtain prompt orthopedic consultation for an unstable pelvic fracture

 Failure to promptly apply external stabilization to an unstable pelvic fracture

Special Concerns:

 Pregnant patients

o Patients in later stages of pregnancy are at increased risk for

complications.

o Risk of placental abruption and uterine rupture is great.